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APRIL 3 1937 i
THE LANC
Offices: 7, ADAM STREBT, ADELPHI, W.C.2.
Telegrams: LANCET, RAND, LONDON.
Telephone: TEMPLE BAR 7228 and 7229.
No. XIV., oF Vor. I., 1937. LONDON, SATURDAY, APRIL 3, 1987.
No. 5927. VoL. COXXXII. Founded 1823, PUBLISHED WEEKLY. Registered as & newspaper.
p. 128— Price 18S.
Annual Subscription :
Inland £2 2s. Abroad £2 lOe.
()XFORD MEDICAL PUBLICATIONS.
SEE PAGE 2.
DEN OSIS OF MENTAL DEFICIENCY.
By HENRY HERD, M.A., M.B., Ch.B.
‘Pp. 284. Demy 8vo.
Fully illustrated with 39 half-tone and 12 line blocks.
Price 12s. 6d. net.
** A concise and practical guide to the recognition of mental
deficiency on modern lines.”—PUBLIO HEALTH.
Hodder & Stoughton Ltd., Warwick-square, E.C.4.
DL BEASES OF THE THYROID GLAND.
WITH SPECIAL REFERENCE TO THYROTOXICOSIS.
By CECIL A. JOLL, M.S., B.Sc., F.R.C.S. (Eng.).
Crown 4to. Fully Illustrated. £3 3s. net.
ee No
raise is too high for the author of this great book.
It must be considered as the standard work on thyroid disease.
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THE LANCET]
CANCER TESTS AND TREATMENTS
By P. N. Panton, M.B. Camb.
DIRECTOR OF THE CLINICAL AND RESEARCH LABORATORIES
OF THE LONDON HOSPITAL
SCARCELY a year passes without the publication
of some new cancer test or cancer treatment, often
from a reputable source and usually with high
claims for specificity or effectiveness. It happens
that a number of such claims have been investigated
by various workers in the London Hospital labora-
tories and it seems worth while to bring together
the results of their investigations with a view to
establishing some criteria by which a diagnostic test
in particular should be judged before advising its
adoption as a practical method.
For each test investigated the observers have
visited, and worked when possible, in the laboratories
of origin, in order to ensure accuracy in the practice
of the method; and in the case of some tests, either
a reliable technician from the original laboratory
or the author himself has put the method on trial
here. When special apparatus has been necessary it
d has been obtained in the country from which the
= test derived.
For most of the tests investigated it has been
claimed that a very high percentage of accurate
results is possible, and that this has been demon-
'.--strated when the clinical diagnosis was concealed
. from the technician by the use of numbered specimens. '
But this precaution of numbering specimens may
5) give an entirely false idea of the value of a test,
since it appears that there is sometimes coédrdination
between ‘clinician and laboratory worker by which
| the clinical diagnosis is adapted to the result of the
4 t. The conditions insisted upon at the London
~ Hospital are given in the description of the test
«d most recently investigated, the Freund-Kaminer
>—reaction. Many cancer tests are associated with or
pe Geer upon theories concerned with the nature and
à treatment of cancer and reference is made to some
. of these treatments. In addition, one treatment
not associated with a test is briefly described.
Abderhalden Test
f Abderhalden first described his test in 1912 and
zin the following two years over 300 papers, almost
x all of which were confirmatory, appeared in the
_% German medical press. Originally put forward as a
test for pregnancy, it was subsequently claimed as a
means of diagnosing disease in almost any organ and
¢ particularly as a test for cancer. The test depended
~ upon the presence of ferments specific for any
———
AAA
in pregnancy, for breast-cancer tissue, and so on.
The presence of the ferments was detected both by
dialysis, after mixing the albuminous substrate of
the tissue with the serum to be tested in a dialysing
tube impermeable to albumin and examining the
dialysate for peptone, and- by the polariscope using a
peptone with the serum. These claims were investi-
gated by Dr. J. O. Gavronsky in a laboratory specially
fitted for the purpose and after two periods of work
in Prof. Abderhalden’s laboratories. The results of
an investigation of 121 cases were published by
Gavronsky (1915). It was found that there was no
specificity in these ferments, and that while the sera
of normal patients rarely interacted with any sub-
5927 ae
ADDRESSES AND ORIGINAL ARTICLES
products abnormally present in the blood, for placenta -
[APRIL 3, 1937
strate, the sera of most febrile and pregnant subjects
and of many cancer patients reacted with any sub-
strate whether placental or cancerous. A remark-
able feature of the vast amount of work originally
published on these tests, much of which came from
the Halle laboratories, was the unanimity with which
series after series of nearly 100 per cent. correct
results were obtained from numbered bloods.
Bendien Test
Bendien, in 1931, claimed that in a cancer subject
the fraction of serum proteins precipitated by a
sodium vanadate-vanadic acid buffer solution and
dissolved in sodium bicarbonate gave a characteristic
ultra-violet absorption curve. Proteins from cases of
tuberculosis were also said to show a characteristic
absorption curve. Dr. Bendien, a general prac-
titioner with a special knowledge of spectrophoto-
metry, was greatly handicapped by the publicity
given to his work by the lay press in Holland and in
this country. The test was investigated in these
laboratories by Prof. J. R. Marrack, Dr. F. Campbell
Smith, and Dr. E. R. Holiday, and in Holland with
the help of Dr. Bendien. The investigation was
confined to the reliability of the spectrophotometric
observations. It was found almost at once that
the yellow solutions of protein-sodium vanadate in
sodium bicarbonate rapidly faded and finally became
colourless on exposure to light, and that the two
absorption curves obtained before and after fading
corresponded respectively to the tuberculosis and
the cancer curve of Bendien. The same result could
be obtained from the sera of cancerous and non-
cancerous subjects and a report to this effect on the
investigation of 49 cases has not been contradicted
in any published work (Smith, Holiday, and Mar-
rack 1931). The test and a form of treatment
controlled by it is still practised, but the test mainly
relied upon is the sodium-vanadate. precipitation and
not the absorption curve.
Schubert-Dannmeyer Test
This test was first brought to my notice by Dr.
A. J. Orenstein and was investigated in these labora-
tories by Dr. Holiday and Dr. Campbell Smith after
Dr. Holiday had spent sufficient time in Hamburg
to acquire the technique. The test was developed
from the hypothesis that the lipin fraction of cancer
serum is altered. Schubert claimed to be able to `
detect this alteration by the difference of certain
electrical properties between a lipin extract of cancer
serum and that from normal serum. The method
consisted of preparing a suitable extract with hexane
and measuring the rate of discharge of a quantity of
electricity through the extract. It was claimed that
in extracts from normal sera the discharge was
complete, whereas in cancer serum extracts a certain
charge always remained ‘“ residual potential.” The
test was examined in two series of cases and a report
published in 1935 (Holiday and Smith). The authors
concluded that ‘‘the method as it stands seems to
us to be of no clinical value as a diagnostic test for
cancer.”
The King Cancer Treatment
A treatment resulting from the work of Dr. A. C.
King in Kenya was investigated at the request of
the British Empire Cancer Campaign. Dr. King
adopted the theory that extracts of certain organs
injected. into the blood stream might cause necrosis
| O
794 THE LANCET]
of cancer cells. The tissue which he chose for extrac-
tion was marrow from the long bones of oxen. He
used a glycerin extract filtered through a bacterial
filter and diluted to 10 per cent., giving to the patient
a considerable series of intravenous injections. A
small series of cancer subjects submitted to the treat-
ment at Dr. King’s hands. The patients were selected
and observed throughout and after the treatment
by Mr. Glyn Bowen. The treatment appeared to be
without effect. i
Fuchs Test
The Fuchs test has attracted considerable attention
and in very large series of cases an accuracy of over
90 per cent. has been claimed. The test depends
upon the observation of Fuchs that the serum of
normal persons digested all fibrin except that of
normal subjects, while the serum of cancer patients
digested all fibrin except that of cancer subjects.
In the actual performance of the tests the results
depend upon determinations of minute amounts of
non-protein nitrogen for which the author has devised
@ special gpparatus since the limits of error of the
usual methods exceed the minute differences found
in disease.
Working in the laboratories of Prof, D. T. Harris,
Dr. Fuchs carried out the test in two series of cases
selected by me on the same condition as those
prescribed for the Freund-Kaminer reactions. The
first series consisted of 44 cases, and of these the
results were correct in 25 and wrong in 19, both
false negatives and false positives occurring. The
series was discontinued in order that Dr. Fuchs
might control his reagents with known normal and
cancer sera. A second short series was then begun
and of 13 cases the test result was wrong in 7. On
these findings the test would appear to have no
value, but it is proper to add that Dr. Fuchs believes
that some fault must have been present in one of
the reagents and he proposes to repeat the test ina
future series.
Freund Tests and Treatment
Prof. Freund, working now in the Pearson Insti-
_ tute in Vienna, has during the last fifty years
elaborated a theory of the causation of cancer upon
which diagnostic tests and treatments of cancer are
based. He believes that a substance produced
mainly by the thymus and able to destroy cancer
cells is present in childhood and that as age advances
this “normal substance” diminishes. Also that
foods rich in animal fats effect a change in the
intestinal flora so that fats are digested and sub-
stances produced which protect cancer cells from lysis
by the normal substance, Evidence for these state-
ments is offered in the results of the diagnostic tests.
The original Freund-Kaminer test was based on the
claims that normal sera lysed some 60 per cent. of
cancer cells in suspension and sera of cancer subjects
a smaller percentage, also that cancer sera added to
normal sera inhibited the lytic action of the latter.
As further evidence of Freund’s hypothesis, it is now
said that an abnormal coliform bacillus resistant to
1 per cent. hydrochloric acid can be isolated from
the feces of cancer subjects, that this bacillus grown
in milk rich in cream produces an ether extractable
substance having antilytic properties similar to the
substance found in the serum in cancer, and that
the bacillus is agglutinated by the sera of cancer
subjects but not by normal sera. A further claim,
which appears inconsistent with recognised immuno-
logical processes, is that this cancer-protective
DR. P, N. PANTON : CANCER TESTS AND TREATMENT
[APRIL 3, 1937
substance gives a positive skin reaction in cancer
subjects.
These theories are linked with a series of diagnostic
tests and with the treatment of cancer. The treat-
ment depends upon an alteration of the diet designed
to prevent the formation of the cancer protective
substance and the injection of the ‘ normal” sub-
stance extracted from the urine of horses. The
dietary treatment has been in use for twenty-five
years, the treatment by normal substance for only
two or three years. Mr. Glyn Bowen visited the
Pearson Institute at Vienna and found it difficult to
assess the value of the treatment owing to the
inadequacy of the records, but no extravagant claims
are made and no decision can properly be arrived at
until a series of controlled cases has been examined
in one of the large general hospitals, such as that
at Linz.
For the purposes of the test Dr. Hans Loewenthal, —
who was already familiar with the Freund-Kaminer
reaction, visited the Pearson Institute in Vienna to
acquire the technique but the actual performance of
the tests in these laboratories was the work of Miss
Kolmer, the chief technician in Prof. Freund’s
laboratory. Her work was carried out with scrupulous
care and with any assistance that she required from
Dr. Loewenthal.
The conditions of the test were as follows. The
series was to consist of not less than 100 cases selected
by me. Cancerous and non-cancerous cases were to
be in approximately equal numbers, but the order in
which cancer or non-cancer material reached the
laboratory was to be indiscriminate. The number of
the case only was known to the laboratory and the
final laboratory diagnosis was to be positive, negative,
or indefinite and recorded before the clinical diagnosis
was disclosed. The cases chosen as examples of
cancer were patients shortly to be operated upon
and concerning whom a histological report was
reasonably probable. The majority were examples
of carcinoma of the breast, or of epithelial surfaces,
or of the intestinal tract. Bender and Kretz of the
General Hospital, Linz, recording that in 1434 cases
91 per cent. of cancer patients gave a positive result
and 84°9 per cent. of non-cancer cases a negative
result, suggested that the 15:1 per cent. of false
positives among the non-cancer cases might be
explained by the precancerous state. The non-
cancerous cases in this series were therefore selected
chiefly for their youth, many being children or young
adults with broken limbs. No particular selection
of febrile or medical conditions was made and no
cases of pregnancy were included. The tests employed
by Miss Kolmer were those now in use in Vienna
and Linz; the results represent her summary of the
readings of the different tests used.
In all, 134 cases were selected, but in 14 of these
the necessary specimens were not all forthcoming
and in 4 the diagnosis was never established. There
remain 116 cases :—
Of these :
22—or approximately 20 per cent. gave indefinite results.
51 A 44 Rs + correct j5
43 s5 36 oS ay incorrect es
Omitting the indefinite tests, the approximate per-
centage is 55 correct and 45 incorrect.
Of the cancer cases, 58 in number:
14—or approximately 24 per cent. gave indefinite results.
29 Sas 50 j is correct ‘5
15 iG 26 is PA incorrect S
Omitting the indefinite tests the percentage is 66
correct and 34 incorrect.
THE LANOET] DR. G. J. LANGLEY & OTHERS: SERUM TREATMENT OF LOBAR PNEUMONIA [APRIL 3, 1937 795
Of the non-cancer cases, 58 in number:
8—or approximately 14 per cent. gave indefinite results.
22 correct i
Á hi 99 40 39 99
28 a 46 > p ee incorrect j
Omitting the indefinite tests the percentage is 45
correct and 55 incorrect.
Since each result depends upon a summary of
several tests it is difficult to assess these figures
accurately, but the distribution of correct and
incorrect results suggests that it is the outcome of
chance. Certainly these tests on these findings have
no diagnostic value and differ widely from the
standard claimed for them. It is just to make two
observations about these results, the one a general
statement that very few diagnostic tests will give a
90 per cent. accuracy in such conditions as were
imposed here, and the other on a matter peculiar to
these reactions, the single result of which is derived
from four or five different tests. If one or two of
the tests have little value they will depress the value
of the other tests and there was in this series evidence
of this, since the peculiar agglutination reaction
considered’ alone in the last 68 cases of the series
gave 71 per cent. of correct results. Even this
percentage, however, can scarcely be considered
satisfactory. ,
Discussion
The problems of the early diagnosis and the treat-
ment of cancer are so important that one cannot
reject claims to solve these problems even if the
theories underlying them do not seem inherently
probable. There is the further reason for an impartial
examination that both tests and treatments coming
from a reputable source are apt to be exploited by
less scrupulous persons. All the tests described in
this communication, some of which are of con-
siderable antiquity, are still widely used. In some
cases important modifications have been made in the
test and these alterations make the final assessment
of the diagnostic value always open to criticism.
The tests first described here, those of Abderhalden,
are of great theoretical interest and as first described
claimed to be entirely specific, yet in spite of these
claims constant changes were made in the technique
and the changes were mainly in the direction of further
complexity so that one can only conclude that the
original claims were imperfectly controlled. A much.
altered form of these tests is now in use in Germany.
An important underlying cause for the exaggera-
tion of the claims for a diagnostic test in particular
is the usual divorcement of the investigating labora-
tory staff from direct contact with the wards of a
general hospital. Clinical control of tests and treat-
ment have been in general lacking and in some cases
impossible.
In view of the importance of these matters and
the interest taken in them by the lay public, it would
almost seem advisable that some official body should
be responsible for assessing the value of all cancer
tests and cancer cures as soon as they are published.
It was mainly because of the absence of such official
guidance and with the knowledge that exploitation
was contemplated that certain of these tests were
investigated here.
The examination of these diagnostic methods has
involved much time and often highly technical know-
ledge of chemistry and physics, for all of which I am
indebted to my colleagues at the London Hospital.
REFERENCES
| ky, J. O. (1915) Lancet, 1, 119.
Bolder, . R. en gee F. C. (1935) Amer. J. Cancer, 23, 339.
Smith, $. C., Holiday, E. R., and Marrack, J. (1931). Lancet,
2; 507
STUDIES IN THE l
SERUM TREATMENT OF LOBAR
PNEUMONIA
By G. J. LANGLEY, M.D., F.R.C.P. Lond.
READER IN GENERAL THERAPEUTICS, UNIVERSITY OF MAN-
OHESTER ; VISITING PHYSIOIAN, HOPE HOSPITAL, SALFORD
W. Mackay, M.D., F.R.F.P.S. Glasg.
PHYSICIAN, HOPE HOSPITAL; AND
L. STENT, M.D. Manch., Dipl. Bact.
ASSISTANT PATHOLOGIST, CITY OF SALFORD
THE published results of serum therapy in lobar
pneumonia in this country have been based on
comparatively small numbers, so that observations
on yet another modest series will add to the accumulat-
ing knowledge of the subject and help to form the
basis of a critical valuation. The figures in this
series have been collected from a study of 800 cases
arising in the city of Salford over a period of five
years. Of these cases 112 were treated with anti-
pheumococcus serum during the past two and a half
years.
It is very difficult to obtain an estimate of the
incidence and fatality-rates of typed lobar pneumonia
on any large scale, but the fifteenth annual report of
the Ministry of Health shows that 60,000 cases of
pneumonia in all forms were notified in 1933-34,
the fatality-rate being 50 per cent. In the city of
Salford, with a population of 230,000, the number of
cases notified in 1935 was 475 of which approximately
53 per cent. died. While no accurate information
can be gained from these figures it is evident that
the fatality-rate is high and that it is important to
investigate any form of treatment which might
reduce the high fatality-rate of a prevalent infectious
disease. In this series the fatality-rate in 688 cases
of lobar pneumonia of all types (not treated with
serum) was 24 percent. As analysis (into age-groups)
will show this figure is misleading and does not
indicate the true state of affairs.
TABLE [
l Type.
Total Group
cases IV.
I II. III.
800 50% 25% 1% 4%
(404) (197) (7) (192)
TABLE II
Type.
Group
a IV.
I II. III.
No. of cases 336 153 7 192
Deaths .. ü ks 68 61 7 29
100 15
Fatality-rate per cent. 20 40
The classification of lobar pneumonia according to
the type of the infecting pneumococcus shows that
the frequency of the serological types varies in
different countries.4 In Britain Types I, II, and
III are commonly differentiated, the remaining types,
numbering 29, being described as belonging to
Group IV. The figures given in Table I show the
796
type incidence in Hope Hospital, Salford. The
incidence of Type I pneumonia in Salford is rather
higher than that given for other localities in Britain,®
where the average incidence of Type I pneumonia
is 35 per cent.
American workers were the first to point out that
the virulence of pneumococci varies with the type.
This aspect of the pneumonia problem is illustrated
from Salford by the analysis of 688 cases of lobar
pneumonia not treated with serum (Table II). The
patients belonged to the artisan class, no occupation
being predominant.
The importance of age in prognosis has long been
known to clinicians. Advancing years render the
outlook more grave. The striking effect of age on
fatality-rate is easily seen in Table III. It shows
TABLE III
Incidence and fatality-rates, in age-groups and according to
Type, in 688 cases of lobar pneumonia not treated
with serum
Type I. | Type II. | Type III. | Group IV.
Age-
group
Inc Fa. | Inc Fa. | Inc. Fa | Inc. | Fa.
16-19 | 14% | 4% | 15% |17% | — — 18% | 6%
(46) | (2) | (23) | (49 | ©) | (0) | (35) | (2)
20-29 | 29% | 8% | 22% 133% | — — 23% | 5%
(96) | (8) | (33) | (11) } (0) (0) (44) | (2)
30-39 | 26% |22% | 19% |21%| — — 19% |16%
(89) | (20) | (29) | (6) (0) (0) (37) | (6)
40-49 | 17% 132% | 23% 151% | 43% |100% | 21% |29%
(56) | (18) | (35) | (18) } (3) (3) (41) | (12)
50-60 15% |41% | 22% |67% | 47% |100% | 18% |20%
(49) | (20) | (33) | (22) ] (4) (4) (35) | (7)
16-60 |100% |20% |100% | 40% |100% |100% | 100% 115%
(336) | (68) | (153) | (61) | (7) (7) | (192) | (29)
Inc. =incidence ; Fa.= fatality.
In Tables I and III and the following tables the figures in
parentheses denote the actual numbers of cases.
that the fatality-rate increases steadily with age
irrespective of type and that above the age of 40
lobar pneumonia is especially fatal.
From Tables I, II, and III it will be seen also that
about 75 per cent. of cases of lobar pneumonia belong
to Types I and II, and that the fatality-rate for these
types over the age of 40 is much higher than 24 per
cent. In this paper attention is drawn particularly
to the treatment of Type I and Type II lobar pneu-
monia with anti-pneumococcus serum.
In considering the results of serum therapy in
lobar pneumonia it is imperative to recognise the
influence of age on fatality. For this reason the
results are arranged in tabular form in age-groups.
Two other factors must also be remembered (a) the
day on which serum treatment is commenced, and
(b) the dose of serum employed. In America it is
held that treatment should be begun early, if possible
in the first three days. For the purpose of this
investigation all patients between the ages of 16 and
60 were treated whenever their initial dose of serum
could be given before the end of the third day of
illness. The sera employed were Lister Institute anti-
pheumococcus serum Type ‘I concentrated and
Burroughs Wellcome and Co. anti-pneumococcus
serum Type II concentrated.
The results (serum-etreated and non-serum-treated
cases) are set out in Table IV. The two sets of
figures are comparable in that they are derived from
the same case sequence, being differentiated only by
the fact that the cases treated without serum were
THE LANCET] DR. G.J. LANGLEY & OTHERS: SERUM TREATMENT OF LOBAR PNEUMONIA [APRIL 3, 1937
admitted to hospital after the third day of illness.
It was felt to be justifiable and scientifically sound
to use as controls those cases admitted to hospital
after the third day of illness for the following reasons.
An analysis of 457 cases of typed lobar pneumonia
admitted to hospital during the three years ending
TABLE IV
Fatality- rate in age-groups in 112 serum-treated cases
compared with that of 145 cases not treated with serum
Type I Type II.
Age- Without | With Without With
group serum. ; serum. serum. serum.
|
|
Inc. Fa. | Inc. Fa. Pap: Inc. | Fa. | Inc. | Fa. Pap:
16-19 |14% ae 5% | — 12%] — |27% 8% =
(13) (0) (105 (0) (0) (6) | (0) | (12) | (1)*| (0)
20-29 127% [12 %| 26% |6% | 11% | 20 % 130 %|25% | — |27%
eads (3). ats base (2) | (10) | (3) | (11) | (0) | (3)
30-39 | 23% 127 %| 34% | — |26% 118% 122 %| 23% 110 %| 20 %
(22) | (6) | (23) | (0) | (6) | (9) | (2) | (10) | (1) | (2)
40-49 117% |19% 18 % 25% |17% |24% 158 %| 16% [14 %| 57 %
(16) | (3) | (12) | (3)*) (2) | (12) | (7) | (7) | (1) | (4)
50-60 |19% |40 %' 7% | — |40% 126% 154%] 9% 125 %|50 %
(18) | (7) | (5) | (0) | (2) | (13) | (7) | (4) | (1) | (2)
Exp. fa. = expected fatality. * See text.
Sept. 30th, 1934 (before serum was used), showed
that the fatality-rate was not influenced by the
day of illness on admission to hospital. This is shown
in Table V.
The fatality-rates indicate that it is not the gravely
ill patients who are admitted to hospital late in the
disease. If clinical judgment is any guide patients
admitted after the third day of illness are not neces-
sarily more ill than those admitted earlier. Grave
illness is more often than not a reason for non -removal
to hospital.
oe ee ee e a R a ie
iliness Fatal-
on Cases.| Deaths. Cases.| Deaths.| ity
a a
sion. .
lst 30 9 41 10 24°4
2nd | 79 21 28 7 | 250
3rd |117 | 32 7 2 | 285
4th 88 27 2 1 500
5th 65 21
Of the cases set out in Table IV the average day
of illness on admission to hospital of serum-treated
cases was 2-3 days, while that of cases treated without
serum was 4:9 days. It will be seen that the patients
treated without serum did not include a preponderant
number who were admitted late in the disease. In
fact no patients admitted after the ninth day of illness
are included in the control series.
The general nursing care and the use of oxygen
when necessary are common to both groups.
On the whole the results are highly favourable to
serum therapy, especially in patients below the age
of 40. The figures are small and must be interpreted
with reserve particularly as it has chanced that there
is a preponderance of serum-treated cases under
the age of 40 where the fatality-rate in any case is
lower. Further in the age-group 16-19 Type II
THE LANCET]
serum-treated series the fatality-rate is actually
higher than in the same age-group without serum.
A similar unexpected finding is seen in the age-group
40—49 in the Type I series. It may be mentioned
that of the three deaths in the age-group 40-49
above, one case had been under treatment for pul-
monary tuberculosis for seven years and tubercle
bacilli were present with pneumococci in the sputum,
while another case at post-mortem examination was
found to have renal tuberculosis. In the age-group
20-29 Type I serum-treated series the only death
recorded occurred in a pregnant patient with a bleed-
ing placenta previa. The one and only death in the
age-group 16-19 Type II serum-treated cases occurred
in a youth of 18 with pneumonia of both lower lobes
associated with slight jaundice and a daily positive
blood culture. The inclusion of such cases with an
already grave prognosis may explain the unexpected
results when the numbers are so small.
AGGLUTININS IN LOBAR PNEUMONIA
The appearance of agglutinins in the blood-serum
is recognised by some authorities as an indication
of recovery, while others state that their appearance
does not exclude the possibility of relapse or com-
plications. A study of this question in Salford in
84 cases of lobar pneumonia which were not treated
with serum showed that agglutinins were readily
recognised in the blood-serum before, during, or
immediately after the crisis in all but 12 recovered
cases. Failure to detect agglutinins in all recovered
cases has also been noted by others,112 and it has
been suggested that although they are absent a pro-
tective antibody is present. It is well known that
experimental immunisation does not always lead to
the production of antibodies, although a high degree
of resistance is reached. A similar absence of agglu-
tinins may follow an acute Sonne dysentery infection
in some persons during an epidemic though in the
majority agglutinins are present.
In this study of 84 cases 26 were fatal. Agglu-
tinins were absent in 21 of these fatal cases and
present in 5. The presence of agglutinins in the
5 fatal cases suggests that there might have coexisted
with the pneumococcal infection some other previous
pathological process which was aggravated by the
superimposed acute infection. This was fuund to be
the case in 4 of the fatal cases. There was only one
in which death could be attributed to the pneumo-
coccal infection alone.
DOSAGE OF SERUM
The regulation of the dosage of serum for thera-
peutic purposes by the microscopic detection of
passive agglutinins in the patient’s blood-serum was
first used by Sabin,!! and is now a routine procedure
in certain New York hospitals. Some workers ë how- |
In Salford it has
At first it
ever do not think the test reliable.
been used in all serum-treated cases.
was the practice to inject 20,000 units. anti-pneumo- ,
coccus serum intravenously as an initial dose imme-
diately the type was known, but so many cases
required at least one further dose that it was very
soon decided to give an initial dose of 40,000 units.
At night if there was delay in typing, 20,000 units
each of Type I and Type II serum were given as a
first dose. Thereafter further dosage was determined
by the result of the agglutination reaction from day
to day. This subject has been more fully dealt with
elsewhere.’ If agglutination was ‘‘ absent’? a further
dose of 40,000 homologous units was given, or if the
reaction was ‘‘poor’’ or ‘“ moderate” 20,000 units
were administered. This procedure was repeated
DR. G. J. LANGLEY & OTHERS : SERUM TREATMENT OF LOBAR PNEUMONIA [APRIL 3, 1937 797
daily until a persistent ‘‘ good ” reaction was obtained.
Serum was then withheld although clinically the
patient might not appear to have recovered. A per-
sistent “‘ good ” reaction was obtained in some cases
after 20,000 or 40,000 units, but others required
more. In a few patients the reaction was “poor”
even after the injection of 160,000 units, and as many
as 200,000 units have been necessary. The agglutina-
tion reaction does not appear to depend on the
amount of serum administered ë but on the amount
of excess antibody (passive or active) free in the
blood-serum. The average total dosage per recovered
patient is shown in Table VI. It might be expected
TABLE VI
Average total dosage per
recovered patient.
Age-group.
oo Type I. Type II.
16-19 32,000 35,000
20-29 49,000 60,000
30-39 58,000 78,000
40-49 87,000 36,000
50-60 56,000 55,000
16-60, 60,400 56,800
that the total amount of serum per patient would
increase with age because of the diminishing powér
to produce active antibody in older patients. The
Table does not support this expectation. The cost
of serum to the hospital is on an average £3 per
patient—a very modest sum. |
EFFECT OF SERUM
Apart from reducing ‘the fatality-rate serum
therapy shortens the duration of the acute illness
as is well shown in Table VII. The termination of
the acute illness has been recognised as the first.
period of 24 hours during which the temperature does.
not exceed 99°F. The figures in Table VII are in
TABLE VII
Duration of the acute illness in recovered cases treated (a) with
serum and (b) without serum
With serum. Without serum.
Age-group. Type I. | Type II. | Type I. | Type II.
Average days.
16-19 5'1 6'2 8°5 6°5
(10) (11) (13) (6)
20-29 5'5 5'6 8'6 7'0
(17) (11) (23) (7)
30-39 6'2 5'1 7'2 8'3
(23) (9) (16) (7)
40-49 6°8 9°6 8°4
(9) (6) (13) (5)
50-60 4°8 6:0 7:5 7:5
(5) (3) (11) (6)
~ 16-60 5° 5°5 8°3 "5
(64) (40) . (76) (31)
close agreement with those reported by the Thera-
peutic Trials Committee of the Medical Research
Council.® It will be noticed that age does not appear
to have any influence on the duration of the acute
798 THE LANCET] DR. G. J. LANGLEY & OTHERS: SERUM TREATMENT OF LOBAR PNEUMONIA
illness. In some, crisis has been observed immediately
‘after the first injection of serum. The importance of
reducing by 2-3 days the duration of a toxic and
distressing illness is obvious. Increasing discomfort
is avoided and the patient’s general strength con-
served.
SERUM ANAPHYLAXIS
Serum reactions of a mild type were shamed in
12 cases between the eighth and fifteenth day after
the first dose of serum. An erythematous rash
appeared in 7 cases, arthritis in 4, and in 1 case
there was a feeling of general malaise. These anaphy-
lactic symptoms lasted only from one to two days.
It is not possible to incriminate any particular serum
as 10 of the patients had received an initial dose of
both Type I and Type II sera, one had Type I only
and another Type II serum alone. Serum reactions
are nO more common in the treatment of lobar pneu-
monia than in any other disease treated with serum.
COMPLICATIONS
Table VIII is a list of the complications observed.
In the serum-treated groups of cases complications
appear to be less numerous and less varied in character
than in the series treated without serum. Empyema
may be present as early as the fifth day of illness.
BACTERAMIA
At the commencement of the investigation in
Salford it was the practice to take blood for culture
on the day of admission and again at intervals of
two to three days during the acute illness. It was
soon found that any information thus obtained was
not reliable. The figures set out in Tables IX and X,
and XI and XII have been derived from patients from
whom blood for culture was taken daily during the
acute illness.
It must be pointed out at once that the figures are
small. They are merely placed on record and a
note made of the possible inferences. With increase
in age bacteremia seems to be more common and
the prognosis more grave. Irrespective of age the
fatality-rate is always much higher amongst the blood-
[APRIL 3, 1937
culture-positive cases than amongst the blood-
culture-negative cases. The prognostic significance
of bacteremia is apparently the same whether the
infecting pneumococcus belongs to Type I or
Type II. A positive blood culture does not seem to be
more common in Type I cases than in Type II cases.
This tendency is not in keeping with the idea of the
greater ‘‘ invasiveness ” of Type I pneumococci.?
In the groups of patients treated with serum there
were 5 deaths amongst those having positive blood
cultures. In all these cases bacteremia persisted
after the third day of illness, The small numbers
make it impossible to come to any decision as to
the effect of serum on bacteremia. It is meantime
a matter for speculation as to whether the successful
use of serum by shortening the period of the acute
illness prevents a bacteremia which youre arise if
the acute period lasted longer.
GENERAL REMARKS
The numerous factors known to influence the
fatality of lobar pneumonia require the investigation
TABLE VIII
Type I Type II
SERUM-TREATED SERIES SERUM-TREATED SERIES
No. of No. of
(a) 64 recovered cases. cases, (a) 40 recovered cases. cases
Empyema ea ou a en aw ia 2 Empyema as su me s3 sa 1
. Subcutaneous abscess .. as ss is oa 1
(b) 4 fatal cases.
‘(i) Post-mortem examination findings. l (b) 4 fatal cases.
Empyema : os 1
Renal tuberculosis : 1 (i) Post-mortem aa andings
(1) Eo Post-mortem examination not permitted. A Empyema T sg .æ. 1
ctive pulmonary tuberculosis i
Pregnancy. Bleeding placenta previa 1 ay ch rata a examination ai permitted. i
CONTROL SERIES (NOT TREATED WITH SERUM) No obvious complications =... .. ss we 2
(a) 76 recovered cases. : CONTROL SERIES (NOT TREATED WITH SERUM)
Empyema 3 3
Empyema and arthritis ex 1 (a) 31 recovered cases.
Art us (fem ral) thrombos! abscess .. Empyema 1
enous (femora ombosis .. 2e a eK os aes cai
; Jaundice . 2 Pericarditis ee oe oe es ee ee 1
(b) 19 fatal cases. (b) 19 fatal cases.
(i) Post-mortem examination findings. (i) Post-mortem examination findings.
Eme o and pericarditis .. i Empyema on an es va © 4
Empyema, pericarditis, and lung abscess .. — 2 Gangrene of lung ` é ; i z 1
Empyema, ae abscess, and parotitis . os 5 (ii) Post-mortem examination not PONA
e
Ulcerative endocarditis (aortic valve) and meningitis 1 h fibrillation : i
(ii) Post-mortem examination not permitted. Mitral stenosis (probably rheumatic) . 1
Pericarditis 1 | Stomatitis 1 Diabetes mellitus ee š 7
Auricular fibrillation No obvious complications 8 No obvious complications
of a large number of cases and many epidemics.
As already indicated we consider the number of cases
in this study small, therefore we hesitate to make
dogmatic statements. Nevertheless we feel that the
results obtained are very encouraging and we are
convinced that serum therapy was a real help in the
cases treated. Although we have no wide experience
_of the value of serum treatment when it is commenced
later than the third day of illness, it is logical to
demand for anti-pneumococcus serum the same con-
ditions as are laid down for the use of other sera—
namely, early administration and adequate dosage.
We regret the fact that a large number of patients
arrive in hospital at a late stage of the illness, Many
are sent in with a diagnosis of influenzal pneumonia,
a disease which, in Salford at least, is rare. It is
recognised that the diagnosis of lobar pneumonia
on the first or second day may be difficult in a few
cases, but by the third day the signs are usually well
defined. Certain of our first- and second-day cases
have been accurately diagnosed on the history alone.
THE LANCET] DR.G. J. LANGLEY & OTHERS: SERUM TREATMENT OF LOBAR PNEUMONIA [APRIL 3, 1937 799
BLOOD CULTURE RESULTS: TYPE I PNEUMONIA
_ TABLE IX
Cases treated with serum
Ñ t Blood culture. Deaths.
0.0
Age-group cases.
+ve. — ye. +ve. —ve
16-19 ee 6 2 4 — —
(33%) | (66%)
20-29 .. 11 4 7 1 —
(36%) | (64%) | (25%)
30-39 we 14 2 12 — —
l (14%) | (86%)
40-49 4 1 3 1 1
(25%) | (715%) | (100%) |] (33%)
50-60 4 1 3 — —
(25%) | (75%)
16-60 39 10 29 2 1
. (26%) | (74%) | (20%) (3%)
| TABLE X
Cases treated without serum
16-19 è 1 3 10 1 —
(23%) | (77%) | (33%)
20-29 34 8 26 4 , 1
(24%) | (76%) | (50%) (4%)
30-39 29 13 16 8 2
(45%) | (55%) | (62%) | (12%)
40-49 21 6 15 4 1
(29%) | (71%) | (66%) (7%)
50—60 20 12 8 8 3 o
(60%) | (40%) | (66%) | (37%)
16—60 117 42 75 25 7
(36%) | (64%) | (60%) | (9%)
We think.that in the presence of some or all of the
following symptoms or signs—rigor, vomiting, pain
in the chest, dyspnea, and cough—it is justifiable
to administer anti-pneumococcus serum early and
make the diagnosis later as is often done with diph-
theria antitoxin and antimeningococcal serum. A
polyvalent serum should be used until the type can
be determined. Seventy-five per cent. of our cases
belonged to Types I and II. Bacteriological typing
is an essential procedure. It is now both simple and
rapid, and in the majority of instances a correct
diagnosis can be made within 30 minutes. Test sera
are freely available in the open market. Typing
should present no difficulty in a well-equipped hos-
pital or municipal laboratory, and in view of the
serious nature of lobar pneumonia we are strongly
of the opinion that local authorities should make
provision for the typing of pneumococci in order
to assist smaller hospitals and general practitioners.
Although we have used the agglutination reaction
to determine the amount of serum necessary in
treatment, yet we do not consider it essential in the
routine clinical use of serum. It has helped to
economise serum.
The use of serum in lobar pneumonia has given
rise to a certain amount of destructive criticism.
It seems to us that such criticism is unwise while
the method is still under trial, especially as it is the
only scientific means of treatment available. We
maintain that many accepted lines of therapeusis,
if subjected to as searching an analysis as that under-
taken in serum therapy for lobar pneumonia by
many workers in America and in this country, would
probably emerge from the ordeal somewhat dis-
credited.. There is a real danger of premature criti-
BLOOD CULTURE RESULTS: TYPE II PNEUMONIA
TABLE XI
Cases treated with serum
ns A Blood culture. Deaths.
0.0 ;
Age-group. | cases.
+ ve. — ve. -++ ve. — ye.
16-19 re 11 3 8 1
(27%) | (73%) | (33%)
20-29 ae 5 5 — —
(100 %)
30-39 ene 6 2 4 1
(33%) | (66%) | (50%)
40—49 #8 5 ' 1l 4 — —
(20%) | (80%)
50—60 ie 4 1 3 1
(25%) (75%) | (100%)
“16-60 ae 31 7 24 3 —
(23%) | (77%) (43 %)
TABLE XII
Cases treated without serum
16-19 = 9 2 ! 7 1 —
(22%) | (78%) | (50%)
20-29 ea 10 4 6 1 —
a: (40%) | (60%) | (25%)
30-39 Pan 13 4 9 2 1
(31%) | (69%) | (50%) | (11%)
40-49 a 13 9 4 7o —
(69%) | (31%) | (78%)
50—60 en 13 7 6 7 o 1l
(54%) | (46%) | (100%) | (17%)
16-60 oan 58 26 32 18 2 y
(45%) | (55%) | (69%) (6%)
cism discouraging the further production of serum
before an extensive inquiry into its use has been
completed. The treatment is not difficult or trouble-
some. The intravenous route of serum admini-
stration is easy and painless, and anaphylactic
phenomena are no more frequent than in any other
disease so treated. The cost of serum is by no means
high.
Finally we submit that the results recorded from
our study of a comparatively small number of cases
encourage continued investigation into the treatment
of lobar pneumonia with anti-pneumococcus serum.
It is our pleasant duty to thank Dr. G. J. Crawford,
pathologist to the city of Salford, for much help and
advice, and the assistant medical officers and nursing staff
of Hope Hospital for ready and cheerful codperation.
To Dr. J. D. Giles, medical superintendent, Dr. H. Osborne,
medical officer of health, and the health committee we are
indebted for making this work possible. And finally to
Dr. G. F. Petrie of the Lister Institute, and Dr. R. A.
O’Brien of Messrs. Burroughs Wellcome and Co., we offer
our best thanks for supplying serum.
REFERENCES
. Cooper, G. (quoted by Sabin).
. Cowan, J., and others (1930) Lancet, 2, 1387.
. Cruickshank, R. (1933a) Ibid, 1, 563.
— (1933b) Ibid, 1, 621.
. Davies, D. T., and others (1935a) Ibid, 1, 791.
(1935b) Ibid, 1, 849.
. Langley, G. J., and others (1936) Quart. J. Med. 5, 251.
MN o Daun Report for 1935, city of Salford, pp. 20
an ;
. Medical Research Council, Report of Therapeutic Trials
Committee (1934) Lancet, 1, 290.
CO IO? Gr wm OS BS et
J)
10. Ministry of Health, 15th Annual Report, 1933-34.
11. Sabin, A. B. (1930) J. infect. Dis. 46, 469.
12. Sutliff, W. D. (1928) Proc. Soc. exp. Biol., N.Y. 25, 292. |
800 THE LANOET]
ANCYLOSTOMA ANAEMIA
By M. MAHFOUZ FIKRI, M.B., B.Sc.,
- D.T.M. & H. Lond.
LEOTURER IN CLINICAL PATHOLOGY IN THE UNIVERSITY,
CAIRO ; AND
PAUL GHALIOUNGUI, M.D., M.R.C.P. Lond.
MEDICAL TUTOR IN THE UNIVERSITY
I—THE BLOOD VOLUME
IN anæmia due to ancylostoma infestation the
total blood volume has been stated to be increased
to such an extent that although the number of red
cells per c.mm. is greatly reduced, the total oxygen
capacity of the circulating blood is normal (Boycott
and Haldane 1903, Boycott 1911). In 1934 Prof.
‘A. G. Biggam and one of us (P. G.) suggested that this
finding could explain the mildness of the symptoms
these patients complain of, relative to the degree
of apparent anæmia, the idea being that the blood
was only in some way diluted, the total oxygen-
bearing capacity being unimpaired.
METHOD
Before further pursuing the implication of this, we
thought of confirming these results. Our method of
estimating the blood volume was however a different
one. Itis based on the intravenous administration of
congo-red, a dye which is non-toxic and only slowly
excreted, and is described in detail by Todd and
Sanford (1931) after Keith, Rowntree, and Geraghty
(1915) and Rowntree and Brown (1929). The congo-
red we employed was Schering-Kahlbaum’s indicator
(p.g. VI) which was proved to be non-toxic by
intravenous injection into a dog. l |
The number of cases to which the method was
applied was limited by the rarity of pure ancylostoma
infestation. Associated helminthiasis, or dysentery,
_or pellagra were rigidly excluded by careful clinical,
pathological, and sigmoidoscopic examinations. The
subjects were asked to attend the laboratory at
8.30 a.m. without breakfast and were then kept lying
warm and recumbent before the actual performance
of the test. The solution of the dye was prepared
fresh on the.day of the determination, all syringes and
needles were carefully dry sterilised, and after the
subject was weighed the amount of dye for injection
was calculated. Blood was withdrawn from one
arm into oxalated graduated centrifuge tubes to
obtain the hematocrit reading and the plasma colour.
DRS. FIKRI AND GHALIOUNGUI: ANCYLOSTOMA AN AIMTA
[APRIL 3, 1937
the operation taking one minute; and 3 mins.
exactly after the middle of this period blood was
withdrawn from the other arm into another oxalated
graduated centrifuge tube. Calculation of the result
was done exactly as originally described.
In all, 20 cases of ancylostoma anzemia were
examined.. The accompanying Chart shows the
results, the numbers inset in the stippled areas
representing plasma volume per 100 c.cm. of blood.
We also examined 5 normal cases to check our
results and to find out the average normal for our
class of patients. The results are similarly recorded
in chart and compare with results of other authors.
Two cases infected with ancylostoma but not anemic
were also examined. Their blood volumes were 102
and 91 c.cm. per kg. body-weight respectively—i.e.,
slightly higher than the anemic cases, They were
excluded from this series.
RESULTS
(1) The average total blood volume of the
ancylostoma cases is 79°5 c.cm. per kg. of body-
weight—i.e., about or slightly below the normal
(89 c.cm.).
(2) The average plasma volume in ancylostoma
anemia is 62°6 per kg. body-weight—i.e., slightly
higher than the normal (54 c.cm.).
(3) The diminution in total blood volume in
ancylostoma can be accounted for entirely by the
diminution in total volume of red cells.
(4) Taken as percentage :—
Normal. Ancylostoma,
Plasma (%) . 60 78-6
Red cells (%) .. 40 21°4
(5) The total blood volume bears no relation
to the degree of anzemia as indicated by hæmoglobin
percentage, but with increasing degrees of ansemia
the percentage of plasma increases and the corpuscular
volume diminishes,
CONCLUSION
No increase in total blood volume was found in
anzmia due to infestation with ancylostoma ; on the
contrary there may be a tendency to diminution.
II—GLUCOSE-TOLERANCE CURVES
In attempts to explain the causation of ancylostoma
anemia deficient intestinal absorption has been
postulated as one of the contributory factors. Many
authors hold different views, regarding hemorrhage
or a possible toxic factor as being the most important
The solution of the dye was then injected very slowly, cause. In the absence of any balance experiments
deficiency of absorption would
100 Corpuscular volume Ml NORMAL_ be difficult to prove, and owing
Plasma volume T to the difficult and elaborate
30 B character of these observations
A >
80 as well as to the various pos-
70 sible interpretations of their
D 60 X results, we thought of approach-
P = F yf f ing the problem in another way
$ 46 N N N —by investigating the response
= 0 S RNN Y © o a of infested subjects to ingested
© 30 SB SIFD & $ glucose.
20 a a EA ka Ea EE N N A The patients were all examples
jz fr < i Et E y, N S A s i
10 i AE JE J N N of pure ancylostoma infestation,
eee, 49 ° ys
t t ty i
Q z, 8! e 5
a on nt os ar ve A:
k 7 7 7 oe
a be E i i $ LE EA EN BY fd E
30 40 26 45 23 33 46 20 38 25 32 30 I5
HAEMOGLOBIN So
The blood volume in 20 cases of ancylostoma anemia.
the volume in c.cm. per kg. of body-weight. The figur
the proportion of plasma—tLe., c.cm.
- 20 cases.
I5 45 28 18 33
per 100 c.cm. of blood.
B= recognised normal (other authors). C= average
3 ey oo me
<< ¥i ran
A 3 A. at
x R
PAs
The upright columns indicate
es in the stippled areas show
i those harbouring other intes-
tinal parasites or suffering from
dysentery, diarrhoea, or pellagra
being rigidly excluded. This
explains why we could investi-
gate only 18 cases in three years.
a
=
os
38
A= average of the
of 5 normal subjects.
THE LANCET}
Before the actual test the subjects were kept on the
standard hospital: diet for about a week, and then
first thing in the morning 1°5 gramme of glucose per
kilogramme of body-weight was given in 300 c.cm.
of water. The venous blood-sugar was estimated
by Folin and Wu’s colorimetric method before the
patient drank the glucose solution and then every
quarter of an hour subsequently in the first few cases.
Later it was considered that fifteen-minute intervals
for the first hour and then half-hourly intervals were
satisfactory. From a long experience we know that
the average glucose-tolerance curve of our class
of patient does not differ materially from accepted
standards. In the evaluation of the results we
classified them as follows :—
Normal curves: blood-sugar rising 40 mg. per 100 c.cm.
or more above ee level, reaching a maximum in less
than an hour, falling to less than 20 mg. above fasting
level in 2 hours. l
Low curves: maximum rise never reaching 40 mg.
per 100 c.cm. above fasting level.
Delayed rise : continuing to rise longer than 45 min,
Delayed fall: after 2 hours still 20 mg. or more above
fasting level. '
The actual figures are shown in the Table.
e i
S| Blood-sugar estimations. Maximum
À rise above ;
E| 3 Time (hours). | fasting level. Bie
Ty eee r
£ 8 hours
S| 4) 4] 2/4 [1a] 2 |28| 3 [Degree time,
ee ee eee eee ee a
105 j102)105/108; 243/140)117/111)/105) 38 1 +12
82 | 95/112) 136)132/126)115 54 ł +33
90 | — |105| — |110| 124/103 84 14 +13
95 |107/114|721/108|116|111| 98| 92| 26 ł +16
95 |101)/119)127)729/118)114 34 1 +19
80 | 92|/108|717|112|110|105]100 37 ł +25
93 | 93| 98|108|130|111| 96} 85) 82! 37 1 + 3
101 |109 seis bas 114/1261106 25 1} + 5
85} 98)108\114)736)118/113 51 1 +28
80 |154/125/100| 92| 86
82 | 80| 82) 94| 99/106) 95/105) 90| 24 1% +13
96 |125/135|1381133/110| 85) 80 42 i -I11
90 | — | 135| — |105| — | 95 45 + + 5
82 |143/100| 80| 78| 82 7
100 | 95137/151/151; 95| 86 51 ł —14
92 |174|152/104| 90| 85| 86
14| P +| 102 | — | 145| — |137|123/115 43 t +13
i.v. | 105 |192)185|152/125) 95
15 95 |111|137/133)125/100| 88 42 t - 7
i.v. | 95/|182/133/117) 98) 84/105
16 102 |111/117/135| 746)130)118 44 1 +16
i.v. | 87/208/114| 82) 80| 86
17 105 |145|7631152|138|110| 95 58 3 —10
i.v. | 90 |222)180/150/107) 85
18 87| 92| 88)116)113)147/156 69 2 +69
i.v. | 91]212/162:130/105! 80| 84
* Figures in italics show the maximum rise in each case.
t Figures considered abnormal are given in italics.
P+ = Enlarged paroda frequent featureinanæmia in Egypt.
i.v. = Glucose administered intravenously.
RESULTS
Curves were normal in 6 cases, 8 showed a low
curve, 4 a delayed fall, and 9 a delayed rise.
These abnormalities were usually present together,
only 3 cases showing any one of them as an isolated
feature.
DRS. FIKRI AND GHALIOUNGUI :
ANCYLOSTOMA ANAIMIA [APR 3, 1937 801
ee
HCl- (100= 0:1 PER CENT)
|
HOURS
Glucose-tolerance curves in 18 cases of ancylostoma anemia.
att 9 and 12-18 show curves also after intravenous injection
of glucose.
The 18 cases may be divided as follows :—
Normal : ;
Low curve +delayed rise
Low curve + delayed fall.
Delayed rise +delayed fall
Low curve ‘i
Delayed rise
Delayed fall
Total ..
—_
(0 2) | bet peed pni DD emt GD OD
GLUCOSE TOLERANCE AFTER INTRAVENOUS INJECTION
In 8 of the 18 cases the curves were also determined
after intravenous injection of 4 g. of glucose per
kg. of body-weight. In only one was the blood-
sugar appreciably higher than fasting level an hour
after injection (Case 14) while many of them showed
an obvious contrast between the oral and intravenous
curves (see Chart). No difference could be made
out with this method between cases whose oral
glucose curves were markedly different. The 8 curves
may be considered normal,
DISCUSSION
Low glucose-tolerance curves have been found
in sprue and celiac disease (Thaysen 1926, 1929,
1932, and Bennett, Hunter, and Vaughan 1932).
Various explanations have been offered such as
deficient absorption or excessive storage of sugar.
Recently Himsworth (1934) made the interesting
suggestion that these curves could be compared to
the response of subjects previously kept on diets
containing large amounts - carbohydrate, patients
o
802 “THE LANCET] PROF, GREY TURNER: LABOUR COMPLICATED BY THROMBOSIS OF MESENTERY [APRIL 3, 1937
not absorbing fat being on virtually high carbo-
hydrate diets. We were therefore careful to keep
all our patients on a mixed diet for one week before
the actual tests. Besides, in some of our cases the
only abnormality was not the absence or the slight
extent of any rise in blood-sugar but rather its
delayed character. This would make us attribute
these abnormalities to delayed absorption rather
than excessive or too rapid utilisation.
The present paper is only of the nature of a
preliminary note and we are not in a position to draw
any definite conclusions at the present stage of our
work which we intend to pursue further.
SUMMARY `
The glucose tolerance of 18 cases of pure
ancylostoma infestation has been investigated. In
12 there was some abnormality in the extent of the
hyperglycemic response, its duration or its fall.
In 9 of these two or more defects were associated.
The blood-sugar curves after intravenous injection
of glucose were determined in 8 cases. They were
normal and did not correspond to the respective
oral responses.
Interference’ with absorption caused in some way
by the presence of the ancylostoma worms and by
their bites in the duodenum is surmised as an
explanation.
We wish to acknowledge our gratitude to Prof. M.
Omar Bey for his help and advice, and to Prof. A. Ismail
Pacha and Dr. M. Ibrahim for permission to investigate
patients under their care and for their constant encourage-
ment and criticism.
REFERENCES
I
Boycott, A. ©. (1911) Lancet, 1, 720. ‘
— and Haldane, J. S. (1903) J. Hyg., Camb. 3,11).
Biggam, A.G., and Ghalioungui, P. (1934) Lancet, 2, 299.
Keith, N. M., Rowntree, L. G., and Geraghty, J. T. (1915)
Arch. intern. Med. 16, 547.
Rowntree, L. G., and Brown, G. E. (1929) The Volume of the
pled. and Plasma in Health and Disease, Philadelphia,
. 219.
Todd, J. C., and Sanford, A. H. (1931) Clinical Diagnosis by
Laboratory Methods, 7thed., p. 374.
II
Bennett. = P P anten D., and Vaughan, J. M. (1932) Quart. J.
Himsworth, H. P. (1934) Lancet, 2, 845.
— (1934) Brit. med. J. 2, 57.
Thaysen, T. E. H. ey Acta med. scand. 64, 292.
— (1929) Lancet, 1, 1086.
— (1932) A Study in Idiopathic Steatorrhcea, Copenhagen.
LABOUR COMPLICATED BY
THROMBOSIS OF THE MESENTERY
RESECTION OF TEN FEET OF SMALL BOWEL—PATIENT
ALIVE AND IN GOOD HEALTH TWENTY-FOUR
YEARS LATER
By G. Grey TURNER, M.S. Durh., F.R.C.S. Eng.
PROFESSOR OF SURGERY IN THE UNIVERSITY OF LONDON
AT a pathological evening at the Medical Society of
London held on Jan. 11th last, I exhibited a specimen
consisting of 10 ft. 3 in. of the ileum showing
the characteristic effects following thrombosis of the
mesentery (see Figure), This portion of intestine
was excised during the progress of full-time labour
and the following are the circumstances of the case.
The patient first came under my observation in April,
1910, when I was called into consultation by Dr. James
Hudson of Newcastle-upon-Tyne. She was then an
unmarried woman, aged 22, who had the misfortune
to suffer from a ruptured gastric ulcer following a definite
history of stomach illness of 3 years’ duration. The
operation took place 9 hours after the onset, On explora-
tion a large perforation was found about the centre of
the lesser curve on its anterior aspect. The surrounding
area of the stomach wall was much indurated, but the
perforation was partly covered by a neighbouring piece
of omentum. There was a considerable quantity of dirty
looking peritoneal exudate, but this was largely limited
to the neighbourhood of the stomach and to the pelvis,
the area of the small intestine being free. After closure
of the ulcer the peritoneal cavity was thoroughly irrigated,
a Keith’s glass drainage-tube being temporarily inserted
into the pelvis through a small suprapubic incision. As
a final step, posterior gastro-enterostomy was carried out.
The patient made an uninterrupted recovery and left
the private hospital a fortnight after the operation.
She continued to make satisfactory progress, and about
The resected portion of small intestine.
a year later married and in due course became pregnant,
During the early days she was a good deal troubled with
sickness, but that soon passed off and in the later stages
she enjoyed excellent health.
On a Sunday morning in February of 1913 labour
commenced. She was seen by Dr. Hudson who, in view of
the previous history, very carefully examined the abdomen
but found everything in perfect order. It was noted that
the pulse-rate was 72, with a good volume. He left
the house with orders that he was to be sent for when
necessary. As nothing was heard of the patient during
the day, he thought it wise to look in about 9 p.m. and was
then surprised to find her looking white and ill with a very
quick pulse. He obtained the history that the father
had gone up to the bedroom an hour previously and had
been rather alarmed because he noticed that when he gave
his daughter a good-night kiss her face was cold. On
examination the uterus was found to be unusually tender
and this, together with the general condition, suggested
that there might be some concealed accidental hæmor-
rhage. The pains had ceased. There was no external
hemorrhage and the os was only dilated to the size of
half a crown. In view of the grave condition Prof,
Ranken Lyle was called in consultation. After considera-
tion it was concluded that there was probably no accidental
hemorrhage but that some intra-abdominal condition
was complicating the labour. On further inquiry it was
ascertained that the bowels had moved about 5 P.M.,
and that the motion was normal, but a second evacuation
an hour later contained a little blood.
T was asked to see the patient about 1 o’clock the follow-
ing morning. She then looked exceedingly ill with very
blanched lips. The pulse-rate was 140, with a very low
tension, and there was so much difficulty in breathing
that she had to be propped up in bed.. The abdomen was
distended and tender all over. By this time it looked like
a case of severe intra-abdominal hemorrhage, and I could
only conclude that the contractions of the uterus had
probably torn some very vascular omental adhesion
which had resulted from the previous peritoneal inflamma-
THE LANOET]
tion associated with the ruptured ulcer. The possible
significance of the blood in the evacuation was not then
appreciated. It was decided to operate at once and
arrangements were soon made in the patient’s own house.
With Dr. Hudson ‘giving the anesthetic and Prof. Lyle
assisting, an incision was made from the umbilicus to the
pubes. As soon as the peritoneum was opened, blood-
stained fluid escaped, and a great mass of deeply congested,
almost black intestine could be seen in the upper part of
the abdominal cavity on the right side. It was impossible
to explore the abdomen properly on account of the presence
of the uterus, and, furthermore, it was deemed absolutely
essential that the latter should be emptied. Czsarean
section was therefore performed, and a full-time, perfectly
developed, but recently dead child was delivered. The
incision happened to be through the placenta, but there
was no excessive bleeding. The uterus was closed with
catgut sutures. It was then found that many feet of the
lower ileum presented the appearance characteristic of
thrombosis of the mesentery. The gut appeared to
be absolutely beyond the hope of recovery, and therefore
resection was carried out, the upper part of the small
intestine being anastomosed to the cecum by the lateral
method with direct suture. At the conclusion of the
operation it was found that the uterus was contracting
satisfactorily. A pint of saline was left in the abdo-
men and the incision was closed with through-and-
through silkworm-gut sutures. During the course of the
operation, saline was infused under both breasts by the
nurse.
The patient stood the operation perfectly well and was
really in better condition at the end than at the beginning.
The whole proceeding occupied about 1} hours.
The removed intestine presents the usual conditions
found in thrombosis of the mesentery with nothing to
give a hint as to etiology.
During convalescence she ran a temperature as high
as 102° F. for several days, and at 101° F. for about a
fortnight. During all this time the pulse was correspond-
ingly quick. At the end of a week from the date of the
operation an abscess appeared where saline had been
infused beneath the left breast, and was opened—it con-
tained gas and was evidently due to Bacillus coli. About
the third day the lochia were noted to be malodorous ;
this persisted for a fortnight when a slough was dis-
charged per vaginam, after which the lochia gradually
became norma]. It was’ thought that probably the
uterus had also become infected by the B. colt dur-
ing the operation. It was about three months before
the pulse fell to normal, but all through convalescence
the patient took her food well and eventually made a
complete recovery.
For two or three years the bowels were relaxed and
usually moved twice daily, but there was little incon-
venience and she gained weight, though she had to be
careful with her diet. Within two years she became
pregnant again and was delivered of a splendid child
2 years and 8 months after the operation. A year later
there was a miscarriage, but there have been no further
pregnancies and she continues to enjoy excellent health
now 24 years since the intestinal resection.
Throughout these years the patient has been so
well that she could never be persuaded to submit
to any sort of investigation and one can only judge
from her general appearance of well-being and from the
response which she makes to her environment that
the economy of the body remains undisturbed.
Just after the conclusion of the case I sent the
notes to Dr. Hudson who had charge of the patient.
His reply is so interesting a commentary on case
recording that it is worth quoting :—
Dear Mr. TURNER,—I have made some additions to your
report but no corrections. It is the proper surgical thing
to add nothing or subtract nothing from a report, making
it a bald statement of facts, so when I read your report
it was with difficulty I recognised what was an intensely
exciting night. of it. Why bless my soul, we had a taxi
on the run for six hours! Hoping you are well.
I remain, yours truly,
JAMES HUDSON.
DR, A. W. D. LEISHMAN : POLYARTERITIS NODOSA
[APRIL 3, 1937 803
Abdominal emergencies during pregnancy are
rare and in my own experience have been limited to
several cases of appendicitis, gall-stones, and torsion
of the pedicle of an ovarian dermoid. During labour
they are presumably extremely rare, and the example
Shei is here recorded is the only one with which I am
amiliar.
THE CLINICAL DIAGNOSIS OF
POLYARTERITIS NODOSA
WITH A REPORT OF FOUR RECENT CASES
By A. W. D. LEIsHman, B.M. Oxon., M.R.C.P. Lond.
CHIEF ASSISTANT TO A MEDICAL UNIT, ST. BARTHOLOMEW’S
HOSPITAL, LONDON
Polyarteritis nodosa is a rare disease. Oscar
Klotz (1917), a pathologist particularly interested
in arterial disease, states that he performed at least
3000 post-mortem examinations before meeting with
a case. In all, during the seventy years of its
recognised existence about ‘200 cases have been
reported. During the last three years four patients
with this disease have been admitted to St. Bartholo-
mew’s Hospital. In none of these was the diagnosis
made during life, though in the light of previous
experience it was in the last case considered a
possibility.
That the problems set by this peculiar disease are
intriguing is shown by the number of publications
on the subject, but in the main it is the pathologist
who has claimed it, and though all authors agree
upon the difficulties and frequent impossibility of
clinical diagnosis, surprisingly few have attempted
to simplify the clinician’s task. It seemed therefore
justifiable, while giving an account of these recent
cases, to attempt an analytical clinical survey with
a resynthesis which might serve as a foundation for
the clinical diagnosis of the condition.
HISTORICAL NOTE
Rokitansky is credited with the first description
of the pathological condition given in 1852, but the
name of Kussmaul is commonly linked with the disease,
since he was the first to assign a clinical syndrome to
the morbid changes. In 1866 he gave, with Maier,
an account of two cases of a “ hitherto undescribed
peculiar disease of the arteries which is accompanied
by Bright’s disease and a rapidly progressive general
paralysis of the muscles.” This he called peri-
arteritis nodosa, the name which still persists, though
Dickson in 1907 suggested the substitution of poly-
arteritis as being more strictly accurate.
For many years the disease was unrecognised out-
side Germany, and Morley Fletcher’s is the first
English name connected with it. Describing in 1892
what was probably the sixth case, he gave an account
of a careful study of the microscopic changes and
suggested the name arteritis nodosa proliferans.
The early reports were usually of single cases and
concerned mainly with pathology and it was not
until 1914 that the first general survey was made by
Lamb. He analysed the 38 published cases of
polyarteritis nodosa, but it is discouraging to the
clinician to note his conclusion that, saving the
presence of, typical skin nodules, diagnosis during
life is impossible.
In 1921 P. Meyer briefly discussed the points of
diagnostic value obtained from a review of 20 cases,
but the monumental work of Griber in 1926 was
804 THE LANCET]
DR. A. W. D. LEISHMAN : POLYARTERITIS NODOSA
[APRIL 3, 1937
based on 113 cases, though from inadequate descrip-
tion many of these are of little value.
Since then, from the clinical point of view, reviews
by Strong (1928) and Curtiss and Coffey (1929) are
outstanding. Between them these authors collected
and analysed a further 38 cases published in English,
while a French paper by Cathala (1929) is note-
worthy as being one of the few direct attacks upon the
problems of clinical diagnosis.
PATHOLOGY
Though the pathology of the disease is outside the
scope of this article, in brief it may be said that
polyarteritis nodosa affects the small and medium-
sized arteries—in order of frequency those of the
kidneys, heart, liver, the alimentary tract, mesentery,
ar muscles, pancreas, peripheral nerves, and the
rain.
Macroscopically, whitish-grey coloured nodules of
varying size are seen upon the affected artery. Not
infrequently aneurysms are formed and may rupture.
The vessels tend to thrombose and the organ supplied
is consequently often the site of numerous infarcts.
Microscopically it seems, although it is not
universally accepted, that the earliest change is in
the adventitia where great aggregation of poly-
morphonuclear cells together with eosinophils and
monocytes is seen. The media undergo necrosis,
the internal elastica lamina ruptures, and there is
much proliferation of the intima. Thrombosis occurs
but in healed lesions the thrombus may be recanalised.
Other changes in the body are entirely secondary
to the arterial disease.
ZTIOLOGY
The cause of the disease is still unknown. For
many years syphilis was suspected but with the
advent of the Wassermann reaction this has had to
be abandoned. The clinical course suggests an
infection but all attempts to recover a specific
organism both during life and at autopsy have failed.
Harris and Friedrichs (1922) claimed to have trans-
mitted the disease to rabbits by inoculation of post-
mortem material, but this has never been repeated.
It is interesting that an apparently identical morbid
condition has been found in certain of the lower
ni such as the dog, the pig, the calf, and the
eer.
Infection by an ultramicroscopic filtrable virus
is a possibility, but Ophüls (1923), drawing attention
to similarities between polyarteritis nodosa and
acute rheumatism, put forward a further hypothesis
that this disease represents another manifestation
of a streptococcal allergic state.
The Clinical Picture
In the account which follows the diagnostic stand-
point has been maintained throughout; it includes
therefore only those points which are of sufficiently
frequent recurrence to be of value in diagnosis.
Based upon the six most important clinical surveys
it represents the study of at least 150 cases.
The disease occurs three to four times more often
in males. It most commonly affects those aged
10-40, the extremes recorded being 3 months and
78 years.
SYMPTOMS AND SIGNS
The previous history and family history are of no
significance. The onset is acute or gradual in almost
equal numbers. The initial symptoms are not
especially enlightening save that it is worth recording
in order of frequency complaints of: (1) muscular
pains, (2) fever, (3) abdominal pains, (4) cedema, and
(5) general weakness.
The fifteen fundamental signs of diagnostic value
in their order of frequency of occurrence are as
follows :—
l. Fever which does not commonly exceed 100°-101° F.
and is usually of the remittent type, but afebrile intervals
with exacerbations of pyrexia are not uncommon.
2. Increasing general weakness with loss of weight.
3. Albuminuria. |
4. Cylindruria of hyaline and granular type commonly
with microscopic hematuria.
5. Leucocytosis to an average figure of 15,000 to 20,000
per cubic millimetre with absolute increase in the poly-
morphonuclear cells and occasional eosinophilia.
6. Anemia of a microcytic type and only moderately
severe. ,
7. Tachycardia out of proportion to the fever.
8. Abdominal symptoms and alimentary disturbance.
Most commonly these are cramp-like or colicky pains, or
sensations of soreness and heaviness across the abdomen.
Often the abdomen has been surgically explored. Anorexia .
is frequent, with bowel disorder, both constipation and
diarrhea. Vomiting is less common and hematemeses
melæna and acute perforation of the gut are occasional
emergencies. ,
9. Polyneuritis of peripheral type which affects any or
all four limbs with considerable motor loss and muscular
wasting, but slighter sensory changes.
10. Polymyositis is especially pronounced in the limb
muscles and shows itself by agonising cramps and tender
wasting muscles, |
11. @dema is of cardiac distribution.
' 12. Cutaneous lesions. The most characteristic lesion
is a nodule varying in size from a millet seed to a pea,
fixed in the skin but moving on the deeper tissues ; occa-
sionally these are purpuric or vesicular. They are painless
and frequently evanescent; all trace of a nodule may
have disappeared within 24 hours. More rarely and especi-
ally in acute forms of the disease a generalised skin erup-
tion is seen. This may be of the hemorrhagic type,
petechial, purpuric or ecchymotic, and occasionally a
simple erythema or urticaria.
13. Cardiac signs are those of heart failure. without
obvious cause, though electrocardiographic changes may
suggest coronary disease—e.g., thrombosis.
14. Enlargement of the liver (but not of the spleen)
with tenderness.
15. Respiratory symptoms.—Cough with diffuse signs
of bronchitis and bronchiolitis.
It might be hoped that characteristic changes would
be observed in the retinal arteries. Unfortunately this
is not the case. The only changes seen are occasionally
those of albuminuric retinitis, although in one case at
least (1935) occlusion of the central retinal artery occurred.
Even in tabulated form the manifestations of this
disease appear distressingly protean. Various authors
attempting to simplify this picture have distinguished
different clinical types of the disease, thus von
Schrétter (1899) recognised five groups: (l) renal,
(2) abdominal, (3) neuromuscular, (4) cardiac, and
(5) bronchial. In practice, however, such division
fails, for the very reason that complexity of symptom
is one of the most characteristic features of the
disease.
‘The basic clinical picture is that of a severe pro-
gressive toxemia characterised by fever, muscular
asthenia, loss of weight and anemia. These are the
symptoms of the active disease process itself, all
other signs can be ascribed to local arterial lesions,
although frequently these latter effects are so
impressive that the general character of the disease
may be obscured. This is well seen in Case 3
reported here. If this point is realised, the occasional
appearance of more dramatic symptoms, like those of
cerebral or meningeal disease, can be brought into
LANCET]
line with the rest of the picture and will not confuse
the issue.
COURSE
The disease seems almost invariably fatal, although
four undoubted cases have recovered and it seems
likely that an occasional case may recover
unrecognised. The average duration of the illness
is from three to four months, and the commonest
terminations are: (1) cardiorenal failure; (2)
marasmus; and far less commonly (3) sudden local
vascular accidents.
Chronic forms have been occasionally met with.
A very remarkable case with a total duration of 12
` years’ illness was described by Macaigne and Nicaud
(1932) and one of four years’ course by Arkin (1930).
Each of these was characterised by alternating
periods of remission and exacerbation, and this,
Arkin suggests, is a feature of the less acute types,
since each febrile recrudescence indicates the develop-
ment of fresh arterial lesions.
No treatment has been found of any value.
DIAGN OSIS
The difficulties are obvious and are reflected in
the variety of diagnoses that have been made.
Hidden sepsis, typhoid fever, acute abdominal
condition, trichiniasis, nephritis, peripheral neuritis,
myositis, miliary tuberculosis, dysentery, purpura,
septic endocarditis, meningitis, and encephalitis
have at various times been simulated. At least
30 cases, however, have been diagnosed during life,
and though some of these were only discovered at
exploratory laparotomy and others after biopsy
of cutaneous lesions, in a small group the diagnosis
has been made on clinical grounds alone.
The rarity of correct diagnosis must at least in
part be due to unfamiliarity with the disease; it is
suggested therefore that if the following points are
borne in mind this difficulty may, to some extent,
be overcome. (1) The possibility of polyarteritis
nodosa should be considered :—
(a) In any illness characterised by severe progressive
toxemia, with fever, muscular asthenia, and loss of weight.
(b) In any illness having the character of an infection,
where there is complete failure to locate the infection.
(c) In any illness where there are unusual and apparently
unrelated combinations of signs, for example, nephritis
associated with peripheral neuritis, heart failure, skin
rashes, or abdominal symptoms.
(2) The diagnosis of polyarteritis nodosa being under
consideration reference should be made to the
fifteen cardinal symptoms and signs previously given.
(3) The diagnosis may often be clinched by biopsy
of cutaneous lesions or, in their absence, of skeletal
muscle.
Case-histories *
CASE 1l
Miss A. B., aged 69, a retired hospital cook, was
admitted to hospital on May 8th, 1933, under the care
of Dr. Geoffrey Evans, complaining of general weakness,
cough, and fever.
History.—Five months previously she began to feel
off colour, with loss of energy and strength. One month
before admission she lost her voice for a few days and
had shivering attacks at night. There was an evening
rise in temperature to about 100° F. and she remained
in bed. Two weeks later she started to cough with
much colourless watery sputum, and the temperature
remained continuously raised. She noticed increasing
* A full account of the pathology of these cases will be
published by Dr. Robb-Smith.
DR, A. W. D. LEISHMAN: POLYARTERITIS NODOSA
[APRIL 3, 1937 805
shortness of breath with palpitations and on occasions
some swelling of the ankles. There had been no true
night sweats but she had lost weight. At the age of 35
she had had pneumonia, and when 53 she had a right-
sided stroke from which she made a gradual complete
recovery.
The family history was not significant except that her
mother had died of chronic phthisis. Habits were
satisfactory.
On examination she was pale and wasted and looked
older than her years, slightly dyspneeic, and cyanosed.
The temperature was 101°F., pulse-rate 110, and
respirations 30. The eyes were normal with clear fundi
and retine, and normal pupil reactions. Fauces were
somewhat inflamed ; she was edentulous. A lymph node
was palpable in each anterior triangle of the neck and
in the right axilla. The chest showed pigeon-breast
deformity and was very poorly covered. Movement was
poor but equal, percussion note resonant, generalised
rhonchi were heard with fine crepitations at both bases,
especially in the left axilla. The heart was normal in
size and the sounds regular and natural, but the rate was
rapid (100-120). The radial artery was thickened, the
blood pressure 140/70. The abdomen showed no
abnormality except that the liver was palpable a finger-
breadth below the costal margin. There was some
stiffness of most joints and many showed the appearances
of chronic rheumatoid arthritis. The tendon reflexes
in the upper limbs were normal. The abdominal reflexes
were not obtained. Knee-jerks were present. Ankle-
jerks absent. Plantar response flexor. Sensation was
not tested. The urine output was normal, specific gravity
1010-1020; no abnormal constituent found ; : on culture
it was sterile. Blood count :—
Red cells 5,240,000 White cells 36,000-16, ee
Heemoglobin 74% Polymorphs .. 27, 360
Colour-index Lymphocytes 7, ’920
Eosinophils .. "720
Widal reaction: negative to enteric group, Brucella
abortus and B. melitensis. Blood culture was sterile.
Repeated examination of sputum revealed no tubercle
bacilli. Radiograms of chest showed no abnormality
in the lung fields.
Course.—The fever continued, the temperature swinging
in 24 hours between 99° and 102° F. and the pulse between
110 and 120 per minute. The general condition showed
little change. The signs in the lungs persisted and gave
rise to a tentative diagnosis of miliary tuberculosis despite
negative sputa and radiograms. On June 20th (6 weeks
after admission) she first complained of abdominal
discomfort and this became considerable, though on
repeated examination no definite abnormality could
be detected. The stools were now loose but contained
no blood. On July 2nd (8 weeks after admission) she
complained of pain on micturition and a specimen of
urine was found to contain red and white blood-cells, a
few granular casts, and Bacillus coli in profusion. The
infection cleared with treatment, but the urine continued
to contain albumin and macroscopic blood. Weight
had been lost rapidly—over a stone in two months since
admission—and she became progressively weaker.
Examination of the abdomen now revealed general
tenderness, especially in both posterior renal angles,
but neither kidney could be felt. By July 18th (10 weeks
after admission) she was mentally wandering, incontinent
of urine, and gradually became drowsy. The blood-
urea was found to be 120 mg. per 100 c.cm. The tempera-
ture became subnormal and she slowly sank into a quiet
coma and died on July 22nd, 104 weeks after admission.
Autopsy.—Typical nodules were seen in the mesentery.
On section the kidneys showed appearances suggestive
of focal abscess formation, and on microscopic examina-
tion all the kidney vessels showed extreme degrees of
inflammatory change with numeraus zones of infarction.
The coronary arteries showed similar changes and, to a
less extent, those of the liver.
CASE 2
Mr. C. D., aged 45, tape-measure maker, was admitted
to hospital on Jan. 2nd, 1934, under the care of Prof. F. R.
Fraser, complaining of pains and numbness in the legs and
loss of use of the legs.
806 pm MGENI
History.—He was well until 6 weeks before admission
when he noticed, on walking, cramp-like pains in the calf
muscles; these were at first relieved by resting. He
next found difficulty in straightening the legs and the
pains became worse. He managed, however, to remain
at work until 4 weeks before admission when he had to
rest with the feet wp. At this time he lost his appetite
and he thought he was rapidly losing flesh. The bowels
were constipated. While in bed, 13 days before admission,
he suddenly felt pins and needles in the left foot and on
putting the foot to the ground he was unable to feel the
floor though he could still walk. Two days later the
right foot became similarly affected and soon he was
unable to use his legs as they ‘‘gave”’ under him. The
cramp-like pains ceased but he was completely paralysed
and the feet now became increasingly swollen. There was
4 days before admission a gradual onset of numbness in
the left hand with loss of power in the whole limb. Apart
from these symptoms, he had had a tendency to vomit
after breakfast and this had become worse during the last
two weeks. The past history was not significant save
that his work brought him in contact with lead paint.
He was a temperate man,
On examination he was thin, pale, and slightly breath-
less. The temperature was 101-2° F., the pulse-rate 100,
and respirations 29. The eyes were normal, fundi and
retine clear. Teeth were fair, tongue furred, tonsils and
fauces healthy. The thyroid was normal in size and
there were no enlarged lymph nodes in the neck, axille,
or groins. The chest appeared normal but percussion
note was impaired at both bases and many crepitations
were heard. The heart was slightly enlarged, the apex-
beat being } in. outside the nipple in the fifth space. At
the apex a soft systolic bruit followed the first sound and
was conducted into the axilla, the sounds otherwise were
normal, and the rhythm was regular. The radial
artery appeared healthy and the blood pressure was
146/82 mm.Hg. The abdomen was protuberant and
tympanitic; there were no signs of free fluid. No viscus
was palpable and there was no tenderness. The abdominal
reflexes were present. There was cedema of the lower
third of the legs and of the feet on both sides.
Nervous system.—Cranial nerves were normal. The
arms showed no obvious wasting, but there was much loss
of power in all movements of the left arm and hand
and diminished sensation to cotton-wool in the ulnar and
radial nerve distribution of the left hand ; tendon reflexes
were symmetrical but obtained with difficulty. In the
legs the thigh and calf muscles were flaccid and there
was much wasting below the knees; only slight move-
ment at the left hip-joint was possible; all other move-
ments of both legs were abolished, and there was bilateral
foot-drop. There was loss of light touch and pin-prick
sensation over a stocking area in both legs, the left being
more complete than the right. The right knee-jerk was
obtained but the left knee-jerk and both ankle-jerks
were absent ; the plantar responses were flexor. The urine
output was satisfactory; specific gravity 1020; it
contained a trace of albumin but no other abnormal
constituent. The blood :—
Red cells 5,180,000 White cells 19,000
Heemoglobin .. 80 % Polymorphs 15,580
Colour-index .. 0°3 Lymphocytes ; ,660
Large Deron etree 570
Eosinophils > 190
The Wassermann and Sigma reactions wero negative.
Cerebro-spinal fluid: entirely normal, Wassermann and
Sigma reactions negative. The sputum was three times
negative for tubercle bacilli.
-© Diagnosis.—Toxic polyneuritis.
Course.—After a week the temperature had gradually
fallen, to 99° F. but the pulse and respirations remained
at the previous level. He complained much of paræs-
thesiæ and muscle cramps in both legs, and some tingling
in the right hand was felt, but power in this limb remained
good. He continued to cough much watery sputum and
the lung signs were increased. The urine now contained
a cloud of albumin and the deposit showed granular
casts. The blood-urea was 160 mg. per 100 c.cm. A week
later, after some temporary slight improvement, he
relapsed, became dyspnæœic and cyanosed, and coughed
up blood-stained sputum. The temperature, blood, ard
DR. A. W. D. LEISHMAN : POLYARTERITIS NODOSA
[APRIL 3, 1937
respirations all rose; there were signs of consolidation at
the base of the left lung. The next day, though seeming
brighter, he collapsed while being washed and died
suddenly, two weeks after admission.
Autopsy.—The vascular lesions were widespread. The
heart was dilated but the coronary arteries appeared
healthy. There was an effusion in the left pleural cavity
and broncho-pneumonic changes in the left lung. The
intestines were distended and numerous nodules involved
the whole of the alimentary tract and the omentum. The
liver was congested and there was much arteritis with
aneurysm formation. The kidneys had several infarcts
and the arteries in these showed acute changes of poly-
arteritis. The arteries to the leg muscles and nerves were
considerably affected and the sciatic nerve itself was
cedematous and reddened. ;
CASE 3
Mrs. E. F., aged 58, housewife, was admitted to hospital
on Jan. 9th, 1934, under the care of Dr. Hinds Howell,
complaining of passing little urine, vomiting, and
abdominal pain after micturition.
History.—She had been well until five weeks before,
when she had an illness characterised by malaise, head-
ache, and upper respiratory catarrh with cough. This
was diagnosed as influenza. A week later she began to
have abdominal discomfort after passing water and she
noticed she passed very little urine and that it was highly
coloured. She felt very poorly, having constant frontal
headache and vomiting after every meal. The urine was
examined by her doctor and found to contain much albumin.
There had been no visual disturbances. She had been
subject to recurrent cough with sputum but there was no
history of previous kidney disease, tonsillitis, or scarlet
fever.
On examination she was pale and ill, perpetually retching
or coughing; the skin was coarse and dry. Temperature
100:6° F., pulse-rate 92, and respirations 20. The eyes
were normal as regards pupil reactions, discs, and
retine. The tongue was furred and dry, fauces inflamed,
and there was gross dental sepsis. The thyroid was
normal in size. The chest appeared normal but many
coarse rales were heard, especially at the left base. The
heart was not enlarged; the first sound at the apex was
soft but otherwise the sounds were clear and regular.
The blood pressure was 125/75 mm.Hg. The abdomen
was normal, no viscus being palpable. Neither the knee-
jerks nor the ankle-jerks were obtained; the plantar
responses were flexor. There was no cedema of the
ankles. The urine was highly coloured and reduced in
quantity, the specific gravity was 1018, there was a cloud
of albumin present, but no other abnormal constituent.
The deposit contained granular casts and a number of
red blood corpuscles. Culture was sterile. Blood count :—
Red cells.. 4,920, oe | Colour-index 0°85
Heemoglobin ‘ 84° White cells 10,800
Blood-urea : ” 85 mg./100 c.cm.
Diagnosis.—Chronic nephritis, bronchial catarrh, and
uræmia.
Course.—After one week the temperature and pulse
fell and remained normal and the patient felt rather
better though there was still some nausea and retching.
The signs in the chest persisted. The urine output was
greatly diminished and abdominal discomfort was much
complained of, especially after micturition. On Jan. 22nd
some teeth were extracted under gas-and-oxygen anes-
thesia and again on Jan. 26th. Following the second
extraction there was considerable hemorrhage from the
gums and her general condition deteriorated with increase
in the vomiting, cyanosis, and gradual decline into coma.
The temperature fell, the chest became full of moist sounds,
and she died on Jan. 27th, 18 days after admission. The
blood-urea on the day before her death was 380 mg. per
100 c.cm.
Autopsy.—No typical appearances were seen macro-
scopically. The kidney cortex was reduced and the
surface had a peculiar blotchy appearance. On micro-
scopic section however the larger vessels of the kidney
showed pronounced acute peri-arteritic changes, but there
was no infarction. The arteries in the liver were similarly
affected though to a lesser degree.
THE LANCET]
CASE 4
Miss G. H., aged 47, lady’s companion, was admitted
to hospital on June 30th, 1936, under the care of Dr.
Geoffrey Evans, complaining of general weakness.
History.
catarrh with frequent sneezing and also much cough with
a little phlegm. She had become rather breathless and
easily tired and had lost 4 st. in weight within the last
two years. One month before admission she had three
teeth extracted under local anesthetic (cocaine) and the
following day her feet became swollen. A few days later,
after taking a medicine containing 5 grains of potassium
iodide, the whole of the face became swollen and the eyes
closed. After treatment with starch poultices the skin
desquamated, leaving a painful weeping surface, but this
had since gradually healed. At this time she was very
weak and breathless and the ankles remained swollen, so
the major part of the day was spent in bed. Two days
before admission, on putting her feet to the ground she
found they would no longer support her. The appetite
had been fairly good and she had taken a full and varied
diet. The digestion was good and the bowels worked
normally. There were no other symptoms of note. Her
habits were excellent and the only other medicine taken
before admission was Easton’s syrup. She had had no
previous illnesses. No family history of allergy was
obtained.
On examination she was a thin tired-looking woman,
breathless and speaking slowly with an effort but mentally
alert. The temperature was 99° F., pulse-rate 120, and
respirations 29. The musculature was generally flabby
and she was unable to turn over in bed by herself. The
face was covered by a healing granulating surface; the
skin elsewhere was dry and inelastic. On the dorsum of
the hands and the sides of the trunk a peculiar eruption
was seen. This consisted of mauve-coloured raised
patches up to the size of a shilling, several of which showed
surface scaling; they were faintly reminiscent of lichen
planus. The eyebrows were deficient but the hair on the
head was normal. Mucous membranes were pale. Pupil
reactions were normal and fundi and retine were clear.
The tongue was furred, fauces and tonsils were normal,
but there was considerable dental sepsis. The thyroid
was normal and there were no enlarged glands in the neck,
axille, or groins. The veins in the neck were full and
pulsating. The chest was poorly covered but movement
was good. Breath sounds were harsh with prolonged
expiration universally; rhonchi and sibili were heard
in the upper zones of both lungs and coarse rales at the
bases. The cardiac impulse, forcible and heaving, was
seen in the sixth space, the apex-beat being in the nipple
line. The heart was not enlarged to the right of the
sternum. The rhythm was regular, a loud systolic bruit
replaced the first sound at.the apex, but the sounds at the
base were clear though the pulmonary second sound was
much accentuated. The radial artery was somewhat
thickened. The blood pressure was 130/110. The
abdomen was very lax and abdominal reflexes were not
obtained. The liver, enlarged and palpable three fingers-
breadth below the costal margin, was smooth on surface
and tender. No other viscus was palpable; there was
no tenderness and no free fluid. The arms appeared very
thin with muscles much wasted ; there was bilateral wrist-
drop. Movements of the upper arms were weak, the grip
was poor, and no voluntary movement was possible
at the wrist-joints. All tendon reflexes in the upper
limbs were present symmetrically ; there was no sensory
loss but the muscles were tender on pressure. All the
muscles of both legs were wasted and both feet were
cedematous. The legs lay externally rotated and there was
bilateral foot- and toe-drop. Both little toes were blue and
cold but pulsation was felt in the dorsalis pedis arteries.
Movements at the hip and knee were weak and required
great effort and there was no movement at either ankle-
joints. Both kmee-jerks were absent; the right ankle-
jerk was also absent but the left ankle-jerk was obtained
on reinforcement. Plantar responses were flexor. There
was some hypoesthesia over the dorsum of both feet
and vibration sense was markedly diminished.
The urine was diminished in output; specific gravity
1025; it contained albumin (0:14 g. per 100 c.cm.) ;
`
DR. A. W. D. LEISHMAN : POLYARTERITIS NODOSA
[aren 3, 1937 807
centrifuged: deposit showed 8-10 white cells and 2—4
red cells per field and many granular and epithelial casts ;
on culture it was sterilo. Blood count :—
Red cells . - 3,750,000 panes
Heemoglobin a 10 % 7 mg./100 c.cm.
Colour-index ge 0°9 se shoietanl:
White cells .. 11,000 | 136 mg./100 c.cm.
Polymorphs 6,435 Serum protome
Lymphocytes 4,40 g-/ ee c.cm.
Eosinophils 55 Album on . 1°9 $
Large mononuclears 165 Globulin .. .. 1°29
Radiography of the chest showed general e
of the heart and appearances compatible with congestion
in the lung fields. Electrocardiogram showed a regular
sinus rhythm at 107 per minute with low voltage QRS
complex and inverted T wave in lead ITI.
A diagnosis was not made, but for the most part opinion:
favoured a conception of a cardiovascular renal sclerosis
with heart failure and a peripheral polyneuritis of unknown
toxic origin.
Course.—The temperature remained about 99° F. and
the pulse-rate averaged 110. The cedema increased in
the legs and in the lumbar region; the right hand also
became swollen. The blood pressure improved to
158/98 mm. Hg following digitalis therapy, but the
patient became progressively weaker and in the second
week lost control of the sphincters. A fresh violet-coloured
eruption made its appearance on the left hand. Dr. A.C.
Roxburgh was unable to identify this with any known
skin disease. At the end of the second week temperature,
pulse- and respiration-rates began to rise and a crop of
petechiz appeared on the trunk and limbs. A blood
culture taken at this time remained sterile. The blood-
urea increased to 90 mg. per 100 c.cm. and the patient
slowly sank into a coma with low-grade delirium and
died on July 18th, two and a half weeks after admission.
Autopsy.—There were widespread changes. The heart
was dilated and there was a recent infarct at the apex
with much softening of the muscle. Bilateral pleural
effusions were present and the lungs showed many small
infarcts. Small nodules were seen on the arteries of the
mesentery. Both kidneys and the liver contained infarcts
and microscopically the arteries of every organ examined
showed the changes of polyarteritis. The sciatic nerves
were swollen with patchy hemorrhagic areas ; many vessels
in their neighbourhood contained nodosities.
Cases .. ni 1 |
(1) Fever .. .. .. + | + + +
(2) Weakness with loss of
weight ies D + | + = +
(3) Albuminuria .. ʻi a È + +
(4) Cylindruria p koy re J
(5) Leucocytosis .. + + + +
(6) Anæmia ea aa + — — +
(7) Tachycardia + ! — — +
(8) Abdominal and ali-
mentary signs cs + + =o E
(9) Polyneuritis .. os +* | + +* +
(10) Myositis rae sni — + au +
(11) Œdema.. Ke ae — + — +
(12) Skin lesions .. vs — | — — +
(13) Cardiac signs .. a - . + — +
(14) Hepatomegaly.. aa + |! = — +
(15) Respiratory signs es + + + +
~ Toa eo o o a e | a
* These patients had absent ankle-jerks.
COMMENTS
Reviewing these cases in the light of the previous
discussion it is interesting to note that three out
of the four were women and that they were all
beyond the common age-period. In Cases l, 3, and
808 THE LANCET]
4 the earliest complaints were typical—i.e., general
weakness, fever, and pains in the legs. The course
of the illness was acute (8 weeks) in two cases, slowly
but gradually progressive in one (74 months), and
of long duration (2 years) with an acute terminal
exacerbation in the last. In the Table are summarised
the fifteen cardinal signs of diagnostic value in
relation to each case.
From this it will be seen that Case 4 presented a
typical clinical picture and should certainly have been
diagnosed. Cases 1 and 2 were reasonably suggestive,
while Case 3 with such purely localised signs was
obviously beyond the possibility of clinical diagnosis.
Summary
Four new cases of polyarteritis nodosa are described
in detail, The clinical findings are reviewed, and
from a survey made of 150 cases previously published
a composite clinical picture has been drawn. It is
believed that familiarity with this clinical picture
will facilitate the diagnosis of the disease, which
until now has generally been first recognised post
mortem.
I am indebted to the physicians in charge for permission
to publish the notes of these cases, and wish to express
my thanks to Dr. A. H. T. Robb-Smith for the post-
mortem reports and to Dr. Geoffrey Evans for much
helpful criticism.
REFERENCES
Arkin, A. (1930) Amer. J. Path. 6, 401.
Bernstein, A. (1935) Amer. J. med. Sci. 190, 317.
gatnala, J. (1929) J. Mea, Chir. Prat. 100, 183.
„ona CO ace Pes Ann, intern. Med. 7, 1354.
Dickson, W. E. Oaa J. Path. Bact. 12, 31.
gorenen H ; (1 0) eitr. path. Anat. 11, 323.
Grüber, G. B. KEOYA Hyg. TORT: 18, 319, n es 381, Piha
Harris, We H., and Freidrichs, A
(1917) IRAY med. Res. 37,
V. (1922) J. ed,
eat, A.» Maier, R. 1866) yen f. klin. Med. 1, 484.
Lamb, A. (1974) Arch. intern.
Macai ene, M., and Nicaud, P P. 1982) Pr. méd. 40, 665.
Oona Ww . (1921) Berl. klin. W schr. Bare
Rokits stately, Oo intern, Med. $3 in a (1852) Denksch
yon Rokitans -» quote y Epp Pelle enkschr.
: Akad. Wiss. Wien, 4,
von Schrëtter, L. (1899) Wien klin. Wschr. p. 404.
Strong, G. F. (1928) Canad. med. Ass. J. 19, 534,
CYSTIC DEGENERATION OF THE
CHORIONIC VILLI IN THE
SIXTH DECADE
By CHARLES HOLuoési, M.D.
(From the Surgical Clinic, University of Tisza Istvan,
Debrecen, Hungary)
To the pathologist the ztiology of cystic degenera-
tion of the chorion villi is still unsettled. The fact
that none has been accepted explains the numerous
and extraordinary theories that have been advanced to
account for its occurrence.
Some claim it to be fetal, others maternal in
origin, while some even attribute it to a certain type of
sperm cell. The following are other factors held
to be responsible :—
Degeneration of the ovum or its parts caused by the
hyperfunction of the corpus luteum; hypofunction of
the corpus ; a circulatory disorder ; injury to the placental
capillaries by toxic products from the maternal blood
stream ; over-production of mucous tissue within the villi,
into which it extends, at first alone but afterwards
accompanied by blood-vessels ; a maldevelopment of the
blood-vessels.
Among the more notable experiments are those
of Aichel (Szathmary 1926), who by macerating the
DR. C. HOLLÓSI : CYSTIC DEGENERATION OF CHORIONIC VILLI
[APRIL 3, 1937
placenta in animals was able to bring about cystic
degeneration in the chorion villi. In hydatidiform
mole secondary corpus luteum cysts appear in the
ovary ; these vary in size and are generally bilateral.
Cottalorda (1923) has shown that cystic degeneration
in the ovary was present in 59 per cent. of the cases
of cystic degeneration of the chorion villi, and in
9-4 per cent. of the cases of chorion epithelioma.
The appearance of a vesicular mole is peculiar.
The mass may be as large as a man’s head, covered
more or less with decidua, which upon incision
reveals innumerable small cysts, some as large as
grapes or even as hen’s eggs, connected with each
other or with the base of the chorion by pedicles of
varying thickness. A microscopical section through
a villus shows distended cells, with an over-production
of epithelial cells, the Langhans’ cell layer, and the
irregular syncitium cells.
Cystic degeneration of the chorion villi may occur
at any age. Evidently the disease occurs most
frequently in multiparse between forty and fifty and
very seldom above this age; one case is reported
of a girl aged nine, Estimates of its incidence vary
from 1 : 650 to 1: 1347.
CASE-HISTORY
A multipara, aged 54, was sent by her physician with a
diagnosis of malignant tumour of the uterus. Menstrua-
tion had began at 13, recurring at regular 28-day periods
lasting 4-5 days. She married at the age of 16, and had
15 normal pregnancies. At the age of 44, in her last
pregnancy, she gave birth to twins, after which her periods
stopped. In January, 1924, there was a slight hemorrhage,
and its repetition led her to visit her physician, who upon
examination diagnosed malignant tumour of the uterus
and directed her to the clinic for operation.
The day after her arrival at the clinic a rather
serious hemorrhage occurred necessitating physiological
infusions. A rather large mass of cystic chorion villi
was discharged (Fig. 1). To check the hzemorrhages
after the uterine cavity had been well irrigated drugs
were given to con-
tract thé uterus.
The patient was
medium sized and
well developed.
Thoracic organs
normal.
Vaginal examina-
tion.—Scars of peri-
neal laceration due
to delivery. Large
vaginal vault; ero-
sion of external os
which admitted the
first phalanx of
middle finger; bloody
discharge. Enlarged
uterus about the
size of a fetal
head, soft, normal
fixation; no adhe-
sions. Urine normal.
The diagnosis was
erosion of the cervix,
methropathia, and either submucous fibromyoma of the
uterus or carcinoma of the body. She was carefully
curetted and a pathological examination was made of the
scrapings. For one week her temperature was high, but
three weeks later she left the clinic cured.
Pathological report (by Prof. F. Orsés).—The material for
the examination consists of a mass of swollen vesicular
moles embedded in clotted blood. The vesicles are of
various sizes. Among these vesicle-like villi there are
several that are of normal thickness and type. These,
upon closer examination and after longitudinal sections
were made, are seen to be cross-sections of the processes
of the vesicular villi. No normal blood-filled vessels are
1.—Mass of cysts discharged
FIG.
per vaginam.
centimetres.)
(The scale is in
THE LANCET]
found, although here and there the remnants of what
might have been blood-vessels: can be discerned. The
vesicles are in various stages of degeneration. In some
the outer epithelial layer is quite normal with the nuclei
staining well; in some it is degenerate ; while in others
it is entirely absent. Some have completely degenerated.
even in the stroma. The cells of the cyst are distended
and loosened, the interstices being filled with a coagulated
mucous fluid. In some vesicles the outer cellular wall
shows crowding, and as a result of shrinkage resemble
the gyri of the brain. Where the epithelial layer of the
re
AP 4™
y Py i d
7 j
tt (iF ji?
FIG. 2.—Section of scrapings from uterus.
vesicle is in fairly good condition various changes can
be seen: in some places the epithelial cells are low and
cuboidal, in others pseudo-polypi formations are present.
Where the epithelium is thickened certain cells are dis-
tended forming a pseudo-lumen giving the epithelial layer
a ragged appearance. The epithelial layer closely resembles
the Langhans’ layer, while the syncytium is rather poorly
represented (Fig. 2).
A recent examination—the patient is now 65—showed
the following: rectocele, cystocele, a senile atrophied
vaginal vault, a normal small uterus, no adhesions.
External os is normal.
DISCUSSION
The clinical diagnosis of these cases, unless vesicles
are discharged, is often very difficult, especially
before as well as after the menopause. Hzemorrhages
at this age quickly lead one to suspect malignant
tumour of some sort. If the characteristic cysts are
discharged there can be no doubt as to the nature
of the case. Curettage is of great importance, but
the dangers of perforation must not be forgotten
(Fromme 1909).
` The prominent symptoms associated with cystic
degeneration of the chorion villi are rapid increase in
the size of the uterus and discharge of blood or of
bloody serum,
After examining the patient one could exclude
everything but the uterus as the source of the hemor-
rhage. One first thought of carcinoma of the body,
but the size and softness of the uterus could not
entirely exclude fibromyoma, though the infrequency
of hzemorrhages from a fibroid after the menopause
was against it. Curettage made the diagnosis certain.
No matter at what age cystic degeneration of the
chorion villi occurs the patient is put out to three
serious dangers—fatal hemorrhage, septic infection,
and chorion epithelioma. In 50 per cent. of the cases
chorion epithelioma develops after cystic degeneration |
and this is why it is important to keep the patient
under close observation. It may develop even after
many years, but in this case it has not yet been noted.
Some advocate radical treatment, but the middle
path is perhaps the best—close observation of the
patient with bi-monthly examinations.
In my opinion there is a close connexion with the
condition of the ovum. This patient’s last delivery
was twins at the age of 44. Another theory is that
MR. LYSAGHT AND MR. WILLIAMS : PERFORATED PEPTIC ULCER
[aren 3, 1937 809
the mole is due to inclusions of embryonic tissues
that may be influenced by hormones during preg-
nancy. At the menopause, when the influence of the
pituitary gland diminishes, it is possible that these
changes act as an irritant to the embryonic remains
causing their growth. The part played by the
hormone can be explained by the fact that in 36 per
cent. of the cases the mole occurs in women over 45.
It is quite possible that a known hormone is respon-
sible, but it may be that unknown hormones are
the activating agents. If these should be discovered
light might be thrown upon the cause of malignan
tumours at this stage of life. _ l
REPEATED PERFORATION
PEPTIC ULCER
WITH SUBSEQUENT TREATMENT
OF A
By A. C. Lysacmr, F.R.C.S. Eng.
CONSULTING SURGEON TO THE PONTYPOOL AND DISTRIOT
HOSPITAL; ASSISTANT SURGEON TO THE CARDIFF
ROYAL INFIRMARY ; AND
W. Barry WILLIAMS, B.Sc., M.B. Wales
SURGEON TO THE PONTYPOOL AND DISTRICT HOSPITAL
A PERFORATION of a peptic ulcer occurring more
than once in the same patient is fortunately not very
common. With regard to the results of patients
treated by simple suture of the perforation opinion
varies a great deal, but in our experience the results
are very good and agree with Prof. Grey Turner’s }
figures (1927) over a long series of cases in which
50 per cent. are cured and 74 per cent. are so well
that they do not require further operative treatment.
To have the misfortune to perforate a peptic ulcer
four time in as many years must be considered
extremely rare, and we therefore record a case in which
this occurred with the treatment given and lessons
learnt about the case. |
CASE REPORT
A miner, the patient was aged 26 at time of first perfora-
tion. There was no previous history of importance.
A sister had been treated for congenital syphilis, but his
Wassermann reaction was negative and he showed none
of the usual stigmata. It is of interest to note that his
father died of a ruptured gastric ulcer in 1934. It is also
important to record that he stoutly denied any gastric
trouble whatever—dyspepsia or discomfort until his first
perforation in 1932, since when he had never been freo
from pain or vomiting of varying intensity until his
gastrectomy last year.
The first perforation occurred on Feb. 8th, 1932. The
patient was taken suddenly ill with acute abdominal
pain at 2.30 P.M. while at work. He was admitted into
the Pontypool Hospital and the perforation on the anterior
wall of the pylorus was repaired by one of us (W. B. W.);
the abdomen was closed with drainage.
He continued to have severe gastric symptoms in spite
of medical treatment, and on Sept. 14th at 3 a.m. he
perforated a second time. W. B.W. once again repaired
a perforation in the same situation as before, and the
abdomen was closed with drainage.
After this he remained fairly well for about two years
and he returned to work, but was never really free from
dyspepsia and vomiting. He lost considerable time from
work with this trouble and his doctor stated that he
was always very tender in the epigastrium. These
symptoms increased in intensity, and on Dec. 11th, 1934,
a posterior no-loop gastrojejunostomy was performed by
a colleague. This operation did not relieve his symptoms
in any way, and his condition rapidly deteriorated until
1 Turner, G. G. (1927) Quoted in Rowlands and Turner’s
“ Operations of Surgery,” Vol. 2. 7th edit., London, 1.
810 THE LANCET]
ROYAL SOCIETY OF MEDICINE : MEDICINE
[APRIL 3, 1937
on July 22nd, 1935, six months later, he perforated for the
third time and was repaired by Mr. Ioan Jones of Cardiff.
Once again after this, in spite of careful medical treat-
ment, dyspepsia returned worse than ever, and he fell into
a very bad state of health and the fourth perforation
occurred on August 18th, 1936. The perforation was in
the same situation as the previous three—the anterior
wall of the pylorus—and this was repaired by Dr. J. P.
Jenkins of Pontypool.
No improvement occurred in his health after this, and
he may be said to have gone from bad to worse. When
seen for the first time by one of us (A.C. L.)he appeared
a thin man with an anxious expression, obviously in
continuous pain; this pain was uninfluenced by diet,
rest, or alkalis. He said that he was in continuous trouble,
folt that another perforation was imminent, and was
prepared to undergo any operation however dangerous
if thore was a chance of bringing about some improve-
ment. Examination showed scars of previous operations,
considerable epigastric tenderness, and obvious loss of
weight; no mass could be felt. He was put on a light
nutritious diet and gentle daily gastric lavage, with only
slight improvement in his symptoms, and it was considered
that further laparotomy was essential.
The operation on Nov. 21st, 1936, was by no means an
easy one. It was performed under a combination of
local and general anesthesia. As might be expected, a
lot of adhesions required dividing; when the anatomy
was fully defined it was found that the spleen had become
adherent to the stoma and there was a large ulcer at this
situation. When the spleen was detached the stoma was
opened into ; it seemed as if the spleen had closed a perfora-
tion of an anastomotic ulcer. The gastrojejunostomy was
undone and a wide gastrectomy then performed by the
usual Polya method. Afterwards it was found that the
jejunum which had been closed after detachment was
very constricted, so that the operation was concluded
by an entero-anastomosis. The patient made an
uninterrupted recovery.
Subsequent progress.—It is only three months since his
last operation, so of course it is too soon to claim that he
is quite cured, but his progress is so satisfactory that
one may hope that is so. He married on discharge from
hospital. He states that for the first time for 44 years he
can eat anything without any pain, discomfort, or vomiting.
His weight before the last operation was 7 st. 11 Ib. and
is now 8 st. 13 lb. He says “‘ he has never felt so well in
his life, and wishes he had had the operation years ago.”
The case presents the following points of interest :—
(1) The complete absence of gastric or dyspeptic
symptoms before his first operation in 1932, after this he
was never free from trouble until his gastrectomy in 1936.
(2) The fact that his father died from a perforated peptic
ulcer.
(3) The failure of the gastrojejunostomy either to
ameliorate his symptoms or to prevent perforation—two
of the perforations occurred after the gastrojejunostomy
had been performed. At the last operation an anastomotic
ulcer was found.
This is the fourth time in our experience that an
anastomotic ulcer has formed in conjunction with
perforation. . In*the previous three cases the gastro-
jejunostomy had been performed at the time of
perforation ; and in our opinion is a striking criticism
of the practice of performing gastrojejunostomy
at the same time as the perforation is closed.
It would be interesting to know whether patients
who perforate peptic ulcers are also more prone to the
formation of anastomotic ulcers if a gastrojejunostomy
is performed. At any rate, it seems that if simple
suture of the perforation does not cure the peptic
ulcer and further, operative treatment appears
necessary, gastrectomy may prove more suitable
than gastrojejunostomy.
: MEDICAL SOCIETIES
ROYAL SOCIETY OF MEDICINE
SECTION OF MEDICINE
| AT a meeting of this section on March 23rd a
discussion on the
Effects on the Respiratory System of
Asphyxiating Gases
was read by Dr. STUART BLACKMORE of the Home
Office air-raid precautions department. He confined
his remarks to phosgene, since, although there was
a difference of opinion in military circles as to whether
lung irritants would be used in war, it was agreed
that, if they were used, phosgene was the most likely
to be tried. Its action was not yet fully understood.
Œdema of the lungs, the essential lesion, was probably
a direct action on the cell, perhaps caused by an
alteration in the acid-base equilibrium. This was
certainly true of chlorine and in many of the chlorine
compounds, such as phosgene, it was the chlorine
element which determined toxicity. On the other
hand, there was the German view that the cdema
was a secondary phenomenon, the primary effect
being on the nervous system.
Much more was known about the pathological
effects produced by phosgene than about their
ætiology. The main factor was lack of oxygen
caused by mechanical obstruction by water in the
alveoli. At an early stage a thin layer of water
could be demonstrated on the alveolar epithelium
and although there might be no impairment of
function at that stage complete rest was needed or
sudden death might result. Clinically, there were
two well-defined types, the plum-coloured or blue
type, showing signs of CO, retention, and the more
serious grey type in which anoxæmia predominated.
The blood became very concentrated and it was worth
considering whether apparatus for testing the degree
of concentration of the blood might not be required
on a large scale, as in cholera epidemics, The
pathology of the lung lesions in mustard gas poisoning
was, of course, quite different. The essential lesion
here was a burn with consequent inflammation and
secondary infection ; no anoxs#mia was present.
The one essential of treatment was oxygen.
About that there was no argument Administration
could not begin too soon or go on too long. Bleeding
was definitely useful in the early stages: it acted
perhaps by promoting absorption of the fluid in
the alveoli. Atropine had proved valueless and was
contra-indicated. Opinions differed on the value of
transfusion and on the solution to be used. In
America urease was favoured and also emetine
to cause a prolonged constriction of the capillaries.
In this country, however, Barcroft had decided that
transfusion had not proved of any value.
Dr. R. V. CHRISTIE supported the German views.
He suggested that the experiments of Aschoff and
` others in 1920 in which vagal section was shown to
render an animal immune to phosgene had not been
disproved. Much attention had subsequently been
paid in Germany to “ vagal pneumonia” and it
seemed probable to him that the lung œdema was
caused by irritation of the vagal nerve-endings. The
dyspnea was certainly not due to anoxemia, as a
recent discussion on flying at high altitudes had
shown. He believed that the Germans favoured
glucose solutions for transfusion.
THE LANCET] `
In answer to questions, Dr. BLACKMORE regretted
that in France and in this country too much emphasis
had been laid on the vesicant gases, to the exclusion
of interest in the lung irritants. Provided the lungs
were previously healthy and mustard gas could be
excluded, it was true that the lung irritants left no
disability and produced either death or complete
recovery. No fibrosis followed, in contradistinction
to mustard gas. Certainly no predisposition to
tuberculosis was caused. He knew of no instance of
lumbar puncture being used in treatment, but thought
that other drugs of the atropine group might be tried.
There was no evidence that phosgene acted as a
general protoplasmic poison. As regards the method
of election for the administration of oxygen, conserva-
tion must be kept in mind. It might have to be
given for days or even weeks. He knew of a case
which had recovered after two weeks’ continuous
oxygen, though in three-quarters of the fatal cases
the patient died in the first 24 hours. Some sort of
mechanism like the Haldane apparatus was therefore -
necessary which would prevent waste during expira-
tion. It was not necessary to warm the oxygen,
but a reduction valve and flow metre were almost
essential. The rate of administration should be from
3 litres per minute increased up to 10 litres per
minute if almost immediate clinical improvement
was not shown. Above 10 litres the oxygen concentra-
tion in the alveoli did not increase. It should be
given for 25-minute periods with 5-minute intervals
to observe the clinical effect of discontinuance.
Administration of oxygen was difficult as the patients
were dyspnoic and restless and there was much
expectoration and sometimes vomiting.
SECTION OF COMPARATIVE MEDICINE
AT a meeting of this section on March 24th, with
Mr. G. W. Duncan, the president, in the chair, a
discussion on
Nutrition and its Effect on Infectious Disease
was opened by Prof. S. J. COWELL. He pointed out
the difficulty of making controlled observations on
the influence of one factor alone in the nutrition of
human beings. While, therefore, a connexion between
faulty feeding and susceptibility to infectious disease
had been generally admitted, the evidence on which
specific changes in diet had been related to definite
types of infection was conflicting. Investigations
of the subject had fallen into three groups. In the
first, attempts were made to correlate the incidence
and course of an infection with diets characteristic
of different races, social groups, or institutions ;
an example of this was Nicholls’s survey in Ceylon
suggesting that the malaria epidemic of 1933-34
would not have been prevented but might have been
less disastrous had the masses been better fed. Other
examples were Orr and Gilks’s observations of two
East African tribes—the one which ate mostly cereals
showed more admissions to hospital for bronchitis,
tropical ulcer, and malaria than the other which
lived chiefly on meat, milk, and raw blood—and
those of Spence and M‘Gonigle‘who separately studied
the possible relation of diet to bronchitis. In the
second group attempts were made to determine the
effects of changes in diet on the incidence of infectious
diseases both in a whole population and in isolated
communities. From time immemorial famine had
been thought to bring pestilence closely in its train,
and many held that the increased incidence of tubercu-
losis in Central European countries towards the end
of the late war was due to the restricted diets. The
ROYAL SOCIETY OF MEDICINE: COMPARATIVE MEDICINE
[APRIL 3, 1937 811
third group of observations was concerned with the
part played by individual food constituents in
determining resistance to infections. Severe lack
of vitamin A was associated with bacterial invasion
in all species of laboratory animals and the same
relation had been reported in man, but studies of the
effect of liberal supplies of it had been inconclusive ;
conflicting results had been reported by different
observers of its use in puerperal infections, pneumonia,
measles, and common colds with perhaps a slight
preponderance of evidence of benefit to colds. The
speaker had observed no effect on the winter sickness-
rate among R.A.F. recruits, nor on the occurrence
of otitis media complicating scarlet fever from giving
vitamin-A concentrate. Such results could not be
interpreted as proof that the vitamin played no part
in determining the resistance of human beings to
infections but suggested that dramatic effects could
not be expected from giving vitamin A to patients
likely to be already receiving a sufficiency.
Speaking of vitamin D, Prof. Cowell said that
clinicians recognised the tendency of children with
rickets to develop bronchitis and pneumonia, though
in one or two careful studies pneumonia had been
found to attack as many children with well-calcified
bones as with radiological evidence of rickets. The
mechanical obstruction to respiration provided by a
deformed and yielding chest wall might explain in
part the tendency generally believed to exist of
rickety children to succumb to pneumonia. Vitamins B
and C had each been put forward as preventives of
infection, and iron deficiency had been shown by
Dr. Helen Mackay to be associated with high incidence
of infection of the respiratory tract in infants. The
speaker felt that good nutrition was more likely
to determine the course an infection would take
than whether infection would occur. The available
evidence relating to man so far did not warrant the
view that one isolated food constituent was responsible
in any specific way for maintaining the body’s
resistance to infection. It was possible that an
optimum state of nutrition, lasting for a longer period
of life than had been aimed at in most tests, was
necessary to secure the maximum degree of resistance
to infection. :
Miss HARRIETTE CHICK, D.Sc., pointed out that the
variables influencing incidence of infection included,
besides the state of nutrition, the dosage of infection,
the virulence, and such factors as chill, fatigue, and
anxiety. In any acute epidemic these other variables
had the greater influence, having a wide range of
variation and only a short time to work in; they were
relatively less important in slow chronic conditions.
The state of nutrition was more likely to be important
in determining the course and sequel of infections
than their incidence: thus influenza or measles might
run through a public school as quickly as through
a school whose children received a diet which was
deficient according to modern standards. The
severity of the 1918 influenza epidemic might have
been due to the poor state of nutrition. Dr. Chick
then gave two examples of chronic disease apparently
influenced by nutrition: the first was the infective
conjunctivitis which a few decades ago had been
widespread among poor children (though never among
the better-to-do) but was now extinct. The second
example was the incidence of tuberculosis in. two
parts of Austria; between the years 1913 and 1919
the deaths from tuberculosis remained almost constant
in Salzburg, a rural area getting plenty of butter
and meat, whereas in Vienna, where the diet was
poor quantitatively and qualitatively at the end
of the war, the deaths had nearly doubled.. It seemed
812° THE LANOET]
that resistance to infection might be affected by
diet while susceptibility was not. Under properly
controlled experimental conditions any one specific
food factor could be an anti-infective agent, be it
iron or vitamin A; but as most infections entered
by the nasopharynx, animals suffering from deficiency
of vitamin A were particularly susceptible. Dr.
Chick then described some unpublished experiments
carried out with Sir Charles Martin and Dr. Bird
at Cambridge. They had produced in pigs an
intestinal condition resembling a disease of maize-
eating humans. The pigs received one of three diets :
one consisted mostly of maize; in the second the
maize was replaced by wheat and barley; in the
third yeast was added to the maize diet. Those on
the maize alone died, after 8 or 9 weeks, of an infection
of the cecum and colon; those on the second diet
developed diarrhea but eventually pulled through ;
the third group grew rather faster than ordinary
pigs. Apparently there was either some latent
infection which could only manifest itself when the
diet was deficient, or some organism ordinarily non-
pathogenic which was then able to invade the tissues.
All attempts to isolate the organism had failed.
The factor in the yeast rendering the diet satisfactory
was water-soluble and heat-stable and was the anti-
infective vitamin to that particular condition; its
Telation to the vitamin B, complex had not been
determined.
Mr. LESLIE Harris, Sc.D., said that the excretion
of vitamin C normally depended on the intake in the
diet; in controlled humans however the excretion
suddenly dropped when the subject had a cold or
influenza. It normally increased after a test dose
‘but failed to do so in scorbutic children. He had
been examining the excretion in infective conditions
and found that it was decreased in acute rheumatism
in childhood and in tuberculous infection; even
during convalescence cases of acute rheumatism
continued to excrete reduced quantities, and this
finding seemed to tally with the clinical fact that the
convalescent children were liable to relapse. Infective
conditions apparently reduced the saturation of the
tissues to vitamin C, so that patients even when
receiving ample supplies excreted it at a lower level
than the controls, and the lowered secretion might
have some diagnostic value. The question remained
whether vitamin-C deficiency was the result of
fever or the cause of infection. The speaker had
estimated the vitamin-C content of the tissues and
the suprarenals of guinea-pigs infected with tuber-
culosis and had found the content much lower than
in the tissues of normal animals; it appeared that
the vitamin had been taken up by the tissues. It
was certain that deficiency of that vitamin reduced
the resistance of guinea-pigs to infection and many
workers agreed that similar effects were observed
in man. ‘If it played some specific part in defence
this might be that it was required by formative cells
for in its absence scar tissue and hair failed to form.
It had also been suggested that it played a part
in the formation of blood-cells and antibodies; as
a high concentration had been found in leucocytes
the theory that it was concerned in antibody forma-
tion was plausible, but so far treatment by vitamin C
dosage had been disappointing. |
‘Mr. J. T. Epwarps, D.Sc., spoke of the effects of
nutrition in foot-and-mouth disease. He had been
working with rats and had found that the better
nourished animals were more susceptible to the disease.
Further work had shown that the addition of raw
liver and carrot to a diet increased the susceptibility
and that the less susceptible animals were definitely
LIVERPOOL MEDICAL INSTITUTION
[APR 3, 1937
anemic. Hedgehogs which were very liable to
catch the infection did not do so when hibernating.
It seemed then that the susceptibility depended
partly on increased metabolism rather than on one
specific factor. These findings had their parallel
in veterinary experience, for animals seemed particu-
larly prone to contract foot-and-mouth disease
when m prime condition and at the prime of life.
Mr. H. H. GREEN, D.Sc., said that mal-nourishment
was generally believed to predispose to helminth
infection. Definite experimental evidence was difficult
to obtain on the subject but in one series of experiments
poorly nourished animals had shown a greater
capacity to produce helminth eggs.
Dr. D. F. ©. Wrtson described how she had
investigated 2000 children of different creeds in the
Punjab and had come to the conclusion that there
was no very definite relation between food deficiency
and malaria.
Dr. WARREN CROWE said he had produced experi-
‘mental arthritis in the rabbit by injection of strains
of streptococci and had found that those of his
animals receiving a diet deficient in vitamins did not
develop arthritis, whereas those on full diets did.
He suggested that the arthritis was a disease of
reaction to a noxious agent; if the animal were
sufficiently weakened by poor diet there was no
reaction. This conjecture was supported clinically,
for patients after lying in bed with arthritis often
complained that the pain was worse, although they
were really better. A parallel might be found, he
thought, in the post-mortem findings of officers
dying of influenza in 1918; those who died had
often been “fighting fit” and only ill two days;
they died of drowning from their own reaction.
Mr. A. L. BACHARACH thought that all constituents
of diet might play an anti-infective part but that
together they acted not as their sum but by integra-
tion. Resistance might depend on two factors, but
the effect of lack of one only be shown when the other
was lacking too. He mentioned that vitamin-C
excretion was reduced in benzene-poisoning, pregnancy
and lactation, and that any theory to explain the
reduced excretion in fever should also explain it
in those conditions. He thought that the benefit
of giving ascorbic acid might not be shown during
the course of one, illness, but might build up the
reserves for the next.
Dr. HARRIS supposed that the increased activity
and. demands on the body during pregnancy and
lactation might explain the reduced excretion in
those conditions.
LIVERPOOL MEDICAL INSTITUTION
AT a pathological meeting of this institution on
March llth, with Mr. R. KENNON in the chair,
a paper on the
Pathological Aspects of Criminal Abortion
was read by Dr. W. H. Grace. He pointed out
that the Offences against the Person Act used only
the word “ miscarriage,” meaning the emptying of
the uterus at any stage of the pregnancy, and made
no attempt to define the word “ unlawfully ”? or to
define “‘ lawful’? emptying of the uterus ; moreover
there was no difference in the nature of the crime
if the uterus did not contain the products of concep-
tion. Death following criminal abortion was usually
either (1) quick, being often due to shock, and more
rarely to air embolism, or (2) delayed, due to sepsis.
The abortionist was more likely to be caught if death
THE LANCET]
was rapid. The methods of procuring criminal
abortion were (1) violence applied generally, including
rolling downstairs and kneading or compressing
the abdomen; (2) internal administration of drugs,
on which Dr. Grace remarked that “‘ there is no drug
and no combination of drugs which, when taken by
the mouth, will cause a healthy uterus to empty
itself, unless it be given in doses sufficiently large
to endanger seriously, by poisoning, the life of the
woman who takes it”; and (3) mechanical injuries
to the uterus and its contents, either by uterine
sounds, catheters, wire, pieces of wood, umbrella
ribs, hairpins, penholders, and the like, or by injection
of fluids such as solutions of soap or sodium
bicarbonate. In describing his method of examina-
tion in cases of suspected criminal abortion, Dr. Grace
emphasised the importance of keeping all objects and
organs which might be used as evidence.
Dr. E. CRONIN LOWE spoke of the difficulty often
met with in cases in which death followed self-
attempted abortion, Frequently there was no
evidence of damage to uterus, cervix, or vagina, and
death ‘had apparently resulted from shock. It was
important, as Dr. Grace had said, to collect any
fluid in the vagina, for sometimes this provided the
only evidence of attempted interference. He thought
that right-sided pelvic infection should arouse
suspicion of interference by mechanical means,
probably carried out by someone other than the
deceased.
Dr. W. A. Mackay, speaking of the relation between
medicine and the law, said that doctors were in no
sense criminal detectives, and when abortion was
suspected usually nothing should be done. In
case of death, however, information to the police
became a duty.
Mr. M. Datnow pointed out that “‘ general violence”
as a cause of abortion must include the associated
shock and fright, for often severe physical injury did
not disturb pregnancy. In experiments on animals
he had used many of, the well-known abortifacient
drugs but had never succeeded in bringing about
abortion ; in fact some actually tended to prolong
the period of pregnancy. An exception was lead,
which almost always produced abortion. Mr. Datnow
did not think that injection of fluids would bring about
abortion, unless the fluid was injected into the uterine
cavity. He drew attention to certain soap pastes
which were being extensively used on the Continent
to bring about abortion therapeutically. _
Mr. C. H. WALSH stated that in his opinion criminal
abortion was on the increase. A favourite method
was the use of intra-uterine injection which left
little or no trace, whether of trauma or of incriminat-
ing material, He agreed with Dr. Grace that there
was no known drug taken by mouth which would
procure abortion without disabling or killing the
mother. He instanced the death of a woman lately
admitted to hospital moribund as the result of taking
an overdose of the ‘“‘ female pills ” so consistently and
largely advertised in the daily press.
Congenital Microcolon
Dr. W. E. Cooke and Dr. G. RONALD ELLIS said
that congenital narrowing or obliteration of the
intestines was rare and that the incidence of congenital
microcolon appeared to be less than 1 in 522,802 post-
mortems. They had, however, encountered 2 cases
within six months. Both were in males.
The only symptom was vomiting, and the condition
was diagnosed at exploratory laparotomy. The rectum
was examined before operation and was found to be normal
in each case. Post mortem the duodenum and jejunum
LIVERPOOL MEDICAL INSTITUTION
[APRIL 3, 1937 813
were empty and flaccid, and the ileum distended with’
inspissated meconium. Towards the cecum the ileum
became less distended. The cæcum contained a little
meconium, but the contents were chiefly cell debris,
The colon and in fact the whole canal was patent through-
out. The colon contained cell debris but no meconium.
No peritoneal bands were present. Microscopically the
duodenum and jejunum appeared stretched, but the
walls and lymphoid tissue seemed normal. The muscular
coat of the ileum was hypertrophied. The mucous mem-
brane of the colon was normal, but the muscular coat
was hypertrophied. In one case the gut had rotated and
the colon was in the normal position; in the other the
gut had not rotated and the whole of the colon was on
the right side.
Many theories had been propounded to explain the
condition, including peritoneal bands, absence of
vis-a-tergo occlusion of the bowel lumen and want
of patency of the ileocecal valve, and insufficient
blood-supply. The probable explanation, however,
lay in defective nerve-supply; anatomically the
colon was normal. The nerve-supply of the colon
from the ileocecal valve onwards to its junction
with the rectum obtained its motor fibres from the -
pelvic visceral nerve (the sacral division of the -
parasympathetic) and the inhibitory fibres from
the inferior mesenteric ganglion (sympathetic). - The
condition was a lack of relaxation—an achalasia.
As Greig suggested, the anatomical ‘structure was
perfect, but the meconium had passed so far and no
further because the next segment—in this case the
ce#cum—had never opened to receive it.
Tuberculous Kidney with Giant Ureter
Mr, A. S. KERR and Mr, Kennon showed a kidney,
which was almost entirely replaced by tuberculous
caseous material, removed from a woman aged 34.
She had had urethral pain and extreme frequency of
micturition for two years. There was no hematuria, but
the urine contained thick pus in which many tubercle.
bacilli were found. On cystoscopy the bladder held only
two ounces and the mucosa was much congested. The
right ureteric orifice was raised and congested, and there
were bullæ around it. The left orifice appeared normal.
Intravenous indigo-carmine was excreted from the left
side in good concentration in 44. minutes, but none was
seen from the right side in 15 minutes. Uroselectan
showed normal function and appearance on the left side,
but no dye was excreted by the right kidney. A sample
of urine removed from the left kidney by ureteric cathe-
terisation was found to be free from tubercle bacilli.
Nephrectomy was therefore performed, and it was noticed
at operation that the lower four inches of the ureter were
enormously dilated and thickened compared with the
pencil-like upper four to five inches. As much as possible
of the ureter was therefore removed.
The interest of the specimen lay partly in the
great dilatation in the lower part of the ureter and
partly in the fact that within three weeks of the
operation the patient was able to retain urine for
periods up to four hours, and had passed as much
as 10 oz. in a single act of micturition. The question
arose whether the ureteric dilatation was due to
destruction of the ureteric orifice and reflux of urine
from the bladder, or to stenosis of the orifice and
excessive internal ureteric pressure. The very rapid
reduction in frequency of micturition suggested that
there might have been a reflex arc between the
diseased kidney and the micturition centres. |
Mr. CHARLES WELLS said he thought that tuber-
culous kidney was often associated with dilatation
of the ureter. This could be followed in X ray
pictures down to the level of the bladder, where there
was usually a gap between the ureteric and the bladder
shadows. This gap was due to the thickness of the
' .excellent guide.
814 THE LANCET] |
bladder wall and there was little doubt that it was
obstruction at the bladder wall which caused the
dilatation. This obstruction was first due to spasm
and later to fibrosis, which might in time lead to
complete occlusion of the orifice. The recognition
of spasm as a factor was important because the
healthy kidney might often have a dilated ureter
from this cause and the existence of dilatation of the
ureter alone was, therefore, not a safe criterion of
tuberculosis of the corresponding kidney. In treat-
ment the recognition of a dilated ureter was
necessary because all such ureters needed to be
removed together with the kidney. -Nephro-ureter-
ectomy took very little longer than simple nephrectomy
and had two strong points to recommend it. First,
the removal of the whole of the source of tuberculous
REVIEWS AND NOTICES OF BOOKS
[APRIL 3, 1937
material gave the bladder a very much better chance
of rapid convalescence, and secondly, the risk of
sinus formation in the wound was greatly diminished.
It seemed likely that patients suffering from persistent
sinus did so for exactly the reason that they had
dilated ureters obstructed at the level of the bladder
capable, therefore, of discharging only upwards
through the wound.
Mr. KERR, Prof. R. E. KELLY, and Mr. KENNON
reported two cases of post-anal dermoid and Mr. KERR
and Mr. KENNON a case of suprasternal dermoid.
Dr. T. F. HEWER and Dr. DouGLAS BIGLAND described.
a case of subarachnoid hemorrhage from the circle of
Willis, and Dr. ELLIS one of cerebral abscess associated
with bronchiectasis.
REVIEWS AND NOTICES OF BOOKS
The Public Health Act, 1936
By Davin J. Brattiz, LL.M., Assistant Solicitor
to the Beckenham Corporation. London: Solici-
tors’ Law Stationery Society Ltd. 1937. Pp. 503.
40s.
THE vast new Public Health Act, which rewrites
the health provisions affecting England outside
London, will come into force next October. Those
who are accustomed to the geography of the old
Acts which it supersedes will have to learn their
way afresh. Mr. Beattie’s book will be found an
The case law, so far as applicable
for the elucidation of clauses which now reappear
in a new context, is faithfully set out. A particularly
useful feature is the comparative table which shows
in parallel columns the references to repealed enact-
ments and their present equivalents, The depart-
mental committee which reported on the consolida-
tion of enactments relating in the first place to local
authorities and local government, and in the second
to public health have built themselves an abiding
monument in the Acts of 1933 and 1936. As Sir
Gwilym Gibbon points out in his foreword to Mr.
Beattie’s book, these Acts represent a new legislative
technique. A committee of experts was equipped
with a Treasury draftsman. Its draft Bill was not
pure consolidation; there was substantial amend-
ment though not of a controversial kind. Judicious
changes were made in the course of rendering the
old laws more simple, uniform, and concise. These
changes were not effected by a separate amending
Bill. The committee thus ran the risk, in combining
consolidation with amendment, of exposing its
draft Bill to the copious and sporadic amendments
which private Members of Parliament might casually
seek to insert. Fortunately the private Members
behaved with noble self-control; and the Bill on
which such devotion had been lavished was allowed
to preserve its well-considered symmetry and to
pass into law with remarkable swiftness. It is not
entirely convenient that separate health codes should
exist for London and for the rest of England when
there is so much common ground. Part 10 of the
new Act (dealing with canal boats) is expressly
applied to London. On the other hand the parts
dealing with baths and washhouses, with infant life
protection, and with the registration of nursing-
homes have to be duplicated in the parallel new
Public Health (London) Act. Some will think that
more might have been done to keep the metropolis
and the provinces in line. The drafting of the two
codes seems to have been by different hands; nor
did one hand always know what the other hand was
doing. Thus, when the Public Health Act repealed
a number of specified enactments, it was apparently
necessary to provide that if any of the repealed enact-
ments were wholly or partly re-enacted in the Public
Health (London) Act (which received the Royal
Assent on the same day), an Order in Council might
declare certain passages in the new Public Health
(London) Act to be equivalent to those repealed
enactments, and thereupon those passages in the
Public Health (London) Act would be repealed too.
In the last few days an Order in Council has appeared.
This method of legislation may be watertight but
nobody can pretend that it makes things easy for
the layman. This, however, is not a matter to be
blamed on Mr. Beattie who has done all he could to
enlighten us about the law as it will be next October.
1. Nutritional Factors in Disease
By Writ1am RosBert Fearon, M.B., Sc.D.
F.I.C. London: William Heinemann (Medical
Books) Ltd. 1936, Pp. 141. 7s. 6d.
2. Normal Diet and Healthful Living
By W. D. Sansom, M.D., Chief of the Staff of the
Sansum Clinic, Santa Barbara, California; R. A.
Harr, M.D., Member of the Staff of the Clinic;
and Ruru BOWDEN, B.S., Dietitian of the Clinic.
London : Macmillan and Co., Ltd. 1936. Pp. 243.
8s. 6d.
1. Tu1s is an essay which gained for its author
the Buckston Browne prize awarded by the Harveian
Society of London in 1935. It would be unfair to
criticise because it fails as a somewhat superficial survey
of a subject which could not be properly dealt with
in less than several volumes, At the same time it is
difficult to escape the feeling that the author has
attempted both too much and too little ; for example,
the discussion (p. 45) of the relation of protein excess:
to nephritis is less of a summary than a brief set of
references to a series of somewhat contradictory
papers. Throughout this essay we have been unable
to discover any clear ‘outline of the important con-
ception of conditioned deficiency diseases in which
a normal diet fails to give proper nutrition owing
to some failure by the body to assimilate or utilise
essential food factors. It is the absence of any dis-
cussion of this conception that makes us dubious of
the author’s rationale for his conclusion that there
are three main determining factors of nutritional
disorder : inherited constitution, physiological strain,
and conditions of modern civilisation.
THE LANCET]
2. The authors of this book have made a practice
of discussing questions of nutrition with groups of
their patients, and have therefore acquired skill in
describing the known scientific facts in terms under-
standable by the layman. They are doubtless justi-
fied in their belief that much good has resulted to
the patients as a consequence of this education, and
they have set out here the main facts which their
experience leads them to believe should be empha-
sised in such discussions: Even at a time when far
too many books of doubtful value are appearing
on{questions of diet this one can be recommended
as eminently sound. i
Bainbridge Essentials of
Physiology
Eighth edition. Edited and revised by H. HART-
RIDGE, M.D., Sc.D., M.R.C.P., F.R.S., Professor
of Physiology, University of London at St. Bartholo-
mew’s Medical College. London: Longmans,
Green and Co., Ltd. 1936. Pp. 651. 14s.
In the preface we read that “ new chapters have
been written on the nutrition of the heart, on the
oxygen-carrying power of the blood, on the vitamins,
on tissue oxidation, on synapses, and on pregnancy
and parturition. Additional paragraphs have been
inserted in many other chapters.” The editor has
preserved the original design of the work, which
consists of sixty short chapters chopped into sub-
divisions ; these rarely consist of more than one
paragraph, each of the paragraphs having a heading
of heavy black type. The length of the paragraphs
is the only indication of their relative importance.
To the experienced physiologist the book reads
rather like a newspaper, and does not seem ideally
arranged for learning. But a considerable proportion
of students have shown that it meets their needs,
and by some of them in every generation ‘“ Bain-
bridge and Menzies ” is regarded as a kind of testa-
ment, The facts of physiology are to be found in
it, briefly stated, stripped of much that lends them
interest in more leisurely treatises, but undeniably
present. There is a type of mind—and here no
criticism is implied—which feels safer when adding
to its knowledge brick by brick, and making certain
that each brick is in place before adding the next.
The size or importance of the brick does not matter ;
that is the architect’s business. It is sufficient to
know that if each one has been faithfully laid in its
place the finished structure must be reasonably
stable. ‘‘ Bainbridge and Menzies” is probably the
only English text-book which presents physiology
in a form suitable for such students, and therefore
has its own niche. Moreover there must be a large
number of students who have studied a larger
book who will find it invaluable for revision purposes.
If the historical reasoning which lies behind it, but
finds little place in it, is understood, it becomes an
excellent manual for reference.
and Menzies’
Alltagsorthopddie des Praktischen Arztes
By Regierungsrat Dozent Dr. SIEGFRIED ROMICH.
Wien: Aesculap-Vorlag. 1936. Pp. 59. M.2.70.
Tuis little book sets out to cover in 59 pages the whole
field of orthopsedic practice as it affects the general prac-
titioner. Itis surprising that the attempt should have
succeeded to such a measure. In a short intro-
duction Prof, Spitzy points out that while each
specialist has leisure to ‘‘ play in his own backyard,”
REVIEWS AND NOTICES OF BOOKS
[APRE 3, 1937 815
ephemeral controversies have little interest for the
general practitioner; what he wants is undisputed
facts of practical value. He is provided here with
insight into the nature of orthopedic conditions
and into the difficulties that are likely to be encoun- ©
tered in their treatment, as well as with suggestions
for simple measures, to which the commoner types
respond. For example, the author shows that functional
inefficiency depends not only on the structure of the
organ but also on the ratio of the demands made
on it to its inherent strength, a point frequently
overlooked in practice. Either the low-arched foot or
the cavus foot may become painful when subject to
excessive strain, but each needs a different type of
shoe and height of heel. Arthrosis deformans,
again, the non-infective form of joint disease due to
slow wearing out of the joint tissues, will develop
in any patient who lives long enough, but may occur
in early adult life as the result of abnormal strain,
as in an unreduced congenital dislocation. In regard
to hallux valgus, the author reminds us that this is
always a symptom of flat-foot, and protests that
the fashion of putting such “ minor operations ” as its
correction at the end of a long list and leaving them
to an inexperienced operator accounts for some at
least of the unsatisfactory results obtained. The
surgeon tends to forget that what is “ minor” to
him is a major disability to the patient. In con-
nexion with surgical tuberculosis, the wise observa-
tion is made that all these cases run a natural course
of invasion and healing which can be modified but
not reversed by treatment; the measures applied
in the first stage may diminish, but will not eliminate,
tissue destruction, while any form of treatment
applied during regression is likely to acquire more
credit than it deserves.
In the final chapter on plaster-of-Paris the modern
controversy on the relative merits of padded and
unpadded plasters is disposed of by the shrewd com-
ment that both are bad when badly applied, while
either is efficient in expert hands. Prof. Spitzy
emphasises the part which general practitioners can
play in the early diagnosis of crippling conditions
and in directing them to centres for efficient treat-
ment, while he reminds us of the economic importance
of fiat-foot and “rheumatism” as sources of dis-
ability in the working-class population, even amongst
adolescents. An English translation of these crisp
pithy chapters would be welcome.
Cunningham’s Text-book of Anatomy
Seventh edition. Edited by J. C. Brasu, M.A.,
M.D., F.R.C.S. Edin., Professor of Anatomy, Uni-
versity of Edinburgh ; and E. B. Jamieson, M.D.,
Lecturer on Anatomy in the University. London:
Humphrey Milford, Oxford University Press. 1937.
Pp. 1506. 42s. :
SOME years have gone by since the last issue of
this famous text-book saw the light. In the interval
Prof. Robinson has retired from the chair of anatomy
at Edinburgh ; this edition is in the joint charge of
his successor and his experienced senior assistant.
The book is now produced in the new English (B.B.)
revised terminology, and is thus in line with the
latest anatomical treatises. Since the list of contri-
butors was printed we observe that two of them have
died, Prof. Francis Dixon and Sir Grafton Elliot Smith ;
the former after he had finished his revision of the
classical section on the urogenital system. The section
-on the central nervous system, from the masterly pen
of Sir Grafton Elliot Smith, remains as a monument
` 816
to his erudition, with some little additions and
alterations made by him, and others by his associates,
Dr. Una, Fielding and Prof. A. Durward. Most of
the contributors to this edition are new, and they
- have reason to be proud of the book they have pro-
duced ; it is a great work, worthy of the place “ big
Cunningham ” occupies in the forefront of anatomical
literature. Much added material in the text and
several figures and radiograms have been included
in a book which, in some indefinable way, seems less
formal than its predecessors in the treatment of
matters anatomical, and this is all to the good.
THE LANCET]
Synopsis of Surgical Anatomy
Third edition. By ALEXANDER LEE McGREGOR,
M.Ch. Edin., F.R.C.S. Eng., Lecturer on Surgical
Anatomy, University of Witwatersrand ; Assistant
Surgeon, Johannesburg General Hospital. Bristol:
John Wright and Sons, Ltd.; London: Simpkin
Marshall Ltd. 1936. Pp. 664. 17s. 6d. |
CERTAIN additions and changes have been made
in this third edition, and the general character of
this excellent little book maintains a high standard.
We would like to see some notice taken of the sexual
difference in ossification times and fusions, and
indeed in some other respects, but that is the only
criticism we can make,
Modern Discoveries in Medical Psychology
By Currrorp ALLEN, M.D., M.R.C.P., D.P.M.,
' Psychotherapist to the Institute of Medical Psycho-
logy. London: Macmillan and Co., Ltd. 1937.
Pp. 279. 8s. 6d.
THE author of this introduction to modern psycho-
logical medicine has systematised his exposition by
showing the progress of psychopathology through the
history of the personalities who have made the
leading discoveries. Mesmer and the work of his
followers, Liebault and others, are first considered
in relation to hypnosis. The contributions of Janet
and Morton Prince to the structure of the mind show
us how the modern theories of the unconscious were
made clear in the study of hysteria and multiple
personalities. Neither of these celebrated clinicians
went beyond superficial analysis of personality, and
their treatment was largely suggestion and hypnosis
with a view to reintegration. Prince, however, is
shown as preparing the ground for an understanding
of Freud inasmuch as he recognised the importance
of emotional disturbances as precipitating factors.
Freud naturally comes in for the lion’s share of the
book and a mead of praise which could only have
been given by an ardent devotee whose exposition is,
however, simple and accurate. Alfred Adler and
C. G. Jung do not arouse Dr. Allen’s admiration.
The former is regarded as superficial and his organ
jargon as nothing more than an extension and per-
haps an exaggeration of a Freudian concept. Jung’s
theory of types and his concept of the collective
unconscious receive proper attention but are perhaps
rather too easily dismissed as tending to mysticism.
Kretschmer’s theories on the relation of body and
mind and their connexion with clinical types are
treated somewhat superficially. The book closes
with an appreciation of Pavlov which is warmer than
one would have expected. Pavlov and Freud are
made to stand out as the two great figures in modern
clinical psychology. Both have their roots in biology,
and their divergences would appear to be due to
REVIEWS AND NOTICES OF BOOKS
[APRIL 3, 1937
little more than differences of language expressing
ultimately the same Determinism.
This is a volume that can be safely placed in the
hands of the student of psychopathology provided
that his critical faculties will not be blinded by the
bright light of the author’s partisan enthusiasm.
Common Sense and Psychology
By ALAN MaBERLY, M.A., M.B. London: Frederick
Muller, 1936. Pp. 160 5s.
Dr. Maberly has contracted into a small space a
considerable amount of information regarding modern
theories of psychology with particular regard to the
personality and his disturbances. In a brief.space
he attempts, howbeit in a popular fashion, to explain
mental mechanisms, the significance of sex, and
the relationship of parent to child. Common sense is
certainly the mainspring of this book, and the author
has in large measure succeeded in avoiding the com-
plexities of modern theories. Unfortunately in the
last chapter, which deals with fear and guilt, he has
not been very successful in coming to grips with this
central problem of modern psychopathology.
The book could be read with profit by an intelligent
layman, and by doctors who have so far not taken
much interest in medical psychology.
Allergic Diseases
Their Diagnosis and Treatment. Fourth edition.
By Ray M. Batyeat, M.A., M.D., F.A.C.P.,
Associate Professor of Medicine and Lecturer on
Diseases due to Allergy, University of Oklahoma
Medical School. Assisted by RALPH BOWEN,
B.A., M.D., P.A.A.P. Philadelphia: F. A. Davis
Co. 1936. Pp. 516. $6. or
THE physician studying allergy is apt to be appalled
by the complexity of the subject, and perhaps dis-
mayed by a certain lack of precision, though not
always of confidence, when he consults the expert.
He may wonder how much he may rely for instance
on such methods as skin testing, or on trial diets in
the detection and elimination of allergens. Dr.
Balyeat’s book offers him a full account of this
difficult subject, copiously illustrated by pictures
and case records. This edition includes several
new chapters, among them the use of intratracheal
iodised oil in the treatment of obstinate asthma,
which the author finds valuable in combination with
other measures.
We read in the preface that the primary xtiological
factor in migraine is usually food sensitisation. The
evidence supplied is hardly convincing. Of the
author’s cases about one-half gave a positive reaction
to foods on skin testing, but many foods that gave a
definite skin reaction seemed to have no clinical
significance in relation to migraine, and other foods
whose ingestion was followed by attacks of migraine
gave no skin reaction; further a reaction to a
suspected food might be negative when tested in
one area of the skin and positive in another. One
of the five cases recorded was found to be sensitive
to twenty-two foods, elimination of which has been
followed by freedom for eight months except for two
attacks.
This book is written primarily for the enea
practitioner, but contains a wealth of technical
detail which the specialist in allergy will be able to
sift to greater advantage.
THE LANCET] i
THE LANCET
LONDON: SATURDAY, APRIL 3, 1937
THE SALE OF NOSTRUMS
LEGISLATORS in the United States are preparing
measures for the stricter control of the medicine
trade. If they are successful, there will be fresh
hope for similar provisions in our own country
where a select committee of the House of Commons
has lately produced a report! on the medicine
stamp duties. Although the select committee
viewed our problems from the fiscal angle only,
the report mentions that there was, incidentally,
authoritative evidence that the poorer and less
well-educated classes of our people spend more
money than they can afford on remedies of little
or no efficacy, with an accompanying danger to
health as. a result of their not seeking medical or
surgical treatment in time. These deliberate
comments on the obsolescence of the medicine
duties and on the exploitation of the public by
the appeal to fear merely repeat what has often
been officially recorded before. But, as the debate
on the Medicines and Surgical Appliances (Advertise-
ment) Bill showed a year ago, the Parliament at
Westminster is liable to discount this kind of
advice as a sinister and self-interested attempt by
registered medical practitioners to deprive poor
sufferers of the really valuable advantages of
unorthodox medicine. |
There are now before the legislature of the State
of New York proposals which resemble and improve
upon Mr. Duckwortn’s Bill of last year. The
measure proposes to set up a Consumers’ Bureau
in the New York department of health, with powers
to refuse the registration of any proprietary food
or drug and to control the advertising of such
articles. The manufacturer will not be allowed
registration unless he submits the complete formula
of his product; if this bureau deems it potentially
injurious, registration will be refused. This Con-
sumers’ Protection Bill, as it is named, will also
prohibit any representation of palliative or thera-
peutic effect on any of a list of 42 diseases and will
curb the extravagant claims displayed on labels
or in advertisements of any kind. Meanwhile
two other Bills are pending in Congress; thus the
problem is being attacked both in the federal and
in the several States’ legislatures. It is unwise to
dogmatise about American statutes and their
prospects. Wide legislative powers were left in
the hands of the several States when the historic
constitution was framed in the seventeenth century.
Limited powers (e.g., where inter-state commerce
is concerned) were permitted to the federal legisla-
2 See Lancet, March 6th, p. 591.
THE SALE OF NOSTRUMS
[APRIL 3, 1937 817
ture. A great part of the time of the supreme
court of the United States is devoted to deciding
the validity of laws where one legislature is alleged
to have trespassed into the domain of another.
One of the functions of the federal government is
the Post Office; federal powers can therefore be
used to suppress mail-order frauds by “‘ closing
the mails ” to quack remedies much. in the same
way as our own Post Office can restrict the postal
traffic in Irish Free State sweepstake tickets and
literature. In America the National Food and.
Drugs Act of 1906 requires that the patent medicine
package must declare the presence and amount
of eleven specified drugs; if the package contains
an advertisement of healing powers which is
demonstrably false, the Government can intervene.
Dr. A. J. Cramp, in the introduction to the third
volume of his ‘‘ Nostrums and Quackery,”’ reviewed
in our columns a fortnight ago, pointed out to his
fellow-countrymen the shortcomings of the Act
of 1906. It deals with advertising only on or in
the trade package, not with collateral advertising
in newspapers or on hoardings or by wireless
publicity. It requires the declaration of only
eleven out of thousands of drugs. It confines the
word “drug” to substances used for the cure or
alleviation of disease and thus it exempts cosmetics _
which may often contain dangerous drugs.
Dr. Cramp has hinted that the business slump of
1929 has made the moment less propitious for
sterner legislation against quack remedies. In
times of prosperity, he suggests, reputable journals
may exercise a rather rigid censorship of medical
advertising. When hard times come, the standard
is lowered. Many newspapers and magazines
which helped to educate public opinion and to
secure the passing of the 1906 Act are said to have
been recently willing to admit advertisements of
patent medicines to their columns where once such
matter would have been unwelcome. He puts a
high estimate on the money spent in advertising
campaigns. A maker of patent medicines is
quoted as having said that this expenditure
amounts to nearly one-half of the manufacturer’s
costs. The United States newspapers are said to
derive more profit from the advertisement of
quack medicines than the makers themselves
from the manufacture. Sentimental statements
that patent medicines are the poor man’s medicine
omit to tell the poor man how large a part of the
price of the alleged remedy has been spent in
convincing him that he suffers from something
which it is sure to cure.
The two Bills now before Congress, according
to a recent summary in the Journal of the American
Medical Association, propose to regulate the sale in
inter-state commerce of devices for the diagnosis
and cure of disease in man or other animals or
devices affecting any function of the body. Both
Bills propose to prohibit the advertising (among
persons other than the medical profession) of any
drug or device represented as having therapeutic
effect upon Bright’s disease, cancer, tuberculosis,
infantile paralysis, venereal diseases, and heart or
vascular diseases. If this prohibition is enacted
818 THE LANCET]
CEREBRAL GLIOMAS
[APRIL 3, 1937
both by the federal and State legislatures of
America, it will be no small encouragement to
revive the similar proposals to which the Parlia-
ment at Westminster refused a second reading
last year.
CEREBRAL GLIOMAS
‘WHEN making a diagnosis of cerebral tumour
the neuro-surgeon endeavours to answer three
questions. Is a tumour present? Where is it
situated ? What is its histological nature ? Correct
answers may be given to the first two questions
in a very high proportion of cases, but the third
one is a much more difficult one to answer. In an
account of his experiences with 100 cases of glioma of
the cerebral hemisphere, Prof. L. PuusmpP discusses?
these aspects of diagnosis. He divides his cases
into three categories, according to their clinical
evolution, and each group is correlated with the
operative findings. In 45 cases the symptoms and
signs developed in a slow and progressive manner,
which is considered to indicate a benign lesion ;
in 32 of these the tumour was an astrocytoma.
The next group (number unstated) includes those in
which the symptoms developed in paroxysms, with
periods of amelioration. In three-quarters of these
a cystic tumour was found at operation. Prof.
PuuseErP believes that aggravation of symptoms
is due to hemorrhagic infarction of the tumour,
and recession follows cystic degeneration of this
area. Some authorities. are more inclined to
associate cyst formation with an exacerbation of
‘symptoms. Group three consists of cases with
an “acute” history; in these the tumour was
soft and ill-defined, typical of spongioblastoma
multiforme. Oligodendroglioma is also placed
in this category. This tumour has long been
regarded as benign and of slow growth, tending to
calcify, but from a study of its natural history
it is clear that eventually it may acquire malignant
characteristics, and in some areas its histological -
picture may be very like that of a spongioblastoma
multiforme.
To distinguish between glioma and meningioma
the following investigation has been found valuable.
If the patient with a suspected glioma is given
an intravenous injection of hypertonic saline the
general symptoms (headache and vomiting) are
likely to improve, but the focal signs to persist
or even to be aggravated if the diagnosis is right.
If the tumour is actually a meningioma focal signs
as well as general symptoms will show improvement.
Prof. Puuserr avoids the partial removal of a
glioma, believing that this procedure leads to
activation of the remaining portion of the growth.
If, by reason of its location the tumour cannot be
entirely removed, he employs a two stage “ physio-
logical”? method. At the first session the brain
is incised until the tumour is exposed, the bone of
the osteoplastic flap is removed, and the wound
closed. Two or three weeks later when the flap
is again reflected, the tumour will be found to have
migrated nearer the surface of the brain. Total
ablation of the tumour can then be effected with
1 Brux. méd. Jan. 31st, 1937, p. 494.
minimal sacrifice of healthy brain. The bone of the
flap is also removed as a routine measure when the
tumour is “soft ”’—i.e., spongioblastoma multi-
forme, for this provides ample decompression
in the event of a recurrence of the tumour. When
a cystic tumour has been dealt with, a small portion
of the overlying bone is removed so as to form a
window. Any further collection of fluid can easily
be aspirated through this opening. For. those
cases in which the tumour cannot be removed,
decompression is obtained by performing an
extensive craniectomy immediately over the
tumour. The classical subtemporal decompression
is never utilised, for in PuusEpr’s view the other
procedure gives a much better result. Various
arguments are offered in support of “focal”
decompression, and these are considered to out-
weigh very considerably the disadvantage of
disfigurement. |
It is unfortunate that though many figures are
given in this article they are difficult to follow,
being set out partly in actual numbers and partly
in percentages. This is especially disappointing
where late results are under discussion. For
example, of the 28 cases of astrocytoma 3 are still
alive 10-12 years after operation, and apparently 8
survived 4-6 years. These figures compare favour-
ably with those given by CatRns in his recent survey
of the ultimate results of operations for intra-
cranial tumours. The vast majority (86 per cent.)
of patients operated on by Prof. Puusrrr for
spongioblastoma multiforme died within a year
of operation. Some of the patients with this type
of tumour were decompressed and the tumour
treated by deep X radiation. These showed
a very slight gain in longevity as compared with
those in which a radical removal of the tumour
was attempted. The opinion is given that the
functional results also were slightly better in
those cases treated by radiation. i
INHERITANCE OF RESISTANCE TO
INFECTION
In recent years much work has been done,
especially in America, on the problem of the
inheritance of resistance or susceptibility of
laboratory animals to different bacterial and virus
infections. The accumulated data were summarised
and reviewed in 1934 by A. Braprorp Hi in a
report to the Medical Research Council! Him.
concluded that between strains of the same species
differences in mortality from specific infections
had been shown to exist, which could be ascribed
to differences in genetic composition; that within
strains selective breeding had given results which,
in some respects, lacked uniformity and made
interpretation difficult, but in general led to the
conclusion that resistant and susceptible lines could
be developed, and that the factors for resistance
were dominant to those for susceptibility. How
far these factors were specific, giving immunity to
only one infection or to similar types of infection,
how far they might extend their influence over a
1 Spec. Rep. Ser. med. Res. Coun., Loni. No. 196.
THE LANCET]
wide range of dissimilar harmful agents, was a
problem to which the available evidence gave no
conclusive answer. |
One of the most assiduous workers in this field
has been LesLI® T. WEBSTER of the Rockefeller
Institute for Medical Research. In his earlier
work, and in that of other investigators, the
development of resistant stock was based upon
breeding from survivors to infection. An objection
to that procedure has been raised—namely, that
the progeny may prove more resistant to the
infection because of their selection through mor-
tality resulting through infection conveyed by the
previously infected parents, or by a transfer
similarly conveyed of an active or passive immunity.
Elaborate tests have been made which show that
such factors are not likely to be the whole explana-
tion of the enhanced resistance of the progeny,
but the probability remains, as WEBSTER himself
admits, that the persistent infection is a factor in
raising the resistance of the tested offspring. In
his later work WEBSTER has carefully avoided this
difficulty by breeding again from uninfected
parental stock whose first litters have been proved
to be very resistant or susceptible to various
infections. By this means he has developed lines
of mice which differ widely in their reactions to
different agents. In a paper recently published 2
he gives an account of the position which has
been reached in this way, and also full details of
later tests with a variety of bacterial and virus
infections. By rigid selection, testing and ‘dis-
carding procedures, on over 13,000 mice for 12
generations from 1930 to 1934, three main inbred
lines, reacting with reasonable uniformity, have
been produced. The first of these is very sus-
ceptible to infection with B. enteritidis and prac-
tically all mice of the latest generations succumb
to the test dose with this organism ; they are also
susceptible to an induced virus infection (encepha-
litis, St. Louis type, is employed) and 80-90 per
cent. die at test. They are termed bacteria-
susceptible-virus-susceptible. |The second line
appears to be equally susceptible to the bacterial
infection but are resistant to the virus, for less
than 10 per cent. succumb to the test with it; .
they are termed bacteria-susceptible-virus-resistant.
The third line shows considerable resistance to
B. enteritidis, 17 per cent. dying at test, but
nearly all succumb at the test with virus; they
are termed bacteria-resistant-virus-susceptible. A
fourth line resistant to both bacterium and virus
is at present being developed.
The first three lines have given sufficiently
stable mortality-rates for it to appear likely that
cross-breeding and back-cross experiments would
allow the mechanism of inheritance to be analysed,
and the results of such tests are now reported.
They support the conclusion previously reached
that with the infecting agents used resistance is
dominant over susceptibility ; the factors do not
appear to be sex-linked, and those regulating
resistance to B. enteritidis are not related to those
regulating resistance to encephalitis virus. Finally,
2 J. exp. Med. 1937, 65, 261-286.
MORPHIA AND BILIARY COLIC
[APR 3, 1937 819
the tests indicate that the mechanism of this
inheritance may be relatively simple for the
mortality-rates of the F,, F,, and back-cross mice
approximate roughly to those expected on the
basis of two single-factor crossings. It seems,
however, that the type of general title given to
the lines—e.g., bacteria-susceptible-virus-resistant—
may be somewhat misleading. All the lines
appeared equally (and highly) susceptible to a
strain of mouse passage rabies virus, so that the
factors involved may be more narrowly specific
than the titles suggest.. The nearest approach to
a solid immunity is a virus-resistant strain of which
only 18 out of 269 died at test.
The work here reported has clearly and inevitably
been laborious, for large numbers of mice of each
generation in. each line, and the cross-breeding
experiments, must be bred for valid conclusions. ©
Also complications creep in; environmental
influences are difficult to control, and changes in
_ mortality-rates sometimes take place which cannot
be readily explained and are attributed to unknown
environmental causes. WEBSTER has done much
to overcome these difficulties ; his present paper is
an addition to the subject matter that well
deserves careful study.
MORPHIA AND BILIARY COLIC
IT is astonishing how little we still understand
about that commonest of symptoms, pain. An
investigation that succeeds in defining any single
type of pain and displaying its mechanism is
therefore always welcome and valuable. Butsou,
McGowan, and Watters, of the Mayo Clinic,}?
have by very simple methods thrown light on a
variety of pain which may arise in the biliary |
tract after cholecystectomy and which naturally
brings disappointment to both patient and surgeon.
A T-tube left in the common bile-duct for post-
operative drainage was connected by means of
rubber tubes and a Y-junction to a manometer
and a reservoir, and the system filled with saline.
When the reservoir was shut off, the manometer
recorded the pressure obtaining in the biliary
tract, and in one case a regular association could
be demonstrated between rise of pressure and
attacks of pain in the right upper abdomen extend-
ing round the costal margin and to the shoulder-
blade. A means of inducing this pain was found—
namely, morphia—which was shown by Rmaocu ®
in 1914 to increase the tone of the sphincter of
Oddi.. In fourteen experiments, the subcutaneous
injection of one-sixth of a grain of morphine
caused a pressure rise beginning in 24 to 4 minutes
and reaching a plateau of 20 to 35 cm. of water
in 10 to 15 minutes. During the rise pain began,
and for about 10 minutes gradually increased ;
then it died slowly away as the morphia exerted
its analgesic action on the central nervous system.
The raised pressure, however, persisted much
longer. If at this stage the reservoir was made to
1 Butsch, W. L., McGowan, J. M., and Walters, W. (1936)
J. Amer. med. Ass. 106, 2227.
3 — — — (1936) Surg. Gynec. Obstet. 63, 451.
3 Reaoh (1914) Wien, klin. Wschr, 27, 73.
820 THE LANCET]
communicate with the rest of the system it could
be raised by hand until a'head of pressure was
attained, sufficient to force the sphincter of Oddi,
when saline flowed through the tubes and into
the duodenum. The head of pressure required
was a measure of the tightness of sphincteric con-
traction, and the method showed it to be much
higher after morphia than before it. Confirmation
of this finding was obtained by injecting radio-
opaque oil into the common bile-duct, and photo-
graphing it. Before morphia was given, the oil
would fill the common duct and pass in con-
siderable amount into the duodenum; after
morphia, however, the injection would force oil up
into the hepatic ducts, which with their tribu-
taries appeared clearly outlined on the films while
the duodenum remained almost or quite empty.
THE OLD ASHMOLEAN MUSEUM
[APRIL 3, 1937
Codeine and Dilaudid, like morphia, produced a
spasm of the sphincter of the common bile-duct.
The experiments are few but their results are
so striking that they should make us think twice
about giving opium alkaloids to patients with post-
cholecystectomy colic. Then what shall we give ?
The authors have further tracings showing a sharp
and satisfactory fall in the pressure inside the bile-
duct as soon as amyl nitrite is inhaled, or shortly
after glyceryl trinitrate is placed under the tongue.
These were much more effective in relaxing the
contracted sphincter than many other drugs
tried, and they also brought relief of pain. This
piece of work is a neat example of how the
physiologically minded surgeon can turn to good
account the opportunities that surgical. operations
afford.
ANNOTATIONS
THE SIGNIFICANCE OF ANTIFIBRINOLYSIN
Tillett and Garner’s observations on the fibrinolytic
activity of streptococci, and on the development of
resistance to this action, opened a new field in the
study of streptococcal infection. They themselves
showed that plasma clots from patients convalescent
from known infections by Streptococcus pyogenes were
highly resistant to lysis by cultures of this organism,
and it was not long before others extended this
method of study to conditions of more doubtful
nature. Hadfield, Magee, and Perry t! were the first
to show that resistance to fibrinolysis was developed
during the course of rheumatic fever, an observation
which has since been confirmed by others, and now
forms part of a serological argument fundamental
to the conception that rheumatic fever is an allergic
reaction to streptococcal products. Some observa-
tions now published by Waaler? are interpreted as
questioning the validity of this conclusion, on the
ground that the development of antifibrinolysin
appears not to be a strictly specific reaction. This
study embraced in the first place 31 cases of appa-
rently infective polyarthritis of various types, and
in half of these resistance to fibrinolysis was developed
and varied in degree with the activity of the disease,
as has been observed in rheumatic fever itself; an
exception was afforded by 5 cases of Still’s disease,
all of which gave negative reactions. In this there
is nothing inexplicable or inconsistent with existing
belief, since other antibodies to S. pyogenes have
been found in the serum of patients suffering from
multiple arthritis. But Waaler has also found in-
creased resistance to fibrinolysis in patients suffering
from bacterial endocarditis demonstrably due to
streptococci of other types, four being ©. viridans
and one S. fecalis, and in two patients with the most
pronounced reactions there was not even a history
of rheumatic fever. He concludes from this that
the reaction is non-specific and must not be accepted
as evidence of infection by S. pyogenes. This con-
clusion is open to criticism on two grounds. One
concerns the reaction itself; the question here is the
interpretation to be placed on a certain degree of
resistance, and those who have worked with this test
have found it difficult so to standardise conditions
as to place reliance on much more than a simple
positive or negative result. The other concerns the
i e a
Hadfield, G., Magee, V., and Perry, C. B.(1934) Lancet, 1,834.
2 Waal er, E. J. clin. Invest. January, 1937, p. 145.
nature of his five cases of bacterial endocarditis.
In spite even of a negative history, the probability
is that they had their origin in a rheumatic endo-
carditis, and since it has been found by Von Glahn
and Pappenheimer ? that active rheumatic lesions in
the form both of bacteria-free vegetations and of
Aschoff nodules in the myocardium may still exist
at the time of death from bacterial endocarditis, it
cannot be assumed that the rheumatic process is in
these cases simply a thing of the past.
THE OLD ASHMOLEAN MUSEUM
AMONG the various good causes in Oxford which
may get help from the appeal which the university
has lately made we hope sympathetic consideration
will be given to the Old Ashmolean or, as it is now
called, with a sad loss of elegance as well as historical
interest, the Museum of the History of Science. The
building, inside and out, is one of the loveliest in
Oxford, built by an unknown architect at the end
of the seventeenth century to house the miscellaneous
collections of Elias Ashmole and the Tradescants.
Part of the building housed the first chemical labora-
tory, and was the meeting place of the early scientists.
It was in one way and another neglected and deterio-
rated, some of the exhibits disappeared, and the
proctors ordered a mouldering dodo to be burned,
though happily its head and legs survived. But in
the last 20 years there has been a renaissance. Dr.
Lewis Evans gave his unrivalled collection of mathe-
matical instruments, and Mr. R. T. Gunther, LL.D.,
entered on his enthusiastic curatorship which ordered
what was there and found much else of great interest
and historical importance in the cellars and attics of
various colleges; once the museum took life again,
gifts and loans came in abundance. As our readers
will remember Dr. Gunther has also published a
series of volumes on the early history of science in
Oxford. As has always happened, science and
medicine were in the early days more intimately
associated than they are now, and there is a great
deal of medical interest in the museum—old pharma-
cists’ cabinets with the drugs waiting to be critically
examined, microscopes, a Valentine’s knife, phle-
botomist’s gear, perflatory spoons for administering
cod-liver oil, and much else that appeals both to
the curious and to the serious student. The present
trouble is that Dr. Gunther’s curatorship has been
3 Von Glahn, W. C., and Pappenheimer, A. M. (1935) Arch.
intern. Med. 55, 173.
. THE LANCET]
so successful that the museum has hopelessly out-
grown its accommodation which is limited to the
topmost of the three floors of the building of which
it needs the whole. The bottom and middle floors
are occupied by the Bodleian Library and by the
Jexicographers who are engaged on a new edition of
Lewis and Short. If these can be moved elsewhere,
which should not be difficult, the Old Ashmolean
will at comparatively small cost be able to blossom
out into what it is quite ready to be—one of the most
attractive institutions in the university.
HISTAMINE AND RENAL LESIONS FOLLOWING
_ SHOCK
SmncE the circulatory depression resulting from
injection of histamine is likely to diminish the secre-
tion of urine, Bjering! has investigated the fall
of blood pressure and the reduction of the urea and
creatinine clearance that follow injection of hista-
mine. He finds that the reduction of the renal
function is not always proportional to the fall in
blood pressure, and he concludes that histamine must -
have some direct action on the renal blood-vessels.
It is to be noted, however, that the experiments
were done on patients suffering from various diseases
that might modify the findings. In a further paper
Husfeldt and Bjering? describe two cases of
patients dying in uremia eight days after receiving
severe injuries. Post-mortem section of the kidneys
showed absence of blood from the glomerular tufts
and some degeneration of the tubules. On the histo-
logical appearances the authors dispose of trauma to
the kidneys or incompatible blood transfusion as
causes of this lesion, and they suggest that it is due
directly to defective renal circulation during shock ;
they mention that histamine may cause albuminuria
as well as deficient function. Adrenaline and Ephe-
tonin (synthetic ephedrine) may also produce albu-
minuria, and it is interesting to note that signs of
renal damage did not develop fully until three days
after the injury, with a rising blood pressure indicating
vasoconstriction.
PAY BEDS IN LONDON VOLUNTARY HOSPITALS
THERE are many people able and willing when
they are ill to pay the cost of maintenance in a hos-
pital, as. well as a reasonable fee for medical attend-
ance, but who cannot afford the usual charges of a
nursing-home. In many of the London voluntary
hospitals beds are now available, either in cubicles,
single rooms, or small wards, for persons of moderate
means. The number of such pay beds has increased
from 590 in 1920 to 2112 last year, and details are
given in the new edition of a list? issued by King
Edward’s Hospital Fund for London. Medical and
surgical fees are not as a rule included in the weekly
charge; they are arranged between patient and
consultant, or more commonly through the family
doctor. The normal weekly charge as given in the
list does not include anesthetist, extra nursing,
exceptionally expensive drugs or dressings, treat-
ment by electricity or light, radium or X rays, patho-
logical examinations, or operating theatre expenses.
The list calls attention to the two contributory
schemes which facilitate for all parties the use of
these pay beds. For persons with incomes not ex-
ceeding £6 a week (for a married man with children
under 16) there is the Hospital Saving Association ;
for persons whose incomes exceed this limit there
1 Bjering, T. (1937 A Ada med. scand. 91, 267.
usfeldt, d Bjering, T., Ibid, p. 279.
Copies may be obtaived from Messrs. ’ George Barber & Son,
val-street, E.C.4, 3d. post free.
FREEZING AND THAWING THE TISSUES
exudation into the injured tissues themselves.
[APRIL 3, 1937 891
is the British Provident Association. A number
of societies approved under the national health
insurance scheme also provide hospital treat-
ment for their members. It is difficult to state |
precisely how many approved societies do so, for
quite a number of them exclude women from hospital
benefit and others only pay in respect of members
who were in the society during a more spacious time
when money for this purpose was accumulating.
A useful list of these societies and of the limitation
in the benefit provided has just been issued * by the
Central Bureau of Hospital Information.
FREEZING AND THAWING THE TISSUES
WE are familiar in this country with the work of
Sir Thomas Lewis on the reaction of the tissues to
local injuries, and with Sir William Bayliss’s humoral
theory of secondary shock. The former demonstrates
the liberation of a histamine-like substance at the
site of injury, and the latter postulated the dissemina-
tion of a chemical substance from areas of massive
injury causing a general loss of plasma from blood-
vessels to tissues. A similar condition was brought
about by histamine, and “histamine shock” and
secondary surgical shock were thought to be identical.
Nowadays this interpretation of secondary shock
has been practically discarded, with the reservation
that it may account for some features of the condi-
tion. A view which is gaining ground, chiefly due to
work from America, is that the loss of fluid from the
circulation can be sufficiently accounted for by
The
original experiment of Cannon and Bayliss, who
occluded the circulation to an injured limb and stated
that shock was absent until the circulation was
released, has not, it is said, ‘been satisfactorily
repeated. This is curious, for if, the modern theory
is correct loss of fluid from the blood stream into the
injured tissues could not take place unless these were
included in the circulation, and if! they were tem-
porarily excluded it would be reasonable to expect
shock to occur on restoration of the blood flow. » -
There seems no doubt, however, that extensive
local injury can abstract sufficient fluid to con-
centrate the blood as much as 50 per cent. and lower
the blood pressure to about 80 mm. Hg in:
experimental animals. This has been confirmed by
H.:N. Harkins and P. H. Harmon.’ of Chicago for
injury by freezing in anesthetised dogs, and they say
that the exudate resembles blood plasma very closely
in composition. They also point out that although
this brings freezing into line with burning and
mechanical injury, the exposure to extreme cold of
sufficient of the body to produce shock in the human
would bring about death from other causes.
Their communication is interesting from a more
immediately practical point of view in that it casts
doubt on the traditional conservative treatment of
frozen tissues. The evidence they have collected up
to the present suggests that rapid thawing is no less
effective and no more harmful than slow thawing.
Their criterion is the extent of gangrene and so forth
in narcotised animals; but in ordinary therapeutics
the factor of pain would have to be taken into account
and might well be decisive in determining which
treatment to adopt. This again brings us back to
the question of shock. It has been shown in Cannon’s
laboratory that repeated injections of adrenaline
will ultimately cause a fall of blood pressure and
increased blood concentration; this is supposed to
“Memo. No. 108 from the aitector of the Bureau, 12,
Grosvenor-crescent, London, S.W 4
5 J. clin. Invest. ist, 16, 213.
822 THE LANCET]
' be a result of continued peripheral vasoconstriction
with consequent asphyxia and increased permeability
of the capillary walls. Yet another theory of shock
emerges from this work to account for those cases in
which trauma is absent, though if established it
would apply equally to traumatic cases. It is postu-
lated that a sudden intense stimulation, such as an
explosion, might overstimulate the sympathetic-
adrenal system and bring about the same results as
persistent administration of adrenaline. The possi-
bility of a general effect in severe local injury is
therefore reintroduced, and it seems that the final
picture of secondary shock might closely resemble
the condition described by Bayliss, although he was
at fault in the interpretation of his experimenta and
regarded nervous effects as having been excluded.
ANTECEDENTS OF PYORRHCEA
AT a meeting of the odontological section of the
Royal Society of Medicine on March 19th, to which
the Birmingham Odontological Society had been
invited, Dr. Wilfred Fish reviewed the local and
general effects of oral sepsis in the light of Okell and
Elliott’s observation that tooth extraction may
cause transient bacteremia, and the further con-
clusion, by Maclean and himself, that streptococci
and other organisms in pyorrhoea are normally con-
fined to the periodontal sulcus and do not actually
invade the tissues. Thus situated, he believes, such
organisms may produce disease by the diffusion of
toxic products into the local tissues or by the further
dissemination of soluble toxic matter into the system
generally. Alternatively both local and general
diseases may follow the actual traumatic intro-
duction of the organisms themselves into the blood
stream by extraction of the tooth, or even by chewing
hard food.! . This bacteremia associated with tooth
extraction or with naastication is likely to be harm-
less unless the-organisms are arrested somewhere in
‘circumstances favourable -to their growth. They
--may, for example, be entrapped in a vessel of the
alveolar bone by ‘bruising with the forceps during
extraction ; or 4 slight blow on a bone, such as the
tibia, at a moment when organisms happen to be
circulating in the vessels concerned might also
imprison the germs -and leave them to multiply
and produce osteomyelitis; or, again, as Okell and
Elliott pointed out, they may attack the fibrinous
vegetations of a simple endocarditis. To prevent
this last catastrophe, Dr. Fish holds that no dead
tooth should be extracted from a patient with endo-
carditis, and even a live tooth should be removed
only when there is urgent necessity, and only after
careful cauterisation of the periodontal sulcus. He
recommended that patients with simple endocarditis
and also much chronic gingivitis should keep to
soft food ; they must not brush or rub the teeth and
gums, since this also causes a bacteremia, and the
only permissible treatment is to dress the. gum
margins very gently with a paste of zinc oxide and
oil of cloves which is carried on wisps of cotton-
wool into the periodontal sulci and left there for
several days. This eliminates pus from the pocket.
The local effect of toxic absorption from the pocket
is eventually ‘‘ pyorrhea’’—a breakdown of bone
and fibrous tissue which deepens the pocket and
loosens the tooth. But Dr. Fish was at pains to
explain that it is by no means necessary to extract
the teeth in order to prevent both the toxic absorption
and bacterzmia, since the organisms are living on
the surface in the periodontal sulcus. Pyorrhea, he
1 See Lancet, Jan. 2nd, 1937, p. 31.
“ EPILEPSIA ”’
[APRIL 3, 1937
maintains, can be cured by cutting away the pockets
in which the organisms grow and afterwards rubbing
the surfaces of the gum to harden and hornify them,
thereby preventing toxic absorption. “In this way
the patient keeps his teeth, gets a clean mouth
instead of a dirty one and is safe from the remote
effects of oral sepsis.” It is useless on the other
hand to extract a few dead teeth or teeth hopelessly
loosened with pyorrhæœa and leave infected gum
margins round the rest. Every gum margin histo-
logically examined by Dr. Fish has shown some
degree of chronic inflammation, and every patient
suffering from toxic absorption should in his opinion
have a careful toilet of the gum carried out on the
remaining teeth in addition to the extraction of any
that are hopeless. Only thus can accurate clinical
conclusions be drawn concerning the effects of orak
sepsis on the general health.
IN MEMORY OF ALFRED KEOGH
THe Army Council have decided to name the new
barracks in the course of construction for the R.A.M.C.
Depôt and Army School of Hygiene at Aldershot
the ‘‘ Keogh Barracks’? in memory of Sir Alfred
Keogh, who was Director-General, A.M.S., from 1905
to 1910 and again during the late war from 1914 to
1918. That Keogh’s memory should be kept alive
by the Army Council, and indeed by us all, is right.
No one man ever did so much for the Service which
he ornamented, and to which during the war the
country owed so great a debt. He was the first to
see that wherever connexions could be established
between the civilian and military doctor, the advan-
tage would be great and direct. During his first
term as D.G.M.S. he visualised how civilian medicine
could be made to codperate with the R.A.M.C., not
only in times of peace but in times of emergency ;
and when those times arrived with a world war a com-
prehensive plan was already in existence to meet
the enormous difficulties of the medical department
of the Army. Without Keogh’s prevision vast trage-
dies might have occurred. He had looked forward
with an uncanny anticipation, so that he was able to
gather round him from the beginning of the struggle
a fine personnel organised from civilian doctors and
representative consultants, and to find material for
special war hospitals. The foundation of the R.A.M.C.
College represents only a part of what the Service owes
to Keogh. His large performance was to utilise the
medical knowledge of the country with intelligence and
economy during a period of tremendous strain; if
similar strain occurs again, this country knows,
mainly thanks to Keogh, how it can best be met.
“EPILEPSIA”
THE case for international coöperation is nowhere
stronger than in the field of medical research. In
various ways, and in different countries, the problem
of epilepsy, for instance, is being attacked by
individual neurologists, psychiatrists, biochemists,
and social workers ; but want of knowledge of the
activities of others and lack of any coördination has
hampered progress and rendered valueless many good
pieces of individual work. For four years before
the late war an international league existed to pro-
mote coöperation among medical men who were
interested in epilepsy and to broadcast information
about what different countries were doing. After
twenty years of inactivity this league has now been
resuscitated, and we have received the first number of
its new journal Epilepsia, which will be published
in future, at least once a year, under the editorship
THE LANCET]
of Dr. H. I. Schou of Denmark.! The journal is
printed in English, and the story it tells is a hopeful
one. The League has made a good start with a
membership of about 250, and already there are
flourishing branches in America, Scandinavia, and
Great Britain, with promise of more to be added
shortly. The first number of the journal is necessarily
introductory in character. The outstanding feature
is an able survey of the problem of epilepsy and the
means of attacking it by Dr. W. G. Lennox of Boston,
the president of the League. Dr. L. J. J. Muskens of
Amsterdam discusses the ideal facilities for the treat-
ment of epilepsy, emphasising the need for special
hospitals at which all incipient cases should receive
thorough investigation. Some account is given of
the facilities for the residential treatment of epileptics
that now exist in different countries, and many of us
will find useful the detailed and complete list of
institutions for epileptics in Great Britain. It is
hoped that future numbers of the journal will contain
a résumé of research work carried on in different
countries. We are glad to know that the British
branch, with over a hundred members, has already
had a successful meeting, and we understand that
the secretary of this branch, Dr. Macdonald Critchley
(137, Harley-street, London, W.1), hopes to hear
from other medical men who are interested.
AFRICAN HORSE-SICKNESS
For nearly 50 years veterinarians in South Africa
have been striving to combat horse-sickness, a disease
first described by some of the early explorers of the
African Continent, which has made it almost
impossible to use susceptible horses and mules
throughout vast tracts of country. The late Sir
Arnold Theiler and his colleagues at the Institute of
Veterinary Education and Research of the Union
of South Africa, Onderstepoort, identified the causal
agent as a filtrable virus many years ago and directed
their attention to devising methods of protecting
equines from infection. Apart from the testing of
empirical prophylactic and therapeutic procedures
advocated by farmers and others from time to time,
two lines of research have been followed, the one being
to identify the method of spread of the disease, and
the other to produce a satisfactory active immunity.
All epidemiological evidence indicates that infection
is transmitted by a night-tlying insect vector such as
the mosquito. Apart, therefore, from testing the
protective value of measures designed to ward off
such insects, extensive attempts have been made to
identify the species of insect responsible. In their
reports of the investigation O. Nieschulz, A. H.
Bedford, and W. O. Neitz? describe the: feeding on
infected horses of 4500 clean mosquitoes belonging
to the genus aédes and their failure to transmit the
disease when subsequently allowed to feed upon
susceptible animals. Various other genera besides
aédes are possible vectors and the identification of
the vector might well become a tedious process of
elimination. Fortunately, owing to recent improve-
ments in methods of immunisation indicated below,
the identification of the vector has become a problem
of academic rather than practical interest. Attention
has also been centred on the natural reservoir of
infection. Horses are known to harbour virus for
many months after recovery, but the presence of
1 Epilepsia. The journal of the ere oneh League against
Epilepsy. Second series. Edited by I. Schou lansa.
Denmark), in conabor tion with Tylor T (England), William
G. Lennox (Boston), and L. J. J. Muskens (Amsterdam). Pub-
lished by Levin and Munksgaard. Copenhagen. 3s. 6d.
2 andere ingore J. vet. Sci. 1932, vol. 3.
AFRICAN HORSE-SICKNESS
[APRIL 3, 1937 823
such virus is difficult to demonstrate. Since horse-
sickness has appeared among susceptible horses
introduced into districts where no equines were
previously to be found, it seems unlikely that equines
constitute the only important natural reservoir.
Dogs can be artificially infected, but there is no
evidence that this circumstance has any epidemio-
logical importance.
As to immunisation, until recently equines had to
be used for investigations, which were thus cumber-
some and expensive ; nevertheless research proceeded
steadily and a significant advance was made by the
discovery of a strain of virus of low ‘pathogenicity
but reasonably good immunising capacity. Using
this strain a method of immunisation was developed
of administering a double inoculation consisting of
an intravenous inoculation of mild virus followed
six days later by a combined intravenous inoculation
of virulent virus and nearly half a litre of immune
serum. For many years this form of inoculation was
practised in many parts of Africa with reasonable
success. According to du Toit (1934) 2-3 per cent.
of horses died from horse-sickness as a direct result
of the immunisation, 3—4 per cent. died as a result of
breakdown of immunity, and 0°1 per cent. died of
acute liver-atrophy (‘‘ staggers ’’) following immunisa-
tion. These figures apply to police horses kept under
good conditions ; amongst farm animals losses were
higher, and in view of the high cost of the immune
serum and the large dosage required, the occasional
breakdown of immunity and the inexplicable though
rare occurrence of acute liver-atrophy this method
though useful was clearly far from ideal. Formolised
virus was then tried, but three injections were
required in horses followed by a dose of virulent
virus to secure a strong and lasting immunity, and
such a procedure was clearly unsuitable for routine
use.
At this stage the reports of American workers
on yellow fever presented a new method of attack.
M. Theiler (1930) reported the infection of white
mice with yellow fever virus by means of intra-
cerebral inoculation, the virus becoming neurotropic
during the course of brain passage; later Sawyer,
Kitchen, and Lloyd (1932) reported that such neuro-
tropic virus had low lethal and high immunising
capacity. O. Nieschulz (1932) and R. A. Alexander
(1933) discovered independently that mice could be
infected with horse-sickness by intracerebral inocula-
tion, the virus becoming neurotropic during passage.
Nieschulz failed to demonstrate sufficient attenuation
of the virus for immunisation purposes, but Alexander,
working at Onderstepoort, found that after about
100 mouse-brain passages neurotropic virus could
safely be injected subcutaneously into horses and
that animals so injected developed a strong immunity
to pantropic virus. In developing the neurotropic.
virus for immunisation purposes the existence of
antigenically distinct virus strains had to be considered.
Working with three different neurotropic strains
Alexander (1936) * found that horses inoculated with
a mixture of three strains showed as a result a strong
immunity to all three. It would appear therefore
that no antagonism exists between virus strains.
Whether a polyvalent vaccine is really necessary or
not can only be proved by extensive field trials.
The most recent report by Alexander, Neitz, and
du Toit (1936) * records the immunisation of equines
with neurotropic virus in a large field experiment
in which a reasonable estimate of the value of the
new technique could be made. A trivalent vaccine
3 Ibid, 1936, 7, 11.. 4 Ibid, p. 11.
824 THE LANCET]
was prepared by mixing filtrates of emulsion of
brains of mice infected with three important virus
strains.. The preparation of such a vaccine is com-
plicated by the fact that the incubation period of the
virus in mice differs for each strain; the authors
claim, however, that the procedure. was quickly
reduced to a simple and inexpensive routine. The
- vaccine was issued as 10 c.cm. doses for subcutaneous
inoculation, and it was found that about 600
standardised doses could be prepared from 48 mouse
brains. During the period 1934-35 1815 police horses
were immunised by single inoculations of the new
vaccine. There was no mortality as direct result
of the inoculation and no adverse after-effects were
reported except for a breakdown of immunity in
0°66 per cent. of animals when exposed to natural
infection. Among 28,659 other horses and mules
from various sources, 3 deaths were reported which
may have been due to vaccination and the immunity
broke down in 0°87 per cent. of animals. So much
is known of the usual incidence of horse-sickness
when no immunisation has been carried out that the
value of the vaccine would appear to have been
demonstrated, in spite of the absence of controls
in this particular experiment. Incidental points
remain to be investigated: for instance, possible
after-effects of neurotropic vaccination upon fecundity
or pregnancy, the possible formation of irrepar-
able lesions in the central nervous system followed
by paralysis, the duration of immunity and the
length of time vaccinated animals remain reservoirs
of infection. These considerations are of minor
importance; the new neurotropic vaccine stands
out as a highly satisfactory outcome of many years
of patient and unremitting research.
A DEMAND FOR ACTION
‘*‘To inquire into...the diet of the people, and
to report as to any changes therein which appear
desirable. ...”
SucH is ‘the task of the Advisory Committee on
Nutrition appointed by the Minister of Health and
the Secretary for Scotland; and in presenting their
first report they claim that ‘‘ this is the first occasion
in history that a comprehensive survey, statistical
and physiological, of the diet of a whole nation has
been set on foot by any Government.” The report 1
is a preliminary description of the situation as it is
to-day, with suggestions about the changes imme-
diately needed. The Committee range themselves
clearly on the side of those who preach the advantage
to be gained from an adequate supply of the right
kinds of food. ‘‘ We believe,” they say, “‘ that better
physique and health can be obtained and resistance
to disease increased by the application to human
diets of recent knowledge which demonstrates the
importance of certain classes of food for proper
nutrition.” They admit that the facts lately brought
to light are too complex for the layman to grasp, but
they consider that the practical lesson to be learnt
from these facts is very simple indeed: it is merely
that we must include in the dietary of the whole
community—and especially of mothers and children
1 Ministry of Health. First Report of Advisory Committee
on Nutrition. London: H.M. Stationery Office. 1937. Pp. 52.
1s. The members of the Committee are: Lord Luke (chairman) ;
Mrs. ge ae Barton; Mr. J. N. Beckett ; Dr. G. F. Buchan ;
Prof. E. P. Cathcart M.D., F.R. R. R. Enfield: Dr. J.
Alison Glover: ; Dr. J. M. Hamill ; "Hr. A. Bradford Hill, D.Sc. ;
Sir Gowland Hopkins, a R.C.P., P.R.S.; Dr. Donald Hunter : ;
Mr. E. M. H. Lloyd : Dr. E. Mellanby F.R.S. ; Sir John Orr,
M.D., F.R.S.; Miss Ruth Pybus; Mr. E. C. Ramsbottom :
M. Vallance : Dr. T. W. Wade; Mr. J. R. Wilis; and
Mr. E. M T. Wiltshire; with Mr. W. J. Peete and Mr. N. F.
McNicholl as secretariesand Dr. H. E. Magee as medical secretary.
The late Mrs. Chalmers Watson, M.D., was also a member.
A DEMAND FOR ACTION
[APRIL 3, 1937
—enough of the ‘“ protective foods.” The term
“ protective,” originally given by McCollum to milk
and green vegetables, is now applied generally to all
foods rich in the nutrients that research has shown
to be essential for health—especially milk and milk
products, green vegetables, fruit, and eggs. The
consumption per head of most foodstuffs has increased
in this country since before the late war, the largest
increases being in condensed milk, fruit, butter,
vegetables (other than potatoes), eggs, tea, margarine,
and cheese. Indeed, the consumption of butter and
margarine together is now, per head, 56 per cent. higher
than it was in 1909-13. On the other hand the quantity .
of cereals used has fallen by nearly 10 per cent. and
of fresh milk and cream by 6 per cent. Examining
the national food-supply as a whole the Committee
find no aggregate deficiency of calories, fats, or
proteins, but they hold it probable that there are
deficiencies, of fat and of animal protein at least,
among the very poor. They underline Sir John Orr’s
conclusion that the consumption of the best foods
—fresh milk, butter, meat, fish, eggs, fruit, and
vegetables (other than potatoes)—rises progressively
with income, whereas that of flour and potatoes
remains nearly constant, while the amount of mar-
garine and condensed milk used goes down; and in
order to secure more complete data they propose
further investigation of income distribution, family
budgets, and domestic wastage. They believe that
the national consumption of fruit and vegetables is
too low, especially among the poor; but what they
chiefly regret is that the present national consumption
of liquid milk is less than half their optimum of
seven-eighths of a pint per head per day. Children,
they say, should have 1-2 pints, expectant or nursing
mothers about 2 pints, and the rest of us half a pint ;
and without going into the economics or politics of
milk they ‘“‘ deplore the fact that, while the volume
of milk offered for sale is growing and there is
a substantial surplus which it is beyond the capacity
of the liquid milk market to absorb, there should be
at the same time a severe deficiency of milk in the
diet of large sections of the population. That under-
consumption of a foodstuff so important as milk
should exist in a country so eminently suited for
milk production, is a matter towards which we
cannot remain indifferent.” They hope that in
dealing with this problem the primary objective of
the State will be to ensure that a sufficient supply
of safe milk is brought within the purchasing
power of the poorest—a measure which in their
opinion would do more than any other to improve
the health, development, and resistance to disease
of the rising generation. The steps already taken
towards this end, such as the milk-in-schools scheme,
are a good beginning, but as the Committee rightly
say, they do not provide enough milk for all mothers
and children who need it, while very little provision
is made for adolescents. It is encouraging to find
that the report has already borne first fruit in a
circular addressed to local authorities by the Ministry
of Health, urging them to review their present
arrangements in the light of the recommendations
now so strongly made.
MODEL TRAFFIC LIGHTS FOR CHILDREN.—The Save
the Children Fund, in conjunction with the Ford
Motor Company, Ltd., is issuing an ingenious model
which by manipulation shows successively the familiar
red, amber, and green of the streets, and is intended to
teach children how to cross the road in safety. Copies
may be had free of charge on AP POCONO to the fund at
20, Gordon-square, London, W.C.1
THE LANCET]
[APRIL 3, 1937 825
PRINCIPLES OF MEDICAL STATISTICS
XIV—FURTHER FALLACIES AND
DIFFICULTIES
The Crude Death-rate
IN using death-rates, or fatality-rates, in comparison
with one another, or as a measure of the success
attending some procedure, it must be remembered
that such rates are usually affected considerably by
the age and sex constitution of the population
concerned. The fact that the death-rate of Bourne-
mouth in 1935 was 13-3 per 1000, while the rate
in Bethnal Green was only 10:3, is no evidence of
the salubrity of the latter area. The greater propor-
tion of old persons living in Bournemouth compared
with Bethnal Green must lead to a higher death-
rate in the former, since old persons, however well-
housed and fed, die at a faster rate than young
persons. The 1931 census shows that there were at
that time 2} times as many persons in Bournemouth
as in Bethnal Green at ages over 75 years, 70 per
cent. more at ages 50-74, and 10 per cent. less at
ages 10-40. Any population containing many persons
round about the ages of 5 to 20, where the death-rate
is at its minimum, must have a lower total death-
rate than that of a population containing many
infants or old people, at which points of life the death-
rate is relatively high, even though comparisons at
every age show an advantage to the latter. For
Spee the following fictitious figures may be
taken. i
| District A. District B.
Age- ' i
can ! eer geared Pond Tea a
years).` Popula- rate opula- rate
en: lan Deaths.| Der Hon a- |Deaths! Der
1000 1000
0- 500 ) 1 2°5
15- 2000 - 74% 8 4 300 } 28 % 1 3°3
30- 000) 5
4 000 10 2000 18 9
60- 500 726% 20 40 2000 } 72% 70 35
75+ 100 15 150 400 50 125
Allages | 6100 67 11°0 | 6100 145 23°8
Comparison of the two districts shows that B has in
every age-group a lower death-rate than A. Yet its death-
rate at all ages, the crude death-rate, is more than double
the rate of A. The fallacy of the crude rates lies in the
fact that like is not being compared with like: 72 per
cent. of B’s population is over age 45 and only 26 per cent.
of A’s population; in spite of B’s relatively low death-
rates at these ages over 45, the number of deaths registered
must: be higher than in A’s smaller population and
therefore its total death-rate must be high.
Comparison of the rates at ages is the most satis-
factory procedure for then like is being placed
against like, at least in respect of age (so long as the
age-groups are not too wide; in the above example
they were made unduly wide for the sake of
compression and clarity).
The Standardised Rate
At the same time a legitimate desire is often felt
for a single mortality-rate, summing up the rates at
ages and yet enabling satisfactory comparisons to
be made between one rate and another. For this
purpose the standardised death-rate is required. For
its calculation (by what is known as the direct method)
the mortality-rates at ages in the different districts
are applied to some common standard population,
to discover what would be the total death-rate in
that standard population if it were exposed first to
A’s rates and then to B’s rates at each age. These
total rates are clearly fictitious for they show what
would be the mortality in A and B if they had
populations which were equivalent in their age-
distributions instead of their actual differing popula-
tions. But these fictitious rates are comparable with
one another, and show whether B’s rates at ages
would lead to a better or worse total rate than A’s
rates if they had populations of the same age type.
For example, if the standard population taken for A
and B consisted of 500 persons in each of the age-groups
0-15 and 75 and over, 2500 in each of the age-groups 15-30
and 60-75, and 3000 in each of the age-groups 30-45 and
45-60, then in this standard population A’s death-rates
would lead to a total of 235 deaths and B’s rates to 201
deaths, giving standardised rates at all ages of 19°6 and
16°8 per 1000. Taking a population of the same age-
distribution thus shows the more favourable mortality
experience of B, and the fallacy of the crude rate is
avoided. (The deaths that would occur at each age in the
standard population, at the death-rates at ages in each
district, are found by simple proportion ; they are summed
and divided by the total population in the standard to
give the standardised rate.)
Clearly these fictitious but comparable rates will
be affected by the choice of the standard population.
It must be observed, however, that their absolute
level is not of interest ; it is the relative position that
matters and, within limits, this relative level is not
likely to be materially altered by the use of different
standards.
The example taken above is, of course, a very.
exaggerated one and such gross differences in popula-
tion are unlikely to occur in practice. On the other
hand the differences that do occur in practice are
quite large enough to make the use of crude rates
seriously misleading.
For instance, the crude death-rate, in England and Wales,
of women from cancer was 103 per 100,000 in 1901-10 and
139 in 1921-30, a very appreciable rise being shown.
The corresponding standardised rates were 94 and 99;
clearly the larger number of women living in the older
age-groups (where cancer is more frequent) in 1921-30
compared with the number in 1901-10 is largely responsible
for the increase in the crude rates, and no more subtle
factor need be looked for.
With the present increasing proportion of persons
living at later ages (owing to the fall in birth- and
death-rates) it is certain that the crude death-rate
from all causes in England and Wales will in time
begin to rise, in spite of the fact that the death-rates
at each age may continue to decline.
Comparison of death-rates may also be affected
by the sex proportions of the populations considered,
for at most ages and from most causes females suffer
a lower mortality-rate than males. Standardisation,
therefore, is sometimes made both for sex and age.
(The methods and the alternative method of indirect
standardisation are fully described and illustrated in
Woods and Russell’s ‘Introduction to -Medical
Statistics.’’)
The principles of standardisation are often applic-
able in experimental work. For instance, some form
of treatment is applied to certain persons and others
are kept as controls. If the two groups are not
equal in their age-distribution a comparison of the
total result may be misleading. A comparison in each
separate age-group must be made, or to reach a total
figure the two sets of rates at ages can be applied to
826 THE LANCET]
some selected standard population. A useful method
is to use the treated group as the standard and
calculate how many deaths would have taken place
in it if it had suffered the same fatality-rates at ages
as the controls. This expected figure can then be
compared with the observed figure.
In considering published crude rates—death,
fatality, incidence, &c.—one must always put the
questions: do the populations on which these rates-
are based differ in their age- or sex-distribution, and
would such differences materially influence the com-
parability of the crude rates? Crude rates them-
selves should never be accepted without careful
consideration on those lines.
Statistics of Causes of Death
In making comparisons between death-rates from
different causes of death at different times or between
one country and another, it must be realised that
one is dealing with material which is, in Raymond
Pearl’s words, ‘fundamentally of a dubious
character.” The recorded incidence of a particular
cause is influenced by such factors as international
_ differences in nomenclature, differences in tabulation,
medical fashions in nomenclature, and the frequency
with which the diagnosis of cause of death is made
by medically qualified persons. One or two simple
examples of the risks of comparison may be taken.
MORTALITY FROM CANCER
The crude death-rate from cancer in the Irish
Free State is well below that registered in England
and Wales. Part of this difference may be due to a
more favourable age-distribution of the population
in the Free State—i.e., standardised rates should be
used in the comparison—but it is likely that it also
arises from differences in the certification of death.
In the Irish Free State considerably more deaths are
ascribed to senility than in England and Wales—15 per
cent. in the former in 1932 against about 4 per cent. in
the latter. Such a difference cannot inspire confidence
in the death-rate from such a disease as cancer, in which
the majority of deaths fall at advanced ages. In general,
in comparing the cancer death-rates of different countries
or of the different areas of the same country—e.g., rural
and urban—it is not sufficient to pay attention to the
cancer rubric; other headings such as “ uncertified,”’
“senility,” and “‘ ill-defined causes’ must be taken into
consideration, and an attempt made to determine whether
transferences between these rubrics are likely to play a
part.
The kind of indirect correlation that one may
observe is this. It is stated that the cancer death-
rate is associated with the consumption of sugar,
and the level of the former is compared with some
measure of the latter in different countries. It is
found that the countries with a low consumption of
sugar have relatively low cancer death-rates. But
it is at least possible that those countries which have
a high standard of living have a relatively higher
sugar consumption, and also a higher standard of
vital statistics, and therefore more accurate cancer
death-rates, than countries with a low standard of
living and less accurate vital statistics. Other
“ causes” of death—e.g., ill-defined and old age—
would need study as well as those attributed directly
to cancer.
MATERNAL MORTALITY
It is well recognised that the maternal death-rates
of different countries are affected. by the varying
rules of tabulation in vogue. A sample of deaths
associated with pregnancy and childbirth that took
place in the U.S.A. was assigned by different
PRINCIPLES OF MEDICAL STATISTICS
[APRIL 3, 1937
statistical offices of the world to puerperal and non-
puerperal groups according to the rules of those
offices (Children’s: Bureau Publication No. 229). The
variability was considerable. In the U.S.A. 93 per
cent. were tabulated to puerperal causes, in England
and Wales 79 per cent., in Denmark 99 per cent,
Such differences make international comparisons
precarious.
MORTALITY FROM RESPIRATORY CAUSES
In England and Walés bronchitis and pneumonia
show pronounced differences in their incidence in
different parts of the country at certain ages. It
appears that the ‘“ bronchitis” of one area may
include deaths which would be attributed to pneu-
monia in another. For instance, the Registrar-
General concludes that “at both extremes of life
London appears to call pneumonia many cases which
are elsewhere regarded as bronchitis” (Registrar-
General’s Annual Report, Text, p. 85, 1932). Such
“ internal ” differences are always closely considered
by the Registrar-General and his reports are invaluable
to all who are concerned with the changes in the
causes of death.
The Average Age at Death
The average age at death is not often a particularly ~
useful measure. Between one occupational group
and another it may be grossly misleading. For
instance, as Farr pointed out three-quarters of a
century ago, the average age at death of bishops is
much higher than the corresponding average of
curates. But making all the curates bishops will not
necessarily save them from an early death. The
average age at death in an occupation must, of
course, depend in part upon the age of entry to that
occupation and the age of exit from it—if exit takes
place for other reasons than death. Bishops have a
higher age at death than curates because few men
become bishops before they have passed middle life,
while curates may die at any age from their twenties
upwards.
The following misuse of this average is taken from
a report on hospital patients. -
It is stated that in 31 cases of renal hypertension which
came to autopsy the average age of death was 45. ‘* Thus
the common fate of the renal hypertensive is to die in
the fifth decade of life.” This may be a true statement of
fact, but it clearly cannot be deduced from the average
age; the average might be 45 years without a single
individual dying in the fifth decade. The report continues :
In 86 cases of essential hypertension which came to
autopsy the average age at death was found to be 60,
while in 20 cases seen in private practice the average age
at death was nearly 70. `
“Thus, the fate of the non-renal hypertensive is very
different from that of the renal. The subject of uncom-
plicated essential hypertension may reasonably expect to
live into the seventh or even the eighth decade.”’
The first deduction is probably valid, though obviously
information regarding the variability round those averages
is required. The frequency distributions of the age at
death for the two groups should be given. The “ reason-
able expectation ” has no real foundation in the figures
given. If the subjects of uncomplicated essential hyper-
tension mainly live into the seventh or eighth decade
one might reasonably adopt that as an expectation.
But if the average age is derived from individual ages at
death varying between say, 40 and 90, one has no justifica-
tion for using that average as an expectation.
The author regards statistics as ‘‘ dull things ” and
therefore refers to them as “ briefly as possible ’—
so briefly that in his hands they are of very little use.
A difference in the average ages at death from, say,
silicosis in two occupations may imply that in one
THE LANCET]
occupation the exposure to risk is more intense than
in the other and thus leads to earlier death; but
this interpretation can only hold, as is pointed out
above, so.long as the employed enter the two occu-
pations at the same ages and give up their work at
the same ages and to the same extent. It is usually
very difficult to secure satisfactory evidence on these
points, and the average ages at death must be
regarded with some caution.
Problems of Inheritance
Literally hundreds of disorders or derangements in
mankind have been recorded as showing evidence
of hereditary factors. The evidence mainly consists
of the appearance of the disease or disability in a
more or less orderly fashion among related indi-
viduals. In many instances there is no doubt that
hereditary factors are important but in others their
presence is difficult of proof, in the inevitable
absence of controlled breeding experiments and
the impossibility sometimes of distinguishing
genetic from environmental influences. Cases are
reported, for example, of a familial incidence of
cancer; a man whose father died of cancer of the
stomach died himself of cancer in the same site, while
his wife died: of cancer of the breast and their six
children and one grandchild all died of various forms
of cancer. This is a very striking family history
but it is not necessarily evidence of an inherited
DR. R. N. SALAMAN : PLANT VIRUSES
[APRIL 3, 1937 827
factor. If each of these individuals had been known to
have passed through an attack of. measles we should not
deduce a particular family susceptibility to measles,
since we know that measles in the whole population
is so widespread that a familial incidence is bound
to occur very frequently. Similarly we want to know
the probability of observing a series of familial cases
of cancer merely by chance. Even if that probability
is small it must be remembered that the field of
observation amongst medical men is enormously
wide and a few isolated instances of multiple cases
cannot be adequate evidence. Usually, too, only one
part of the field is reported in medical literature, for
notice is taken of the remarkable instances and no
reference made to the cases in which no inheritance
is apparent. The data required in such a problem
are reasonably large numbers of family histories,
so that, if possible, it may be seen whether the
distribution of multiple cases differs from the
distribution that might be expected by chance,
or whether the incidence in different generations
suggests a Mendelian form of inheritance. Even if
the distribution of multiple cases differs from that
expected on a chance hypothesis, the question of a
common family environment cannot be ruled out—
e.g., multiple cases of tuberculosis may occur more
frequently in families of a low social level not through
an inherited diathesis but through undernourishment.
A. B. H.
SPECIAL ARTICLES
PLANT VIRUSES
AND THEIR RELATION TO THOSE
AFFECTING MAN AND ANIMAL *
By REpDcurre N. Sarama, M.D. Camb., F.R.S.
DIRECTOR OF POTATO VIRUS RESEARCH STATION,
UNIVERSITY OF CAMBRIDGE
THE first virus disease of any kind to be recognised
as such was mosaic in tobacco; it was Mayer of
Holland in 1886 who demonstrated both its infec-
tivity by sap inoculations and the absence of any
fungi or bacteria in the infective juice. Long before
this a protean type of disease producing leaf defor-
mity, dwarfing, and reduction of crop in variable
degree had been recognised in the potato, and refer-
ences to it go back for over 150 years. The disease,
which was very widespread in England, was regarded
as the result of prolonged vegetative reproduction
that had induced an incurable senility. The only
remedy for this, it was maintained, was to discard the
old and create new varieties from true seed, obtained
by the fertilisation of the female portion of the flower
with pollen generally of some other variety. There
was in fact a widespread if subconscious sympathy
with a plant on whom had been enforced a celibacy
which was regarded as unnatural and abhorrent by
the agriculturist. That the plant reacted by becoming
peevish and degenerate was only what might be
expected. The cry of “back to nature” came from
the heart. This view persisted in many quarters in
this country even so late as the last war, indeed I
may claim some share in helping to dispel the myth
which as late as 1912 was firmly held in certain
influential quarters.
* A lecture given before the Southampton Medical Society,
Jan. 13th, 1937.
EARLY WORK
In some years this degenerative disease of the
potato was so severe and the resultant crop so bad
as to threaten the continuance of potato cultivation
in this country. In 1778 the Agricultural Society of
Manchester invited essays on the cause and possible
cure of the trouble. These were printed and some 15
years ago, with Prof. W. Brierley’s help, I was fortunate
in discovering a copy and making parts of them
known once more. Much interest lies in the fact that
the chief diseases complained of seem to have been
either a chronic form of crinkle—probably a secon-
dary result of infection with the Y virus—or leaf-
roll. . One competitor felt convinced that the green
. fly was the cause of all the trouble, thus forestalling
by about 140 years the discovery made by Oortwijn
Botjes in 1920 that the virus disease leaf-roll was
spread in the field by aphids.
Returning to tobacco mosaic, which has ever
remained the classic subject for virus research, it
was Iwanowsky who in 1892 showed that juice from
a diseased plant remained infective after passing
through a porcelain filler which would hold back
bacteria. He further showed that the infective
agent multiplied indefinitely within the plant. The
virus, he found, was highly resistant to alcohol and
to drying, and he regarded the disease as due to
something either held in solution or carried by
minute particles in the cell plasma.
Beijerinck (1899), ignorant of Iwanowsky’s work,
investigated with great thoroughness the disease
Mayer had described and reached similar conclusions.
He deseribed the infective agent as a “contagium
fluidum,” and recognised that peach yellows, which
Erwin Smith in 1888 had shown was communicable
by budding or graft, was but another example of
the same trouble. Löffler and Frosch’s discovery
that the infectious agent of foot-and-mouth disease
828 THE LANCET]
followed in 1892, the first animal disease to be shown
to be due to a virus.
: As with most great discoveries, it is seldom that
the whole credit can be ascribed to a single individual,
or the advent of the new knowledge precisely dated.
Since the sixteenth century and probably earlier the
broken tulip has been much prized by horticulturists
and has been the frequent subject of the Flemish
master’s brush. In 1928 Miss Cayley proved that
“ break ” was a communicable virus disease of. the
tulip. It may be noticed in passing that the Parrot
variation in the tulip is genetic and not pathological.
Another set of observations which foreshadowed
our present-day knowledge of plant virus diseases
followed the introduction of the variegated Abutilon
about 1868. This and similar variegated plants were
studied by Baur, who in 1907 showed that some varie-
gations, including that of Abutilon, could be com-
municated to the normal green-leaved plant by the
insertion in the latter of a variegated scion, and
named the condition infective chlorosis. To-day we
recognise it as yet another example of a virus disease,
of which the yellow-margined euonymous is a further
example. —
The Nature of Viruses
Although animal virus diseases have received, till
recently, more intensive study than those of plants,
yet the importance of the latter is not a whit less
when viewed from the academic point of view.
The social values, or rather loss of values, occa-
sioned amongst man and animals by viruses may
appear greatly to outweigh those occasioned in the
plant world, but it is well to remember that if in the
former group are to be found such widespread scourges
as those produced by the viruses of small-pox, yellow
fever, and influenza in man, and that of rinderpest
in cattle, any of which may decimate whole popula-
tions, in the latter group are to be found diseases
which if not checked would endanger many of our
staple food crops, and through want or malnutrition
occasion trouble of no less magnitude.
The nature and properties of viruses cannot profit-
ably be discussed in watertight compartments, and
I shall therefore draw my examples and inferences
from both the animal and the plant world. Later I
shall make a short survey of the action of some of
the chief viruses which affect plant life in this country
and of the methods being devised to combat them.
DEFINITION
It is perhaps significant of both the rapid advance
no less than the fluidity of modern scientific con-
ceptions to-day that when we attempt to define
what we mean by a virus we find no simple expression
which without reservation will meet the facts as
regards the majority of the viruses we know.
A short time ago the possession of three negative
qualities was considered an adequate criterion.
These were :
(1) The virus agent was a particle too small to be
resolved by the optical apparatus of an ordinary micro-
scope no matter how high the power.
(2) A virus was not held up by porcelain filters that
retained the smallest known bacteria.
(3) A virus could not be grown in any medium apart
from living and dividing animal or plant tissue cells.
It was moreover understood that all these properties
qualified an agent, tacitly assumed to be living, which
in plant or animal induced such a disordered meta-
bolism as to constitute a morbid state. In other
words, a virus was a disease agent and the disease so
induced was a Virosis.
DR. R. N., SALAMAN : PLANT VIRUSES
[APRIL 3, 1937
Let us consider in how far these characteristics
are in accord with our knowledge to-day. It will be
best to begin with the last and work backwards,
A virus ts a pathogenic agent—We now know of
virus agents which in both the plant and animal
worlds produce no symptom of disease in any indi-
viduals so far tested. Thus in 1936 I isolated a
strain of the potato X virus I have called X® which
so far has not been found to produce any patho-
logical reaction and yet affords abundant evidence
of its virus nature, a fact which we will discuss later. ft
Barnard (1935) has demonstrated the existence of a
saprophytic non-pathogenic virus in filtered horse-
serum, and recently Laidlaw (1936) has shown that
similar viruses occur in London sewage. There is
nothing surprising in these facts; they merely
_remove one of our associated criteria for a virus—
viz., pathogenicity.
A virus can only multiply in the presence of living
cells.—In general this remains true, although Eagles
and Kordi (1932) state that they have cultivated vac-
cinia virus in cell-free media, a claim not generally recog-
nised. On the other hand, the agent responsible for
bovine pleuropneumonia, which on the basis of size
and filtrability is classed as a virus, is readily culti-
vated on artificial) media. Laidlaw’s saprophytic
viruses are also cultivable on ordinary media, and
Barnard’s horse-serum virus has been tracked down
through three or four passages. Whilst other viruses
may be for certain intrinsic reasons incapable of
independent growth, there seems no reason to doubt
that many viruses, both plant and animal, will ulti-
mately be cultivated, when we know enough about
their physical and chemical nature to ensure a suit-
ably adjusted environment.
A virus can pass ordinary bacterial filtere.—This is
demonstrably untrue for many viruses including some
of those which infect plants. So far as the defini-
tion is an expression of particle size, then it is true
enough that virus particles are small enough to pass
a Berkefeld No. 3, but many in fact do not do so;
this is due to their electric charge being such as to
cause adsorption on to the porcelain filter as well as
to aggregation of particles which may vary with
the pH of the suspension. The same virus may
pass a gradacol membrane of smaller pore size.
Of late a great deal of work has been done by
Elford and his co-workers on animal viruses and by
my colleague Kenneth Smith (1936) on plant viruses,
and we have learnt much about the size of virus
particles and the physical conditions which deter-
mine ultrafiltration.
Virus particles are too small to be resolved by the
optical system of an ordinary microscope.—The ques-
tion of resolution is of course a property of the wave-
length of the light employed. When ordinary white
light is used the smallest particle visible is about
0-2 u or 200 mu, but definite resolution does not occur
till the object possesses a diameter of 250 mu. Dark-
ground illumination methods will allow the recogni-
tion of particles of less size than 250 mu, but it is a
shadow, not an image that is seen. Barnard (1931),
however, employing “ultra-violet light with a wave-
length of 275 my, as compared with that of 400-
700 mu which represents the range of the visible
spectrum, has obtained sharp photographs of several
viruses, and in particular that of ectromelia, a
virus disease of the mouse whose particle size he esti-
mates as 0-13 u. Vaccinia lesions, as is well known,
contain intracellular bodies composed of a vast
number of minute particles which on appropriate
t XE has since been shown to produce a morbid reaction in
Capsicum annuum.
THE LANCET] |
DR. R. N. SALAMAN : PLANT VIRUSES
[APRIL 3, 1937 829
staining are just visible under the ordinary high
powers of the microscope, but in this case a particle
which is below the limit of resolution is rendered
visible by being made to appear considerably bigger
than it really is by reason of the pigment deposited
on it. :
The only disease agents which actually fulfil all
the negative qualifications are the bacteriophages
and the virus of the Rous sarcoma.
Perhaps Gardner’s (1931) definition of a virus—
viz., “an infective agent below the size-limit of
microscopic resolvability °—is as much as we dare
predicate to-day of these bodies.
NATURE OF THE INFECTIVE AGENT
It is very doubtful whether in plants we have any
true counterpart to the rickettsia group of animal
diseases as illustrated by typhus, where large masses
of minute cocci-like organisms are found in the intes-
tines of the infected vector, the body louse.. These
bodies are generally regarded as the infective agents.
Swezy and Severin (1930) have described a similar
condition in the vector of curly-top of sugar beet,
Eutettix tenella, but there has been no confirmation
of the relations between these bodies and the virus.
The mycetomata of aphids, composed of masses of
symbiotic saccharomycetes which are to be seen in
both infected and non-infected individuals, are
apparently different structures and not specially
related to virus diseases other than that''they are
present in the aphids, a family pre-eminent for its
capacity to act as vectors of plant viruses.
The question whether viruses are living bodies or
not is one of surpassing interest both to exact science
and philosophieal speculation. The solution of the
problem demands complete freedom from a priori
judgment. At best we may expect the answer to be
equivocal in that while some viruses may more
properly be described as “living ” in the same sense
that the smallest cocci are, others may prove to be
closely related to enzymes which are not living,
while still others should be regarded as standing at
the threshold of life.
SIZE
When we pxamine the sizes of viruses and bacteria
we see a gradual transition from the relatively giant
bacterium Bacillus prodigiosus to a disease agent
such as that of foot-and-mouth disease. Below
is a table and diagram of particle sizes from which
we can calculate that the volume of the former is
421,075 times as great as that of the latter, which
is only about six times the volume of a hemoglobin
molecule. Such minute agents might well be con-
sidered to possess a fundamentally different status
to that of a bacillus so enormously greater in volume,
The two plant viruses that have been most studied
are those of tobacco mosaic and potato virus X, the
relative diameters of which are 30 and 75 my
respectively, so that the volume of the X virus is 15
times that of the tobacco virus, and 1/15,625 that of
B. prodigtosus,
If size may be regarded as an aspect of the mole-
cular complexity of the particle, and the fundamental
attributes of life—reproduction and respiration—as
demanding a certain minimum complexity, then
complex organic particles when they exceed a certain
level of molecular size might be expected to evolve
new properties differentiating them from particles
of smaller size. Such a new property might be that
of self-reproduction. The views as to how particles
of the size of tobacco mosaic and bacteriophage are
reproduced will be referred to directly. While multi-
plication of the virus particle in animals is in general
associated with disturbance of the host’s metabolism,
amounting to a state of disease, this is frequently
not the case in plants.
That there are such radical differences between
different viruses may be seen in the case of psitta-
cosis and vaccinia with their relatively large particles
on the one hand, and with tobacco mosaic with its
small particle on the other.
The virus of psittacosis has been studied by Bedson
and Bland (1932) who have shown that the process
of particle reproduction that takes place within the
cells of the host presents a recognisable life-cycle of
the virus particle itself. Now the particle size in
this case is 275 mu, which is 762 times the volume
Bacillus prodigicsus - :
(diomeler) Ẹ
Psittacosis 275mp
Vaccinia iSOmp
Rabies 125 mp
Rous sarcoma 10Omp
Fowl plague 75mp
Potato virus x 75 mp
Bacteriophages 25- 6omp ©
Tobacco mosaic 30mp o
Haemocyanin 24mp °
Yellow fever 22 mp o
Foot and mouth disease 10 mp .
Oxyhaemoglobin 5-6 mp
Table showing particle sizes of representative animal and plant
viruses, with those of some bacteria and protein molecules
or i ‘pena tare 1 mp=1,000,000th millimetre (Smith
a e y
of the tobacco mosaic virus and but 1/20 the
volume of B. prodigiosus. Here a relation between
size and direct reproduction is demonstrated. In
the case of vaccinia, while no such cycle has been
demonstrated, it is known that the cell inclusions,
Paschen’s bodies, are composed of great numbers of
minute ‘“‘ elementary bodies” 150 my in diameter.
Each particle is thus about 125 times the volume of
the tobacco virus particle and 4 of the volume of
the psittacosis virus. The physical properties of
such a virus might be expected to be nearer to that
of psittacosis than that of tobacco mosaic.
A word may be said here about intracellular
inclusions or, as they are often called in articles on
plant viruses, X bodies. The intracellular bodies in
animal virus infections are either intra- or extra-
nuclear, in plants they are always extra-
nuclear. In several animal virus diseases, notable
vaccinia and fowl-pox, the inclusion has been shown
to be built up of minute bodies, which are presumably
the active virus agents. Weissenberg (1929) has
described in fishes a similar condition, but in this
case the cell attains colossal dimensions and the
inclusion body composed of very minute particles
almost completely fills it.
In plants, cell inclusions are not general, though
they occur in many virus diseases, including infection
with tobacco mosaic and potato X virus, but are
absent from the Y virus of the potato and leaf-roll.
830 THE | LANCET}
Sheffield and Henderson Smith (1931) have studied
their formation in the living cell. In an infected
cell agglomeration of denser cytoplasm takes place,
and the small masses thus formed impinge on one
another and eventually coalesce to form a large extra-
nuclear vacuolated body. Whether such contain
more virus particles than reside elsewhere in the
cell is highly probable but not proven. Just as not
all plant virus infections are accompanied by
inclusions, so not all the cells of an infected plant
contain them—in fact, it is only a minority that
do so. |
Tobacco mosatc—the first virus in animal or plant
to be recognised as such—is to-day in the very
forefront of biochemical and biophysical research.
In 1936 Stanley prepared a product. showing certain
crystalline characters from the juice of tobacco plants
infected with mosaic; he elaims that it represents
the virus agent, and that the crystals are protein
auto-catalytic enzymes, which on introduction into
suitable hosts bring about the transformation of
normal cell constituents to a like body. It will be
recognised that this view is identical with that of
Bordet’s in relation to the multiplication of bacterio-
phage, and presents similar difficulties. F.C. Bawden
has improved on Stanley’s technique and found that
such crystals were readily obtained from the common
as well as from two variant types of tobacco mosaic,
and confirmed Stanley in that they are absent from
normal tobacco juice. The crystals from the three
sources, which were identical in appearance and
physical properties, on inoculation to healthy plants
reproduced the three original specific types of
reaction. The crystals consist of protein and in
solution behave as doubly refracting liquid crystals
which Bawden and others (1936) have found to be
composed of very elongated molecules of enormous
size with a molecular weight in the neighbourhood
of 10—8 and possessed of distinctive physical properties.
Whether these crystals are in fact the virus agent
cannot be positively affirmed—that they contain the
virus in a highly concentrated form is certain, for
dilutions of 10-9 are still active. Nevertheless, Chester
(1936) testing Stanley’s crystals by Dale’s anaphy-
lactic method has shown that they contain an unspeci-
fied but quite definite amount of protein that is
certainly not virus. This and the fact that the
crystals account for 80 per cent. of the total protein
of the plant suggests the possibility that Stanley’s
isolate may be a crystalline form of protein, itself a
product of the reaction of the virus on the healthy
plant protoplasm, and that the specific virus particles
are adsorbed to it. Crystals of this kind have only
been obtained from plants infected, with the virus
of tobacco mosaic, though whether the host. is a
tobacco or a tomato is immaterial. Efforts to obtain
the like from plants infected with the X potato virus,
the virus of tobacco necrosis, and many others have
failed. ł{ |
PROPERTIES
The physical properties of plant viruses vary very
much; some behave to heat, light, and chemical
ł Since the delivery of this lecture, much progress has been
made along these lines both in America and in this country.
Stanley and Wyckoff (Science, Feb. 12th, 1937) have isolated a
protein with crystalline character and verv high virus con-
centration from plants infected with Wingard’s tobacco ringspot,
and similar but non-crystalline heavy proteins from plants
infected with the “ X ” virus of the potato and cucumber
mosaic. Beard and Wyckoff (Science, Feb. 19th, 1937) have
isolateda like body from suspensions of Shope’s papillomatosis,
a virus disease of rabbits.
The trend of opinion both in America and in England, where
important work on the purification and properties of these
protein molecules is actively proceeding, is to regard them as
being the actual virus agent to which the term “living,” as
generally understood, bardly applies.
DR. R. N. SALAMAN : PLANT VIRUSES
[APRE 3, 1937
reagents in much the same way as do bacteria, but
the behaviour of some others—and it is noteworthy
that they are those of very small size—is peculiar,
thus tobacco mosaic is not inactivated till a tempera-
ture of 90° is obtained, whilst it and tobacco necrosis
will withstand the action of absolute alcohol for many
months. These same viruses can also be desiccated
and maintain their full virulence indefinitely. Again,
tobacco mosaic crystals are almost immune to proteo-
lytic enzymes, though pepsin eventually destroys
the active agent in raw juice, while trypsin is without
effect. There are other plant viruses however which
are extremely sensitive to heat and chemical reagents
or to keeping whether in most or dry conditions out-
side the plant ; amongst such are to be found three
of the most widely spread and infectious viruses—
viz., the potato virus Y, tomato wilt, and cucumber
mosaic.
Animal viruses are endowed to a high degree with
the capacity of inducing in their hosts a variety of
antibodies. It is less well known that many plant
viruses are equally antigenic. Rabbits inoculated
with tobacco mosaic juice or Stanley’s crystals, or
with the X virus of the potato and several other
plant viruses, produce antibodies that are absolutely
specific to the virus employed, and its related strains
and their presence can be demonstrated as preci-
pitin, complement-fixation, or neutralisation reactions.
Certain viruses, such as the Y potato virus and the
virus of sugar-beet mosaic and tobacco necrosis,
have failed to call forth any antigenic response in
the rabbit. It should be noted that the injection of
plant virus juices has not produced the slightest
pathological reaction in the rabbit nor has any virus
agent yet been found which is pathogenic to both
plant and animal.
VARIATIONS
A word must be said about the variations or strains
of certain viruses which are found in nature or
induced in the laboratory. Multiplicity of strains
is much more pronounced in the plant than the
animal viruses, thus there are some 70 variations
of tobacco mosaic, 40 of cucumber mosaic, and 5 of
the X potato virus. If the tendency to vary be
regarded as evidence of adaptability, and adapta-
bility as a peculiar function of living matter, then
we are confronted with the fact that the virus with
one of the smallest particles—viz., tobacco mosaic—
varies the most.
A few examples are known where plant viruses
have been induced to vary by passage through certain
hosts and by treatment such as heat. I have con-
verted a virulent potato X virus into a harmless
variety by passage through a sugar-beet and a
virulent potato Y virus both by passage through
a schizanthus and by heat into one of much less
virulence, — |
ANTIGENIC AND PROTECTIVE REACTIONS
In 1933 I described some observations in which it
was shown that if a plant were inoculated with the
G strain of the X potato virus and some ten days `
later this was followed up by an inoculation with a
severe virulent strain of the same virus, then no
reinfection took place and the plant remained to all
appearances completely healthy, though of course
it still contains the mild protecting strain. The whole
phenomenon bears a close resemblance to that of
vaccination. ,
Subsequently I found that Thung in Java in
1931 had shown that a tobacco plant infected with
a virulent and crippling form of tobacco mosaic could
THE LANCET]
not be further infected with a different but rather
less virulent form of the same virus. The two obser-
vations probably have the same explanation: once
a cell is infected with a given virus all affinities as
regards that virus are satisfied, and no other strain
can obtain an attachment. It is a case of first come
first served. The protection afforded is rigidly
specific. There is no doubt that this type of pro-
tection is cellular in nature, whereas the animal
examples so far reported are humoral. |
Recently Findlay and MacCullum (1937) have
reported a case of protection in yellow fever which
appears to be of the same nature as that described
above, resting on a cellular basis, and not as is general
in animals on a humoral one. In plants we have no
evidence at all of humoral immunity.
In nature potatoes are often protected against the
severe X virus strain by a pre-existing infection
with a milder type. Such protection has probably
been in force ever since potatoes have been cultivated
on a large scale.
The effect of virus infection in plants may be
roughly grouped as follows :—
(a) Mottling of the leaves only.
(6) Deformity and crinkling of the leaves, generally
accompanied by mottling. The deformity may go as far
as the more or less complete suppression of the leaf or its
conversion into a thread-like structure.
(c) Necrosis, either as isolated spots or patches on the
leaf, destruction of the phloem vessels in the veins, as
streaks on the stem or as a dieback from the top, the
growing point.
` (ad) In nearly every case there is a pronounced dwarfing
.of the plant as a whole, which may be so extreme as to
make the plant unrecognisable.
(e) The floral organs are frequently imperfect or de-
formed, causing a varying degree of sterility, or there
may be little or no deformity and yet a considerable
measure of sterility.
Some characteristic deformities such as the con-
version of the leaf lamina to threadlike structures
in tomato, and the curl and discoloration of the leaf
in potato leaf-roll simulate genetic mutations or con-
genital deformity respectively.
These and other facts have given some support to
the thesis that a virus agent may be an hereditary
gene freed somehow from the chromosome and capable
of more or less independent life in the cytoplasm.
This theory, though attractive, is without any experi-
mental backing.
Reaction to Infection
The potato illustrates very clearly two charac-
teristics that are common in virus diseases of plants
and are also encountered in virus infections in
animals. The first is the carrier, the second the
disease complex,
THE CARRIER
Every potato plant in the U.S.A. harbours one or
more strains of the virus X. In the majority of cases
it produces nothing more than a transient faint
mottle which disappears as the plant attains maturity ;
often there is nothing to denote its presence. In a
few of our own varieties such as Epicure and Arran
Crest the same virus is lethal in its effect. Many
years ago my colleague Le Pelley and myself found
(1930) that every King Edward plant that exists con-
tains a virus which when communicated by grafting
to such varieties as Arran Victory or Arran Chief
produced a crippling and incurable disease which
we called paracrinkle, yet the King Edward plant
itself shows not the slightest sign of ill-health. The
presence in King Edward of this virus, which is not
DR. R, N. SALAMAN : PLANT VIRUSES
[APRIL 3, 1937 831
sap-inoculable, and so far as we know not conveyed
by insects, presents a unique problem. Every one
of the milliards of King Edward plants grown since
its introduction twenty-five years ago has been
derived from the original single seedling which
theoretically at least must have obtained and carried
this virus. Whence it was derived and how it gained
an entry remain unknown. A solution of this problem
might well throw light on the origin of viruses.
TRANSFERENCE OF PLANT VIRUSES
In general the transfer of a virus disease from plant
to plant is effected by the intermediary of an insect,
and in the majority of cases by a sucking insect.
Foremost amongst them are the aphids the most
catholic of which in its tastes is the peach aphid or
Myzus persice, which conveys amongst many other
diseases leaf-roll and leaf-drop-streak in potato and
mosaic in cauliflowers, and from them carries it to
many of our garden flowers. Next come the hoppers,
which feed in a similar manner to the aphid, and are
responsible for conveying many very widespread
plant diseases such as curlytop in sugar-beet, streak
in maize, and yellow asters. Both families of insects
are provided with an extremely fine proboscis which,
inserted between the pallisade cells of the leaf, pene-
trates into the fine phloem terminals. Feeding on a
diseased plant results in the insect’s saliva being con-
taminated with the virus and the insect on passing
to the next plant transfers the disease. If the plant
is a healthy one, it may then become infected. Tomato
spotted wilt, a most infectious disease, which readily
attacks an enormous and diverse range of host
plants, is spread by means of a thrips which feeds by
a superficial rasping process. The thrips can only
pick up the virus when in the larval stage, it retains
the virus and conveys the disease during its
adult life. |
An interesting consideration is the degree of
specificity displayed between insect and virus in the
case of plant and animal respectively. In animal
disease a strictly specific relation is rare; that
between the body louse and typhus and trench fever
seems to be the closest. Dengue, while commonly
conveyed by the mosquito Stegomyia fasciata, seems
able to make use of two other species on occasions.
In plants we have several examples of a close
relationship between vector and virus, such as in
curlytop of sugar-beet and Eutettix tenella, aster
yellows, and Ctcadula sexnotata, streak disease of
maize and Otcadulina mbila, while many others are |
conveyed by the aphid Myzus persice and one or
two closely related aphids. The problem suggested
by this close relationship must be left without further
discussion, as we have no certain evidence as to any
developmental relationship between virus and insect.
As to what happens to the virus within the insect
is another problem which has not been solved. In
some cases an incubation period supervenes which
implies some reaction between virus and insect, in
other cases it is probably a question of mechanical
transference only.
Tobacco mosaic and the potato X virus, both very
infectious, do not appear to have any insect vector.
It is interesting that in both these cases spraying
with an atomiser a suspension of infected juice on
to the leaves of a healthy plant is enough to produce
infection.
VIRUS COMPLEX
By a virus complex is meant a disease induced by
the combined effect of two or more distinct viruses.
The clinical picture that results from this may be
832
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DR, R. N. SALAMAN : PLANT VIRUSES
(APRIL 3, 1937
quite unlike that occasioned by the action of
either.
The following example in potatoes will illustrate it.
The virus XĈ produces no effect on the variety President.
The virus A produces at most a slight veinal mottle.
The combination X° and A produces a severe crippling
crinkle,
Similarly :—
The virus X produces mild mottle or no effect on the
variety President.
The virus F produces no effect.
The combination XÏ and XF produce bright permanent
interveinal mottle.
Similar results arising from the coexistence of two
Or more viruses can be demonstrated in tobacco.
I have found (1932) some evidence that in certain
cases in the potato an opposite effect to that described
as a. result of a virus complex may result. The
presence of two or more viruses in the same plant,
any one of which would normally produce a serious
disease, may result in a reduction of morbid symptoms,
the plant being then converted into a carrier. Thung
has reported a similar phenomenon in tobacco.
TYPICAL DISEASES
_ Thanks very largely to the work of Kenneth Smith
(1936) we have greatly extended our knowledge in
the last year or two of the virus diseases of plants
both in our gardens and in glasshouses. Reference
to his paper (1936b) will open the eyes of some to the >
fact that their glasshouses and gardens are veritable
virus museums. I will only refer to a few of the more
outstanding cases.
Tomato spotted wilt—This virus is one of the most
destructive diseases that affects the tomato. It is carried
by the ubiquitous glasshouse thrips and attacks a yery
large number of plants of many diverse families, but even
more important is the fact that it is carried or produces
but minor symptoms by some. In a commercial house a
devastating epidemic has been known to occur as a con-
sequence of the grower keeping a few favourite but
infected nasturtium plants in his house from which the
thrips spread the infection; a similar danger may arise
from infected chrysanthemums. Some of the chief garden
flowering plants affected are asters, marigolds, cinerarias,
dahlias, lupins, and poppies, whilst in the greenhouse
primulas, capicastrum, and particularly lilies of the amarylis
type. Weeds such as the dock, the bindweed, and solanum
nigrum may all serve as centres of infection.
Cucumber Mosaic.—This virus, which has been studied
for many years in the Cucurbitacez, is now found to have
gained a footing in most gardens. It particularly affects
marigolds, asters, delphiniums, and lupins. It produces
a flecking or breaking in violas.
Cabbage Mosaic.—Cabbage plants of all kinds are most
commonly affected with a virus which causes considerable
distortion of the leaves and a mottle; on old plants black
rings develop and dark green bands along the veins.
This virus is frequently conveyed by the aphis, Myzus
persice, to stocks and wallflowers, and produces in them a
breaking of the flower ; when infected some of the best of
the old self-coloured purples bear only washy streaked
flowers.
Mosaic or stripe disease of bulbous plants.—Chiefly
affects the leaves by inducing light stripes on the leaves
of narcissi and daffodils. The flowers often develop a
similar streak and all the plants are weakened.
Tulip Break.—There are three types of break recognised.
(1) Full break: in which the basic yellow or white meso-
phyl tissue is exposed by the withdrawal of the red or
purple of the epithelial layer. This is probably due to
the interaction of two viruses. (2) Self break: the self
colour is intensified, producing a streak; one virus only
appears to be at work. (3) Clotted break : in which large
splashes of intensified colour occur on the petals of the
dark purple shiny varieties. ‘The viruses are conveyed
by three species of aphids. Anuraphis tulipe which lives
on the bulbs and transits the diseases from bulb to bulb
in store, and Myzus persice and Macrosiphum get, which
feeding on the leaves convey the disease in the open.
Pelargoniums, especially the varieties Paul Crumpel and
King of Denmark, are subject to a disease that causes
much spotting and leaf-curl in the old leaves. Young
leaves in older plants appear to be normal. No vector
has been found.
Prevention
It may be asked what protection have we against
these subtle virus pests, from whose attacks in plants
there is no real recovery. Attempts have been made
along several lines which I cannot do more than
briefly outline. |
Cultivation of naturally immune varieties.—These
are rare and in general the immunity to be of com-
mercial value must be transferred by appropriate
breeding to a newly built up variety. Success has
been obtained with the Long Chinese variety of
cucumber against cucumber mosaic. The sugar-
cane industry is to-day built up on two varieties—
“ Uba ” resistant to mosaic and “‘ PoJ. 213 ” resistant
to streak. The result has been an enormously
increased crop which with our present-day economics
has resulted in widespread distress.
Cultivation of carriers This has been, uncon-
sciously, the policy of potato breeding for the last
fifty years at least. A good variety is one that reacts
but mildly or behaves as a carrier to the more pre-
valent virus diseases. It is the behaviour of the
variety in the second and subsequent year to infec-
tion which determines its future utility. No variety
withstands all virus attack, nor any that of the Y virus
without some, and generally considerable, damage.
Good husbandry.—The eradication of weeds, which
are in Many cases virus carriers, especially the wild
solanum species; the thorough cultivation of head-
lands and removal of hedges that shelter insects ;
above all, the destruction of “‘ ground keepers ’’—
i.e., potatoes or “roots” left in the earth after the
harvest—are all of value in keeping crops free from
virus infection. Other treatments have been directed
against the insect vector. In America large enclosures
covered with a muslin of 22 mesh to the inch have
been erected over areas as big as 32 square rods.
Naturally such inclusions can only be used for special
seed crops and need very careful supervision lest
they act as forcing houses for aphids. Sprays have
been tried but so far as the potato crop is concerned
it would need very frequent application of a nicotine
emulsion to be effective. Rogueing of crops and
isolation of special cultures of plants are all used and
can be very successful; they are however only
practical on a small scale. |
Vaccination.—A new line of attack on the plant
virus problem is being worked out in Cambridge.
Following up the discovery that it was possible to
vaccinate a plant against a severe virus an attempt
is being made to prepare a suitable vaccine against
the virus of the disease which troubles us most in
the potato field—the Y virus. There is reason to
hope that it may succeed. It has already been pointed
out that nature herself makes use of protective
vaccination in the potato, but that is not her only
weapon. It is clear that if there is no focus of dis-
persion for a virus, there will be no spread. If,
therefore, a plant is so acutely susceptible to a parti-
cular virus as to succumb almost at once, and if,
further, it loses all vegetative power in its tubers
if it has any, then not only is the patient eliminated
but the disease also. This actually occurs in the
THE LANOET]
MEDICINE AND THE LAW.—PARIS
[APRIL 3, 1937 833
case of the potato variety Epicure, which is at once
the most susceptible, one of the oldest, and most
vigorous variety of potato we have.
Conclusion
Although the incidence of virus disease in our
field and crops and glasshouses has undoubtedly
increased, there is no reason for undue pessimism.
What is needed is more research on virus diseases
and a closer understanding between the pathologist
and the plant breeder. It is the latter who needs.
to realise that when by his breeding methods he
gives us large and ever larger crops, bigger and
whiter fruits, and the like, he has almost certainly
discarded en route a number of hereditary genes
which alone or in combination with others may be
responsible for that vague but important character—
constitution.
REFERENCES
d, J. E. 11931) sas eves Soc. Series B.
Barnar
— (193 5) Brit
wden, F., and ee aore 1936) Nature, 131, 468.
109, 360.
Baur, E. (1907) Ber. dtsch. es. 25, 410.
Bedson, S. P., and Bland, fo “1959 Brit. J. exp. Path. 13, 461.
eij ck, M. W. (1899) Zbl. Baki. 5, ao 310.
Botjes, J. G. O. (1920) che Wagenin
Cayley, D. M. (1928) Ann. appl. Biol. ts. "529.
Ch » K. S. (1936) Phytopath. 6,
meat H., and Kordi, A. H. (1932) Proc. roy. Soc. Series B.
Findlay, G. M.,and MacCullum, F. O. (1937) (inpress) J. Path. Bact’
Gardner, A. D. (1931) wath aes Uireiniorobes, London: p: 40°
Iwanowsky, D. (1899) Zbl. Bakt. 5, 250
Lalas’ boa. -. and Elford, W. J. (1936) Proc. roy. Soc. Series B.
Loeffier and Frosch (1898) Zbl. Bakt. 23, HAS
Mayor A. (1886) Toan: Versuchsw. 22
Salaman, R. N. (1932) Proc. roy. Soc. Suo E. 110, 186.
(1933) Nature, 131, 468.
and Le Pelley, R. (1930) Proc. otoy. Soc. Series B. 106, 140.
Sheffield, Frances, and Smith, (1931) Ann. appl. Biol.
Smith, 'E. (1888) ATE Dept. Agr. Div. of Bot. Bull. No.
S K. M. (1936)
mit h; Sci. po. Twent. Cent. 119, 413.
— ’(1936b Sci. Hort.
tanley, W. (1936) Pkilopaih 26
Swezy, Olive, and Severin, H A 20, 169.
Thung, T. H. É 81) Ned-Ind. rats Congr. Java, p. 450.
Weissenberg, R. (1929) Z. Fortbild. 26, 555.
MEDICINE AND THE LAW
Unlicensed ‘‘ Special Establishment ”’
Last December the public control committee of
the London County Council revoked! the licence of
-` Dr. Stavros Constantine Damoglou for carrying on .
an establishment for massage and special treatment.
The decision seemed to be based in part on state-
ments that he represented himself as able to cure
blindness in incurable cases. On being notified, he
disputed the Council’s authority; it extended, he
maintained, to masseurs only and not to persons
with medical qualifications. He wrote that he
intended to continue to treat his patients by methods
of his own invention, as he had done for the years
1915 to 1931, without any licence. His patients, he
said, consulted him as their last hope; he would
stand by them to bring them hope, relief, and in
many cases complete recovery. Dr. Damoglou
having preferred to defy the Council rather than to
exercise his right of appeal, the L.C.C. caused him to
be summoned on March 17th at the Marylebone
police-court. It was admitted by the prosecution that
in certain cases of blindness due to nervous disorder
the defendant could be very helpful. As,a medical
man he could carry on his establishment without a
licence if he produced a certificate signed by two
registered medical practitioners to the effect that he
was a suitable person. Dr. Damoglou, giving evidence,
said that he was a fully qualified medical man. He
protested that his was not a massage establishment
1 See Lancet, 1936, 2, 1482.
- Mr.
within the London County Council Act; he treated
his patients by solar ray and gave them advice upon
diet ; the great majority received benefit and many
were cured. The magistrate imposed a fine of £10
with costs, warning the defendant that, if he com-
mitted the offence again, the maximum penalty of
£50 would be imposed.
Patient and Radiologist’s Renae
The Court of Appeal recently . discussed the
question whether:.a doctor is obliged to allow a
patient to see a radiologist’s report. The point arose
on the appeal of Mrs. Rubra, widow and executrix
of Dr. Henry Rubra, against the verdict of £5000
damages awarded to Mrs. Connolly for alleged
negligence on the part of Dr. Rubra in treating
Connolly, who died of tuberculosis in 1933.
During discussion in the Court of Appeal Lord
Justice Slesser referred to Mrs. Connolly’s request to
see a copy of the radiologist’s report; she had |
received what the judge called a misleading reply.
Lord Justice Greene then inquired whether it was the
practice in the medical profession not to let the
patient see reports of this kind. Mr. Thomas
Carthew, K.C., appearing for Mrs. Rubra, replied
that many members of the profession regarded these
reports as confidential; it was, he added, in the
discretion of the general practitioner who had sent
the patient to the specialist to decide whether the
patient should see the report or not. Lord Justice
Greer, the president of the court, doubted if there
was any practice of keeping this information secret ;
much must depend on the doctor’s view of the intelli-
gence of his patient. As Mr. Carthew observed, a.
patient is in the hands of his doctor; many patients
might be seriously upset by being given the information.
The appeal was not concluded before the Easter
vacation. When judgment is given, we hope to
discuss the case further. It has been a striking
instance of the risks inherent in the new law whereby
a personal action now no longer dies with the person .
concerned. Mrs. Connolly’s claim in connexion with.
the death of her husband was begun while Dr. Rubra
was still alive. Dr. Rubra was then in bad health ;
he died not long afterwards. His widow obtained
leave to continue the defence. In denying the
allegations of negligence she may well feel that the
position of the defence is prejudiced by the death of
one who would have been the principal witness on
that side.
PARIS
(FROM OUR OWN CORRESPONDENT)
SANATORIUMS OR SANATORIA
THe Anglo-Saxon observation that the French
would rather be in the wrong than vague may be
reconsidered in the light of a recent discussion in
the French medical press over the respective philo-
logical merits of sanatoriwms and sanatoria. The
indiscriminate and alternating use of both terms in
the Anglo-Saxon countries may perhaps be good
enough for their natives with their weakness for
irrational compromise and inaccurate and nebulous
impartiality. The correspondence began with an
(as it proved) ill-advised attack on a writer who had
committed himself to sanatortums. Why had he not ’
given expression to his classical education by writing
sanatoria? The fat was soon in the fire, and issue
was joined by numberless medical philologists endowed
with a classical education, spare time, lexicographic
libraries, and a sense of burning injustice, one way
834 THE LANCET]
or the other. As a matter of fact, it was practically
all one way: the sanatortwms had it by an over-
whelming majority. It seems that while the adjective
sanatorius is good Latin, sanatorium was coined so
recently that it is not to be found in the dictionary
of the Academy published in 1878. The 1935 edition
of the same dictionary had, perforce, to mention
sanatorium, but added that the plural was sana-
toriums. The Larousse dictionary hedges by men-
tioning both plural forms; but of course Larousse
is. nowhere in the presence of the Academy’s dic-
tionary. When the lists have been cleared after this
battle, the turn will doubtless come of serums
Versus sera.
PATHOLOGY IN STONE
Senlis, which is 33 miles from Paris, has two very
interesting museums, one of which contains a collec-
tion of some medical interest. It contains more than 300
Gallo-Roman ex-votive offerings representing different
Part of the collection.
parts of the body. These were placed by patients
before the altar in a temple erected to Mercury which
stood close to the town. There are a number of heads,
each with an expression of pain ; since most of these
are heads of women, it is thought that they were
Ex-votive offerings.
Models of a foot, breasts, and a heart.
placed in the temple by sufferers from headache.
Breasts, hands, feet, abdominal organs, and even
hearts, are among these objects. Archxologists
declare that this collection is superior to the similar
collection of ex-votives in Rome. |
IRELAND
(FROM OUR OWN CORRESPONDENT)
COLLABORATION BETWEEN HOSPITALS
A GENERAL meeting of the Irish National Associa-
_tion of Hospitals was held in Dublin on March 16th,
with Prof. T. G. Moorhead, the president, in the
chair. Some forty or fifty institutions were repre-
sented. The object of the meeting was to consider
the draft memorandum and articles of association.
It was soon made clear that some of the representa-
tives present, in particular those representing some
IRELAND.—UNITED STATES OF AMERICA
[APRIL 3, 1937
of the voluntary hospitals of Dublin, were nervous
lest some of the powers proposed to be given to the
association should interfere with the independence
and autonomy of individual institutions, and various
amendments were carried which tended to limit the
powers of the association. Agreement was arrived
at on the several points raised, and it was arranged
that the draft memorandum and articles should be
considered again at a meeting to be held in the last
week of May. The objects for which the association
is established are: (a) to maintain an information
bureau ; (b) to provide opportunities for discussion ;
(c) to publish papers and reports of conferences, dis-
cussions, and proceedings connected with hospital
management and administration; (d) to codperate
in any movement for the prevention, treatment, and
- cure of disease, and for the provision or extension of
facilities for hospital treatment; and (e) to under-
take any other work that may seem desirable to
promote the welfare of patients and those engaged
in their care, or the improvement of “ hospitals of
every description in Ireland or elsewhere.” The
association, however, is not to make any recommenda-
tion in regard to the internal administration of any
hospital or in regard to any particular mode of
therapy or the treatment of any patient or patients.
THE HOSPITAL SWEEPSTAKES
The twentieth draw of the sweepstakes in aid of
the Irish hospitals was held on March 15th and 16th.
The gross receipts, and also the proportion available
for the hospitals, showed a rise over recent sweep-
stakes, being in fact the highest since the corre-
sponding sweepstake of 1935. The aggregate sum
collected for the hospitals from the twenty sweep-
stakes is a little over £2,500,000, of which about a
third has been disbursed. The retention of so large
a sum as £7,000,000 in the hands of the trustees has
given rise to a certain amount of criticism. The-
Government, however, with the aid of the Hospitals
Commission, wishes to make a thorough survey of
the whole hospital problem in the country, in order
that a satisfactory system may be evolved and
established, and it is unwilling to allow the funds to
be dribbled out prematurely in temporary projects.
Moreover it is understood. that the
wishes to make the future maintenance of the volun-
tary hospitals secure by adequate endowment before
it authorises the erection of large buildings. It is
clear that hasty action might be dangerous, but it is
hoped that the Government may soon make its
decision on some of the more urgent parts of the
general problem. The increasing pressure on the
Dublin voluntary hospitals in particular demands
early consideration.
UNITED STATES OF AMERICA
(FROM AN OCCASIONAL CORRESPONDENT)
ADMINISTRATION OF PUBLIC HEALTH SERVICE
RATHER more than a year ago President Roosevelt
appointed a committee to examine the desirability
of reorganising the executive branch of the federal —
. government. In his message to Congress of Jan. 12th
the President presented this committee’s report.
Among its very comprehensive proposals is the
establishment of twelve major executive departments
to carry out functions that are now performed by
more than a hundred independent agencies, adminis-
trations, authorities, boards, and commissions. One
Government .
THE LANCET]
of these departments would be that of Social Welfare
“to administer Federal health, educational, and
social activities.” Some medical organisations are
already protesting against the transfer of the public
health service from the Treasury department to such
a bureau. They fear no doubt that a medical service
would be placed under the direction of some lay
social worker. While it is true that a layman who
thinks he knows something about public health
administration might be a poor exchange for a
secretary of the Treasury who knows he knows
nothing about it, still the service is even now in charge
of a lay woman, Miss Josephine Roach, assistant
secretary of the Treasury, for whose appointment all
public health workers are grateful. The gain to
health administration of having all public health
functions, now scattered through half a dozen
different departments, gathered under a single
department chief would be enormous.
SCHOLARSHIPS FOR PRACTITIONERS
The Commonwealth Fund has published its
eighteenth annual report, recording the expenditure
GRAINS AND SCRUPLES
[APRIL 3, 1937 835
of some ‘two million dollars in accordance with the
desire of its founder, Mrs. Stephen V. Harkness, “to
do something for the welfare of mankind.” Those in
charge of the Fund are strongly persuaded of the
value of post-graduate education in medicine.
Scholarships designed not to make specialists but
to enable family doctors to catch up with modern
medicine have been granted to 379 physicians to
study at Harvard, Tulane, Vanderbilt, and other
medical schools. Promising undergraduates have
also been given scholarships on the understanding
that they enter practice in towns of less ‘than 5000
population.
Thirty-one British university students have been
invited to spend two years in the United States as
fellows under the Fund. Prof. W. L. Bragg, of the
University of Manchester, has been elected to the.
. British committee of award that selects these fellows.
It is said that former fellows have been busy during
the past year both in writing about American affairs
for British readers and in broadcasting from Great
Britain to the United States.
GRAINS AND SCRUPLES
Under this heading appear week by week the unfettered thoughts of doctors in
various occupations.
Each contributor is responsible for the section for a month ;
his name can be seen later in the half-yearly index.
FROM A TADDYGADDY
I
Tinker, tailor, soldier, sailor,
Rich man, poor man, taddygaddy, thief.
“I dressed him, and God cured him.” So wrote
Ambroise Paré, over and again, in his case book.
What a lot it tells us of the man, and in how few
words. He was a great surgeon, but he was much
more than that: he was a great doctor. Often when
bored or depressed by the importunities of patients
and their friends I dip into his book in search of
refreshment, and never in vain. There is always
something fresh, He was a gentle person, a kindly
person, and he carried in his pocket a pen that could
sting: a tool very necessary to him, for he was a
pioneer in days when pioneers were not popular.
Eager for surgical reform he met bitter opposition,
but he met his critics on more than equal terms.
How he did it we can read for ourselves in his descrip-
tion of how he came to realise the ill effects of boiling
oil as a dressing for gunshot wounds, with his con-
clusion, ‘‘ Then I determined never again to burn
thus so cruelly the poor wounded by arquebuses.”’
That determination, it need hardly be said, met with
the hearty disapprobation of the orthodox, the
physicians who were very superior indeed, the sur-
geons of the long robe who would not condescend to
operate. Paré, a barber surgeon, was not tied to
convention as were those more magnificent ones, and
felt himself free to attack not: only the boiling oil
methods, but the use of the actual cautery. Con-
fronted by bleeding gunshot wounds he insisted on
the use of the ligature in place of red hot irons, and
was denounced as a surgical heretic. There are some
of us who can remember the battles that raged around
the question of antisepsis, and later asepsis. They
were fierce enough, but somehow they lacked the
picturesqueness of Paré’s controversial style. Perhaps
that was fostered by his circumstances. He spent
most of his time on or near the battlefield in days
when battlefields were spectacular, and for many
years he was court doctor during a highly coloured
period of history. Catherine de Medici and her’ sons
were his patients. It was owing to her good offices
that he, a Huguenot, survived the Massacre of Saint
Bartholomew. I like to feel, and I think with reason,
that the friendship existing between Catholic queen
mother and Huguenot court doctor was based upon
the outstanding honesty and charm of the man.
* * a
Why was it that surgery as Paré found it was so
horrifying ? For that matter it was horrifying for
centuries after him. It is on record that in Italy
in the thirteenth century, three hundred years before
his time, asepsis was practised and general anæs-
thesia employed. And not only in Italy. Tom
Middleton, the English poet-dramatist, wrote in the
very early sixteen hundreds :
T’ll imitate the pities of old surgeons
To this lost limb, who, ere they shew their art,
Cast one asleep, then cut the diseased part.
The doctors had forgotten, but the poets had not
forgotten. Nor had the common people. What had
caused the doctors to forget? That is one of the
greater mysteries in the history of our craft. Why did
doctoring, once gentle, become the crude thing that
it undoubtedly did? How was it that the nursing
sisters of Rahere’s foundation, gentlewomen living
according to religious rule, were replaced by those
terrible women of whom we may read over and over
again right down to the days of Dickens, and con-
cerning whom it was found necessary to lay down
rules in at least one great hospital, forbidding them
“to drink or dice with their patients”? It has
been suggested that the Black Death, which swept
away so many and so much, succeeded in submerging
medical culture. It is a suggestion worthy of con-
sideration, We know that it affected, terribly, the
members of our kindred calling, the clergy. The
best of both, doctors and priests, who stuck to their
-
836 THE cea
posts perished. Those who remained lost the con-
fidence of the people. In Germany so little were the
doctors regarded that we find an edict was fulminated
compelling plague patients to take the medicine
ordered by the doctor or suffer the consequences—
suspension on a gibbet, after death, with a coffin...
We may smile, forgetting the popular sentiment of
that day. That the doctors had “ lost face,” as the
Chinese put it, is evident. But there was more in it
than just that. The best of the doctors were dead.
Their teachings were forgotten or went unheeded.
Men did actually forget. And of our brethren the
clergy it is recorded that there arose parish priests
who could not so much as interpret in the common
tongue the words of their mass books. The need for
men was urgent: the supply of suitable men was
just simply not there.
* a great catastrophe ignorance took the place of
knowledge. . . l
æ * *
For centuries after the coming of the Black Death
medicine was a matter of crude ignorant horror.
King Charles II, happy during his days of well-being
with the Spirits of Skull with which he liked to
experiment, died slowly under the ministrations of
thirteen doctors, all doing something different, and
everything unpleasant. Queen Anne’s entire family
perished. The Princess Charlotte, daughter of that
queer person who afterwards became King George IV,
was hurried to untimely death by court doctors whose
idea of treating a delicate young married woman
was to bleed and purge, and then bleed and bleed and
bleed. Poor girl, it is no wonder that when her baby
came she and it passed out. And even so the
orthodox doctors refused to learn. A wise man
rediscovered general anæsthesia. He suggested that
it might be used to mitigate the pains of childbirth.
The orthodox shook their heads and muttered into
their beards this and that about “‘ the curse of Eve.”
It was the will of God, so they asserted, that women
should bring forth children in agony. But the Queen,
Victoria of blessed memory, knew better. When the
next little prince or princess was due she spoke the
word. Forthwith she was given the pain-destroying
essence to sniff. Women owe, and have owed, to
Queen Victoria a great deal more than they, perhaps,
have ever realised. She overruled the prejudices of
the doctors who seemed to think that pain, suffered
by others, was a good thing in itself and divinely
ordained. She put her foot down hard, as was her
———
PANEL AND CONTRACT PRACTICE
As the direct consequence of .
[APRIL 3, 1937
way. No doubt, common sense would have prevailed
in any event, but she hurried matters along.
x * *
I feel that we family doctors miss a vast deal by
not digging back into the past. We are all panel
doctors now, and we assert that we are too busy to
read. We leave that to the consulting people of
Harley-street or wherever it is. It is a poor plea.
Harley-street has no more leisure, and probably no
more inclination, for reading than we have, or ought
to have. We G.P.’s (I prefer the old-time word,
Taddygaddy) have no right whatsoever to shelter
behind the excuse of ‘‘ no time.” We have time for
golf, for bridge, for motoring shop—that devas-
tating exercise. Why not time for reading? There
is so much worth digging into. How many of us,
I wonder, have discovered the Regimen Sanitatis of
Salerno ? It is a storehouse of medical common sense,
and was written a very long time ago, nobody knows
by whom. Fashioned originally in rhyming dog-Latin,
there is a rhyming English translation which anybody
with a few shillings to spare may buy for himself.
It is good for us to read rhyme (I say nothing of
poetry), for it serves to remind us of our student
days and the rhyming aids to memory which were
such very potent helps in time of trouble. Do you
remember... ?
Tamarinds figs prunes and senna,
Cassia pulp and coriander :
With sugar water and liquorice
To make the filthy stuff taste nice.
That sort of thing. Why it should linger in my
memory I have no idea. Nearly fifty years have
gone by since I first heard those lines in the materia
medica museum of my school. The information they
convey is of no conceivable value to me, but the
memories they stir are of a value that may not be
counted. So with the Salerno rhymes. They tell
of a time when the practice of medicine was some-
thing to be taken not too seriously: when it was
very much a matter of joyous common sense.
If thou to health and vigour wouldst attain,
Shun weighty cares—all anger deem profane,
From heavy suppers and much wine abstain.
Nor trivial count it, after pompous fare,
To rise from table and to take the air.
Shun idle, noonday slumber, nor delay
The urgent calls of Nature to obey.
These rules if thou wilt follow to the end,
Thy life to greater length thou mayst extend.
PANEL AND CONTRACT PRACTICE
The London Figures
ACCORDING to statistics submitted to the London
insurance committee the number of persons entitled
to medical benefit in London at the end of 1936
was 1,901,746 as compared with 1,871,321 in the
previous year; during the same period the numbers
on the lists of insurance practitioners have increased
from 1,774,755 to 1,836,822. The number of practi-
tioners on the committee’s medical list was 2162
and the average size of their insurance practices was
842 persons. There were 1063 chemists under contract
with the committee at the end of 1936 who are carry-
ing on business at 1294 establishments within the
county and 391 outside.
More Dispensing
The cost of providing medicines for insured persons
has increased both as a whole and per unit. During
1936 8,996,825 prescriptions were issued in London,
costing £296,391 as compared with 8,561,492 in 1935,
costing £279,033. The average cost per prescription
rose from 7°82d. in 1935 to 7°91d. in 1936, the average
number of prescriptions per person from 4°85 to
4°99, and the average cost per person from 3s. 1:93d.
to 3s. 3:°43d. Reference to the table giving the figures
from 1927 to 1936 shows that the increase has not
been continuous during the decennium. In 1927
8,743,249 prescriptions cost £297,605, the average
cost of each of the 4°92 prescriptions per person being
817d, and the cost per person 3s. 4°16d. Comparing
these figures with those for 1936 it will be observed
that while a quarter of a million or so more prescrip-
tions were issued in 1936 to an insured population
approximately 25,000 higher than in 1927, the total
cost of the prescriptions was less by something like
£1000. The most abstemious year of the period was
1930 when the number of prescriptions was 8,129,038
and the cost £258,522. In that year the average
THE LANCET]
THE SERVICES
[APRIL 3, 1937 837
number of prescriptions per person was 4°31, the
average cost per prescription 7°63d., and the cost
per insured person 2s. 8°89d.
Prescriptions for insulin numbered 34,027 or
- 16,276,700 units for an average of 1247 patients per
month, the total value being £6717.
Disallowed Prescriptions
Last year 464 prescriptions were disallowed in
respect of articles which were not prescribed appliances,
and 79 in respect of preparations which do not form
part of medical benefit. Of the disallowed articles,
51 were finger- or thumb-stalls, 49 were non-scheduled
dressings, 48 thermogene and capsicum wool, 34
glass tubes and rods, 25 hypodermic needles (not
for insulin), 22 elastic hosiery, 20 atomisers, inhalers,
sprays, and the like. The favourite however was
eye-shades which were disallowed 83 times. Other
disallowed appliances were arch supports, breast
pump, corn pads, douches, forceps, funnels, hypo-
dermic syringes (not for insulin), litmus paper,
nipple shield, powder insufflator, rubber gloves,
spinal jacket (not according to schedule), spirit lamp,
sputum flask, syringes, temperature charts, clinical
thermometer, trusses, vaccination pads and shields,
and wrist straps. Of the disallowed preparations
29 were for saccharin tablets, 17 for charcoal biscuits,
13 for casein glycerophosph., 6 for virol, 3 for
roboleine, and in addition single prescriptions for
fumigating pastilles, lactose, peptonising powders,
rennet tablets, burnt sugar, and shampoo powder.
The total value of the 543 disallowed prescriptions was
only £38 18s.
Practitioners’ Fund
Insurance committees have now been notified of
the final apportionment of the Central Practitioners’
Fund (England) for 1936 which has been determined
at £6,868,855. London’s share of the fund (being
12:1858 per cent.) is £837,025, which allows of a
distribution of £44,172 over and above the amount
provisionally determined earlier in the year. , This is
nearly £14,000 more than the corresponding sum
distributed in respect of the year 1935 and the result
will be that London practitioners will receive for
1936 9s. 2°53d. per unit of credit as compared with
9s. 1:17d. for 1935.
THE SERVICES
REORGANISATION OF THE INDIAN MEDICAL
SERVICES
WHEN provincial autonomy comes into operation on
April lst under the new constitution, considerable
changes in the organisation, distribution, and terms of
service are to be made in the military medical
services in India. These are the result of a prolonged
investigation, extending over more than three years,
into the whole organisation for both peace and
war. l
The strengths of the three military medical services
in India—the R.A.M.C. in India, the military branches
of the I.M.S., and the I.M.D.—will be fixed so as to
provide for the minimum medical requirements of
British and Indian troops in peace time. There will
still be a civil branch of the I.M.S., recruited as
hitherto from the military branch, and consisting of
not less than 220 officers, of whom 166 will be
British. It will maintain a war reserve, on which
the Army in India must rely for its increased require-
ments in an emergency; attend British members of
the superior civil services and their families; and
fill posts under the Central Government and the
Crown representative. A new list of posts reserved
for I.M.S. officers in civil employ has been adopted,
involving a reduction from 207 to 172 for British
and Indian officers, but the present rights of officers
already in civil employment will be fully preserved.
Recruiting for the I.M.S. will still be by nomina-
tion on the recommendation of.a selection board,
held four times a year as hitherto. Indian members
will be recruited in India and will normally be given
short service commissions for five years, after which
selection will be made for permanent commissions
from among those who desire to continue in the
Service. British members will be recruited in London
and will be appointed to permanent commissions to
fill European vacancies.
Revised rates of pay for future entrants have been
introduced, which will bring basic pay more into
accord with Indian standards, without materially
altering the total emoluments received by British
members of the Service, who draw sterling overseas
pay. At the same time the time-scale of promotion
to major has been accelerated throughout by two
years. Improvements have also been made in the
rates of pay drawn in the second, third, eleventh, and
twelfth years of service. An increased outfit allow-
ance of £75 will be granted to new entrants, and the
maximum period of antedate granted for high quali-
fications and special experience is raised from 1 year
to 18 months. l
Six additional colonelcies will be provided on the
military side of the I.M.S., and a suitable number of
increased pensions, equal to those of colonels, will
be eventually awarded to officers on the civil side.
An officer transferred to civil employment will be
on probation for two years. Thereafter he will retain
a right to revert to military employment under
certain conditions until he has spent 7 years in civil
employment or has had 17 years of total service.
After this he will, if it is agreed that he shall remain
in civil employment, be transferred to a special
supplementary: list and will not normally be eligible
for military promotion- above the rank of lieutenant-
colonel. This system follows that in vogue for other
military officers in civil employ—e.g., in the Indian
Political Department.
ROYAL NAVAL MEDICAL SERVICE
The Admiralty announce that the appointment has
been approved of Surg. Rear-Admiral Percival T. Nicholls,
C.B., K.H.P., to be Medical Director-General of the Navy
in succession to Surg. Vice-Admiral Sir R. W. Basil Hall,
K.C.B., O.B.E., K.H.P., to date July 2nd, 1937.
Surg. Comdrs. T. Madill to President for course, and
P. J. A. The O’Rourke to Drake for R.N.B. l
Surg. Comdrs. (D) J. L. Edwards to Drake for R.N.B.,
and T. E. Breveter to Drake for R.N. Hospital, Plymouth ;
and T. Hunt to St. Angelo for R.N. Hospital, Malta.
The following officers qualified at the examination for
promotion to Surg. Comdr. held recently: Surg.
Lt.-Comdrs. F. G. B. Crawford, D. A. Newbery, J. J.
Keevil, F. Dolan, F. W. Besley, and T. L. Cleave.
Surg. Lts. (D) E. C. Jenet to Ganges; W. A. Dickie and
F. S. Roff to Pembroke for R.N.B.; and W. I. N. Forrest
to Victory for R.N.B.
ARMY MEDICAL SERVICES
The Army Council have decided to name the new
barracks about to be built for the Royal Army Medical
Corps Depôt and Army School of Hygiene at Aldershot
the ‘‘ Keogh Barracks” in memory of the late Lieut.-
General Sir Alfred Keogh, G.C.B., G.C.V.O., C.H. That
(Continued at foot of next page)
838 THE LANCET]
[APRIL 3, 1937
CORRESPONDENCE
INFLUENCE OF SCHOOL ROUTINE ON THE
GROWTH AND HEALTH OF CHILDREN
To the Editor of THE LANCET
Sir,—In view of the interest which is being
aroused by Mr. John Allan’s paper in your issue of
March 13th, would it not be desirable to quote more
fully from the context in the report referred to there
—i.e., “The Health of the School Child ” for 1935 ?
On pp. 12-13, for instance, it is stated that :
“|... The only practical measurements in common use
which, so far as we know, can help the assessment are
those of height and weight. But stature and weight,
though important, may, as was shown last year, by them-
selves be fallacious guides to the nutritional state, and
must be regarded simply as an important part of the
evidence to be considered by the medical officer in forming
his general impression. Frequent measurements of height
and weight are, however, of great value inasmuch as they
are the best indices we have of the rate of growth.”
The italics are mine, but the extract quoted, and
indeed the actual references in the report to weight,
height, and growth, and conclusions derived there-
from do not give me the impression gained from it
by Mr. Allan, that:
= <“, . estimates of nutritional states are now being based
on clinical observations only, standards of height and
weight for age being no longer applied... .”’
With regard to the intervals occurring in the
increase of height and weight of children which are
revealed by more frequent measurement, Corry Mann
has drawn attention to this; but he regarded such
cyclic or irregular growth periods as normal, and
based his conclusions as to progress on observations
taken at longer intervals. He. evidently associated
gain in weight with rest periods, and loss with physical
activity.1 Mr. Allan’s more minute investigation of
1 Mann, H. C. C. (1926) Spec. Rep. Ser. med. Res. Coun., Lond.
No. 105, p. 12.
these periods, covering 14 years, and their evident
association with periods of activity and rest in school
environment is therefore particularly interesting,
whether or not they are held to be “normal”
reactions to the pressure of the child’s physical and
mental education. As to whether such pressure, at
any particular school, is in the long run good or bad
for the child needs further investigation. If merely
on the lines of physical standards, these would need
to be applied at longer intervals, even up to that
between the date of entry and leaving school, while
such development as increased vital and mental
capacity are not necessarily accompanied by linear
growth or increase in weight, and yet they may be
accepted as evidence of cause and effect of an
improved nutritional state. .
As to children in one school being more stunted
than in another, this can and should be verified by
applying age-height standards, but it is certainly
expedient to observe the parents before seeking a
cause in the school routine. There is an example of
such a high proportion of small children in a day-
school near London. The parents are of small stock,
and the grandparents are migrants from the north.
There is also a type of child known to the children’s
hospital as the “ Austin 7”: feeding it with gland
extract or milk does not convert it into the “ Rolls-
Royce ” type.
As these small children can and do become efficient
people, and more pathological forms of dwarfism occur
before school entry, it seems that, beyond securing
the stimulus afforded by milk, it is most practical
to take the height attained as the basis for other
measurements ; and if the height-weight standards
are to be applied, they should be correlated by some
reference to cross-section, of whioh chest circum-
ference is a rough expression. It can be easily shown
that with equal sitting-height, weight varies directly
with chest circumference, and this is evidently only
THE SERVICES (continued from previous page)
very distinguished officer was Director-General Army
Medical Services from 1905 to 1910 and again during the
war from 1914 to 1918.
The following changes are announced :—
Col. H. H. A. Emerson, D.S.O., was promoted super-
numerary Major-General on March 26th, and will continue
in his appointment at the War Office as Director of Hygiene,
Col. J. W. L. Scott, D.S.O., was promoted to Major-
General on March 26th, and leaves the War Office to be
Deputy-Director of Medical Services, Eastern Command.
Major-General FitzG. G. FitzGerald, C.B., D.S.O.,
vacated medical charge at Horse Guards on March 26th.
Col, F. Casement assumed the post of Deputy Director-
Genera] Army Medical Services on March 26th.
Col. S. W. Kyle is the new Assistant Director-General
at the War Office.
The War Office announces that applications are invited
from medical men for appointment to commissions in the
R.A.M.C. Candidates will be selected for commissions
without competitive examination, must present themselves
in London for interview about April 22nd, and normally
must not be over the age of 28. Successful candidates
will be given short service commissions for five years,
and then may apply for a permanent commission. Those
not selected willretire with a gratuity of £1000. Particulars
and forms of application may be obtained on application,
either by letter or in person, to the Assistant Director-
General, Army Medical Services, the War Office, London,
S.W.1.
ROYAL ARMY MEDICAL CORPS
Capt. J. E. Swyer to be Maj.
C. M. Arthur to be Lt. (on prob.).
SUPPLEMENTARY RESERVE OF OFFICERS
J. Montgomerie to be Lt.
TERRITORIAL ARMY
The King has conferred the Efficiency Decoration upon
the undermentioned officers under the terms of the Royal
Warrant dated Sept. 23rd, 1930: Lt.-Col. W. L. M.
Gabriel, Lt.-Col. K. Pretty, and Maj. and Bt. Lt.-Col.
G. Whittaker.
Hon. Maj.-Gen. Sir Richard H. Luce, K.C.M.G., C.B.,
V.D., T.D., vacates the appointment of Hon. Col. R.A.M.C.
Units, 46th (N. Mid.) Div.
Lt. N. J. Nicholson to be Capt.
Lt. S.-R. Trick to be Capt.
Lt. D. P. MacIver, M.C., late 12th Bn. A. and S. H.,
to be Lt.
' Capts. W. F. Mulvey and J. W. Graham resign their
commissions.
Lt. A. McC. Campbell, from 8th Bn. A. and S.H. Scouts,
to be Capt. -
Capt. T. H. Wilson, from Univ. of Lond. Contgt. (Med.
Unit), Sen. Div., O.T.C., to be Capt.
P. O’Donnell to be Lt.
TERRITORIAL ARMY RESERVE OF OFFICERS
Maj. W. Barclay, M.C., from Active List, to be Maj.
Capt. J. W. Lobban from Active List, to be Capt.
H. D. Kendrick to be Lt. (Army Dental Corps),
INDIAN MEDICAL SERVICE
Majs. to be Lt.-Cols.: D. Sanyal, S. M. A. Faruki.
B. B. Gadgil, D. P. McDonald, A. N. Sharma, P. N.
Basu, and J. J. Rooney.
Lt. (on prob.) J. G. Thomson to be Capt. (on prob.).
THE LANCET]
an expression of the ordinary physical relationship
between height, cross-section area, volume, and
weight. Efforts directed to increasing chest circum-
ference might conceivably arrest growth in length
temporarily, but lead to increase in weight in the
next rest period. In the accompanying illustration,
one might expect the physical development of other
boys in the same school to be along the lines of their
Nutritional Survey, Summary Record
(Series J., B.M. 100 Boys)
Residential school: estimate of—
A B C P Points
1. Nutrition ss .. 19 .. 253.. 26.. 2.. 261 ,
2. Home condition ore 0 .. 204 .. 64 .. 32 .. 76
3. School output . 105 .. 149 .. 45 .. 1 .. 312
Trunk(or eitting)height in inches.
27 28 29 30 3I 32 33 34 35 36
gayouy UT 438909
mpe
©
eight in pounde......
32 33 34 35
=
26 27 28 29 30 3I
Combined table and graph showing the desirability of con-
dering simultaneously the various complementary factors
in nutrition and growth, just as the temperature and pulse
chart is usually considered in conjunction with the clinical
notes in a hospital record.
schoolmates, or at least between the minimum and
maximum boundaries traced by 1000 more children
in the same district. It might well take place in
cycles of height, breadth, and weight increase. The
low weights marked ‘“‘C” appear to be sufficiently
explained by delayed chest development, those
marked ‘“ D” are more likely to be due to mal-
nutrition. As the latter are among the elder boys
the stress of puberty in addition to other anxiety
causes have been considered in detail in three -
subheadings of each of the three divisions of the
summary. Under each subheading the boy can get
an estimate as follows: A = excellent (2 points);
B = satisfactory (1 point); C = unsatisfactory
(— 1 point) ; D = bad(— 2 points). These details are
not shown in the Table.—I am, Sir, yours faithfully,
J. E. CHEESMAN,
Medical Inspector, Kent Education Committee.
Bromley, March 29th.
ERGOTAMINE TARTRATE IN MIGRAINE
[APRIL 3, 1937 839
SURGICAL BRUCELLOSIS
To the Editor of THe Lancet
SIR, —On my return from South Africa I have read
. with great interest Dr: J. L. Edwards’s report in
your issue of Feb. 13th of a case of “fixation ”
abscess of bone due to brucella. This is the first case
of what might be termed surgical brucellosis occurring
in this country of which I have heard, but there are
many reports in the literature of such occurrences
in the Mediterranean area due to infection with
Brucella melitensis, and there have been a few such
reports in recent years in connexion with both the
melitensis and abortus varieties of brucella. Thus
Botreau-Roussel and Huard reported in 1931 a case
of osteomyelitis of the lunate bone of the wrist in.a
soldier of 20 probably due to Br. melitensis, the infec-
tion having been acquired in the course of a local
epidemic of undulant fever in man and abortion in
goats in the village of La Souche (Ardéche); Hardy,
Jordan, and Borts reported in 1936 a series of cases
of undulant fever in Iowa which included osteo-
myelitis of various long bones and one of the small
bones of the wrist; Grilichess reported a case in
1930 from Switzerland in which the patient, a farmer
of 29, developed a small abscess on the dorsum of
the right foot from which Br. abortus was grown in
pure culture, —
It is interesting in this connexion to note also that
local abscess formation in the conditions known as
poll-evil and fistulous withers are quite common in
horses in America, Germany, Holland, and other
Hardy, A. V., Jordan, C. F., and Borts,
H. (1936) J. Amer. med. Ass. 107, 559. . Grilichess, K. R.
I an, Sir, yours faithfully,
WELDON DALRYMPLE-CHAMPNEYS,
Ministry of Health, Whitehall, S.W., March 23rd.
ERGOTAMINE TARTRATE IN MIGRAINE 7
To the Editor of THE LANCET
Srr,—As a very great sufferer, in past days, from
. this dyscrasia, I suggest to Dr. Kelly, and warn your
readers, to put no trust in drugs, or at present any
product from a laboratory. Years ago I asked a
distinguished physician, now ‘in the shades,”
“how about your migraine?” He dramatically
replied, “ Better; I have passed the change of life.”
I am well on in the seventh decade and can answer
as he did. The change begins in the mid-fifties.
I believe the only remedy is: a dark, well-ventilated
room, long drinks of water, and, with 5-minute
occasional intervals, a 24 hours’ sleep. The out-
standing point of this procedure is, there is no drug
aftermath.
I am, Sir, yours faithfully,
W. BURROUGH COSENS,
Tunbridge Wells, March 30th.
To the Edttor of THE LANCET
Sir,—From my personal experience of the relief of
migraine headache by ergotamine I can add one
small point to those enumerated by Dr. Kelly. In
my own case I was for several years almost incapaci-
tated for three days every fortnight: since taking
Femergin hypodermically about 60 attacks have
been aborted with no failures. The attacks however
are more frequent than they used to be.
I have found that the beneficial effect of the drug
is aided by taking food at the same time. Whereas
840 THE LANCET]
when I first used femergin I frequently had to
repeat the dose in 1-2 hours to stop the attack,
I now find that one dose is enough if food is taken
at the same time,
I am, Sir, yours faithfully,
ELIZABETH L. FLEMMING,
Upper Wimpole-street, W., March 29th.
HYPOGLYCAZMIC SHOCK IN THE TREATMENT
OF SCHIZOPHRENIA |
To the Editor of THE LANCET
Srr,—Being partly responsible for the introduction
of hypoglycemic shock for schizophrenia into this
country and the first to use it here, I welcome Dr.
Russell’s clear-cut article in your last issue (p. 747),
PARLIAMENTARY
FACTORIES BILL IN COMMITTEE
THE Factories Bill was further considered by a
standing committee of the House of Commons on
March 23rd.
: DANGEROUS CONDITIONS
On Clause 38 (which provides that if on complaint
by an inspector a court of summary jurisdiction is
satisfied that any part of the works, machinery, or
plant used in a factory is in such a condition, or so
constructed, that it cannot be used without risk of
bodily injury, or any work is carried on in such a
manner as to cause risk of bodily injury, the court
may prohibit the use of that part of the factory or
prohibit its use until it is repaired or altered, or
require the owner to take steps for remedying the
danger) Mr. SILVERMAN moved an amendment
providing .that the clause should be mandatory
instead of permissive by leaving out the word “ may ”
and inserting the word ‘‘shall.” He said that the
court should not be left with discretion in the matter
of making an order where they were satisfied that
an offence had been committed.—After discussion,
Mr. Lioyp said it did not make any difference
‘whether the word “ shall ” was inserted, though he
feared that it would not have the result expected by
- supporters of the amendment.—The amendment was
agreed to. '
Mr. Ruys DAVIES moved an amendment to leave
out ‘‘ danger to life” and to insert “ risk of bodily
injury.” Under the clause as it stood he said the
court would only be entitled to make an order if
the inspector was satisfied that a workman was
about to be killed. He wished to enable the court
to make an order when an inspector was satisfied
that a workman was liable to bodily injury.—Mr.
LLOYD said that a tremendous power was given under
the clause and it should be circumscribed within
proper limits. He accepted the broad principle, but
the amendment went too far. He thought it would
be better if they made the amendment read “ risk
of serious bodily injury.’ —The amendment was
agreed to in this form.
On Clause 39 (Power of court of summary juris-
diction to make orders as to a dangerous factory)
Mr. Rays Davis said that amendments had been
put down on danger to health. He wished to know
whether the interpretation of “ bodily injury” in
the interpretation clause included injury to health.—
Mr. LLOYD : Yes, Sir, that is included in the definition
clause.
. DRINKING WATER
On Clause 40 (Supply of drinking water) Mr. BURKE
moved an amendment to provide that when the
supply of drinking water did not consist of a drinking
jet there should be provided and maintained at
every point of supply a reasonable number of clean
drinking vessels. He said that those who had experi-
ence of factories knew how very inadequate the
PARLIAMENTARY INTELLIGHNCE
[APRIL 3, 1937
and agree with his conclusions Eleven cases have
been treated at the Royal Edinburgh Mental Hospital
since March, 1936, and in the 526. periods of hypo-
glycemia no alarming incidents have occurred, In
certain cases of prolonged coma there is deficient
absorption of the glucose feed by the stomach, when
larger amounts of intravenous glucose should be
given. In my experience after-shock is only likely
to occur when more than 1 c.cm. of adrenaline has
had to be given, or when the patient has refused his
ordinary meals after the feed. Smoking should not
be permitted until one hour after the feed, as it
tends to precipitate the hypoglycemic symptoms, or
cause a return of these.
I am, Sir, yours faithfully,
Edinburgh, March 26th. H. PULLAR STRECKER.
INTELLIGENCE
provision often was for the supply of water to the
workpeople, and realised the advisability of ensuring
that in addition to the water-supply being adequate
the drinking vessels themselves should be kept clean.
He would prefer that instead of having any drinking
vessels at all there should be at suitable points in
the factory a basin with a jet of water. That ensured
cleanliness for everyone using the jet. It would be
better in many cases for the workers to go thirsty
all day rather than use over and over again, one after
another, one dirty can which they could not wash
properly unless they washed it in the water they
were going to drink. From the health point of view
he felt that this clause was weak and might be easily
strengthened at very small cost.
Mr. LLOYD said he agreed with the mover of the
amendment that it was important to have proper
supplies of drinking vessels. In his experience he
much preferred the jets. Provisions rather similar
to those contained in the amendment were inserted
in the Drinking Water Welfare Order which had
wide application to factories, but not to all, and
particularly not to small factories. In this Bill the
term factory applied to something which they had
not always been accustomed to regard as a factory,
but rather as a workroom. A dressmaker’s establish-
ment with a dressmaker and one assistant was
actually a factory under this Bill. They had to be
careful to consider such small places as that. While
accepting the principle he could not accept the
wording of the amendment. He would suggest that
the amendment should read: ‘‘ Except where the
water is delivered in an upward jet, from which the
workers can conveniently drink, one or more suitable
cups or drinking vessels shall be provided at each
point of supply with facilities for rinsing them in
drinking water.” The last part was intended to
apply to small establishments.
Mr. BURKE withdrew his amendment in favour
of the amendment suggested by Mr. Lloyd.
CLEANLINESS
On Clause 41 (Washing facilities) Mr. MANDER
moved an amendment the object of which he said
was to extend washing facilities to every factory in
the country.—Sir E. GRAHAM-LITTLE said that it
was not only in the factories where dirty and offensive
materials or processes were used where washing was
required. It was just as essential in factories where
cleanliness was of paramount importance in the
processes, such as in the preparation of food. In a
great factory in Chicago the employees who packed
sandwiches were actually manicured before going
into the factory. If the Under-Secretary would
accept the requirements of this amendment he
would move that the word ‘“ cleansing ’’ should be
substituted for the word ‘‘ washing.’’—Mr. BANFIELD
said that food was being prepared in all kinds of ways
and canned or bottled in many factories, and the
tremendous advantage of suitable washing facilities
THE LANCET]
had been proved in the packing industry. As a
result of consultation with the Home Office a Washing
Facilities Order was issued and led to vast improve-
ment both in the food trade itself and in benefit to
the men and women engaged in the industry.—Mr.
WELSH said that he wished the committee could see
the changes that had taken place in the miners,
and particularly the young men, as a result of the
provision of pit baths.
Mr. LLOYD said that the Government accepted
the view that the provision of washing facilities was
very important as a general question in view of the
rising standards of life of our people. But there
were certain difficulties involved. ashing facilities
were provided under the Dangerous Trades Regula-
tions and Welfare Orders and a considerable number
of industries were covered. This clause was really
an attempt to carry these processes further by giving
@ quicker method of extending washing facilities to
other industries; but after listening to the discussion
that day he thought that the matter ought to be
considered with a view to bringing forward wider
proposals. He could not accept this amendment at
that stage. This was an expensive part of the Bill.
It would not be reasonable to require in every case
the provision of elaborate washing facilities if they
were not really going to be used. If the amendment
was withdrawn he would undertake to go into the
matter before the report stage with a view to widening
the proposals in the clause.
The amendment was negatived.
Mr. SHORT secured an amendment that a sufficient
supply of soap and clean towels conveniently situated
should be provided under the clause.
On Clause 42 (Accommodation for clothing) Mr.
MANDER moved an amendment to provide that the
clause should apply to all factories. He said if work- -
people came to a factory, no matter what the pro-
cesses were that were carried on, and they were
soaked through with rain facilities should be pro-
vided for drying their clothing before they went
home.—Mr,. LLOYD promised to look into the matter
before the report stage.—Mr. VIANT said that many
men working on buildings for example were com-
pelled to work in very inclement weather. They
ought not to be expected to work in wet clothes.
Rheumatism was extraordinarily prevalent in the
building trade, and he hoped that the Under-Secre-
tary would try to meet this difficult point.—The
amendment was withdrawn.
FIRST AID
On Clause 44 (First aid) Mr. BROAD said that as
drawn the clause only provided for first-aid boxes in
factories where mechanical power was used. He
moved an amendment to remove that limitation.
There were many dangerous operations in places
where no mechanical power was used and minor
injuries might lead to major trouble, such as septic
poisoning. It would be no burden for employers in
factories without mechanical power to make such
elementary provisions for first aid as could be found
in any decent home in the country.—Mr. LLOYD
said that in this case, as in an earlier one which the
committee had discussed, they had to remember that
the Bill covered very small establishments. Would
it be reasonable to require the provision of a first-aid
box in a dressmaking establishment with one prin-
cipal and an assistant? According to Home Office
records there were small establishments where acci-
dents occurred rarely, or were unknown. In cases
where dangerous operations took place in factories
without mechanical power undoubtedly first-aid
boxes ought to be provided. But they could be
required under the Bill through the safety or welfare
regulations, and he could assure the committee that
in any such case the Home Secretary would require
the provision to be made.—After further discussion,
Mr. LLOYD promised to look into the matter further
and the amendment was withdrawn.
Sir E. GRAHAM-LITTLE moved an amendment to
provide that the first-aid boxes should be examined
PARLIAMENTARY INTELLIGENCE
[APRIL 3, 1937 84]
annually by a factory surgeon. He said that the
inspection of first-aid boxes was as necessary as the
inspection of fire appliances, and they should be
inspected as well as used by a competent person.—
Mr. LLOYD said the Home Office did not think it
was really necessary that the first-aid boxes in fac-
tories should be examined by a surgeon. The con-
tents of the boxes were prescribed in detail by the
‘Secretary of State under orders, and therefore it
was an easy matter for the factory inspector to make
certain that the right ingredients were in the boxes.—
Sir E. GRAHAM- replied that it was not so
much the right ingredients as their condition. It
was the aseptic character of the dressings which was
required and that could not be estimated by simple
inspection.—Mr. LLOYD said that that was a matter
which he would consider further. The Home Office
considered that the factory inspectors were capable
of checking the contents of the boxes, and he was
advised that there was not much risk of deterioration
of the contents for a reasonable period. He would
however look further into the question of the aseptic
part of the dressings. With regard to the qualifica-
tions of those who applied the first aid, that again
was a question of distinction between very small
workrooms and large factories. It was conceivable
that in a large factory it might be a reasonable require-
ment to have someone proficient in first aid, although
he was advised that ‘‘ a responsible person,’’ which
was the term used in the Bill, should be capable of
dealing with most of the minor first-aid assistance
which was necessary. He would however recon-
sider the question with a view to making some dis-
tinction between large factories where it might be
reasonable to have someone experienced in first aid
and cases where it would not be reasonable.
The amendment was withdrawn.
AN AMBULANCE ROOM IN EACH FACTORY
Mr. Ruys Davies moved an amendment to ‘ensure
that where more than 150 persons were employed in
a factory a suitably equipped ambulance room should
be provided, and such arrangements should be made
as to ensure the immediate treatment there of all
injuries occurring in the factory. He said that there
was always a danger unless there was an ambulance
room where an injured workman could be properly
treated that septic poisoning would set in. It was
an astonishing fact that in this country, for some
reason he did not know, whereas the health of the
community had improved enormously the statistics
of sickness and disablement arising from injuries
showed an increase every year. His view was that
speeding-up had something to do not only with the
rate of sickness but with the number of small acci-
dents which were constantly occurring. He hoped
that the Home Secretary would look with a kindly
eye on this amendment.
Sir JoHN SIMON said that he looked on this amend-
ment with a great deal of sympathy; the only
question was the best way of doing it. When they
came to the end of this clause they would have made
provisions under which welfare regulations could be
made dealing with ambulance and first-aid arrange-
ments. Already under the existing factory code
welfare orders had been made by the Home Office
which required an ambulance room. The point
about which he felt some doubt was whether they
should lay it down in the Statute that where there
were 150 workpeople there should be an ambulance
room. He was advised that the question did not
depend on the number of the workpeople. He urged
that the better way of dealing with the matter was
by welfare orders.
The amendment was withdrawn.
BUILDING IN SCOTLAND
In reply to a question by Mr. MATHERS in the House
of Commons on March 23rd, Mr. ELLIOT, Secretary
of State for Scotland, said that five meetings had
been held with representatives of employers and
operatives representing practically all the organisa-
842 THE LANCET]
PARLIAMENTARY INTELLIGENCE
[APRIL 3, 1937
tions in the building industry in Scotland, at the
first of which he was himself present. Information
has been placed before the building industry showing
the approximate amount of public work (including
houses, schools, hospitals, &c., and building for defence
requirements) that it is desired to carry out within
the next few years. The representatives of the
industry were asked to examine and consider whether
the available supply of skilled labour in the different
trades was sufficient to enable the various programmes
to be carried out; and, if not, to suggest methods by
which the supply could be increased. The repre-
sentatives of the industry were prepared to make
recommendations designed to secure such progressive
increase in the number of skilled operatives as might
be necessary, provided that assurances are given of
reasonable continuity of employment. Under the
provisions of the Housing (Scotland) Act, 1935,
the Exchequer contributions at the present rates
are payable for houses completed by March 3lst,
1938, and the question of the rates for the three years
immediately following that date must be reviewed
in consultation with the associations of local
authorities after Oct. Ist this year. In view of the
importance to local authorities of knowing what their
financial position will be after March 3lst, 1938,
it was his intention, said Mr. Elliot, to submit
proposals to Parliament for the continuance of the
present rates of Exchequer contributions under the
Housing (Scotland) Act, 1930, and ‘the Housing
(Scotland ) Act, 1935, for the three years beginning on
April 1st, 1938, that is to March, 1941. The Govern-
` ment were closely watching the position in regard
.to supplies and prices of materials, and will keep in
touch with local authorities and producers in the
matter. He was arranging, Mr. Elliot added, for
meetings with the associations of local authorities
to discuss the question of planning these building
programmes so as to ensure the maximum degree
of continuity of progress. When these negotiations
were concluded there would be made possible a marked
improvement in the recent rates of house building
by local authorities, and that as further operatives
become available the rate could be progressively
expanded.
Replying to further questions Mr. Elliot said that
the arrangement did not involve the abrogation
of trade-union rules, and that the present rate of
assistance would be guaranteed for the lifetime of
this Parliament.
NOTES ON CURRENT TOPICS
Cardroom Workers and Respiratory Illness
In the House of Commons on March 25th
Mr. SUTCLIFFE asked the Home Secretary whether
he was now able to announce the names of the
committee to be appointed to inquire if a workable
scheme could be devised for providing compensation
_ for cardroom workers disabled by respiratory illness.—
Sir JoHN SIMON replied: Yes, Sir. The following is
a copy of the arrant of Appointment of this
committee :—
“I hereby appoint: Mr. W. D. Ross, O.B.E., M.A.,
LL.D., D.Litt.; Mr. P. N. Harvey, F.I.A.; Mr. T.
Hutson; Prof. GEorGE R. Murray, M.D., F.R.C.P.;
and Mr. W. F. WACKRILL, O.B.E., to be a committee
to consider and report whether an equitable and workable
scheme can be devised for providing compensation in the
case of persons who, after employment for a substantial
period in cardrooms, or certain other dusty parts of
cotton spinning mills, become, or have become disabled
by respiratory illness as indicated in the Report of the
Departmental Committee on dust in cardrooms ; and, if so,
to make detailed recommendations as to the provisions
to be included in such a scheme, more especially as to the
persons to whom benefit should be payable and the rates
and conditions of benefit, the medical and other machinery
for administering the scheme, the method of financing the
scheme, and its approximate cost. And I further appoint
Dr. W. D. Ross to be chairman and Mr. C. P. Gourley to be
secretary of the committee.” ,
In the House of Lords on March 23rd, the Marquess
of DUFFERIN AND AVA introduced a Bill to provide
for the regulation of the fumigation of premises and
articles by hydrogen cyanide. The Bil was read
a first time.
In the House of Lords on March 23rd the Public
Health (Drainage of Trade Premises) Bill was read
the third time and passed.
In the House of Commons on March 23rd
Mr. BALDWIN, Prime Minister, presented a Bill to
regulate the salaries payable to those holding certain
Administrative Offices of State. It provided addi-
tional: salaries for members of the Cabinet holding
offices at salaries less than £5000 a year, a salary
to the existing Prime Minister, pensions to those
who have been Prime Minister, and a salary to the
Leader of the Opposition. It also simplified the law
about the capacity of those holding offices of profit
z ay and vote in Parliament. The Bill was read the
st time.
In the House of Lords on March 24th the Deaf
Children (School Attendance) Bill passed through
Committee. The House of Lords adjourned for the
Easter recess on March 24th until April 7th. The
House of Commons adjourned on March 25th until
April 6th.
QUESTION TIME
TUESDAY, MAROH 23RD
Sickness and Ill-health in the Army
Mr. SORENSEN asked the Secretary of State for War
how many were discharged from the Army. through
sickness and ill-health during 1936; and how many of
these received or would receive, either pensions or some
kind of financial assistance.—Mr. Durr Cooper replied :
During 1936, 1786 men were discharged from the Army and
Army Reserve as invalids. I regret that the information
asked for in the second part of the question is not available,
but during the year referred to 1800 new applications for
disability awards were preferred. Pensions, permanent
and temporary, were awarded in 398 cases, and gratuities
in 813 cases.
Slow-burning or Inflammable Films
Mr. Day asked the Home Secretary whether, in view of
the changes that had taken place in the cinematograph
film-producing industry since the case of the Victoria
Pier (Folkestone) Syndicate, Limited, versus Reeve, which
was decided in 1912, with reference to the meaning of
slow-burning or non-inflammable films, aid the confusion
among local licensing authorities as to the application
of same to present-day sound films, he would consider
the appointment of a departmental committee to consider
these difficulties and to advise and enable him to introduce
legislation to clarify the position.—Sir JoHN Simon
replied : I do not think it necessary to appoint a depart-
mental committee, as I propose to refer the question of
slow-burning or non-inflammable films to an advisory
committee on the Cinematograph Act, 1909, which my
right hon. friend, the Secretary of State for Scotland, and
I are in process of constituting.
Mining Explosions in Britain and France
Mr. Rowson asked the Secretary for Mines if he could
give comparative figures showing the number of explosions
in the British mining industry and the French mining
industry, and the number of persons killed in such
explosions during the last 15 years.—Captain CRooKSHANK
replied: There may be some doubt whether the figures
are strictly comparable but they indicate that the French
record in regard to explosions is proportionately so much
better than our own that the French Government has been
asked to give facilities for an investigation to be made into
any differences in their conditions or practice. The
investigators will be Major Hudspeth, Deputy Chief
Inspector of Mines, and another officer of my department,
and they will leave for France as soon ‘as the necessary
arrangements can be made with the French Government.
The following is a statement showing the number; of
THE LANCET]
explosions and the number of persons killed thereby at
mines under the Coal Mines Act in Great Britain and at
coal and lignite mines in. France during the years 1920-—
1934.
GREAT BRITAIN. FRANOE.
weer: Explosi Explosions
xpiosions| Person xplosions' Persons
involving involving K
death. killed. death. killed.
1920 16 ' 26 3 4
21 15 19 4 25
22 14 — 73 3 3
23 16 60 1 2
24 18 35 2 2
25 11 29 1 1
26 5 1 2
27 11 72 4 13
28 15 36 — —
29 13 34 4 35
1930 18 70 2 9
31 12 | 107 — —
32 13 | 69 — —
33 35 — —
34 11 — —
| 296
Note—Owing to the absence of detailed particulars of each
separate accident in the case of France, there may be a few
cases in which death was due to asphyxiation without an
explosion having taken place.
Grants for Slum Clearance
Mr. WILFRID RosBerts asked the Minister of Health
whether a final decision had been reached as to whether
or not housing grants for slum clearance would be payable
after March 31st, 1938 ; and whether only houses actually
completed by that date would be eligible for Government
grants.—Sir KrinesLEy Woop replied : Under Section 109
of the Housing Act, 1936, I am called on to review after
Oct. lst, 1937, in consultation with the Local Authorities
the Exchequer contributions payable for slum clearance
and the abatement of overcrowding. The section provides
that contributions at the existing rates will be payable for
houses completed by March 31st, 1938. Local authorities
will soon be letting contracts for houses which will not be
completed till after that date, and I have received a
number of representations on the matter,
The completion of slum clearance and the abatement of
overcrowding are vital elements in the health services
of the country. I am anxious to preserve the continuity
in this housing programme, and to avoid the disturbance
which might result from a position of uncertainty. I
have therefore given some preliminary consideration to the
matter. I cannot under the statute carry out my
review or submit proposals to Parliament till after
Oct. lst, 1937, and these proposals must be made in the
light of the facts as they then exist. When I do submit
proposals it is my intention to include among them pro-
visions under which the new existing rates of Exchequer
contribution will continue without alteration for houses
built in replacement of unfit houses or for the abatement
of overcrowding which are completed by Dec. 31st, 1938.
Model Diet in Mental Hospitals
Mrs. TATE asked the Minister of Health in how many
mental hospitals in England and Wales the model diet for
an entire four-week period had been introduced as recom-
mended in the 1924 Report of the Departmental Committee
on Dietaries in Mental Hospitals.—Sir Kınasıesy Woop
replied: I understand a number of mental hospitals
have adopted a dietary for a four-week period though
I am not aware of the exact number. The matter is
determined by the visiting committee of the local authority
generally upon the advice of the medical superintendent.
I am advised that the standards recommended by the
Committee on Dietaries have been generally adopted.
WEDNESDAY, MAROH 24TH
Medical Research in East Africa
Mr. MATHERS asked the Colonial Secretary whether
any steps had been taken as to the result of the recom-
mendation of the Conference on the Codrdination of
General Medical Research in East Africa that research
into the social and economic development of the African
PARLIAMENTARY INTELLIGENCE
[APRI 3, 1937 843
should be undertaken by the Medical Research Council.—
Mr. OBRMSBY-GORE replied: I assume that the hon.
Member is referring to the report of the conference held
in January, 1936. The recommendation of that conference
was not that research be undertaken by the Medical
Research Council but that, in order to help if it was decided
to make an application for funds, a body of experts should
visit East Africa. The report was examined by the
Tropical Medical Research Committee of the Medical
Research Council and by the Colonial Advisory Medical
Committee, who advise me that they doubt whether any
useful purpose would be served by such a visit and that
further assistance could best be rendered by the visit of
individual experts to study special problems as they
arise. I regret that at the present time there are no
funds available from which such a scheme of further
research could be financed, and I observe from the Report
of the Conference that the minimum sum required for
their scheme was stated to be at least £30,000 or £40,000
& year.
Medical Certificates and School Meals
Mr. Moraan Jones asked the President of the Board of
Education whether he would make arrangements
whereby local education authorities could delegate to
headmasters and headmistresses of schools authority to
give meals to necessitous children without waiting for a
certificate from the medical officer of the authority.—
Mr. GEOFFREY SHAKESPEARE, Parliamentary Secretary
to the Board of Education, replied: I am sending the
hon. Member a copy of the Board’s Circular 1443, from
which he will see that there is no requirement that a
certificate should be given by the school medical officer
before children may receive free meals. It is for the
local education authority to decide whether children should
be fed, and in paragraphs 4 and 5 of the Circular they are
urged to invite reports from school. medical officers,
teachers, and others in regular contact with the children
from day to day, and to make interim arrangements,
pending full investigation, for the immediate feeding of
children recommended for meals. i
THURSDAY, MARCH 25TH
Spirochetal Jaundice Order
Mr. WrinpDsor asked the Home Secretary whether he
was now prepared to make the necessary order for the
scheduling of spirocheetal jaundice as an industrial disease,
as recommended by the Home Office Committee.—
Captain MarcGrEsson, Parliamentary Secretary to the
Treasury, replied: The drafting of this order has been
found to raise some points of difficulty, which are being
gone into, but my right hon. friend hopes that the matter
will be settled at an early date.
Drunkenness in Armament Areas |
Sir ROBERT Youne asked the Home Secretary whether,
in view of the increased drinking and drunkenness in some
towns concerned in the new measures for national defence,
and in particular in Warwickshire, where a chief constable
had drawn attention to the considerable increase
of drunkenness and disorderliness since the drinking
hours were lengthened, he would call for an inquiry
into the influence of the various kinds of extended drinking
facilities upon public order and industrial efficiency,
especially in the armament manufacturing areas.—
Captain Mararsson replied: The grant of extended
drinking hours lies, generally speaking, in the discretion
of the local justices, who can be trusted to take due account
of all relevant circumstances in their locality. My right
hon. friend does not think that there is any ground for the
institution of such an inquiry as is suggested by the
hon. Member. |
Infectious Diseases Hospital for Retford and
Worksop
Mr. BELLENGER asked the Minister of Health whether
he had yet approved a scheme for the provision of an
infectious diseases hospital for the urban and rural districts
of Retford and Worksop.—Sir Kin@sLEyY Woop replied :
The scheme of the Nottinghamshire County Council for
the provision of adequate hospital accommodation for
the treatment of infectious diseases in that county was
844 THE LANCET]
approved by me on Oct. 10th, 1935. I have since received
from the local authorities concerned applications for
provisional orders for the establishment of joint hospital
boards for that part of the county in which the districts
to which the hon. Member refers are situated. These
applications are under consideration.
Appointments under Midwives Act, 1936
Mr. Vrant asked the Minister of Health if, when issuing
regulations in connexion with the Midwives Act, he
instructed the medical officers of health when making
appointments to confine such appointments to those who
possessed a certificate in midwifery and also the certificate
of a State-registered nurse.—Sir KINGSLEY Woop replied :
The Midwives Act, 1936, does not empower me to issue
regulations with regard to the qualifications of midwives
to be appointed under the Act. Im the circular which I
addressed to local supervising authorities on Sept. 18th
last I drew attention to the importance of absorbing into
the new service as many as possible of the independent
midwives, at present in practice, and the circular made
no suggestion that appointments should be confined to
midwives who are State-registered nurses. I should
deprecate any such limitation in the case of the appoint-
ments first made by local supervising authorities under
the Act.
Prepared Fruit Juice
Mr. DE LA BERE asked the Minister of Health whether
he was aware that cases existed of manufacturers who
made synthetic or semi-synthetic products labelled as
genuine fruit juice, or prepared fruit juice, which contained
no foundation of real fruit; and whether he would take
steps to prevent such mis-description.—Sir KINGSLEY
Woop repliéd: . On the facts as stated it would appear
that the matter can be dealt with by the responsible
local authorities under the Food and Drugs (Adulteration)
Act, 1928, and I do not think, therefore, that any special
action on my part is necessary.
Indictable Offences
Mr. SHort asked the Home Secretary the number of
persons found guilty of indictable offences during 1935
and 1936, respectively, the number of juvenile offenders,
and how the latter were dealt with.—Sir JoHN SIMON
PUBLIC HEALTH
N
u
[APR 3, 1937
replied: The number of persons found guilty in 1935
of indictable offences was 69,849. Of these offenders
25,543 were under the age of 17. Of the offenders under
the age of 17, 9 per cent. were sent to Home Office Schools,
5l per cent. were placéd under the supervision of a
Probation Officer, 8 per cent. were bound over without
an order for supervision, and 24 per cent. were dismissed.
Figures for 1936 are not yet available. `
Health Insurance and Medical Treatment
Sir ROBERT GOWER asked the Minister of Health if,
taking the figures for the last five years, he could state the
average number of insured persons who had never used
the services of their panel doctor.—Sir KinesLEY Woop
replied : In each of the five years 1932 to 1936 the number
of insured persons in England and Wales who, although
entitled to medical benefit had not chosen an insurance
doctor, was on the average about 495,000. I cannot give
a similar figure of the number of persons who have chosen
a doctor but have not used his services.
Clinics for Mental and Nervous Diseases
Mr. Rays Daviss asked the Minister of Health how
many clinics were operating, under the control of his.
department or the Board of Control, for persons suffering
from incipient mental or nervous diseases, together with
their location and availability.—Sir KivestEy Woop
replied: I am having this information compiled and will
send it to the hon. Member as soon as possible.
Ministry of Labour versus a Manchester Hospital
Mr. ELLs Smirg asked the Minister of Labour whether
he had considered the report by the Manchester Royal
Infirmary Medical Board on the building which the Ministry
of Labour intended to erect adjoining the central branch
of the Manchester Royal Infirmary; and what action
he proposed to take.—Mr. E. Brown replied: I would
refer the hon. Member to the reply given on this subject on
March 8th.—Mr. Smits : Has the Minister considered the
very serious report prepared by the medical board, and, if
he has, will he give his personal attention to this matter
in order that satisfactory arrangements can be made
between the two parties ?—Mr. Brown: I am giving my
personal attention to this matter.
PUBLIC HEALTH
A Five-Year M. and C.W. Scheme for
London
On April Ist comes into operation the scheme by
which the L.C.C. and the councils of the metropolitan
boroughs make a fixed contribution for the next
five years to the voluntary associations providing
M. and C.W. services in the county of London. The
four largest annual contributions are these: North
Islington infant welfare centre, £4319; Royal College
of St. Katharine infant welfare centres, £3860;
Violet Melchett infant welfare centre, day nursery
and mothercraft training home, £3535; Salvation,
Army mothers’ hospital, £3034. The conditions
attached to the grants are that the council shall be
satisfied of the efficiency of the services provided
and that a reasonable number of the persons are
using them, that no reduction or alteration of the
services shall be made without the consent of the
council, that the premises are open to inspection at
all reasonable times, and that a copy of the annual
report with a statement of accounts and auditor’s
certificate shall be sent each year to the council.
On the other hand, the council may not terminate
or reduce the annual contribution without the con-
sent of the Minister of Health, and any dispute or
difference between the council and a voluntary
association must be referred to the Minister whose
decision shall be final.
INFECTIOUS DISEASE
IN ENGLAND AND WALES DURING THE WEEK ENDED
MARCH 20TH, 1937
_Notifications.—The following cases of infectious
disease were notified during the week: Small-
pox, 1 (Derby); scarlet fever, 1791; diphtheria,
1068; enteric fever, 24; pneumonia (primary or
influenzal), 1288; puerperal fever, 37; puerperal
pyrexia, 115; cerebro-spinal fever, 25; acute
poliomyelitis, 3 ; acute polio-encephalitis, 1 ; encepha-
litis lethargica, 8; dysentery, 20; ophthalmia
neonatorum, 90. 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 26th was 3305, which included :
Scarlet fever, 852; diphtheria, 1041; measles, 26; whoop-
ing-cough, 568 ; puerperal fever, 18 mothers (plus 10 babies) ;
encephalitis letbargica, 282; poliomyelitis, 1. At St.
Margaret’s Hospital there were 15 babies (plus 6 mothers)
with ophthalmia neonatorum.
Deaths.—In. 122 great towns, including London,
there was no death from small-pox or enteric fever,
19 (1) from measles, 1 (0) from scarlet fever, 21 (3)
from whooping-cough, 36 (4) from diphtheria, ‘45 (14)
from diarrhoea and enteritis under two years, and
171 (21) from influenza. The figures in parentheses
are those for London itself.
Birmingham reported 5 deaths from measles, Hull 2. Fatal
cases of whooping-cough were scattered over 15 great towns,
Liverpool and Middlesbrough had each 3. Fatal diphtheria
was reported from 26 great towns, Liverpool and Birmingham
each 3. Deaths from influenza have slightly increased: Bir-
mingham reported 10, Leeds 7, Sunderland and Cardiff each 6.
The number of stillbirths notified during the week
was 281 (corresponding to a rate of 41 per 1000
total births), including 51 in London.
THE LANCET]
[APRI 3, 1937 845
OBITUARY
JOHN DAVID MALCOLM, M.B., F.R.C.S. Edin.
THe death occurred on Saturday, March 20th,
suddenly at Sheet House, Petersfield, of Mr. John
David Malcolm, in his day a well-known obstetric
surgeon. The son of Dr. John Malcolm of Edinburgh,
he received his medical training at the University of
Edinburgh and Guy’s Hospital, and graduated as-
M.B., C.M. Edin. in 1881, taking later the diploma of
F.R.C.S. Edin. He held the resident appointments
at the Royal Infirmary, Edinburgh, and then decided
to practise as a specialist in London. He made a
considerable mark with careful reports of clinical
work contributed to the Transactions of the Medical
and Chirurgical Society, the Medical Society of
London, and our own columns. He was elected to
the staff of the Samaritan Free Hospital, was president
of the obstetric and gynzcological section of the
Royal Society of Medicine, was awarded the Liston
Victoria Jubilee prize of the R.C.S. Edin., and
gained a high position in his specialty as a careful
and successful operator. He had retired from the
medical profession for a considerable time and was
approaching his -eightieth birthday at the time of
his death.
Dr. Cuthbert Lockyer sends us ihe following
appreciation :
there now remain only two of the eleven men who
made up the staff of the Samaritan Hospital at the
end of the last century. In 1898, which dates my
own connexion with that institution, the staff was
composed of five physicians and six surgeons. The
physicians were Drs. Boulton, Routh, McCann, Roberts,
and Tate. The surgeons were Messrs. Meredith,
Doran, Malcolm, Butler-Smythe, Targett, and Corrie
Keep, and the distinction which then existed between
‘physician’ and ‘surgeon’ was one of vested
interests. The activities of the former were confined
to. vaginal surgery, whilst to the latter came all the
laparotomies. The anomaly of this arrangement was
emphasised by the fact that the academic surgical
qualifications of the ‘physicians’ (as exemplified by
possession of the F.R.C. S. Eng.) were higher than
those of the ‘surgeons.’ A certain struggle for
equality was animated and Mr. Malcolm, as one of
the privileged ‘surgeons, finally acquiesced in the
removal of an anachronism. When the late Mr.
J. H. Targett retired in June, 1899, I took his place
and thus became assistant to Mr. Malcolm. This
meant helping at all his operations, at first in hospital
only, and later in private as well. This relationship
continued for a few years only » it lasted long enough
however, and was sufficiently intimate, for me to
appreciate the value of a training which in its austerity
is obsolete at the present day, but which, none the
less, I should have been sorry to miss. Those were
the days when the principle of total isolation for
abdominal cases was insisted on, and accordingly
laparotomy was only carried out in small rooms
containing one, or at most, two beds each. There
was no resident officer and the assistants’ duties
embraced the functions of house surgeon and porter
combined, whilst the nurse in immediate charge of
an operation-case would remain on duty continu-
ously for more than 48 hours. In 1896 Mr. Malcolm
was granted seven surgical beds and, if I recollect
rightly, these were distributed among half a dozen
small rooms. In 1905 the number of his beds was
increased to eight.
“ Malcolm had inherited many of the attributes of
‘With the death of John Malcolm.
his predecessor and master, Knowsley Thornton,
including a certain brusqueness of demeanour which,
whilst alarming at first, was found later to be only a
surface-display and became far less evident as time
went by. Looking back after a lapse of more than
a quarter of a century one recalls Malcolm as a
colleague who merited respect for his outspokenness
and his honesty of purpose, for his indomitable energy
and perseverance, for his loyalty to, and willingness
to help, a colleague, and even for his pertinacity in
opposition. It would be safe to say that he had no
enemies among his hospital colleagues and this may
be explained because we always knew what was to
be expected of him, At the Samaritan the governing
body induced him to continue his services beyond
the age limit of 60 years, and it was universally felt
‘that the reputation of the institution was enhanced
by his services. His death will be accounted a-severe
loss not only by his old colleagues who survive him,
but by all those with whom he came in contact at
the Samaritan and at the Royal Society of Medicine.”
JOHN ARNOLD JONES, O.B.E., M.B. Vict.,
F.R.C.S. Edin.
WE regret to announce the death of Dr. Arnold
Jones at the age of 57 which occurred suddenly on
March 23rd. He had been in poor health for some
time past following a severe illness last winter, but
recently had seemed much better and his sudden
death came as a great shock to his relatives and
many friends.
Arnold Jones was a Manchester student and
obtained the degrees of M.B., Ch.B. in 1903. After
a post as house surgeon to the Manchester Royal
Infirmary he successively held residential posts at
the Royal Ear Hospital, London, and the Birmingham
and Midland Ear and Throat Hospital. By this time
he was well on the way to taking up his specialty
and supplemented his education in that branch of
surgery by a period of study in the Viennese clinics.
He held the posts of honorary surgeon to the St. John’s
Hospital for Diseases of the Ear and Throat, honorary
aurist to the Royal Manchester Children’s Hospital
and to the St. Mary’s Hospitals. From his early-
student days “Jimmy Jones” was recognised as a
fluent speaker and a keen debater, and many an
otherwise dull evening has been enlivened by his
shafts of wit and repartee. He was a man of very
strong opinions which he never hesitated to express,
and if his views sometimes aroused opposition they
invariably attracted attention and were a fruitful
source of discussion. In his own branch of surgery
he soon became an authority both as a clinician and
an operator, and his contributions to his subject
were always listened to or read with attention.
During the war he served with the 29th General
Hospital in Salonika, where he was appointed con-
sulting aural surgeon and laryngologist to the British
Expeditionary Force. He was awarded the O.B.E.
for his services and retired with the rank of major.
No man had a wider circle of friends made in his
youth and retained with increasing affection as the
years passed by. Ready for any fun which might be
afoot in his younger days, Jones was the life and soul
of the party. Always an omnivorous reader, he
leaned upon this as a recreation more and more as
time passed but to the end nothing gave him greater
joy than a reunion with his old friends. His death
is a personal loss to his many friends, all of whom
846 THE LANCET]
will unite in offering their sympathy to his widow
and two children.
“C. P. L.” and “H. T. A.” write: ‘‘ Arnold
Jones, or ‘Jimmy,’ as he was affectionately known
to his colleagues, during his long period of service
at the Royal Manchester Children’s Hospital, was
punctilious in the performance of his duties, and .
very successful in dealing with children. His mastoid
operations were particularly successful. He paid
special attention to the after-care of his patients,
and never spared himself in their service. As a mark
of the appreciation of his services he was elected a
member of the board of governors. He was a man
of strong opinions, fearless in his support of them,
and a loyal friend who will be much missed by his
patients, both private and hospital, and by his
colleagues, many of whose oe had been under
his care.”
MABEL PAINE, M.B. Lond.
WE have received the following graceful and
pathetic tribute from Prof. Harold Balme to Dr.
Mabel Paine, who died in a Surrey nursing-home on
Easter Monday.
“ Born in Maidstone in 1874, Mabel Paine joined
the London School of Medicine in 1892. She
graduated at London University in 1900, held resi-
dent posts at the Elizabeth Garrett Anderson Hos-
pital and Chelsea Infirmary, and then took up general
practice in Kensington. During this period she
‘became interested in infant welfare work, and also
became clinical assistant at two of the chief hospitals
for diseases of the chest. In 1917 she commenced
consulting practice and was appointed assistant:
physician to the Elizabeth Garrett Anderson Hospital.
Four years later she was made a full physician, but
in 1927, when at the height of her work, her health
gave way, and after struggling on heroically for
some months she was at length compelled to give up
her practice and resign her appointments.
“ During the severe illness which followed, the
nobility and beauty of her character fully revealed
themselves. For over eight years she lay an invalid,
battling against an insidious renal infection which
racked her strength with recurrent attacks of pyrexia
and pain and defied every resource. of medical and
. surgical science. Throughout this wearisome time
her courage, patience, and keen scientific interest in
every new form of therapy endeared her to nurses
and doctors alike, whilst her richly stored mind made
her companionship a source of constant profit and
delight. Old patients from all parts of the country
came to visit her, each testifying to the depth of
affection they bore her and the debt they owed to
her personality and skill, ‘The humblest woman
God ever made’ was the description given of her
by one of her patients, whilst a former colleague
recently spoke of her as ‘the gentlest of spirits and
soundest of opinions.’ Her life and her influence will
ever be fragrant memories to all of us who had the
privilege of her friendship.” —H. B.
HERBERT ANDREW, M.B. Edin.
Dr. A. H. T. Andrew, who died at Holbrook,
Suffolk, on March 22nd in his 54th year, was born
at Northampton, educated at Bedford Modern
School and St. Edward’s School, Oxford, and pursued
his medical studies at Edinburgh University’ where
he graduated in 1910. Although a good footballer,
holding a regular place in the University Rugby
fifteen, he was even in his undergraduate days a
OBITUARY
[APRIL 3, 1937
student of nature, spending much of his spare time
in observing, photographing, and stuffing birds. He
already loved his gun, rod, and artist’s brush. After
holding resident hospital appointments in Edinburgh,
Dublin, and Northampton, he settled in practice at
Leiston, Suffolk, where he remained for fifteen years.
He held a commission in the Territorial Army and
on the outbreak of war in 1914 was attached to the
lst East Anglian field ambulance and served through
the Gallipoli campaign in the famous 29th division.
He was transferred with that division to France,
where he belonged to the 88th Field Ambulance
and was also for a time attached to the Ist Royal
Inniskilling Fusiliers. In 1917-18 he worked in
the casualty clearing zone, first as an anesthetist, but
finally realising his laudable ambition of being
appointed a surgeon ; in that capacity he worked in
the 53rd Clearing Hospital till the armistice. In
. 1927 he relinquished his practice at Leiston, but
remaining faithful to the county of his adoption
transferred to Holbrook, where in addition to his
ordinary work he became medical officer to the
Royal Hospital Naval School, an appointment which
he held till his death.
A war-time friend and comrade writes: ‘‘ Two
years of almost constant association with Andrew
as a tent-fellow cemented a friendship that death
alone can destroy, and although mileage precluded
frequent meetings in the years of peace, I retain a
vivid memory of a debonair officer, no matter how
depleted of sleep and rest, indefatigable, self-
sacrificing, and the best companion in a surgical
team that any surgeon could desire. His affability
and charm enhanced our popularity as a visiting
team to other clearing stations in times of battle
His fortitude was shown in his final illness, At the
graveside last week the huge concourse would have
surprised one who was himself so modest; it was
a tribute to the matchless worth, of the general
practitioner. The corner of Suffolk between Stour
and Orwell has been robbed by death of a devoted
doctor and a great gentleman.”
Dr. Andrew married Ethel Rosamond Candy and
leaves a widow and six children.
JOHN ATTLEE, M.D. Camb.
Dr. John Attlee, who died on March 8th at
Wellingborough, was the son of the late John Attlee
of Dorking. He was educated at Amersham School
and St. John’s College, Cambridge, and graduated
with honours in the Natural Sciences Tripos in 1889,
proceeding for his medical training to St. Bartholo-
mew’s Hospital with the Shuter scholarship. He
graduated as M.B., B.Chir. Camb, in 1892 and did some
useful research work under the late Prof. Kanthack.
He had clinical appointments at his hospital, at the
Hospital for Consumption, Margaret-street, and the
Royal Westminster Ophthalmic Hospital, and from
the outbreak of war until 1919 he held the post of
ophthalmic surgeon to the Victoria Hospital for
Sick Children. Dr. Attlee practised in the Grosvenor-
square district for more than forty years before his
retirement last October, and his personal qualities
no less than his professional skill contributed to
his all-round success. He made certain con-
tributions to medical literature of a practical nature
and was always deeply interested in developments
either in theory or treatment.
Dr. Attlee was 67 years old at the time of his death,
and is survived by a son and a daughter.
[APR 3, 1937 847
MEDICAL NEWS|
University of Cambridge
Dr. S. D. Elliott has been appointed university demon-
strator in the department of pathology.
The following have been appointed examiners for the
diploma in medical radiology and electrology: Mr.
G. Stead and Mr. B. L. Worsnop, Ph.D. (Part I);
Ff. Roberts, Dr. Russell Reynolds, and Dr. E. P.
Cumberbatch (Part II).
University of London
At a recent examination the following candidates were
successful :—
D.M.R.
Part I.—I. A. Abou Sinna, Pranatharthihara Arunachalam,
Staion ‘hatterjea, Phyllis M. Fraser, D. W. Smithers, and R. C. W.
Applications for grants from the Thomas .Smythe
Hughes fund for assisting medical research are invited
in our advertisement columns. They should reach the
academic registrar of the university by May 15th.
Society of Apothecaries of London
At recent examinations the following candidates were
successful :—
Surgery.—C. L. Blacklock, Univ. of Camb. and Guy’s Hosp. ;
G. Pascall and R. A. Stenhouse, Guy’s Hosp.; R. G. Stitt,
Westminster Hosp.; G. Theophilus, Univ. of Oxford and St.
George’s Hosp. ; ; R. H. S. Thompson, Univ. of Oxford and
Guy’s Hosp. ; T. Van Der Walt, London Hosp.; and W. W.
Willson, Univ. of Oxford and St. Mary’s Hosp.
ici 7 gh, Roy. Free Hosp.
Attenborough, Roy. Free Hosp.
Midwifery. —W. J. Bold, Westminster Hosp.; E. E. Bullock,
Univ. of Leeds; E. S. Reed, Univ. of Camb. and St. Mary’s
Hos F. J. C. Smith, London Hosp. ; ae Theophilus, Univ.
of Oxford and St. George’s Hosp.; W. Willson, Univ. of
Oxford and St. Mary’s Hosp.; and W. G. Doman, Guy’s Hosp.
The following candidates, having completed the final
examination, are granted the diploma of the society
entitling them to practise medicine, surgery, and mid-
wifery : C. L. Blacklock, R. G. Stitt, G. Theophilus, and
W. W. Willson.
University of Leeds
At recent examinations the following candidates were
successful :—
Forensic Medicine. —V. M.
M.D.
H. Kitching, L. Nagley, A. B. Raper, and J. F.
FINAL EXAMINATION FOR M.B., OH.B.
L. Glick, E.
Warin
Part I.—J. bien a E. prenanonie D. Brook, W. L.
Carruthers, J. Cross, . Drucquer, D . Feather, Dorothy
Haigh, E. Hyman, E w. Jackson, W. R ‘Jackson, R. A.
Keighley, E. S. Levy, S. Mi idden, Kathleen V. Miller, R. okon.
J. Overton, G. F. Reid, F. Robinson, J. W. eno eye o H.
Segerman, W. M. H. EEA I.S. E EE Ae A. W. Taylor, A. P. B.
Waind, A. J. Ward, T. I. Watkins, D. C. Wiliams, Kathleen
Wilson, and K. B. Wood.
Part II.—K. B. Aske, A. A. Driver, R. W. Ellis, V. P. Geog-
hegan, I. R. Gray, G. W. Green, G. W. V. Greig, T. Hardy,
G aeth M. Hosking, K. K. Hussain, S. Lask, R. F. Lawrence,
N. Livingstone, Agnes M. Mitchell, F. P. Raper, J. A. Rhind,
A. H. Rhodes, Joyce M. Rhodes, I. D: Riley, C. H. Robinson,
G. B. Robinson, H. Silverman, J. T. Sykes, D. Taverner,
H. Thistlethwaite, L. G. Tophan Mats Townend, Leila M.
Wainman, J. W. Walker, and F. D. Webster.
Part III.—J. A. Rhind (first- e nOn), A
I. R. Gray, G. W. Green, G. W. V. Greig,
Taverner (second- class honours), Rosemi a
ZR T. Hardy, Gwyneth M. Hosking, K. K.
A. Driver,
Riley, and D.
Blackwood. R. W.
Hussain, 8. Lask,
F. Lawrence, N. Livingstone, Agnes M. Mitchell, F. P.
Ba er, A. H. Rhodes, Joyce M. Rhodes, C. H. Robinson, G. B.
Ro inson, J: O: T: Sykes, H. Thistlethwaite, L. G. Topham,
Leila M. Wainman, J. W. Walker, and F. J. D. Webster.
FINAL EXAMINATION FOR B.CH.D.
K. M. Newbould (second-class honours).
FINAL EXAMINATION FOR L.D.S.
Davidson, R. M. Dent, A. B. Halliwell, H. H. Hammond
Sanderson, N. Stannard, J. O. Sykes, and
D.P.H.
P. R.
H. Pogson, F. H.
F. Wainwright.
A. D. B. Broughton.
British College of Obstetricians and Gynæcologists
The following candidates have satisfied the examiners
and have been awarded the diploma of the College :—
P. H. te Anderson, W. ai Bigger, R. G, Buxton, Jane O.
French, S. Gawne, W. Gerrard, R. Hirson, C. W. C.
Karran, `M ay F. St. J. Ù. Millar. G.P. Milne, Atea. Newham,
J. Cawshaw Paymaster, Marg: aret F. Robertson, Sophie Schiller,
Ranajit Sinha, Dorothy M. Stewart, and Clifford Tetlow.
Royal College of Physicians of London
An additional Prophit scholar will shortly be appointed
to codperate with the present scholar in the conduct of
a survey into the incidence and progress of tuberculosis in
selected sections of the community. Special experience in
tuberculosis is not essential. Applications should be sent
to the assistant registrar of the College, Pall Mall East,
London, S.W.1, before April 26th. Further particulars
will be found in our advertisement columns.
King’s College Hospital
Sir Walter Langdon-Brown will address the Listerian
Society at this hospital on Wednesday, April 7th, at
8.15P.m. He willspeak on the integration of the endocrine
system. Medical students and practitioners are invited
to attend.
Radiological Congresses
The twenty-eighth congress of the Deutschen Röntgen-
Gesellschaft will be held at Breslau from April 12th to
14th. Further information may be had from Prof. Frik,
Brickenallee 22, Berlin, N.W.87. It is also announced
that the International Radiological Congress will be held
in Chicago from Sept. 13th to 17th.
Institute of Medical Psychology
On April 20th, 21st, and 22nd Prof. E. Kretschmer of
Marburg will lecture at the institute, Malet-place, London,
W.C., at 8.30 p.m. He will speak on heredity and con-
stitution in the etiology of psychic disorders; on the
structure of the personality in relation to psychotherapy ;
and on instinct and hysteria. The lectures are open only
to medical graduates and tickets may be obtained in
advance from the educational secretary of the institute.
Royal Navy Medical Club
The twenty-third annual dinner of this club will be held
at the Trocadero Restaurant, London, W., on Friday,
April 16th, at 8 p.m. The general meeting will take
place before the dinner at 7.30 p.m. Information can be
had from the hon. secretary, Surgeon-Commander M. B.
Macleod, R.N., Medical Department, Admiralty, London,
S.W.1.
Demonstrations of Contraceptive Technique
On Wednesday, April 7th, at the C.B.C. clinic at 2.30 P.M.,
a practical 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.
may be obtained in advance from the hon. secretary,
108, Whitfield-street, London, W.1.
Dickinson Scholarship Trust
This trust, which is administered by representatives
of the Manchester Royal Infirmary and the University
of Manchester, awards an annual scholarship in anatomy
of £25, an annual travelling scholarship in medicine of
£300, and in alternate years a scholarship in pathology
and surgery of £75. The scholarships are open to graduates
of any university who have received the three last years
of their medical training at Manchester. The increased
present-day costs of living and travelling have made it
necessary to supplement the travelling scholarship and
the trustees are appealing for additions to the endowment.
The fund may be addressed at the Royal Infirmary,
Manchester.
Vitaminised Margarine
At a meeting of the food group of the Society of Chemical
Industry on March 10th in London, Mr. P. N. Williams,
speaking on the food value of margarine, said that during
the last fifty years it has been shown that both margarine
and the fats used in making it are almost completely used
by the body. ‘It is nearly twenty years,” Mr. Williams
continued, ‘‘since Halliburton and Drummond drew
attention to the almost complete absence from margarine
of certain vitamins normally present in good butter... .
Vitaminised margarine was placed on the market for the
first time ten years ago. To-day the great bulk of
margarine—in Great Britain at least—is adequately
vitaminised in respect of vitamins A and D.”
Tickets —
848 THE LANCET]
MEDICAL NEWS.—MEDICAL DIARY.—APPOINTMENTS `
[APRIL 3, 1937
Battersea General Hospital
At a recent meeting of the board of management Sir
Harold Bellman, managing director of the Abbey Road
Building Society, was elected chairman of the hospital,
and the names of Mr. G. J. Sophian, F.R.C.S., and Dr.
John Speares were added to the membership of the board.
St. George’s Hospital
A donation of £8000 has been received by this hospital
from the executors of the late Mr. Caleb Diplock of
Eastbourne. The gift is to be devoted to providing and
equipping two operating theatres in the new hospital.
The hay-fever clinic which was inaugurated last year
has reopened. Patients will be seen each week-day,
and the medical staff numbers 10; but a 500 applications
for treatment have already been received no more can
be considered at present.
World Congress on Mental Hygiene
The second world congress on mental hygiene will
take place in Paris from July 19th to 23rd under the
auspices of the French League for Mental Hygiene.
Scientific sessions will be held in the morning and after-
noon, and a number of visits to mental institutions
and clinics are being organised. Attendance at the
congress is open to all interested in mental hygiene.
Copies of the preliminary programme and all particulars
may be had from the secretary of the National Council
for Mental Hygiene, 76, Chandos House, Palmer-street,
London, S.W.1. |
International Short Wave Congress
The first International Short Wave Congress will be
held in Vienna from July 12th to 17th under the presi-
dency of Prof. A. d’Arsonval, Marchese Marconi, and
Prof. J. Zenneck. There will be an exhibition of the
newest inventions and their practical application. The
official languages will be English, French, German, and
Italian. The work of the congress will be divided into the
following sections: physics, chemistry and physical
chemistry, and technical physics ; biology ; and medicine.
The secretariat of the congress may be addressed at
the physical medicine department of the Allgemeines
Krankenhaus, Alserstr. 4 Vienna, IX.
= 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.1.
TUESDAY, April 6th. ~-
Orthopedics. 5.30 P.M. (Cases at 4.30 P.M.) Mr. C.
Lambrinudi: 1. Genu Recurvatum. Mr. N. L.
Capener: 2. Intractable Sciatica, due to Prolapsed
Intervertebral Disk. Mr. E. J. Smith (for Mr. St. J. D.
Buxton): 3. Cystic Disease of the Radius. . J. P.
Hosford : 4. Arthrogram to Show Extent of Synovial
Cavity after Synovectomy. Dr. H. S. Taylor-Young
(introduced by Mr. G. R. Girdlestone): 5. Unusual
Defect of the Shoulder. Mr. L. W. Plewes (introduced
by Mr. Girdlestone) : 6. Gross Patchy Rarefaction of
the End of the Long Bones in a Case of Tuberculosis
of the Hip. Mr. K. H. Pridie: Treatment of Fractures
of the Neck of the Femur (with film).
WEDNESDAY.
History of Medicine. 5 P.M. Dr. P. H. Manson-Bahr :
Historical Landmarks in Tropical Medicine.
Surgery. 8.30 P.M. (Specimens on view from 5 P.M.)
Mr. W. Sampson Handley: 1. Melanotic Sarcoma of
Face, Removed by Monoblock Section. Mr. R. Davies-
Colley: 2. Chondroma of Thyroid Cartilage. 3. Ene
larged Spleen of Doubtful Nature. Mr. John Hosford :
4. Endometrioma at the Umbilicus. 5. Cholecystitis
Glandularis Proliferans. Mr. Reginald T. Payne:
6. Acute Parotitis. 7. Adenolymphoma of Parotid.
8. Calcification of Parotids.
FRIDAY.
Clinical. 5.30 P.M. (Cases at 4.30 P.M.) Annual general
meeting. Dr. Neill Hobhouse: 1. Diffuse Sclerosis.
Mr. A. Dickson Wright: 2. Solitary Plasma-celled
Myeloma of the Vertebral Body Causing Paraplegia.
Dr. F. Parkes Weber and Dr. A. Schlüter : 3. Felty’s
Syndrome. Mr. D. C. L. Fitzwilliaams: 4. Series of
Cases of Carcinoma of the Breast Treated by Partial
Amputation. f
Epidemiology and State Medicine. 8.15 P.M. Prof.
Claus Jensen (Copenbagen): Active Immunisation
against Diphtheria by the Combined Subcutaneous
è and Intranasal Method.
WEST LONDON MEDICO-CHIRURGICAL SOCIETY.
FRIDAY, April 9th.—8.30 P.M. (De Vere Hotel, Kensington),
Dr. Edwin Smith, Dr. B. T. Parsons-Smith, and Dr. T.
Skene Keith : Sudden Death.
‘MEDICAL SOCIETY OF INDIVIDUAL PSYCHOLOGY.
THURSDAY, Apri] 8th.—8.30 P.M. (11, Chandos-street, W.),
Dr. H. Crichton-Miller: Puberty and Adolescence
(Symposium on Mental Health in Childhood and
Adolescence IV.).
WEST KENT MEDICO-CHIRURGICAL SOCIETY.
FRIDAY, April 9th—8.45 P.M. (Miller General Hospital,
S.E.) Dr. Jane Hawthorne, Dr. Margaret Green, Dr.
Janet Gray, and Dr. F. A. Beattie: That Contra-
ception is to the Advantage of Humanity.
SOCIETY,
LONDON, JEWISH HOSPITAL MEDICAL
Stepney Green, E.
THURSDAY, April 8th.—4 P.M., Prof. Samson Wright:
- Social Organisation in the Living Body.
LECTURES, | ADDRESSES, DEMONSTRATIONS, &c.
BRITER POSTGRADUATE MEDICAL SCHOOL, Ducane-
road,
MONDAY, April 5th—2.30 P.M., Dr. C. W. Buckleyl:
thritis.
WEDNESDAY.—Noon, clinical and pathological conference
(medical). 2.30 P.M., Mr. E. J. King, Ph.D.: Acidosis
and Alkalosis. 3.15 P.M., clinical and pathological
conference (surgical). 4 P.M., Mr. J. E. H. Roberts:
Surgery of the Chest. 4.30 P.M., Dr. W. E. Gye:
Experimental Cancer Research.
THURSDAY.—Noon, clinical and pathological conference
(obstetrics and gyneccology). 2.30 P.M., Dr. Duncan
White: Radiological Demonstration. 3.30 P.M., Mr.
<. Henry: Demonstrations on the Cadaver of
Surgical Exposures. 3.30 P.M., Mr. Clifford White:
Benign Neoplasms of Uterus.
FRIDAY.—2 P.M., operative obstetrics. 3 P.M., department
of gynecology, pathological demonstration.
Daily, 10 a.M. to 4 P.M., medical clinics, surgical clinics
and operations, obstetrical and gynecological clinics
and operations.
WEST LONDON HOSPITAL POST-GRADUATE COLLEGE,
Hammersmith, W.
Monbay, April 5th.—10 A.M., Dr. Post: Demonstration
of X Ray Films, skin clinic. 11 A.M., surgical wards.
2 P.M., operations, surgical and gynecological wards,
medical, surgical, and gynecological clinics. 4.15 P.M.,
Mr. Green-Armytage: Alarums.
TUESDAY.—10 A.M., medical wards. 11 A.M., surgical
wards. 2 P.M., operations, medical, surgical, and
throat clinics.
WEDNESDAY.—10 A.M., children’s ward and clinic. 11 A.M.,
medical wards. 2 P.M., gynecological operations,
medical, surgical, and eye clinics. 4.15 P.M., Mr. Gibb:
Demonstration of Eye Cases.
THURSDAY.—10 A.M., neurological and gynecological
clinics. Noon, fracture clinic. 2 P.M., operations,
medical, surgical, and genito-urinary and eye clinics.
ae P.M., Dr. W. S. O. Copeman: Respiratory Dis-
orders.
FRIDAY.—10 A.M., medical wards, skin clinic. Noon,
lecture on treatment. 2 P.M., operations, medical,
surgical, and throat clinics. 4.15 P.M., Mr. Simpson-
Smith: Blood per Rectum.
SATURDAY.—10 A.M., children’s and surgical clinic.
medical wards.
The lectures at 4.15 P.M. are open to all medical practi-
‘tioners without fee.
NATIONAL HOSPITAL FOR DISEASES OF THE HEART,
Westmoreland-street, W. .
TUESDAY, April 6th.—5.30 P.M., Dr. Maurice Campbell:
Paroxysmal Tachycardia.
CENTRAL LONDON THROAT, NOSE, AND EAR HOS-
PITAL, Gray’s Inn-road, W.C.
FRIDAY, April 9th.— 4 P.M., Mr. A. Lowndes Yates: Familial
Sinusitis.
ST. JOHN CLINIC AND INSTITUTE OF PHYSICAL MEDI-
CINE, 42, Ranelagh-road, S.W.
FRIDAY, April 9th.—4.30 P.M., Dr. G. T. Calthrop : Demon-
stration of X Rays of Conditions Simulating the Rheu-
matic Diseases.
MANCHESTER ROYAL INFIRMARY.
TUESDAY, April 6th.—4.15 P.M., Mr. Wilson H. Hey:
Diagnosis. 4
FRIDAY.—4.15 P.M., Dr. Charles Don:
, Medical Cases.
GLASGOW POST-GRADUATE MEDICAL ASSOCIATION.
WEDNESDAY, April 7th.—4.15 P.M. (Royal Infirmary), Dr.
David Smith: Hmmatemesis.
11 A.M.,
Demonstration of
| Appointments
CooxKson, J. S., M.B. Camb., Assistant County Medical Officer
for Holland, Lincs. i
JAMIESON, S. . M.B. Glasg., Resident Medical Officer at
Heathfield Infectious Diseases Hospital, Ayr.
MATHESON, BERNARD, M.B. Edin., D.P.M., Second Assistant
Medical Officer at Leytonstone House (L.C.C.).
STEADMAN, H. A., M.B. Lond., D.P.M., First Assistant Medica
Officer at Long Grove Hospital (.C.C.).
Certifying Surgeon under the Factory and Workshop Acts:
Dr. J. W. STRACHAN (Dornoch District, Sutherland).
‘THE LANCET]
Vacancies
For further information refer to the advertisement columns.
Accrington, Victoria Hosp.—H.S., £150.
Bath, Royal United Hosp.—Hon. Asst. Gynecologist and
Obstetrician. H.S. to Ear, Nose, and ‘Throat Dept., at
rate of £150. Also H.P. at rate of £150.
Bedford County Hosp.— First and Second H.S.’s, at rate of £155
and £150 respectively.
Belgrave Hosp. for Children, 1, Clapham-road, S.W.—Two
H.P.’s and two H.S.’s, each at rate of £100
Birmingham,.—M.0. for Maternity and Child Welfare Dept., £600.
Birmingham and Midland Eye Hosp.—Res. Sure., p> £200.
Birmingham, Coleshill Hall.—Res. Asst. M.O., 0.
Blackburn Royal Infirmary.—Res. H.S., Tia
Bournemouth, Royal National S anatorium.—Med. Supt., £800.
Also Res. Asst. M.O., £200.
Brighton, Royal Alexandra Hosp. for Sick. Children.—H. S.; £120.
Brighton, Royal Sussex C ‘ounty Hosp.—Hon, Clin. Asst. to Early
Nervous Disorders Dept.
Bristol Royal Infirmary.—cClin. Anesthetist to Dental Dept., £150.
British Posigraduate Medical School, Ducane-road, W —H'S. -» at
rate of £105.
Burton-on-Trent General Infirmary.—H.S., £150.
Cambridge, Addenbrooke’s Hosp.—Res. Aneesthetist and Emer-
gency Officer, at rate of £130. Also H.P. and H.S. to
Special Depts., each at rate of £130.
Chelienham General and Eye Hospitals.—H.S. to Eye, Ear, Nose,
and Throat Dept., £150.
Chester, Barrowmore Tuberculosis Sanatorium and Settlement,
Great Barrow.—H. P., at rate of £150.
Chichester, Royal West Sussex Hosp.—Jun. H.S., £125.
Colchester, Royal Eastern Counties Institution, dé:c.—Agst. M. O.,
Connaught Hosp., Walthamstow, E.—Med. Reg. Also Cas. O.,
at rate of £175 and £100 res ectively
Dorchester, Dorset County Hosp.—H.S., at > cate of £150.
Dudley, Guest Hosp.—Second H.S., £1 120
Durham County Council.m Asst. School M. O., £500.
East Lothian, East Fortune Sanatorium —Sen. Res. M. O., £350.
pags H yan ` for Sick Children, Southwark, S.E. —H.S., at
° rateo 0.
Glasgow Royal Faculty of Physicians and Surgeons.— Fellowship
- Examination.
Guildford 5 Hoyas Surrey County Hosp.—Asst. Pathologist, £500.
Guy’s Hosp., S.£.—Clin. Asst. for “Radiology Dept., at rate of £150.
Hampstead ‘General and N.W. London Hosp., Haverstock Hill,
N.W .—H.S., at rate of £100.
Harrogate Clinical Laboratory.—Clinica]l Pathologist, £450.
Harrogate, Royal Bath Boat —Res. M.O., £156.
Hosp. Jor Sick Ch A ae Great Ormond-street, W.C'.—Out-patient
e eg.
Hull Royal Tad Seed H.S., at rate of £150.
Bora Borough.—Res. M.O. for Maternity Home, £350.
nge diolcrist Hosp., Denmark Hill, S.E.—Sen. and Jun. Asst.
ologists.
Lancashire County Council.—Consultant P optetriclan, £1000.
Leeds Public Dispensary and Hosp.—Cas. O. and H.S. Also
H.P., eacn at rate of £150.
Leeds University, School of Medicine.—Demonstratorship in
_ Department ‘of Physiology.
r, City General Hosp.—Res. M.O., at rate of £300.
Leigh Talons, Lancs.—Jun. Res. H. S., at rate of £150.
Lincoln County Hosp.—Jun. H.S., at rate of £150.
Liphook, Hants, King radad 3 Sanatorium for Satlors.— Asst.
M.O., at rate of £200.
iuro Royal Children’s Hosp.—Res. H.S. for City Branch
at rate of £100.
Liverpool. Royal Infirmary.—Registrar to Orthopedic and
Fracture Dept., £200.
Liverpool, Royal Southern Hosp.—H.S. to Orthopeedic Dept., at
rate of £60.
Liverpool Sanatorium, Delamere Forest, Frodsham.—Sen. Asst.
to Mea. Supt., £350.
London and Counties Medical Protection Society, Lid., Victory
H A rapes Spake w.C.—Secretary, £1250.
London County Council.—Asst. M.O.’s, Grade I, £350. Also
i rae 0. , Grado Ps £250.
È. —First Asst. to Gynæcological and Obstet.
Bert, ° F280, Also First Asst. to Neuro-surgical Dept.
Jewish Hosp., Stepney Green, E.— Asst. ‘Ansesthetist,
1%
Londo, Toes Hosp., 283, Harrow-road, W.—Res. M.O. to Male
E te at rate of £175
Maccleopetd General Tare —Second H.S., at rate of £150.
nchester, Ancoats Hosp.— Radiological Officer, £300.
Motropolten Hosp. ., Kingsland-road, E£.—Sen. and Jun. H.P.’s
and H.S.’s. Also Cas. O. and Res. Anesthetist, each at
rate of 2100.
iddlesbrough, North Riding Infirmary Cas. O., at rate of £150.
Newark General Hosp.—Res. H.S.,
Newport, Mon., Royal Gwent Hosp.—H. P., at rate of £150.
Also two H.S.’s, each at rate of £135.
Northwood, Mount Vernon Hosp.—H.S.., Be rate of £150.
Norwich Isolation Hosp.—Res. M.O., £45
Nottingham and Midland Eye Infirmary. ae H.S., £200.
eee a General Hosp.—H.S. to Spec. Depts., each at rate
= O0
Ocean Island, dé:c., Central Pacific.—Asst. M.O., £50
Oldham Royal Infirmary. —H.8. Also H.S. to aes Depts.,
cece at rate of £175.
Orford, ngfield-Morris Orthopedic Hosp., Headington.—H.S.,
at a of £100.
Paddi ington paren Children’s Hosp., W.—H.P. and H.S., each at
rate o
Penshurst, Cassel Hosp. for Functional Nervous Disorders.—
Two Locum Tenens, each 8 guineas a week.
VACANCIES.-——-BIRTHS, MARRIAGES, AND DEATHS
St. aa and Mid-Herts Hosp.,
[APRIL 3, 1937 849
nor A Eg of Wales's Hosp., Devonport.—Jun. H.S., at
rate o
fone h and Southern Counties Eye and Ear Hosp.—H.S.,
Portsmouth Royal Hosp.—H.S., at rate of £130.
Reading, Royal Berkshire Hosp. —H.S., Cas. O., and eet to
Spec. Depts., each at rate of £150.
Rotherham Hosp. —Hon. Aneesthetist.
Hoyas rA RoD Fulham-road, S.W.—Second Asst. Patho-
ogis
Royal Chest Hosp., City-road, E.C.—Med. Reg., £50.
Royal College of Physicians, Pall Mall East, S.W.—Prophit
Scholar, £400.
Royal College of Surgeons of England, W.C.—Election of Pro-
fessors and Lecturers. .
Royal Naval Medical Service.—M.0O.’s
Royal Waterloo Hosp. for Children, Eer Waterloo-road, S. E..
Res. Cas. O. and H.P., at rate of £150 and ad respectively.
Salisbury General Infirmary. —Res. M.O.
Onah creeds —Res. H. S.,
150
St. Leonard’s-on-Sea Buchanan Hosp.—Jun. H.S., Bias.
St. Mary’s a for Women and Children, Plaistow, E -—Res,
H.S. and Res. H.P., at rate of £155 and £150 respectively.
Scarborough New Hospital. —Two H.S.’s, each at rate of £130.
Sheffield, J Jessop Hosp. for Women.—H.S., at rate of £100.
Sheffield Royal Hosp.—Post on Res. Med. Staff, at rate of £80.
Sheffield University, Dent. of Bacteriology. —Asst. Bacteriologist
and Demonstrator, £500.
Shrewsbury, Royal Salop Infirmary.—Res. H.S., at rate of £160.
Somers County Council.—County M.O.H. and School M.O.,
5 .
Southampton, Royal South Hants and Southampton Hosp.—Hon.
Ophth. Surgeon.
Stoke-on-Trent, Burslem, Haywood, and Tunstall War Memorial
Hosp —Res. H .P., at rate of £150.
Sunderland Royal Infirmary. —Cas. O., £150.
Swanley, Kent, Hosp. Convalescent Homes,
M.O., at rate of £200.
Truro, Royal Cornwall Infirmary.—H.S., £170.
University College Hosp. Medical School, W.C —Beit Memorial
- ` Fellowships for Medical Hioggarens 400
West Bromwich, Hallam Hosp..—H.P., "at rate of £200.
nee Ophthalmic Hosp., Marylebone-road, N.W.—Jun. Res.
Weymouth Borough, &c.—M.O.H. and School M.O., £800.
Wickford, Essex, Runwell Hosp.—aAsst. Res. Physician, £350.
Wolverham pton Royal. .Hosp.—H.S., at rate of £100.
Worthing Hosp. phthalmic Surgeon.
The Chief Inspector of Factories announces vacancies for
Certifying Factory Surgeons at Stranraer (Wigtown),
Beckenham Cent), and Dorchester (Dorset). Applications
before April 6th.
Births, Marriages, and Deaths
BIRTHS
COWPER.—On March 27th, at Plymouth, the wife of Dr. W. H.
Cowper, Kingsb ridge, of a son.
GALLOWAY.—On Maron 24th, at a Nottingham nursing-home,
the wife of Dr. N. P. R. Galloway, M.B., of a daughter. .
GRAHAM BRYOE.—On March 20th, at West Didsbury, Man-
ener, the wife of Mr. Alexander Graham Bryce, F.R.O.S.,
of a son.
HENSLEY.—On March 24th, at Winchester, the wife of Dr.
E. H. valpy Hensley, of a daughter.
McDONNELL n March 5th, at Gravesend, the wife of Dr.
M. F. McDonnell, of a daughter.
O’COoNNOR-CUFFEY.—On March 19th, at Eastbourne, the wife
of Mr. Desmond O’ Connor-Cuffey, F.R.C.S., of a daughter.
WALKER.—At Chowlands, Rainton Gate Co. Durham, on
March 28th, to Dr. and Mrs. G. F. Walker—a son
Youne.—On March 20th, at Esher, the wife of Dr. ‘Matthew
Y f
oung, of a son. RIAGES
DAVIES—ALLEN.—On March 25th, at St. James’s, Paddington,
J. O. F. Davies, M.B., to Marg aret P. Allen, of Toronto.
aes ee pee —On March 10th, eauieely, at St. Mary Boltons,
London, B. H. Deare, Major-General I. M.S., ret., to Margery,
elder daughter of the late Mr. and Mrs. J. E. Pepper.
FLETCHER—FRANKS.—On March 23rd, in London, Ernest
Fletcher, M- M. B, to Mary Louise Franks, of Rectory Farm,
e e, K
KENDRICK— YOUNG. —On March 22nd, at the Church of the
Holy Name, Esher, Captain G. W. Kendrick, R.A.M.C.,
to Patricia André, eldest daughter of the late "Duke Ran-
dolph Young, O. B.E.
DEATHS
ANDREY: E March 22nd, Alfred Herbert Tresham Andrew,
BENNETT.—On March erg at Watford, Frederick Joseph
Bennett, M.R.C.S. Eng., L.D.S.
GREATREX.—On March 28th: James Burnell pein M.R.C:S.
Eng., of Plumstead Common-road, S.E., 70.
McKERRON.—On are 215b, at Edinburgh, ee obert Gordon
McKerron, M.D. A F.C.0. G., Emeritus Professor of
Midwifery in the eet of Aberdeen.
NasH.—On March 28th, at Hampstead, William Gunner Nash,
M.R.C:S. Eng., L.S. A., late of Welford, Northants, aged 85.
STURROOK.—On March 27th, at Eeoa Lancashire, Alexander
ı 4 Corsar Sturrock, M.D. Edin., R.C.P. Lond., J.P.
WHITTINGTON. —On March 30th, St Hove, Richard "Whittington,
M.D. Oxon.
N.B.—A fee of 78. 6d. ts charged for the insertion of Notices of
Births, Marriages, a Rs.
Parkwood.—Res.
850
THE LANCET]
[APRIL 3, 1937
NOTES, COMMENTS, AND ABSTRACTS .
ANCILLA’S REGISTER
THE Board of Registration of Medical Auxiliaries
was set up last May, and the following representa-
tives were appointed to its council: Mr. H. S. Souttar,
F.R.C.S., Dr. G. C. Anderson, and Dr. C. B. Heald
(British Medical Association), Mr. Vernon Cargill,
F.R.C.S., and Group-Captain H. Cooper, M.R.C.S.
(Society of Apothecaries of London), Mr. R. C.
Elmslie, F.R.C.S., Miss E. W. Bliss, and Miss E. M.
Humble (Chartered Society of Massage and Medical
Gymnastics), Mr. H. J. Ede, Dr. D. D. Malpas, and
Mr. F. Melville (Society of Radiographers), Mr. A. W.
Ormond, F.R.C.S., and Mr. E. G. Harwood (Associa-
tion of Dispensing Opticians). The object of the
board is to maintain a comprehensive register of
those engaged in services ancillary to medicine. The
first issue has now been published.! It consists of
three sections—one giving the names of physio-
therapists arranged topographically, and the second
the names of dispensing opticians similarly arranged,
while the third is an alphabetical list of all the names
which refers the reader to the appropriate local list.
The board is not a qualifying body and at present
recognises the examinations of the Chartered Society
of Massage and Medical Gymnastics, the Society of
Radiographers, the Association of Dispensing Opti-
clans, and the examination for biophysical assistants
of the Society of Apothecaries. But the claims of
other bodies are being considered and the scope of
the register may be widened to include them in the
future. Those whose names are on the register have
signed an undertaking not to do medical work except
under the direction of a medical practitioner, and
doctors are urged to make the fullest possible use of
the register. A copy of it will be supplied on request
free of charge to any registered medical practitioner.
_A DOCTOR IN THE COUNTRY
Ir the publishers of Dr. Philip Gosse’s pleasant
digressions ? from the theme of going for a walk—
in-the country—had consulted the calendar when
they fixed on April lst for the date of its issue they
might have made efforts to get it out before Easter ;
for it is the sort of holiday reading that makes cold
days indoors a delight instead of a penance. He
writes entertainingly as ever: on Park Brow, the
most venerable spot in Sussex; on Sussex Saints
and others; on birds in folk lore, in books, or in
cages; on angling, and on leaving things alone.
In the two last chapters entitled Foreigners, Inn-
keepers, Journalists, and Sportsmen, Nudists, and
Naturalists some of the prejudices and tastes
indicated in Dr. Gosse’s contribution to our Grains
and Scruples columns last autumn are effectively
underlined. To the list, given in an appendix, of
those among the great array of books about Sussex
which have given pleasure to the author of this one,
we would by his leave add another—‘‘ The Four
Men ” by Hilaire Belloc—which no lover of the
county can afford to miss.
SUICIDE IN MENTAL HOSPITALS
A PAINSTAKING study of asylum suicide is described
by Dr. Eric Backlin who has examined the records
of all the Swedish State asylums for 1901-33
(Hygiea, Feb. 15th, 1937, p. 65). The total was
159—only 48 of the victims were women—and though
analysis by three-year periods shows a considerable
increase this is accounted for by an equivalent increase
in the number of patients under care. The size
of the hospital did not seem to affect the suicide-rate,
London :
W.C.1. 1937.
1 National Register of Medical Auxiliary Services.
Tavistock House (North), Tavistock-square,
Pp. 170. 28. 6d.
2 Traveller’s Rest. By Philip Gosse.
Pp. 281. 8s. 6d.
London: Cassell and
Co., Ltd. 1937.
the fault of the hospital personnel.
cautions are more or less worthless.
but this was highest in those where the average
duration of the patients’ stay was shortest—no doubt
because these deal largely with acute psychoses.
While the suicide-rate outside asylums generall
rises with age, it reached its maxima in the Swedis
State institutions at 30-35 for men and at 30-35
and 45-50 for women. The large majority of the
patients had previously betrayed suicidal inclinations
at one time or another, and the fact that they were
not under continuous observation was in some cases
Backlin concludes
that “without a well-trained staff, all other pre-
But the work
of the staff may in this respect be considerably
lightened by certain local and administrative
measures.”’ l
PSYCHOLOGY AND THE CHILD
Prof. Sachs’s achievement in neurology commands
respect for his opinions, but a series of essays on the
child! will hardly enhance his reputation as a
psychologist. The essays on infancy, school age,
truancy, and adolescence are benevolent and common-
place. They tell us little more about the child and
its upbringing than any intelligent, well-balanced
parent already. knows himself. Page after page is
devoted to good-natured moralising, until suddenly
the kindly author of the first eighty pages becomes
the vitriolic opponent of everything that psycho-
analysis has discovered, and the guidance of children
that a knowledge of it might suggest. Everyone
realises that, taken at its face value, psycho-analytic
‘theory is not only unpalatable but difficult to com-
prehend by those who have not studied it at first hand.
It is unfortunate, however, that one who should
write with authority has clearly not given to this
theory the attention it deserves and the objective
criticism that it merits at this stage in the history of
psychopathology.
HIGH WALL
It is rare for novels about private mental hospitals
to ring true. The details in a book with the above
title? appear to be based on first-hand knowledge,
and, if it were not for the author’s note asserting
.the contrary, those familiar with American institu-
tions would be inclined to identify the place described.
It is questionable whether there is much basis for
the publisher’s opinion that the theme of the book
will interest the psychiatrist: the clinical details
in the account of a young man who has an acute
psychosis and subsequently forgets that he has
murdered his wife are rather improbable. It is
the experiences of this patient in the Tri-State
Sanatorium where he and a nurse fall in love with
one another that are the main theme of the novel
which will probably make a greater appeal to the
lay public than to the doctor. .
A DIRECTORY OF NURSING-HOMES.—We have
received from Benn Brothers Ltd. (154, Fleet-street,
London, E.C.4) a copy of the seventh edition of a
directory of nursing and convalescent homes, mental
homes, &c., in England and Wales and Scotland.
The directory gives the names and addresses, arranged
under counties, of all registered nursing-homes for
the several classes of patients, and it is stated that
the information has been obtained either from the
home itself, or from some responsible official source,
or both. The book which contains 280 pages is
well bound in cloth and costs 4s.
1 Keeping Your Child Normal. By Bernard Sachs, M.D.,
former President of the New York Academy of Medicine. New
York and London: Paul B. Hoeber. 1936. Pp. 148. $1.50.
_ 2 High Wall. By Alan R.'Clark. London: Michael Joseph
Ltd. 1936. Pp. 288. 7s. 6d. .
THE LANCET]
[APRIL 10, 1937
ADDRESSES AND ORIGINAL ARTICLES
PATHOLOGY OF THE ADRENAL GLAND
IN RELATION TO SUDDEN DEATH *
By C. Kerra Simpson, M.D. Lond.
ASSISTANT LECTURER IN FORENSIO MEDICINE AT GUY’S HOSPITAL
Two factors have elevated the adrenal gland to its
present-day importance in medicine. One was the
publication by Addison of his famous “ blue book,”
for this prompted Brown-Sequard to perform experi-
mental extirpation of the gland for the first time, and
to study the characteristic manner in which death
inevitably followed. The other factor is the renais-
sance of endocrinology which has taken place in
recent years.
Sufficient scientific fact now invests our knowledge
of the relations of this gland to the maintenance of
life to enable a discussion of its relation also to sudden
death from natural causes to be effected without
recourse to vague theory. The conditions of sudden
death, however, give the problem a distinctly forensic
flavour, and tend to limit the experience to those
engaged in this work. Even here the figures are not
impressive ; it has been my experience to examine
such cases at the rate of 1 in every 500 post-mortem
examinations of subjects of sudden death from all
causes, including injuries.
Nevertheless the morbid anatomy of these glands
with strict relation to sudden and unexpected death
is a subject remarkably well defined; the figures
are small, but the limitation in disease processes is
close. There are few morbid processes which result
in the rapid’ destruction of the essential cortical
element of both glands more or less simultaneously,
and these are the conditions of sudden death.
Development
In order properly to appreciate the effects of
disease of the adrenal glands, it is necessary to
summarise certain of the facts known about their
developmental anatomy and physiology.
Mammals alone possess the permanent enveloping
relation of the cortex to the medulla seen in man
(Fig. 1), although the presence of the essential cortical
tissues is universal, as a distinct organ in the whole
range of amniota—mammals, birds, and reptiles—
and as a homologue, the inter-renal tissue, in all
anamniota as low as hags and lampreys. The arrange-
ment in layers of this cortical element varies, but
its essential characters are constant.
In addition to this characteristic cellular cortex,
there is developed in mammals a third element, a
layer of cells deep to the true cortex, and apparently
concerned solely with the development of masculine
character (Fig. 1). Now at birth the weight of the
adrenal gland is as much as a quarter that of the corre-
sponding kidney; it becomes approximately a
thirtieth of the weight of the kidney in adult life.
This relatively large organ consists of a thin
lamina of true cortex, a wide zone of this third
element, the androgenic ‘‘ masculinising ” tissue, and
a small medulla. Immediately after birth there
occurs a degeneration of the entire androgenic zone,
accompanied by an intense hyperjmia, This may
indeed prove the cause of a fatal catastrophe, destruc-
tive hemorrhage taking place as a complication of
* The Erasmus Wilson lecture delivered to the Royal
pouan aE Surgeons on March 15th.
59
this intense hyperemic state. Reorganisation of
the remains of this androgenic tissue normally takes
place during the first year, and thereafter the element
exists only as a thin lamina, coming into prominence
on the rarest occasions as a malignant masculinising
tumour of the cortex of one gland.
It is clear that, except for the one short post-natal
period during which the androgenic zone is under-
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FIG. 1.—The normal histology of the gland. D, the ‘capsule.
B and C, the adult cortex. Thefetal cortex—the androgenic
zone—is the pigmented layer separating B from the medulla A.
going its hyperemic involution, there is no period of
life at which this tissue has any part to play in the
causation of sudden death. It is entirely androgenic,
displaying an activity confined to sexual development. —
During the development of the true cortex, a free
vascular circulation develops, the arterial tree rami-
fying in the capsule of the glands and sending from
this plexus numerous capillaries, which penetrate
into the medulla to open out into sinusoids from
which venous drainage takes place. The significance
of this rather unusual distribution of vessels lies in
the predisposition to the impaction of arterial emboli,
perhaps particularly emboli of malignant cells, and
therefore to the development of secondary lesions.
The matter will be discussed more fully in dealing
with the morbid anatomy of the glands.
So far as the preservation of life is concerned,
attention may be directed solely to the cortex, for
that this is the essential element in the gland has
been proved beyond all conceivable doubt by experi-
mental extirpation. As to how much of one remaining
cortex is required to stave off signs of deprivation,
experimental opinion varies. Excision of one gland
and either cautery (Crowe and Wislocki 1914,
Biedl 1910) or denervation (Pende 1923, Stewart
and Rogoff 1929) of the remaining medulla shows
survival to be possible provided that from one-
fourth (Bornstein and Gremels 1925) to one-eleventh
(Langlois 1898) of the remaining cortex also survives
intact. Administration of extracts of the cortex to
adrenalectomised animals, doomed otherwise to die,
retains for them conditions of physiological health
which can be maintained almost indefinitely.
Relatively little attention has ever been paid to the
question whether the adrenal cortex can regenerate
sufficiently and with a rapidity necessary to prevent
the development of insufficiency; any process
resembling regeneration is seen so rarely in company
P
852 THE LANCET]
DR. KEITH SIMPSON : THE ADRENAL GLAND AND SUDDEN DEATH
[APRIL 10, 1937
with disease of the organ itself, In the most careful
survey yet made MacKay and MacKay (1932) show
that hyperplasia of the cortex of one gland does
occur after operative excision of the other, but that
it is an inactive process, except perhaps in the rat,
takes nearly three months to develop, and requires
the most encouraging conditions—conditions which
do not hold
when disease is
present. As a
natural process,
therefore, it
need not
occupy further
attention. In
so far as it
concerns rapid
destruction of
the glands,
regeneration is
far too slow
and uncertain
to play any
part in staving
off insuffi-
ciency.
One further
matter requires
consideration.
Accessory cor-
tical tissue,
occurring with
some frequency
in most animals, has been remarked upon with
particular prominence in those of greatest bulk,
including man, but it remains that accessory masses
of true cortex—not androgenic—are uncommon, and
when present never large enough to play any appre-
ciable part in preventing fatal deprivation in the
event of total destruction of both glands. My own
records of the last 2500
cases contain descriptions of
two examples, one of which
was a complete heterotopia
of the cortical element of
that side. The irregular
‘cortical ‘‘ hyperplasias’”’ of
advanced years are of course
of no functional significance
in this respect.
Pathological Anatomy
Pathological changes in
the body after death from
acute insufficiency of the
cortex are, for practical pur-
poses, limited to those by
which the gland itself is
destroyed. It is true that
dilatation of the heart, con-
gestion of the lungs or
pancreas or other organs,
and the presence of bile in
the gastric contents have
been noted in addition, and
even credited with some
significance in relation to
these deaths, but these are
general findings and all too
common to merit any such
distinction. The systemic
reflections of cortical insuff-
ciency are almost entirely
FIG. 2.—Hemorrhagic infarction of the
adrenal gland and the kidney in a new-
born infant.
t A
biochemical and attended by functional disorder rather
than by any structural change visible to the eye.
Even in the gland itself there are but few morbid
processes to be found with any frequency under
these conditions ; three are commonly seen, others
rarely, and it is to these three that I wish to give
attention. They are hæmorrhagic necrosis or hæmor-
rhagic infarction, acute caseative tuberculosis, and
rapid metastatic growth invasion of the gland.
HÆMORRHAGIC NECROSIS OR INFARCTION
The adrenal glands are the site of hæmorrhage,
often extensive, at two periods during life.
Neonatal type. —A tendency to hæmorrhage first
occurs during the hours and days immediately
following birth (Levinson 1935), and as already
explained, this is a misadventure which complicates
the intense hyperemia accompanying physiological
involution of the androgenic (fetal) cortex. It may
occur irrespective of the nature or rapidity of
delivery, but appears to be rather more frequent
after difficult, precipitate, or forceps deliveries. It
is properly attributed, under these conditions, to the
added venous engorgement natural to such occasions,
and is the more likely to provoke hemorrhage in that
it develops rapidly. Krause (1927) draws attention
to the effects also of traction on the hilum of the
gland, and of contraction of the musculature of the
suprarenal veins which may follow traction, both
increasing venous engorgement and adding to the
already serious strain on the sinusoidal and capillary
walls, As Landau (1912) has, however, quite rightly
pointed out, the process is primarily a physiological
one, and not due to any variety of birth trauma
alone. It may develop in the most carefully delivered
Cesarean sections. Both under these conditions and
also under those responsible for hemorrhage in later
years, the extravasation of blood may break out
through the capsule of the gland into the surrounding
connective tissues, accentuating the shock-like
FIG. 3.—Acute hemorrhagic necrosis of both adrenal glands in a girl aged 10 months
following streptococcal septicemia after pneumonia.
THE LANCET]
character of the collapse which follows.
The symptoms are often remarked to
be identical with those of an acute
upper abdominal crisis.
There is, too, another complication
which is not perhaps so remarkable as
it is often overlooked. Thrombosis of
the adrenal veins often accompanies
the effusion of blood into the substance
of the gland. The vein is, after all, in
close communication with sinusoids in
which thrombosis has already occurred,
it is a short vein, half buried in the
substance of a gland swollen and tense
as the result of its distension by blood,
and therefore most likely to become
compressed, adding stasis to the factors
already encouraging thrombosis.
The process of thrombosis may also
extend to involve the renal vein,
especially on the left side where the
suprarenal and renal veins unite before
entering the inferior vena cava. An
example of this occurred under the
following circumstances :—
A primigravida of 35 had a normal
pregnancy interrupted only at the thirty-
seventh week by an attempted external
version. ‘The procedure was unsuccessful
and at term delivery by a breech presenta-
tion took place, being rendered additionally
difficult by reason of extended legs, and
demanding final extraction under anes-
thesia. At birth the child was alive though
pale and rather shocked; it lived for
9 hours without causing alarm, though it
remained pale and cold. It collapsed quite
suddenly, without either convulsions or
cyanosis, about 94 hours after delivery.
Post mortem there were no abnormalities
beyond these shown in the adrenal gland
and kidney (Fig. 2). Each side was affected
similarly, and thrombosis of both adrenal
and renal veins was to be demonstrated
microscopically.
A further specimen of the condition is
shown in the Royal College of Sur-
geons’ museum (Spec. No. 9294.1),
the presentation in this case being a vertex; there
are no records of the other points of interest.
Purpurtc type—A second form of hæmorrhagic
necrosis, also frequently attended by thrombosis of
the attendant veins, occurs at later periods of life,
when the androgenic zone hyperemia has subsided,
and takes place from entirely different causes uncon-
nected with any physiological process. As a conse-
quence of the development of a purpuric (hemorrhagic)
tendency of whatever cause, but more particularly
following septicemia— especially streptococcal —
meningitis, pneumonia, and diphtheria, the most
extensive primary hemorrhages may occur into the
substance of the adrenal gland of either one, or
more usually both sides, disrupting its substance
entirely and frequently distending the capsule to
extraordinary proportions. When the process is
symmetrical both cortices are destroyed with the
greatest rapidity and acute adrenal insufficiency
quickly develops. The condition is well illustrated
by the following case:
A girl of 10 months and without previous illnesses
developed a slight cough and became a little feverish.
The temperature rose to 101° F. For nearly a week the
condition was more or less stationary, then without
apparent reason the child became most apathetic, lost
appetite, and within 8 hours vomited. Convulsive fits
DR. KEITH SIMPSON: THE ADRENAL GLAND AND SUDDEN DEATH [APRIL 10, 1937
853
FIG. 4.—Acute tuberculosis of the adrenal gland in a man aged 22.
developed 2 hours later and continued intermittently
for another 10 hours. Vomiting was repeated during
this period. After 20 hours there appeared some respira-
tory embarrassment and coma developed. The child
died suddenly in its mother’s arms after 21 hours.
Post mortem there was a well-developed acute hæxmor-
rhagic pneumonia of streptococcal type, with minute
friable vegetations on the mitral valve cusps indicating
the spread of infection into the blood stream, and bilateral
hemorrhagic necrosis of the adrenals (Fig. 3). Moderate
distension only was present, but no intact cortical element
was seen with the naked eye. Microscopical examination
of the adrenal veins showed that thrombosis was not
developed.
Scheidegger (1933) has described—in a similar case
in a boy of 64 years who died after massive bilateral
adrenal hemorrhages had developed in company
with streptococcal meningitis—actual permeation of
the capillaries by organisms morphologically identical
with those seen in the meninges. The condition is
also shown in the R.C.S. museum (Spec. No. 800.2)
from a nurse at work in a base hospital jn France
in 1917.
In this case the infection was meningococcal, lasted
24 hours in all, and was terminated by the development
of a coarse purpuric eruption throughout the mucous.
membranes and skin. The adrenal glands were both
disrupted by massive hemorrhages indistinguishable
854 THE LANCET] DR. KEITH SIMPSON: THE ADRENAL GLAND AND SUDDEN DEATH
[APR 10, 1937
be.
THORNTON
SAE L LS
FIG. 5.—Massive invasion of the adrenal gland by metastatic
arising from the stomach in a man aged 55.
from those just described in connexion with streptococcal
pneumonia and septicemia. Examination of smears
from the spleen showed numerous Gram-negative diplo-
cocci (meningococci); the case was also one of
septicemia.
In severe burns the same pathological process is
seen with some frequency, especially in medico-legal
work. Particularly when extensive, hzmorrhagic
necrosis of the adrenal glands may develop with fatal
results, in spite of the absence of infection. I have
records of cases developing as soon as four hours and
as late as seven days after injury. Thrombosis is.
again fairly frequent. This lesion develops as a
result of the combined capillary paralysis and
increased capillary permeability taking place during
the period of shock following burns. It is to be
distinguished from the shock-like crisis accompanying
destruction of the adrenal cortices, in which there is
no increase in the permeability of the capillaries and
no increase in the fluid content of the tissue spaces ;
in fact there is a progressive dehydration of the tissues.
The matter will be referred to again later.
Cystic hematomata may also develop, either under
conditions’in which the capsule bursts and extravasa-
tion of clot occurs, or after repeated smaller hæmor-
rhages, none of which is sufficiently extensive to
cause death. One gland alone may be involved.
Spec. No. 1912.1 in the R.C.S. museum illustrates
this very well.
carcinoma
A woman, aged 44, was in good general
health but suffered from occasional pain in the
left loin. Five years previously an operation
had been performed for a large retroperitoneal
hematocele, lying in the region of the left
kidney and “causing intestinal obstruction.”
The cavity, evacuated of its blood clot, was
marsupialised to the abdominal wall and packed
with gauze. None of the cyst wall was removed ;
recovery was uneventful. The second hemor-
rhage was heralded by 12 hours’ vomiting, and
operation revealed the condition shown. The
relation between the first and second hæma-
tomata was not made clear.
ACUTE CASEOUS TUBERCULOSIS
In the large majority of cases of adrenal
tuberculosis the disease, being secondary,
pursues an insidious course and is attended
by limiting fibrosis and calcification. Addi-
sonian changes have usually become well
developed before death takes place. Tuber-
culosis of the glands is relatively common,
accounting for at least some 70 per cent.
(Guttman 1930) of cases of Addison’s
disease, but rapid destruction of the glands
on both sides likely to cause acute cortical
insufficiency is uncommon. As with growth,
arterial embolism is almost certainly respon-
sible for initiation of the disease, rapid
caseous necrosis, and often bulky prolifera-
tive thickening by soft granulations bringing
about a very considerable enlargement of
the affected gland. The following case is a
good example :
A metal worker, aged 22, arrived home after
a game of football complaining of abdominal
pain and nausea. He had received no injuries
during the course of the match. Vomiting
occurred within half an hour of his arrival,
and was repeated about 14 hours later. Shortly
after this his wife noted twitching of the face
muscles and of the hands, and before assistance
could be summoned he had collapsed in a major
convulsive fit; intense cyanosis and marked
: respiratory embarrassment were present, and
death took place a few minutes later. The total period
of definite illness was less than 3 hours.
Post mortem there was both primary and secondary
apical disease of the right lung, both however progressing
favourably, and massive soft caseous necrosis of both
adrenals (Fig, 4). There was no pigmentation of the skin
or mucous membranes, and no evident loss of weight.
This was confirmed by the wife who described her husband
as having had no illness until the day of his death.
It is especially true of the adrenal gland that with
but little primary pulmonary or mesenteric disease
there may be the most gross destruction by secondary
proliferative and caseous disease (Elsässer 1922).
When this is developed rapidly signs and symptoms
of acute insufficiency may appear, and as in this
case prove quickly fatal. It is of course probable
that a minimum of reserve cortex was present for
some days or possibly weeks before death suddenly
took place; the subject is on the brink of a catas-
trophe without having knowledge of the fact. The
frequency with which exercise, shock, or extreme
variations in temperature cause a precipitation of the
fatal attack is well known, and will be discussed
later.
INVASION BY METASTATIC GROWTH
Although primary malignant growths of both
the cortex and the medulla of the gland may result
in complete destruction of the cortex of one side,
that of the other gland is rarely if ever affected, and
THE LANCET] DR. KEITH SIMPSON :
deprivation of both cortices does not occur; sudden
death from acute insufficiency is not seen in company
with primary malignant growth. Metastatic growth
invasion is, however, a process more likely to result
in the destruction of both glands, since it is so
commonly bilateral. This form occurred in a farm
labourer who dropped dead in a field while “‘ stoning ”’
furrows.
He was aged 55 and,so far as was known, had not had
any illness for at least 25 years, and had not com-
plained in any way up to the day of his death. He
dropped dead whilst moving slowly along a plough furrow,
with several companions, removing stones.
Post mortem he was in a condition of perfect health
as regards the heart and vasculature, but bore a small
ulcerative carcinoma of the body of the stomach, with
several glandular infiltrations in the porta hepatis, and
adrenal glands having the appearance shown in Fig. 5.
There is complete destruction of both cortices, and in the
absence of any other cause of death, the primary tumour
being small, and other organs being healthy, acute adrenal
insufficiency was held to be responsible.
Any organ may give rise to metastases in the
adrenal glands, but some appear to do so with striking
frequency. Willis (1933) describes deposits in 27
out of 323 consecutive cases of carcinoma growth
irrespective of the site of origin, and remarks upon
the frequency of deposit from primary tumours of the
lungs and breast, and from melanomata. In over
a half of these 23 the deposits were bilateral.
It is striking how far the cortex may resist destruc-
tion, remaining as a thin lamina stretched out over
the growth mass. This fact added to the infrequency
of large bilateral deposits is a reasonable explanation
of the rarity of deaths clearly from acute adrenal
insufficiency in a condition as frequently seen as
metastatic deposit in both adrenal glands. Willis,
although not interested in the symptomatology of
his cases, notes the occurrence of asthenia and vomit-
ing as terminal symptoms of cases showing adrenal
deposits at autopsy, but fails to denote their relation
to adrenal insufficiency.
Now something of the vascular anatomy of the
gland has already been said, with particular reference
to the formation of metastases. Those penetrating
cortical arterioles and capillaries running vertically
down through the cortex to the medulla are most
likely to afford embolic sites for growth, and it is
surprising therefore to find that the majority of
these deposits are situated first in the medulla.
There can be no doubt that the arterioles and the
capillaries of the cortex are unusually wide and that
growth emboli may for this reason make their way
successfully to the medulla. Emboli have been
observed in otherwise normal glands by Adams
(1923) and by Robson (1928), and arterial embolism
is undoubtedly the route by which these growths
take origin. They may occur primarily in the
cortex,.or primarily in the medulla, or in both
together (see R.C.S. museum, Spec. No. 2112-3, from
penis). On rarer occasions growth may also infiltrate
direct from contiguous structures or through the
lymphatics (see R.C.S. museum, Spec. No. 2054-1,
lymphosarcoma).
Dosquet (1921) has suggested that the high
frequency of adrenal metastases and cerebral metas-
tases in lung cancer illustrates tissue susceptibility
to growth deposit, both ectodermal nervous tissues
being embedded in a material rich in lipoids.
Pathological Physiology
No description of the morbid anatomy of the
changes in the adrenal glands in relation to sudden
THE ADRENAL GLAND AND SUDDEN DEATH [APRIL 10, 1937 855
death would be complete without a proper analysis
of the exact sequence of events that leads to death,
A close parallel exists between the symptoms and
signs consequent upon experimental extirpation of
the gland and those following deprivation from
natural causes.
Under experimental conditions, in dogs (Banting
and Gairns 1926) surviving less than 50 hours, for
instance, the most striking changes are as follows
(Fig. 6).
(a) An initial period of surgical shock (absent under
natural conditions) : '
Weakness
Loss of appetite.
Vomiting.
Convulsions, and
Respiratory paralysis ;
panied by:
(b) Oliguria or complete anuria, reduced temperature,
oxygen consumption, and body-weight. The basal
metabolic rate falls by as much as 25 per cent.
Changes in the blood chemistry.
and these are accom-
The onset of these changes is insidious, the subject
- becoming apathetic and slow, weak in the hind legs,
then lying prostrate, refusing food and often vomiting.
Muscular twitchings and then frank convulsions
develop, respirations becoming slow and laboured,
and eventually ceasing, though the pulse may still
continue.
In the case of bilateral hemorrhagic necrosis
already described these features developed with
remarkable faithfulness. This infant of 10 months
in turn showed loss of appetite and apathy, lay
prostrate and then vomited, developed fits, went
into coma, breathing ‘‘ with great clutching breaths,”
‘then dying in its mother’s arms quite unexpectedly.
Adverse conditions may precipitate these changes,
as for instance in the case of acute caseous tuberculosis
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FIG. 6.—The physiological changes after adrenalectomy in dogs.
described in which death was precipitated by unusually
vigorous exercise—playing football. In older persons
exertions may be quite mild, as with the case of
growth infiltration in a man who was doing no more
than bending to pick up stones from a furrow and
cast them aside. Extremes of temperature may cause
failure in the same way. The mechanism of this
will be discussed below in connexion with. the changes
in blood chemistry.
BLOOD CHEMISTRY
It is in the examination of changes in the chemistry
of the blood that the causes of death become apparent
856 THE LANCET] DR. KEITH SIMPSON : THE ADRENAL GLAND AND SUDDEN DEATH
(Fig. 7). They are related principally to alterations
in hepatic and renal function consequent upon
deprivation of the essential cortical hormone. Those
changes consequent upon diminution of hepatic
function are reflected in a rise in the cholesterol and
a fallin blood-sugar ; this latter may be so pronounced
as to reach convulsive levels (Porges 1910), and at
the same time there occurs a remarkable diminution
of both liver and muscle glycogen, restoration failing
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Days Following Adrenalectomy
FIG. 7.—Changes in the blood chemistry after adrenalectomy.
to take place after exercise. It is clear that the
cortical hormone is essential either for the normal
synthesis of glycogen by muscle, or for the main-
tenance of the normal balance between blood-sugar
and tissue glycogen.
Diminution of kidney function, related clearly to
dysfunction of both glomerular and tubular elements,
is reflected in a sharp rise in blood-urea and other
non-proteinous nitrogen constituents of the blood,
the urinary output being decreased.
The blood volume is reduced, together with the
_ levels of both sodium and chloride, the urinary output
of these substances vastly exceeding the intake over
any period after the second day (Loeb 1923).
There is no deviation of fluid into the tissues, which
indeed become dehydrated, and no passage of fluid
into the red corpuscles, these becoming increased
in number as the blood concentrates.
Sodium diminishes by as much as 15 per cent. ;
on the other hand potassium values increase by as
much as 42 per cent. and magnesium by as much as
23 per cent., effectively maintaining the falling osmotic
pressure (Baumann and Kurland 1923). There
can be no doubt that this imbalance of kations
alone provides reasonable cause for the variations
in muscle tone and movement observed.
In Fig. 6 it will be noticed that the chloride loss
is relatively less than that of sodium. This results,
of course, in a decrease in bicarbonate and a dis-
turbance in the acid-base equilibrium, the pH
falling.
Now other acute pathological conditions, like
diabetic acidosis and high intestinal obstruction,
are also attended by much the same loss of inorganic
base. They too are remarkable for their resemblance
to the conditions of shock, just as is acute cortical
insufliciency, and they too can be relieved by the
restoration of sodium chloride. Immediate relief
follows adjustment of the electrolyte balance (Soddu
1898). It must of course be remarked that the
[APRIL 10, 1937
condition is distinct from that of “‘ surgical shock ”’ :
it ig rather an intolerance to the various influences
that may cause shock. In some respects the condi-
tions are analogous to those of hypocalc#mia after
deprivation of parathyroid, and in this respect it
would not be unreasonable to attribute to the adrenal
cortex the control of sodium.
Conclusion
Although the loss of sodium and its attendant
imbalance of electrolytes are the most striking of the
processes developing in acute adrenal insufficiency,
the clinical features are not adequately explained
by this succession of changes alone. It is clear
that both hypoglycemia and dehydration have their
parts to play; their importance in the mechanism
of death cannot be ignored. |
Each of these three biochemical anomalies developed
in relation to cortical insufficiency has its experi-
mental champion, Loeb supporting the changes in
sodium metabolism, Britton emphasising the undeni-
able importance of hypoglycemia, and Swingle and
Pfiffner investing the loss of tissue fluid and plasma
~ volume with chief responsibility. Each has claims
which are irrefutable, and it is abundantly clear
that all three collectively, rather than one individually,
are to be held responsible for death.
I wish to express my gratitude to Dr. A. D. Cowburn,
Dr. P. B. Skeels, and Dr. L. F. Beccle, coroners
respectively for South London, Metropolitan Essex, and
South Essex, to whom I am indebted for certain of the
specimens shown.
REFERENCES
Adams, F. D. (1921) Arch. intern. Med. 27, 175.
Banting, F. G., and Gairns, S. (1926) Amer. J. Physiol. 77, 100.
aumann, E. J., and Kurland, S. (1923) J. biol. Chem. 55, 457.
Biedl, A. (1910) Janus, 15, 193.
Bornstein, A., and Gremels, H. (1925) Arch. path. Anat. 254, 409.
aout S. J., and Wislocki, G. B. (1914) Bull. Johns Hopk. Hosp.
25, .
Dosquet (1921) Virchows Arch. 234, 481.
Elsässer, quoted by Mackenzie, J. J. (1922) Endocrinology and
Metabolism, vol. ii, p. 257.
Guttman, P. H. (1930) Arch. Path. 10, 742, 859.
Krause, E. J. (1927) Beitr. path. Anat. 78, 283.
Landau, M. (1912) Frankfurt. Z. Path. 11, 26.
Langlois, P. (1898) Arch. de Physiol. 10, 124.
Levinson, S. A. (1935) Amer. J. Surg. 29, 94.
Loeb, R. F., Atchley, D. W., Benedict, E. M., and Leland, J.
(1933) J. exp. Med. 57, 725.
Mackay, E. M., MacKay, L. L.,and Addis, J. (1932) Ibid, 56, 255.
Pende, N. (1923) N.Y. med. J. 118, 469.
Porges, O. (1910) Z. klin. Med. 69, 341.
Robson, G. M. (1928) Arch. Path. 5, 751.
Scheidegger, S. (1933) Zbl. allg. Path. path. Anat. 57, 163.
Soddu, L. (1898) Sperimentale, 1, 87. .
Stewart, G. N., and Rogoff, J. M. (1929) Amer. J. Physiol.
Willis, R. A. (1934) The Spread of Tumours in the Human Body,
London, pp. 277-80.
—_—_
ROYAL LONDON OPHTHALMIC HospPIraL.—tThe first
full year’s workings at the enlarged Moorfields Hos-
pital show that annual expenditure was nearly £50,000
—an increase of over £5500. More cases were treated
than ever before, a total of 66,877 being reached. Build-
ing operations have cost £181,000 and supporters are being
appealed to for special donations to pay off the debt.
RoyvaL WEst Sussex HOSPITAL, CHICHESTER.—
The Bishop of Chichester presided on March 24th at the
annual meeting of the governors of this hospital. The
financial report showed an excess of expenditure over
income of £211, but the figure would have been larger
but for a legacy of £2000. Subscriptions amounted
only to £1495, which was less than 10 percent. of the
expenditure. It was stated that an economy committee
set up last year had decided that the institution was
economically administered and that it would not be justifi-
able to close down a number of beds, considering the small
sum involved. The West Sussex Associated Hospitals
Contributory Fund had contributed £4453 to the
hospital.
i
THE LANCET]
DIPHTHERITIC MYOCARDITIS
AN ELECTROCARDIOGRAPHIC STUDY
By NorMAN D. Brac, M.D. Aberd., D.P.H.
MEDICAL SUPERINTENDENT TO THE BOROUGH INFECTIOUS
HOSPITALS, SOUTHEND-ON-SEA
COINCIDENT with the decline in laryngeal involve-
nent practically all the serious manifestations of
diphtheria have come to be associated with the
so-called faucial forms of the disease. Here the
diphtheria bacillus, remaining in situ, produces a
variable amount of soluble exotoxin which has a
primary affinity for heart muscle and nerve tissue.
Death in diphtheria results much more commonly
from cardiovascular involvement than from purely
paralytic phenomena, and it is towards the heart
complications of diphtheria that attention will be
directed in this paper.
The electrocardiographic approach to this problem
is not.a new one. American, and continental writers
in particular, having described the gross conductive
lesions of diphtheria and correlated them with
degenerative changes in the bundle of His revealed
post mortem, passed on to study the steps in the
development of minor disorders of cardiac function
which had not previously been recognised, In this
way serial electrocardiograms have come to occupy
a position of some importance in prognosis although
almost every investigator admits that occasionally
they fail to explain the whole mechanism of circulatory
collapse in diphtheria.
fundamental facts, is it reasonable to expect them to
do so. An electrocardiogram is merely a record of
the changing electrical activity within heart muscle
and affords no direct evidence of structural damage—
although this latter may be inferred in many cases
with a considerable degree of accuracy. Moreover
an electrocardiogram cannot reveal changes occurring
outside the heart muscle.
failure which is primarily peripheral in origin a normal
electrocardiogram may be expected even when
death is imminent. But peripheral failure by itself
is a rare event in diphtheria—in the vast majority
of cases the cardiac mechanism is equally involved.
Hence the importance of obtaining precise informa-
tion on the state of at least part of the cardiovascular
system need not be emphasised.
Scope of the Investigation
The present series comprised 100 cases of severe
faucial diphtheria which were subjected to electro-
cardiographic investigation. In order to avoid
moving severely ill cases, four of the diphtheria wards
were wired to the electrocardiographic department.
A standard Cambridge instrument was used through-
out and records were obtained by the falling-plate
method. The first electrocardiogram was taken
immediately after admission; thereafter records
were obtained daily or at intervals of a few days
during the first three weeks and subsequently at
longer intervals until convalescence was established.
It was hoped from such an investigation to obtain
information on the following points: (1) the frequency
of various heart changes in diphtheria as revealed
by electrocardiography ; (2) the prognostic signifi-
cance of these changes; and (3) the persistence or
otherwise of diphtheritic heart lesions.
Before proceeding to study these cases in detail
certain generalisations may be permissible. In the
DR. N. D. BEGG: ELECTROCARDIOGRAPHY IN DIPHTHERITIC MYOCARDITIS
Nor, in the face of certain.
Thus in cardiovascular .-
[APRIL 10, 19387 857
first place direct involvement of part or whole of the
cardiovascular system occurs almost invariably
within the first three weeks of an attack of diphtheria,
although, of course, lesions appearing in this stage
may persist for many weeks. Secondly, circulatory
failure in diphtheria appears in two forms. These
were distinguished by Schwentker and Noel (1929)
on a purely pathological basis into an early and a
late type.
Early circulatory failure appears within the first
few days of disease and represents the sum of toxic
effects on all organs. The principal clinical manifesta-
tions are a fall in blood pressure, a small rapid pulse,
extreme pallor, cyanosis and coldness of the
extremities—a physical state more commonly
associated with conditions of shock than cardiac
failure. Carbohydrate metabolism is invariably
deranged and there is an abnormal body response
to the intravenous injection of dextrose in the
direction of higher blood-sugar findings. Electro-
cardiographic evidence of myocarditis may or may
not be present but is rarely so pronounced as to
indicate impending death—an event which mognenty
does ensue.
Late circulatory failure appears usually between
the third and fourteenth day of the disease. Evidence
of peripheral failure may be present but the outstand-
ing feature is clinical and electrocardiographic evidence
of damage to heart muscle or to the specialised tissue
of the conducting system. Death is also a common
event in late circulatory failure but almost any
degree of myocardial damage may be recoverable
in individual cases and, on the whole, the outlook is
relatively better than in early circulatory failure.
Results
The average day of death in this series from
circulatory failure early or late was the tenth day of
disease and the latest day recorded was the nineteenth
day of disease. Two deaths from broncho-pneumonia
and diaphragmatic paralysis were excluded. A
further study of fatal cases reveals the fact that in
3 cases only could the associated circulatory failure
be described as the early type, and two of these showed
some electrocardiographic evidence of myocarditis.
In contrast, deaths typical of late circulatory failure
numbered 23 and in each case there was electro-
cardiographic evidence of myocardial involvement
with or without the addition of a frank conductive
lesion.
It is possible to divide the 100 subjects of this
investigation into three groups consisting of (a)
those showing no significant abnormality, (b) those
showing evidence of myocarditis without a gross
conductive lesion, and (c) those showing an associated
conductive lesion. The results of such a classifica-
| tion are summarised in the Table.
It will be seen that 84 per cent. of cases developed
some electrocardiographic abnormality as a result
. of diphtheria, and that in no less than 27 per cent.
of all cases this abnormality took the form of a
conductive lesion, the mortality in the latter group
being more than twice that of the group showing no
predilection for the conducting system.
A description of the chief abnormalities revealed
in the three groups is given below, and the significance
of each is discussed. It is necessary to emphasise
the fact that lesions merge into each other and
that combinations of two or more lesions are by no
means uncommon. Hence the classification used
is only one of convenience, in an attempt to study
the salient abnormality of individual cases.
858 THE LANCET]
DR. N. D. BEGG : ELECTROCARDIOGRAPHY IN DIPHTHERITIC MYOCARDITIS
[APRIL 10, 1937 -
TABLE SHOWING CASE-FATALITY IN VARIOUS GROUPS DETERMINED BY ELECTROCARDIOGRAPHIC CHANGES
Myocarditis.
No e e
significant No demonstrable conductive lesion. Demonstrable conductive lesion.
— abnor Total.
mality | |
Slurred Low Changes Paroxys- | Complete | Bundle- Intra-
; mal tachy-| heart- branch |ventricular
QRS. | voltage. | inT. |Moaräia | block. | block. | block.
Cases . ia 16 8 6 35 8 12 6 9 100 |
Deaths ee ie 1 1 0 4 8 8 4 2 28
Case-fatality per cent. 6'2 12°5 0 11°4 | 100°0 66°7 66°7 22°2 28-0
Total mortalit
per cent. zs 6°2 22°8 §1°9 28°0
APPARENTLY NORMAL GROUP
As a normal electrocardiogram varies within
tolerably wide limits, no significance has been
attached to inversion of the T wave in lead III,
or to a low, notched Q RS complex in lead III.
When the tracing is otherwise normal these
variations appear constantly in successive records
and remain uninfluenced by the disease. Alstead
(1932) does not regard evidence of electrical
axis deviation of the heart as significant. In his
experience this change, unless it appeared in serial
records during the course of the disease, was not
associated with an abnormal heart clinically. I
am in complete agreement with this observation and
5 such cases are included here. The remainder,
showing physiological electrocardiograms throughout,
included one in which death occurred from early
circulatory failure. Electrocardiograms taken from
this case on the fourth, seventh, and ninth day
revealed no abnormality and clinical examination
of the heart failed equally to anticipate the sudden
circulatory collapse that took place on the tenth
day of the disease.
MYOCARDITIS GROUP
The abnormalities in this group are associated with
the ventricular portion of the tracing. Evidence
of a minor prolongation of conduction time may
also be present but the main characteristic is not a
gross lesion of the conductive
system,
Q k S complex.—This represents
the first stage of ventricular
activity. Each deflection of a I
normal Q R S complex is recorded
as two uninterrupted evenly shaded
straight lines, which converge to
a sharp point. Pronounced shading
at any point is abnormal and
results in a slurred Q R S. In diph-
theria slurring takes place on the
down stroke of the R wave and
in extreme cases results in a deep
curved S wave (Fig. 1 A)—a direct
precursor of T wave changes. III
By itself it indicates a moderate
degree of myocarditis which is
unlikely to cause death in the
absence of peripheral failure. How-
ever, of 8 cases exhibiting this
abnormality, 1 died of early circu-
Lead
II
amplitudes (Fig.
tricular activity. Normally it is upright and
has an amplitude which should not be less than
0-15 millivolt. In diphtheritic myocarditis the
T wave may be depressed, diphasic, iso-electric, or
inverted. A typical example is shown in Fig. 1B.
T wave changes of any degree commonly indicate
more severe myocarditis. In diphtheria, however,
the outlook is reasonably good, since of 35 cases show-
ing this abnormality only 4 died, death in 1 case
being primarily due to broncho-pneumonia.
Low voltage.—Normally the R wave amplitude does
not fall below 0-6 millivolt except in lead III or less
commonly in lead I. Considerably lower voltages
in all three leads of an electrocardiogram were
occasionally recorded in this series. By itself this
does not appear to have serious prognostic significance,
but when T wave changes are associated with low
lc) severe myocarditis may be
assumed.
Disturbances of the pacemaker.—The heart beat
normally originates in the sinus node, Occasionally
through nervous or other disturbances the pacemaker
may not function properly and the beat may originate
in other parts of the heart. For example, where the
- source of heart rhythm is abnormally situated some-
where in the auriculo-ventricular nodal tissue a record
such as shown in Fig. 2 is obtained. Extrasystoles
on the other hand arise independently of the existing
heart rhythm and always from a focus outside the
FIG. 1.—DEGREES OF MYOCARDITIS
latory failure on the seventh day
of disease.
T wave changes——The T wave
is the final evidence of ven-
A.—Slurring of the R wave and deep curved S in leads JI and III and a biphasic
T wave in lead I. Moderate myocarditis.
B.—The ascending limb of the R wave in lead II is splintered; there is slight intra-
ventricular delay ; the T wave is inverted in each lead. More severe myocarditis.
C.—The maximum voltage of the R wave in any lead is 0°5 millivolt.
The T wave
is inverted in leads I and II. Severe myocardial damage.
THE LANCET] . DR. N. D. BEGG: ELECTROCARDIOGRAPHY IN DIPHTHERITIC MYOCARDITIS
sino-auricular node. In diphtheria they are usually
ventricular in origin and, in common with disturbances
of the pacemaker, do not appear to indicate a myo-
Lead
II
FIG. 2.—The P wave is occasionally buried in or
can be seen jutting out from the Q RS complex.
Nodal rhythm.
carditis of any degree, if the record is otherwise
normal,
Tachycardias not of sinus origin are paroxysmal in
character and represent a rapid and regular succession
of premature contractions which
may arise in an ectopic focus in
the auricle, auriculo-ventricular
junctional tissues, or ventricle.
In the present series one example II
of paroxysmal auricular tachy-
cardia (Fig. 3.4) ending fatally
was observed. Paroxysmal tachy-
cardia of ventricular origin
(Fig. 3 B) was seen on 7 occasions
and it is significant to note that
each patient died within a few
days of the appearance of this
abnormality. , II
Venirtcular fibrillation is prob-
ably a fairly frequent terminal
event in a dying heart muscle,
although Josephthal (1934) records
a case of post-diphtheritic ven-
tricular fibrillation which re-
covered, Attempts to obtain
terminal pictures in this series
were uniformly unsuccessful. This
must be attributed to the time
lost in manipulation of plates
during an exposure; it is a
method of obtaining records that
is ideal for ordinary purposes but
possesses great disadvantages when
a continuous record is desired. An electrocardiogram
taken within half an hour of death is shown
in Fig. 7.
Ooronary thrombosis.—In spite of suggestive clinical
findings, such as severe precordial pain and sudden
diminution in heart sounds, the RS-T segment
Lead
Lead
tachycardia.
tachycardia.
changes characteristic of coronary thrombosis were.
never seen in this series. Other gross lesions may
obscure the electrocardiographic picture in individual
Lead
II
FIG. 4.—COMPLETE HEART-BLOCK
A.—The ventricular rate is slow (32); the auricular rate is 85; there is complete auriculo-ventricular
dissociation ; a ventricular extrasystole recurs regularly after each ventricular beat.
heart-block with coupled beats.
B.—The ventricular rate is fast
independently and regularly.
FIG. 3.—PAROXYSMAL TACHYCARDIA
A.—The rate is rapid (180); the rhythm is regular;
the distinct peaked P waves identify the auricular
source of the tachycardia. Paroxysmal auricular
B.—The rate is rapid (175);
irregular; the P waves are buried in
ventricular complexes.
135); the auricular rate is 100 ; the auricle and ventricle are beating
omplete heart-block with fast ventricle.
[aren 10, 1937 859
cases, but Warthin (1924) was able to demonstrate
only one small thrombosis in 16 diphtheria autopsies, —
and it seems probable that coronary thrombosis
is not a common event in diphtheria.
CONDUCTIVE LESIONS
Complete heart-block.—Auriculo-ventricular block
may occur in three stages. The earliest manifesta-
tion is a delay in auriculo-ventricular conduction
time resulting in a prolongation of the P-R interval
in the electrocardiogram. A further delay will lead —
to dropped beats at regular or irregular intervals. If
conduction is still further disturbed there occurs a com-
plete dissociation between auricles and ventricles which
respectively adopt independent rhythms (Fig. 44).
A characteristic of diphtheritic lesions of the main
bundle of His is that complete auriculo-ventricular
dissociation appears usually without preliminary
changes in the P-R interval. In this respect they
differ considerably from complete heart-block arising
Lead
FIG. 5.—The wide notched
QRS complexes are
directed upwards in lead
III and dowards in lead I.
The T wave in lead I is
opposite in sign to the
main initial deflection but
in lead III it is in the
same direction. Atypical
right bundle-branch block.
the rhythm is
torted
Paroxysmal ventricular
from causes other than diphtheria. Marvin (1925)
however, unlike other observers, did record a
significant P-R delay before the onset of complete
heart-block. Preliminary prolongation of the P-R
interval was not seen in this series, the usual sequence
being some abnormality in the ventricular portion
of the tracing and then, suddenly, complete dissocia-
tion. Diphtheritic dissociation differs from other
forms of complete heart-block in two other respects.
In the first place
it may be very
transient ; complete
heart-block in one
case in this series
lasted only 24
hours. Secondly, it
is not invariably
associated with a
slow ventricular
rate. This is of
some importance
since complete
heart-block asso-
Complete
P2
860
ciated with a fast ventricular rate (Fig.4 B) may be
impossible to detect on ordinary clinical examination.
The outlook in the presence of complete heart-block
has invariably been stated to be grave. In this series
it was no worse than in the presence of bundle-branch
THE LANCET]
Lead
ths
os
ome
a
nee
m
II
t
`
r i
FIG. 6.—The QRS complex is wide (0°12 sec.),
notched and directed upwards in each lead:
the T wave is upright. Intraventricular block.
block ; a third of the cases in both categories
recovered,
Bundle-branch block.—Conduction of the wave of
excitation may be partially or completely blocked
in its passage through either the right or the left
branch of the bundle of His. Typically the electro-
cardiographic evidences of complete block of a branch
of the bundle of His consist of a wide notched R wave
and a T wave opposite in sign to the main initial
deflection. Less commonly the T wave in lead I
or lead III may fall in the same directions as the
QRS complex (Fig. 5). In this series 6 cases
showed bundle-branch block, the right
branch of the bundle being involved only
in one instance.
Intraventricular block—Oppenheimer and
Rothschild (1917) in pointing out the M
seriousness of bundle-branch lesions in
diphtheria included in their description a
partial interference with one of the main
bundle branches. There is some’ doubt
whether electrocardiograms showing incom-
plete block do represent interference with
conduction in the fine ramifications of
the Purkinjé network or in the ventricular muscle.
Characteristically the electrocardiogram reveals a
slurred or notched Q R S widened beyond the normal
limit of 0-1 sec. and a T wave which may be upright,
depressed, or inverted (Fig. 6). Of all conductive
lesions in diphtheria intraventricular block appears
to be the least serious. Only 2 cases showing this
lesion died, and in 1 of these the case made a com-
plete electrocardiographic and clinical recovery from
the heart lesion, but succumbed later to diaphrag-
matic paralysis.
Lead
RECORDS IN CONVALESCENCE
Contrary to expectation electrocardiography does
not yield much evidence of persistent heart damage
after diphtheria. Undoubted examples of permanent
lesions have been recorded but, unless one believes
with Butler and Levine (1930) that diphtheria
predisposes a heart to earlier sclerosis than would
normally have taken place, the striking feature of
the severe myocardial lesions in diphtheria is that
recovery in non-fatal cases should apparently be so
complete. Probably the true incidence of permanent
lesions after diphtheria will not be assessed until a
representative group of children are investigated
periodically throughout an attack and for several
years to follow. In this respect the observations
recorded here are open to the same objection in that
they represent only part of a picture. However,
serial electrocardiograms of 57 cases who had
DR. N. D. BEGG: ELECTROCARDIOGRAPHY IN DIPHTHERITIC MYOCARDITIS
followed by an abnormal S-T phase.
myocardium.
, Butler, Ta and Levine, S. A.
[APRI 10, 1937
developed definite heart lesions in the course of
diphtheria were continued until convalescence was
established. On two occasions only was any evidence
of significant electrocardiographic abnormality
obtained. This consisted in one case of a minor
degree of widening of the Q RS complex following
complete heart-block and in the other case low heart
voltages were recorded following bundle-branch
block,
‘Summary
1. Investigation of a series of 100 cases of severe
diphtheria shows that the great majority develop
cardiac abnormalities within the first three weeks of
the disease. In many cases the exact nature of the
abnormality cannot be recognised except by the
auxiliary evidence of an electrocardiogram.
2. If complete heart-block, bundle-branch block,
or paroxysmal tachycardia appear in electrocardio-
grams during the course of diphtheria, the outlook
as regards recovery is relatively bad.
3. In the presence of other evidence of myocardial
involvement, including intraventricular block, the
prognosis is reasonably favourable.
4, A normal electrocardiogram, particularly within
the first few days of the disease, does not preclude
the possibility of a sudden circulatory collapse
and, in this respect, clinical examination may be
equally misleading. Probably at this stage of the
disease an intravenous sugar-tolerance curve remains
the most sensitive guide to prognosis.
LAOL
FIG. 7.—There is complete auriculo-ventricular dissociation; the ventricular
complex recurs irregularly and consists of a large irregular R
wave
Complete heart-block; dying
5. Except in a small proportion of conductive
lesions, recovery after diphtheritic myocarditis
appears to be complete as judged by electrocardio-
grams taken in convalescence,
I wish to acknowledge my indebtedness to Dr. E. H. R.
Harries for the facilities afforded me in obtaining access
to these records since I left the North Eastern Hospital,
and for his permission to publish this paper.
BIBLIOGRAPHY
Alstead, S. (1932) Quart. J. Med. 1, 277.
1 33) Lancet, 41
Begg, N. D. (1935) Twa 1, “480.
ae Amer. Heart J. 5, 592.
Chamberl B.N., and Airtead, S. (1931) Lancet, 1, °970.
Hoskin, T (i936) Ibid,
Hoyrne, As and, Welf ford, N. T. (1934) J. Pediat. 5, 642.
Jones, T d White, P. O. (1927) Amer. Heart J. 3, 190.
Oa ika Et (1934) Wien. Arch. inn. Med. 26, 15.
Kiss, P. V. Me a Arch. Kinderhetik. 94, 97.
Marvin, H. M 1a Amer. J. Dis. Child. 29 Pah
Nathanson, M. . (1928) Arch. intern. Med.
Oppenheimer, g 5 and Rothschild, M. A. TD J. Amer.
med: a 69, 429
J . (1932) New Engl. J. Med. 207, 864.
Rag Ww. 5: (1930) Amer. Heart J. 5, 524.
Schuppler, H. (1935) Jahrb. f. Kinderheilk. 95
Schwentker, F. F., and Noel, W. W. (1929) Bull” Johns Hopk.
Hosp. 45, 27 6.
Stecher, Be M. (1928) Amer. Heart J. 4, 545, 715.
Warthin, A. S. (1924) J. infect. Dis. 35, 32.
VICTORIA COTTAGE HosPITAL, BARNET.—The Prin-
cess Royal on March 16th reopened this hospital which
has been closed since last summer for extensions. The
extensions cost £21,000.
THE LANCET] DR. T, N. MORGAN & MR. S. G. DAVIDSON:
THE ACTION OF
CORPUS LUTEUM HORMONE ON
HUMAN MENSTRUAL CYCLE
By THOMAS N . MorGan, M.D. Aberd.
LECTURER IN THE DEPARTMENT OF MATERIA MEDICA, UNIVERSITY
OF ABERDEEN ; VISITING PHYSICIAN TO THE WOODEND
HOSPITAL ; AND CLINICAL TUTOR AT THE
ABERDEEN ROYAL INFIRMARY ; AND
SYDNEY G. Davipson, F.R.C.S. Eng.
ASSISTANT IN THE DEPARTMENT OF SURGERY, UNIVERSITY OF
ABERDEEN ; VISITING SURGEON TO THE WOODEND
HOSPITAL; AND ASSISTANT SURGEON TO THE
ABERDEEN ROYAL INFIRMARY
THE
THe physiology of the menstrual cycle has in
recent years been considerably clarified by the isola-
tion of the ovarian hormones and the demonstration
of their pharmacological actions. The present state
of knowledge has however been reached mainly as a
result of animal experiment. It is clear that the
rational use of these hormones in therapeutics will
only be possible when the part which they play in
the human menstrual cycle is fully understood, and
the important details of optimum dosage and time
of administration have been obtained by experiment
in the human subject. The experiments to be
described in this communication were carried out
on normal women with the object of obtaining more
complete information regarding the function of the
corpus luteum, and to determine the dose of corpus
luteum hormone required to produce an effect similar
to that produced by the corpus luteum itself.
= Itis now well recognised that treatment of castrated
animals with cstrone prevents the development of
the regressive changes in the genital tissues conse-
‘quent upon castration, E. Allen (1932) has shown
that the injection of estrone into castrated monkeys
'(Macacus rhesus) will so far simulate the action of
endogenous hormone as to produce not only growth
of the uterine endometrium comparable to that seen
in the normal animal about the middle of the men-
strual cycle, but also reddening of the sexual skin,
a phenomenon which occurs normally in Macacus
rhesus in the mid-menstruum, Zuckerman and
Morse (1935) have been able to produce in primates
a cystic condition of the endometrium similar to
that which may occur in woman and which is asso-
ciated with over-production of cstrone (metropathia
hemorrhagica). This condition has also been pro-
duced in the human subject by prolonged treatment
with ostrone (Kaufmann 1934).
CONTROL OF THE ENDOMETRIUM
So far as the early part of the menstrual cycle is
concerned, therefore, the growth of the uterine
endometrium would appear to be under the control
of the ovarian estrone. With regard to the latter
part of the cycle, it has for long been thought that
the change in structure which the endometrium
undergoes after ovulation is due to the influence of
the corpus luteum. This conjecture is supported by
the finding of Corner and Allen (1929) that the injec-
tion of an active extract of corpus luteum into the
cestrus rabbit alters the structure of the endometrium
from the estrus state to that typical of pseudo-
pregnancy. It was subsequently shown by W. M.
Allen (1930) that the hormone of the corpus luteum
could only produce such a change if the endometrium
was first acted upon by estrone, Later Hisaw,
Meyer, and Fevold (1930), and Smith and Engle
(1932) demonstrated the fact that the typical pre-
HORMONES IN MENSTRUATION [APRIL 10,1937 861
menstrual endometrium could be produced in castrated
rhesus monkeys by treatment with cstrone followed
by corpus luteum hormone. The final integration
of these findings and their application to the human
menstrual cycle was performed by Kaufmann (1934)
who succeeded in reproducing a complete menstrual
cycle associated with the typical changes in the
endometrium in castrated women, by injecting 250,000
mouse units of cstrone every fourth day for 15 days
and following this with 21 clinical units of corpus
luteum hormone daily for five days. Cessation of
the injections was followed by true menstrual bleeding.
It has thus been established that the cyclical
endometrial changes which precede menstruation are
under endocrine control, but the cause of the phenom-
enon of menstruation itself remains obscure. That
the hormone of the corpus luteum is not necessary
for menstruation is suggested by the observation
that in both monkeys (E. Allen 1927) and women
(Corner 1933), hæmorrhage can occur regularly from
the uterus in the absence of ovulation, and therefore
in the absence of a corpus luteum. Further it has
been shown by E. Allen (1927) that, after endo-
metrial growth has been induced in monkeys by
cestrin, the subsequent cessation or diminution of
the dose is followed by uterine bleeding. A similar
finding has been made in the case of women by
Werner and Collier (1933). The view thus gained
support that normal menstruation occurs as a result
of the sudden deprivation of estrin. This hypothesis
is however apparently confounded by the experi-
ments of Engle et al. (1935) who showed that bleeding
following the cessation of cstrin injections can be
prevented by the administration of corpus luteum
hormone and that stopping the corpus luteum treat-
ment is followed by bleeding within 4 to 6 days.
We have thus at least two possible explanations of
the cause of menstrual hemorrhage: (1) that the
hemorrhage occurs when the level of blood cstrone
falls below that necessary to maintain the endo-
metrium; and (2) that the hemorrhage and des-
quamation of the endometrium result from the loss
of corpus luteum hormone consequent upon degenera-
tion of the corpus luteum. |
|. If the former hypothesis is correct it should be
possible to postpone the onset of menstruation in
women by the continuous administration of cstrone.
This has been tested by Zuckerman (1936) and
others, who find that the administration of cstrone
in daily doses of 250—1000 rat units fails to prevent
the onset of menstruation unless the injections are
begun before the time of ovulation. This finding is
explained not by a direct action of the ostrone on
the endometrium but by its action in inhibiting the
production of gonadotropic hormone by the hypo-
physis, so that in the case where cestrone is adminis-
tered early in the cycle, ovulation fails to occur and
no corpus luteum is formed. The endometrium thus
remains under the unopposed: influence of the
exogenous oestrone, and bleeding is delayed so long as
the administration is continued. If however injec-
tions are begun after a corpus luteum is formed,
menstruation occurs at the expected time in spite
of the continuous administration of wstrone. This
interpretation of Zuckerman’s results is supported
by the observation of Hisaw (1935) that in monkeys
the administration of cestrone will prevent the onset
of bleeding after ovariectomy, only if the operation
is performed during the early part of the cycle before
an active corpus luteum is present in the ovary.
As already indicated, our experiments were carried
out to test the second of these theories, by
862
determining first if it is possible to delay the onset of
menstruation by the continuous administration of
corpus luteum hormone during the latter part of the
menstrual cycle, and secondly if, and in what dose,
a corpus luteum hormone would replace the function
of the normal corpus luteum. The hormone used
was Proluton (Schering-Kahlbaum). The active
principle in this preparation is a synthetic derivative
of stigmasterol and has the same formula as that
described for the natural hormone of the corpus
luteum by Butenandt and Schmidt (1934); 5 mg. has
a potency of 20 clinical units. The preparation was
tested by us to prove its activity in altering the struc-
ture of the rabbit endometrium, and in diminishing
the motor activity of the uterus, and was found to
possess both these properties.
It was necessary to perform a number of control
observations, and accordingly the experiments will
be described in three parts :—
(a) Observations on the effect of excision of the recent
corpus luteum on the menstrual rhythm.
(6) Observations on the effect of administering corpus
luteum hormone in the latter part of the menstrual cycle.
(c) Observations on the effect of substituting exogenous
hormone after surgical removal of the corpus luteum.
THE LANCET]
EFFECT OF SURGICAL REMOVAL OF THE CORPUS LUTEUM
For this part of the investigation female patients
requiring operation for chronic appendicitis were
utilised, and only those in whom there was no evidence
of any gynzcological disorder, and who could provide
an accurate menstrual history, were included in the
series.
Where possible the patient was observed in the ward
during one menstruation and the operation was performed
at a selected time in the succeeding intermenstruum. In
this way ten cases were operated upon after the 15th day
_of the cycle counting from the first day of the previous
menstruation; and at the operation the ovaries were
inspected and the recent corpus luteum excised. In each
Cuart 1,.—Laparotomy with Excision of Corpus Luteum
Case
1
Menstruation
Operation
oon QO oae WO WwW
Avge interval
= 1'3 days
jat
©
PEC aa a a aaa
DAYS
cage it was examined histologically to corroborate its age.
It was observed that in cases operated on near the middle
of the menstrual cycle the corpus luteum was fresh and
incompletely formed, whereas in two cases operated upon
late in the cycle the histological appearance of the gland
indicated that ovulation had occurred much later than
the 15th day of the cycle. On the other hand it was
never found that a case operated on shortly after the
15th day showed a degenerating gland.
The time of onset of uterine bleeding, carefully
noted in each case, was never longer than 48 hours
after the operation, the average time of onset through-
out the series being 32 hours (Fig. 1).
t
i
DR. T. N. MORGAN & MR. S. G. DAVIDSON : HORMONES IN MENSTRUATION [APRI 10, 1937
According to Pratt (quoted by Bartelmez 1937)
the effect of surgical removal of the corpus luteum
in precipitating the onset of menstruation is not
specific, and any manual manipulation of the ovary
may induce premature menstruation. To determine
therefore if the operation per se, or the manipulation
necessary in excising the corpus luteum without
actual removal of the gland, would be sufficient to
precipitate menstruation, two additional sets of
observations were made.
CONTROL Group 1.—Cases selected upon the criteria
already described were submitted to operation in the latter
CHART 2.— Laparotomy without Handling Ovaries
Interval
caa DABARA MU SASSA a BSE Saba Mes ca cen a
11 3
12 i 13
13 4
14 9
15 5
16 4
Lurral sials anaal dans Avge 61 days
DAYS
. part of the intermenstruum, and in these the pelvic
viscera were not disturbed, the ovaries being as far as
practicable inspected to ascertain the presence of a corpus
luteum without handling them in any way. In 4 cases of
this group the onset of menstruation was not accelerated
and occurred at or about the expected date. In 2 cases
menstruation appeared earlier than the expected time,
but in no case did menstruation occur as soon after
operation as in the previous group (Fig. 2).
The average interval between operation and men-
struation was 6-1 days. ;
CONTROL GROUP 2.—A third group of 7 cases were
examined in the same way, but in these the ovaries were
delivered at the wound and handled, though the corpus
luteum was notremoved. In 4 cases the onset of post-opera-
tive menstruation was not hastened. In Cases 19, 21, and 22
(Fig. 3) an interval of 5, 3, and 6 days respectively elapsed
between the operation and the appearance of uterine
bleeding. It is interesting to note that in Cases 18, 19,
and 23 small cysts were excised from the ovaries.
Even when, therefore, the traumatisation of the
ovary was as great as in the cases in which the
corpus luteum was removed, the occurrence of post-
operative menstruation was delayed for 5, 5, and 14
days.
THE ACTION OF CORPUS LUTEUM HORMONE ON NORMAL
MENSTRUATION
The experiments just described have shown that
excision of the corpus luteum precipitates the onset
of menstruation. To test the theory that normal
menstruation is brought about by loss of the corpus
luteum, an attempt was next made to delay the onset
of bleeding in normally menstruating women by the
intramuscular injection of proluton. The investiga-
tion was carried out on patients submitted to pro-
longed hospitalisation on account of chronic pulmonary
tuberculosis.
Patients presenting a history of regular menstruation
were selected, and the interval between successive men-
struations was determined over 3 or 4 months in each case.
Shortly before the onset of the expected menstruation,
intramuscular injections of proluton were begun and
continued daily until menstruation started. Since it was
impossible in most cases to foretell with any degree of
certainty the day of onset of menstruation, the cases
THE LANCET] DR. T.N. MORGAN & MR. S. G. DAVIDSON: HORMONES IN MENSTRUATION
[APR 10,1937 863
received courses of injections of the hormone of different
duration. The daily dose was varied from 20 clinical
units to 40 clinical units. It will be seen from the Table
that the administration of corpus luteum hormone in
doses ranging from 60 clinical units over a period of 3 days
to 520 clinical units over a period of 13 days did not delay
Daily | Injec- | Dura-
dose of | tion | Total | tion of
proluton| period (clinical treated
Control duration
No. of intermenstrua]
periods in days. Seer F ae units). ee ed
28 | 30 | 40 | 2| 80 33
28 32 40 11 440 43
34 31 20 3 80 33
40 34 20 3 60 35
24 30 40 6 240 28
28 35 20 3 60 31
31 31 20 3 60 34
29 19 40 10 400 30
32 33 40 5 200 34
30 33 40 11 440 34
34 42 40 11 440 44
34 32 40 9 | 360 32
30 28 40 11 440 36
26 30 40 13 520 30
28 30 40 13 520 32
Onset of Menstruation.—Spontaneous in each case.
the onset of menstruation. In Cases 25, 34, and 36 the
intermenstrual interval lasted 43, 44, and 36 days, that
is 10, 6, and 7 longer than the average duration of three
menstrual cycles, but we have observed even greater
variations to occur spontaneously in the menstrual rhythm
CHART 3.—Laparotomy with Manipulation of Ovaries
Interval]
Opn-Menstrn
(days)
10
* Cyst excised
of normal women so that no importance can be placed
upon this finding. Of great significance is the fact
that in each case of this series menstruation occurred
spontaneously during the course of the injections.
It is apparent from these experiments that the
intramuscular injection of proluton in doses of the
order of 500 clinical units will not delay the onset
of menstruation, and since excision of the corpus
luteum is constantly followed by menstruation within
at most 48 hours, one may fairly conclude either that
the onset of natural menstruation is not determined
by degeneration of the corpus luteum but by some
other factor, or that the substance injected was
incapable of simulating the action of the natural
hormone. It was necessary therefore to determine
how far injection of proluton would replace the
function of the corpus luteum after it had been
excised, —
EFFECT OF ADMINISTERING PROLUTON BEFORE AND
AFTER SURGICAL REMOVAL OF THE CORPUS LUTEUM
Excision of the corpus luteum was carried out in
seven patients coming to operation for chronic
abdominal disease.
The cases were operated upon about the middle of the
menstrual cycle, and injections of proluton in daily doses
of 40 clinical units were begun at various times before
operation, and continued after the operation until men-
struation occurred. The maximum pre-operative injection
Cuart 4,—Excision of Corpus Luteum and Injection of
Hormone
Day Pre-op. Total
of dose dose
opn (units) (units)
19th 100 180
18th 120 200
lth — 80
21st 120 360
16th 200 360
28th 120 280
18th 240 320
period was 6 days, giving a total dose of 240 clinical units.
As in the previous cases the’corpus luteum was examined
histologically to ascertain its approximate age. In this
series, two cases menstruated within 48 hours, two in
72 hours, two in 4 days, and in one menstruation was
delayed for 6 days, after which it occurred spontaneously.
As will be seen from Fig. 4, the time after operation at
which bleeding occurred bore no relation to the dose of
proluton administered before the operation.
Although the interval between operation and men-
struation was longer than the interval in the first
series, where the corpus luteum was excised and no
proluton given, hemorrhage occurred spontaneously
in every case.
DISCUSSION
The foregoing observations show that excision of
the corpus luteum is constantly followed within
48 hours by menstruation, and it is clear from the
control experiments that this result is not due to
trauma of the ovaries. At first sight this finding
seems to support the theory that the onset of men-
struation is caused solely by degeneration of the
corpus luteum, and consequent loss of its secretion,
a view supported by the fact that the intramuscular
injection of hormone before and after excision of the
corpus luteum produced a variable but significant
delay in the onset of bleeding. It was however not
found possible to delay indefinitely the onset of
menstruation, artificially induced, nor was there any
constant relation between the amount of the hormone
injected and the delay produced. It is of course
well recognised that the absorption from the tissues
of fat-soluble drugs, injected in oily solution, is slow
and uncertain, a fact which may serve to explain the
relative inefficiency of replacement therapy. If this
explanation is correct, it is a significant point which |
all those who employ corpus luteum hormone for
therapeutic purposes should keep in mind. On the
other hand, the fact that it was found impossible to
delay in any way the onset of natural menstruation,
by the injection of doses of the hormone much
larger than those which were effective in delaying
menstruation induced artificially, raises the important
question as to whether the onset of normal
864 THE LANCET] MR. A. W. CUBITT: DRIP BLOOD TRANSFUSION IN PROLONGED HÆMORRHAGE [APRIL 10, 1937
menstruation is determined solely by degeneration of the
corpus luteum. Indeed our observations suggest the
possibility that naturally recurring menstruation is
brought about by some factor other than or addi-
tional to degeneration of the corpus luteum, and
consequent lowering of the level of luteal hormone
in the blood.
SUMMARY
1, Excision of the recent corpus luteum is followed
within a period of 1-3 days (32 hours) by menstrual
bleeding having all the characters of normal men-
struation.
2. Surgical manipulation of the ovaries, leaving
the corpus luteum intact, is not followed by men-
struation until a much longer period, average 6-1 days.
3. Injection of proluton, a substance having the
actions of the corpus luteum hormone, before and
after excision of the corpus luteum may cause a
delay of 3-6 days in the onset of menstruation.
4, The injection of proluton in doses up to 520
clinical units into normal women during the latter
part of the menstrual cycle does not delay the onset
of menstruation. It is possible, therefore, that the
onset of normal menstruation is not determined solely
by degeneration of the corpus luteum.
We desire to express our thanks to Prof. David Campbell
_ for valuable advice and criticism in the performance of
this work, and to Dr. Harry Rae, the medical officer of
health, for placing the facilities of Woodend Hospital at
our disposal.
REFERENCES
Allen, i once Contr. Embryol. Carneg. Instn, 19, 1.
1932) Sex and Internal Secretions , Baltimore, p. 446.
Allen, Ww. M. (1930) Amer. J. Physiol. 92, 612
Bartelmez, G. W. (1937) radar Rev. 62.
Butenandt, P., and Schmidt, J. (1934) “Bon ges. Physiol. 67,
1901.
Corner, G. W. (1933) EA Baltimore, 12, 70.
and Alen, W. M. (1929) Amer. J. Physiol. 88, 326.
Engle, E. T., Smith, P. E., and Shelesnyak, M. C. (1935)
Amer. J. Obstet. Gynec. 29, 787.
Hisaw, F. L. (1935) Ibid, p. 638.
— Meyer, ara and Fevold, H. L. (1930) Proc. Soc. exp.
Biol., N. Y.
400.
Kaufmann, C. irae) Proc. 5 Soc. Med. 27, 849, 857.
Smib Lo and Engle, E. T. (1932) Proc. Soc. exp. Biol., N.Y.
Werner, A A., and Colier, W. D. (1933) J. Amer. med. Ass.
33.
Zuckerman, S. Sera Lancet, 2, 9.
— and Morse, A. . (1935) Surg. Gynec. Obstet. 61, 15.
THE VALUE OF PERSISTING WITH
DRIP BLOOD TRANSFUSION IN SEVERE
PROLONGED HAMORRHAGE
By Aran W. Cubitt, B.M. Oxon., F.R.C.S. Eng.
SURGICAL REGISTRAR, MIDDLESEX HOSPITAL, LONDON
‘THE mortality from hemorrhage is still sufficiently
high to cause considerable dissatisfaction with present
methods of treatment. The first aim is to stop
hemorrhage by the most direct means possible.
In some cases it will be clear that surgery is the
method of choice; in others it will be equally clear
that surgery offers no prospect of stopping the bleeding.
In another group of cases it may be very difficult
to decide whether or not an operation gives the best
chance of success, and it may be only after careful
observation of the progress of the case that the right
decision can be made.
In all these circumstances the transfusion of blood
may be necessary during the period of hemorrhage.
It may be given with one or more of three main
objects ; to make possible and safe the direct surgical
intervention which may be necessary for the arrest
of hemorrhage; to protect a patient, already
dangerously exsanguinated, from the risk of further
loss of blood ; or to maintain life until the hamorrhage
stops. After arrest of haemorrhage replacement of
some of the blood lost may be desirable to shorten
convalescence or for other reasons,
The introduction by Marriott and Kekwick (1935
and 1936) of the continuous-drip method of blood
transfusion has overcome most of the technical
difficulties of giving slowly and safely adequate
quantities of blood over a long period. The quantity
of blood required may occasionally be very large.
It is above all in those cases in which the necessity
for operation is in doubt that the method should make
the right decision possible and the right treatment
practicable. We can now afford to observe the
progress of the patient and estimate the probability
of spontaneous arrest of the hemorrhage without
the grave risk to life either of too long delay or too
precipitate intervention.
Too low a hemoglobin content of the blood may
endanger life either by giving too small a margin of
safety in case of increased hzmorrhage or by so
lowering the resistance that the patient succumbs
to broncho-pneumonia or some septic complication
of his condition. Where prolonged bleeding is
occurring from the alimentary tract the question of
nutrition becomes of vital importance. Whatever
may be our opinion of the influence of diet on the
continuance of hemorrhage, it can hardly be doubted
that malnutrition is an added factor of danger and
that intravenous and rectal alimentation over a
prolonged period is a poor substitute for the normal
method. Nourishment can be given by mouth with
greater confidence if blood can be supplied in quantities
sufficient to keep the patient above the danger level.
This paper is written and the cases recorded in the
hope of showing that when really large amounts of
blood are necessary they can usually be obtained and
can be safely given and that persistence and faith
may be rewarded by the survival and restoration
to health of patients who a few years ago would almost
certainly have died of hemorrhage.
CasE 1.—A man of 42 who had been in the army and
had lived in Hong-Kong had had intermittent attacks
of obstructive jaundice for four months, sometimes
accompanied by pain. The jaundice caused a very
trying pruritus. He had some indigestion. He had had
similar symptoms in 1928 and an operation in a military
hospital had relieved them. Details were not available,
but he was said to have had a cyst in the region of the
pancreas. On examination he was moderately jaundiced,
the urine contained bile, and the stools were clay-coloured.
There was a right upper paramedian scar and a large
cystic swelling apparently attached to the right lobe
of the liver and moving with it; it extended almost
down to the umbilicus; it was not tender. Radiography
showed areas of calcification at the periphery of a spherical
tumour. Casoni and hydatid complement-fixation tests
were negative. The Wassermann reaction was negative.
The alternative diagnoses appeared to be hydatid
cyst of the liver or pancreatic cyst. When first admitted
three months earlier, operation was not advised. The
attacks of jaundice, however, had increased in frequency
and severity and irritation was intolerable. A laparotomy
was performed by Sir Alfred Webb-Johnson through a
midline incision above the umbilicus. The cyst was
found to be pancreatic in origin; the common bile-duct,
duodenum, and some very large veins were stretched
over it and dilated. It was impossible to remove the
cyst and it was therefore marsupialised. The fluid in
the cyst was clear and contained diastase, lipasc, trypsin,
urea, and chlorides. About nine days after operation
he began to complain of epigastric pain and anorexia
and the upper abdomen became very distended and
tympanitic; the pain became very severe. It was
THE LANCET]
DR. R. L. H. MINCHIN : CYSTICERCOSIS AS A CAUSE OF EPILEPSY [APRIL 10, 1937 | 865
supposed that this was due to obstruction of the duodenum
by the marsupialised cyst and this supposition was
confirmed by radiography after a small barium meal.
After a few days the symptoms improved, but it was
noted that he looked very pale, and on the fourteenth
day after operation he had a very large hematemesis,
ret ie by a large stool consisting mostly of changed
ood.
The ‘hemoglobin percentage was estimated as 30;
the patient’s blood-group was 4 (Moss) ; the blood pressure
was 85 systolic, 60 diastolic. A continuous-drip blood
transfusion was started. Bleeding continued for 11 days ;
there were several hematemeses, but the main blood loss
was by the bowel. The source of bleeding was presumed
to be varices in the duodenum caused by prolonged partial
obstruction of the veins stretched over the cyst; the
uncertainty of the cause and site of the hemorrhage put
operation out of the question. For the first two days
water only was given by mouth and saline given by rectum,
but rectal alimentation was very unsatisfactory because
of the frequent large melena stools, and as bleeding
showed no sign of abating, Meulengracht’s diet was
started. Injections of Hzemoplastin and calcium gluconate
were given from time to time: 11-7 litres of blood were given
by continuous-drip blood transfusion within ten days.
Some thrombophlebitis occurred and the cannula was
changed into a different vein eight times, with an
interval of a few hours on three occasions, the longest
interval being 284 hours. During these intervals the
hæmoglobin percentage of the blood fell rapidly, massive
melæna continued, and the transfusion had to be resumed.
It was our deliberate policy not to raise the hemoglobin
percentage above 50 as long as bleeding was still going on.
On the eleventh day there was no more melena; the
hzemoglobin was raised to 60 per cent. and the transfusion
was stopped. The hæmoglobin remained at 60 per cent.
for 24 hours and a further 1-42 litres of blood raised it to
80 per cent. The total quantity of blood transfused in
13 days was 13-12 litres; we think this must be a record
quantity in the time. There was no more bleeding and
progress thereafter was rapid. The discharge from the
cyst lessened after several injections into it of 1 in 400
silver nitrate, and 14 weeks after operation the sinus
was healed and the patient a fit man. During the
transfusion occasional pyrexia and thrombophlebitis
were the only untoward events. Invariably while the
transfusion was proceeding the patient expressed himself
as ‘feeling fine,” but during the intervals when the
hæmoglobin was at a low level he felt very weak and ill.
The blood was obtained from 24 donors; they were
all of Group 4 and their blood was also tested for
compatibility directly with the patient’s serum. The
first two donors were from the Red Cross Society’s Trans-
fusion Service because the blood was required urgently
and in the middle of the night. All the other donors were
men who worked at the factory where the patient was
employed. Eighty-six men were grouped, in batches of
a dozen or more at atime. The men and their employers
were very anxious and willing to help and many of those
who were found to be unsuitable were most disappointed.
CasE 2.—A man, aged 35, who had had a gastro-
jejunostomy for duodenal ulcer six years previously.
For the last six months he had had pain after food and
recently there had been loss of weight. He was admitted
with signs and symptoms of internal hemorrhage, though
no hsematemesis or melena had yet occurred. On
admission: hemoglobin, 30 per cent.; blood pressure,
120/70; pulse-rate 120. Transfusion was commenced
within 14 hours of admission and 7-08 litres of blood were
given by the continuous-drip method over a period of
80 hours with an interval of 94 hours. When it was
evident that hemorrhage was still continuing rapidly the
hemoglobin percentage was raised to 50 and laparotomy
was performed 28 hours after the commencement of the
transfusion. A large spurting artery of the transverse
mesocolon was found in the base of an anastomotic ulcer ;
this was ligatured and the opening sutured. The trans-
fusion was continued during and after operation until the
hemoglobin percentage was 70. Good recovery.
It is sometimes objected that such large quantities
of blood as these are rarely obtainable. It is note-
worthy that of the 37 donors bled for these two cases,
only four were Red Cross Society’s donors. A
patient’s workmates are often a willing and valuable
source of blood, and in other cases, if the onus of
responsibility for finding donors is firmly put upon
the relatives, sufficient blood is usually obtainable.
` Iwish to thank Sir Alfred Webb-Johnson and Mr. E. W°
Riches for permission to publish these cases and Dr. F.
Knights, who performed the transfusions.
REFERENCES
Marriott, H. L., and Kekwick, A. (1935) Lancet, 1, 977, and
>
2, 78.
— — (1936) Proc. R. Soc. Med. 29, 337.
CYSTICERCOSIS AS A CAUSE OF
EPILEPSY IN A DIABETIC INDIAN
By R. L. Havmand MINcHIN, M.D. Edin., I.M.S.
PHYSICIAN TO THE GOVERNMENT GENERAL HOSPITAL,
AND ADDITIONAL PROFESSOR OF MEDICINE,
MEDICAL COLLEGE, MADRAS
No case of cysticercosis giving rise to fits in an
Indian has yet been described, though MacArthur
(1933) has reported 22 such cases in British soldiers
returning home after service in India. It is probable
though of course not proved that these cases were
infected with cysticerci derived from their own
worm. Recent work on the development of the
cysticercus stage of Tenia saginata (Penfold, Penfold,
and Philips 1936) shows that in cattle, its normal
host, this cyst never lives more than nine months,
and then stays only in the muscles and never enters
the central nervous system of the infected animal.
Research is certainly required to show whether the
Cysticercus bovis develops and dies with such regu-
larity in other hosts and to calculate the duration
of Cysticercus cellulose in the infected pig and less
normal hosts.
In July, 1936, I saw the Hindu patient described
below, and requested that he should be transferred
to my wards in the Government General Hospital,
Madras, from the Mental Hospital, as the case appeared
to be a combination of diabetes mellitus and idio-
pathic epilepsy, two diseases which an extensive
search in the published reports has failed to reveal
as occurring simultaneously, and which Joslin (1928)
has been unable to discover among the 6000 hyper-
glycemias he investigated. Further, the combina-
tion of these two conditions would disprove the
hypothesis I have advanced (Minchin 1933) that
idiopathic epilepsy is associated with hyperfunction
of the islets of Langerhans, and would also show that
the beneficial results reported from dietetic measures
to control epileptic hypoglyczemics by Thomas (1936),
and the results of partial pancreatectomy described
by Seale Harris (1933) and others, were due to some
other cause than the consequent rise of the blood-
sugar level.
CASE-HISTORY
The patient belonged to a non-vegetarian caste and
had been admitted to the Mental Hospital in November,
1935. He was mentally confused and would give very
little account of himself. No relations or friends could be
traced to give any particulars of the onset of his disease
or any previous medical history.
During the time he was in the Mental Hospital no
improvement took place in his mental condition and
periodic typical major epileptic fits occurred, there being
6 in January, 5 in February, none in March, 1 in April,
none in June, and 2 in July. There was no prodromal
866 THE LANCET]
DR. R. L. H. MINCHIN : CYSTICERCOSIS AS A CAUSE OF EPILEPSY
[APRIL 10, 1937
signs or symptoms of the fits. During this period the
physical condition deteriorated. In June, 1936, a glucose-
tolerance curve was obtained which gave the following
figures :—
Fasting blood-sugar. 4 hr. 1 br. 13 hr. 2 hr.
308 mg. per 100 c.cm. .. 360 364 444 400
Sugar was present in the urine throughout the examination.
On July 20th the opportunity arose of taking a specimen
of blood immediately after a fit and this was found to
contain 500 mg. per 100 c.cm. of glucose. For the reasons
mentioned above he was transferred to the General
Hospital. On admission he was found to be very
emaciated ; there was considerable mental confusion and
he was unable to give any account of himself.
Examination.—The abdominal reflex was active on
both sides; plantar reflexes could not be obtained; the
deep reflexes were absent ; the pupils reacted to light and
accommodation.
Pulse-rate 80, no irregularities ;
dimensions, sounds clear and closed; blood pressure
115 mm. Hg systolic, 80 diastolic. There was advanced
pulmonary tuberculosis in both lungs.
Laboratory reports.—Urine contained 9 per cent. sugar
but no ketone bodies. Blood showed secondary anzmia
but no eosinophilia. Wassermann and Kahn tests
negative. Stools: no ova, amceba, or cysts detected.
Glucose-tolerance curve taken on August 3rd :—
Fasting 4 br. 1 hr. 14 hr. 2 hr.
267 mg. per100c.cm... 333 340 440 440
Sugar was present in the urine throughout the test.
Electrocardiogram showed a slightly increased size of the
P wave but no other abnormalities. Cerebro-spinal
fluid : Wassermann negative.
= From these examinations the possibility of the fits
being due to syphilitic infection was ruled out and
it was considered that the condition might be due to
a cysticercal infection of the brain. The whole of
the body was carefully examined for the presence
of palpable cysts but none were discovered.
On August llth the skull was X rayed. No calci-
fied cysticercal cysts were demonstrated in spite of
four examinations, the only abnormality detected
heart, normal
FIG. 1.—Cysts seen in the left (on the left) and right cerebral
hemispheres.
being a shallowness of the pituitary fossa. Similar
X ray examinations of the thorax and abdomen
failed to show any calcified cysts. Unfortunately the
limbs were not submitted to X ray examination.
The patient remained in hospital and up to the end of
September his condition improved mentally and physically
under strict dietetic measures and administration of small
doses of insulin, so much so that he was able to take a
fairly intelligent interest in his surroundings and gained
10 Ib. in weight. In the first week of October he started
to run a high temperature and signs of more tubercular
' activity appeared in his chest and the percentage of
sugar in the urine increased in spite of insulin injections.
He died on Oct. 20th. 7 :
Post-mortem report.—Chronic ulcerative phthisis left
lung and tuberculous broncho-pneumonia of right lung
with thickened pleura on both sides. Empyema of
sphenoidal air sinus. In the pancreas the islets of
FIG. 2.—Photomicrograph of scolex from cysticercus in pars
| basalis, showing double row of hooklets.
Langerhans were few and far between and those that
were seen were small and atrophic. Alimentary canal
normal; no tapeworm present.
Brain. Weight 2 Ib. 4 oz.; rather small in size. An
opalescent slightly milky fluid spurted out from the left
temporal lobe during the removal of the brain from the
cranial cavity. A cyst of the size of a small pea with a
milk spot was seen in the right anterior central sulcus about
1 in. above the point of division of the stem of the Sylvian
fissure. A whitish nodule of the size of a large pea project-
ing on the surface of the pars basilaris of the left side
(Fig. 1, right). Above this the cortex of the posterior
ends of the middle frontal gyri was softened. The left
temporal pole was soft, cystic, and collapsed. The gyrus
rectus and the medial orbital gyrus of the left frontal lobe
appeared to be softened. On making antero-posterior
vertical sections through the left half of the brain:
(1) There was a cavity of the size of a walnut in the-
anterior part of the temporal lobe ; its wall was very thin
below and had clearly been torn during removal of the
brain (Fig 1, left). (2) A cavity about 1 in. long, 4 in.
broad, and 4 in. deep was present 4 in. above the medial
orbital gyrus and gyrus rectus, the wall being ragged.
(3) An almost circular cavity $ in. in diameter outlined by
a capsule was seen in the pars basilaris containing a
cysticercus which showed under the microscope a scolex
with a double row of hooklets (Fig. 2).
DISCUSSION
From the pathological report it seems that the
cause of this patient’s epileptic fits was a cerebral
infection with the cysticercus of Tenta solium.
It is unfortunately impossible to state the duration
of the infection, but we are justified in assuming that
it is over 12 months, since fits have been present for
this period. Sections of the cysticercus removed
from the frontal lobe show no sign of degeneration
and it is reasonable to assume that these were living
before being placed in fixing material. MacArthur
was unable to give any idea of the duration of the
infection in his cases. In one patient the fits came on
during treatment for tapeworm, while in another fits
first started four years after removal of a worm.
It is interesting to note that in his cases as in the
one described, no calcification of the cysticerci was
found in the brain, and in the other specimens in the
Madras Medical College museum where a brain infesta-
tion is present no calcification has taken place.
Morrison (1934) has described the only case where
THE LANCET]
calcification of cysts in the brain associated with
epileptic convulsions has been found.
SUMMARY
A case is described of epilepsy in a diabetic Indian
due to infestation of the brain with Oysticercus
cellulosæ. This is the first noted in an Indian though .
there have been cases reported in British soldiers.
There is a need for research on the life-history of
this cysticercus cellusi. The importance of finding
some definite cause for epileptic fits in byperglycemia
is demonstrated.’
My thanks are due to Dr. H. S. Hensman for allowing
me to investigate this case, to Dr. A. Vasudevan for
pathological reports, and to Captain L. W. Barnard for
the paeneerepEe:
REFERENCES
S= (1939) J. Amer. med. Ass. 100, 321.
re heave Mellitus, Philadelphia.
Trans. R. Soc.t trop. Med. Hyg. 26, 525.
Arth . L. H. (1933) J. ment. Sci. 79, 659.
3.
Philips, M. (1936) Med. J.
Reine
Penfold, wW G., Penfold B., and
A , 417 (quoted PETES 1936, 2, 752).
Thomas, o ’R. (1936) J. Tenn. med. Ass. 29, 21.
ACUTE PAROTITIS AS A
MANIFESTATION OF LATENT URAMIA
By REGINALD T. Payne, M.S., M.D. Lond.,
F.R.C.S. Eng.
CASUALTY SURGEON TO ST. BARTHOLOMEW’S HOSPITAL
Ir does not appear to be generally recognised that
in certain circumstances acute parotitis may be an
indirect or even early manifestation of unsuspected
uremia. That this is actually the case has been
brought home to me in many instances during the
past few years. This type of parotitis is only likely
to arise in patients who are already ill from some other
disease—particularly in conditions in which latent
-uremia may occur—such as gastric hemorrhage,
acute infections, insanity and in the post-
operative state. The uremia, therefore, may or
may not be of extra-renal type, and, in addition, is
a type which is not accompanied by edema. The
association between established uremia and acute
parotitis is well known, but I do not believe it is
recognised that the parotitis may at times be the
first sign of a latent uremia, or even that the paro-
titis coming on after gastric hemorrhage, &c., may
have a uremic background.
ZEtiology
In such uremic states, ideal conditions are present
‘in the mouth for the development of an ascending
parotitis. The mouth is dry as the result of the
suppression of almost all salivary secretion, and the
tongue and lips are either parched or thickly furred.
The bacterial content of the mouth is much increased,
and it has been demonstrated by Seifert (1926) that
this is especially true of the Staphylococcus aureus,
at least in the post-operative types. Bacterio-
logically, this type of acute parotitis is almost always
due to 8S. aureus. From the pathological point of
view, the process is best conceived as a diffuse
carbuncular infection of the gland extending along
the ramifications of the ducts. This carbuncular
nature is well demonstrated in post-mortem specimens.
The prognosis of acute parotitis in these uremic
patients is not good. The presence of some ante-
cedent serious disease and the existence of some
MR. R. T. PAYNE: ACUTE PAROTITIS AND LATENT URÆMIA
~ capsule.
[APRIL 10, 1937 867
degree or other of uremia make the outcome uncer-
tain. As regards acute staphylococcal parotitis
itself, this is always a serious disease owing to the
anatomical configuration of the gland and its dense
The recent work of Christiansen (1935) on
uremia as the cause of death after massive gastric
hemorrhage has a bearing on this subject. He has
shown that latent uremia is often the cause of death
after hemorrhage from peptic ulceration. The high
incidence of parotitis in this disease, which was
recorded by Rolleston and Oliver in 1909, suggests
at least that the parotitis has a uremic basis. The
factor of buccal infection is obviously an important
one leading to acute parotitis, and this is brought
about largely through the absence of chewing. The
latent uremia that is present in many of these
patients leads to considerable suppression of salivary
secretion. It is the combination of exaltation of the
buccal flora, especially the staphylococci, together
with absence of parotid secretion, that leads to the
development of ascending parotitis. The condition
is comparable to the development of ascending
pyelonephritis after prostatectomy. Rolleston and
Oliver say: ‘‘ Hone attached more importance to
antecedent hematemesis than to oral starvation as
a factor in the causation of this form of parotitis.”’
This would fit in with the present conception of the
sequence of events—namely, hematemesis, uremia,
parotitis.
Treatment
Acute parotitis as an early sign of latent or develop-
ing uremia is especially likely when the patient
already has some antecedent serious disease. I have
so often made a diagnosis of uremia in unsuspected
cases on the grounds that the patient had an acute
parotitis associated with some other disease that I
cannot believe that parotitis is often considered as
possibly the first manifestation of uremia. Treat-
ment of these cases is not considered here in detail,
but the parotitis must always be taken extremely
seriously, since it may well prove a factor bringing
about a fatal outcome. If resolution of the condition
cannot be brought about very rapidly by conserva-
tive measures, there should be no hesitation in
exposing the gland freely by the usual curved incision,
and making a series of transverse incisions into the
fascia and the gland itself. The absence of any gross
collection of pus should not disconcert the surgeon.
Pus will probably pour from the wound within
24 hours of operation. In the post-mortem examples
of acute parotitis to which I have referred there was
no gross collection of pus, but the whole duct system
of the gland was in a state of purulent infiltration
and the gland itself was about six times normal size.
In acute parotitis, death may occur long before
there is any attempt at localisation of an abscess in
the gland. Finally, recognition of the parotitis as a
possible manifestation of urzemia may lead to adequate
treatment of the latter.
REFERENCES
Christiansen, T. (1935) Hospitalstidende, 78, 561.
Seifert, E. (1926) Dtsch. Z. Chir. 198, 387.
Roues a D., and Oliver, M. W. B. (1909) Brit. med. J.
CENTRAL LONDON OPHTHALMIC HosPITAL. — The
Zunz Fund, in accordance with the policy described
in our issue of March 20th (P. 730), has allocated £8000
to this hospital. The year’s surplus has been used to
defray part of the capital expenditure on improvements.
The hospital has become affiliated to the Middlesex Hospital
where nurses will complete their training.
868 THE LANCET]
[APRIL 10, 1937
CLINICAL AND LABORATORY NOTES
TUBERCULOUS VULVOVAGINITIS
REPORT OF A CASE IN INFANCY
By VALENTINE A. J. Swar, M.R.C.S. Eng.
LATE_HOUSE SURGEON, HOSPITAL FOR SIOK OHILDREN,
GREAT ORMOND-STREET, LONDON
TUBERCULOSIS of the vulva and vagina is the
rarest form of clinical genital tuberculosis, and
according to Norris (1928) occurs in about 2 per
cent, of all tuberculous lesions of the genital tract.
Clifford White (1917) states that a quarter of the cases
of this disease occur in children ; adults are commonly
affected at the ages of 30-40.. The following report
of this disease in an infant shows some interesting
features.
CASE REPORT
A female infant, aged 17 months, was admitted to
hospital on account of having difficulty in passing water.
It was first noticed about two weeks before admission
that she cried during micturition and seemed to pass
little urine at a time. One week later it was noticed that
the vulval region was swollen and sensitive to touch.
Past history—A full-term baby; only child; birth
weight 6} lb. ; breast-fed till 8} months old.
Family history.—It was ascertained that there was a
strong family history of pulmonary tuberculosis on the
father’s side. Later it was found that both parents had
active tuberculosis ; the mother has since died of phthisis.
On examination she was a pale, ill-looking child, and under -
weight (191b.). Examination revealed an cedematous
and inflamed vulva; there was an ulcerated area on the
left postero-lateral aspect of the vaginal orifice; this was
very tender. The inguinal glands on both sides were
palpably enlarged, but not tender nor fluctuant. . Apart
from a few small glands enlarged in the neck, the child
appeared otherwise quite normal.
The urine on admission was sterile. A vaginal smear
showed some pus cells and mixed organisms; no gono-
cocci were seen. One week after admission the inguinal
glands became swollen and fluctuating. They were
aspirated and a few c.cm. of thick blood-stained pus was
withdrawn; this contained a few Gram-positive cocci ;
a Ziehl-Neelsen film showed many tubercle bacilli; on
culture only coliform bacilli were grown. The glands
were later aspirated again on several occasions as they
refilled. Animal inoculation of the pus produced a
tuberculous reaction.
Five weeks after admission the child was examined
under an anesthetic. The inguinal glands were incised
and curetted. There was an ulcerated area in the
region of the left posterolateral aspect of the vulvo-
vaginal orifice; the right side was slightly involved.
The edges were irregular, unindurated, and definitely under-
mined. The base was irregular in depth and on its surface
was bleeding granulation tissue. It extended for about
1 in. into the vagina. There was no evidence of any sinus.
The cervix uteri appeared healthy and normal. Rectal
examination revealed no abnormality in the pelvis. A
section of the ulcer margin was excised for biopsy.
Dr. D. N. Nabarro reported that the section showed
well-formed giant cells and systems surrounded by
lymphocytes; there was widespread endothelial cell
proliferation. Staining in a Ziehl-Neelsen film showed
scanty tubercle bacilli to be present.
It was thought that there might have been a focus in
the urinary tract, primary to that on the vulva. The
bladder was cystoscoped by Mr. T. Twistington Higgins ;
there was some urethritis; the bladder neck was some-
what reddened and congested; both ureteric orifices
appeared normal, functioning with a clear efflux. It was
thought inadvisable to catheterise the ureters in view of the
negative findings and the risk of spreading infection.
Uroselectan films appeared normal. The urine was
examined from time to time and no tubercle bacilli were
found. Other investigations showed: Mantoux test,
1/10,000, was positive; Frei’s test for lymphogranuloma
inguinale was negative. Blood count, white cells 17,500
- per c.mm., red cells 3,820,000 per c.mm., hemoglobin
55 per cent.; colour-index 0-7. A radiogram of the chest
revealed a calcareous node at the right hilum.
Treatment.—The local condition was treated with
X ray irradiations and soothing applications. In addition,
general ultra-violet ray therapy was given, as well as
general tonics of iron and cod-liver oil.
Progress.—The child developed subsequently bilateral
otitis media following measles; it was a streptococcal
infection ; she later developed mastoiditis, which necessi-
tated a mastoidectomy ; this was followed by suppurative
- adenitis in the neck. The patient is now having treat-
ment at a sanatorium where she is making very slow but
favourable progress in both her local and general condition.
COMMENTARY
Jameson (1935) in a monograph describes this
condition fully in its many aspects with adequate
references to other reports. The lesion on the vulva
usually occurs in people with tuberculosis in other
parts of the body. Primary lesions, however, have
been reported, but they are very rare, for negative
clinical evidence of other tuberculous foci is insufficient
grounds for regarding a case as being primary in
origin, and many cases post mortem will reveal
microscopic evidence of tuberculosis at other sites.
The mode of infection of the lower genital tract
in every case is difficult to ascertain. The vulva
and vagina may become infected secondarily from
above from lesions in the upper genital or urinary
tract. Descending spread may also occur from other
sites by means of the blood or lymphatic stream.
Direct inoculation of the genitalia can occur by
contamination with the hands of a phthisical subject,
as in a baby requiring frequent attention to its
toilet. In adults, the condition can have a venereal
origin, but this is uncommon.
In the case described the upper genito-urmary
tract appeared clinically free from tuberculosis, while
the lungs showed evidence of past infection, in that
a calcified gland is present in the hilar region. This is
not surprising as the child’s parents both had active
pulmonary tuberculosis and that she was breast-fed
until 8} months old. The pulmonary lesion is
probably of earlier origin than that of the vulva,
and the latter may have become secondarily infected
with dissemination of the disease. Alternatively,
it is possible that the vulva may have become directly
contaminated by the parents during attention to the
baby’s toilet. For it has been shown by Jameson
(1935) at the Saranac Laboratory in New York that
the introduction of a strain of tubercle bacilli into the
vagina of an animal (guinea-pig) can produce tuber-
culous lesions in the lower genital tract. This is
greatly enhanced if the animals are first sensitised
by a previous inoculation with a strain of tubercle
bacilli. Trauma, also, increases the liability to
develop these lesions. Jameson generalises by
analogy that “even in humans tuberculosis of the
vagina and vulva may be of the ascending type
much more frequently than is suspected at the
present time,” and that “upper tract lesions are
usually descending infections.” He gives further
clinical and pathological evidence to substantiate
this statement.
Tuberculosis of this region occurs either in an
ulcerative or hypertrophic form; the former is the
THE LANCET]
CLINICAL AND LABORATORY NOTES
[APRIL 10, 19237 869
commoner, The ulcers may be single or multiple and
may vary in character, forming confluent ulcerated
areas or sinuses. The inguinal glands are involved
late as arule. Dysuria, pruritus, and swelling of the
vulva with some discharge are the commonest
symptoms. On examination other tuberculous lesions
may be found elsewhere. Diagnosis may be difficult,
for typical tuberculous giant-celled systems are
often scanty in the histological sections, and the
Koch’s bacilli may be few.
I am indebted to Mr. T. Twistington Higgins for his
interest and permission to publish the report of this case,
which was under his care at the Hospital for Sick Children,
Great Ormond-street ; also to the pathology department
for the various investigations ; and to Mr. D. Martin for
the photograph.
REFERENCES
Jameson, E. M. (1935) Gyneecological and Obstetrical Tubercu-
losis, London. pp. 52-59.
— Ibid, p. 42 et
Norris, C. 6. (1928
seq.
Quoted by Jameson.
White, C. (1917
ew System of Gynæcology, vol. i, p. 595.
BILATERAL CYSTIC SWELLINGS OF THE
THIGHS OF TUBERCULOUS ORIGIN
By E. A. Devenis, M.S. Lond., F.R.C.S. Eng.
ASSISTANT TO THE SURGICAL UNIT, UNIVERSITY
COLLEGE HOSPITAL
A PAINTER, aged 18, was admitted to hospital on
June 19th, 1936, complaining of a lump in the upper
part of the left thigh.
Eight years before admission he had fractured the left
femur in its middle third, and about six months after this
he noticed the swelling in his left thigh. The lump had
gradually got larger, and for the last two years he had
pain in the region of the lump. The pain was gnawing,
and was worse at night and on lying down. It was not
brought on by walking, but running produced some
pain. He had never been ill before, did not suffer from
night sweats, and had no history of familial tuberculosis.
He was a well-covered stocky youth, and on standing
naked the bulging of the upper part of his thighs gave
him a disproportionately
muscular appearance in
the lower half of his body
(Fig. 1) He walked
without a limp, but
lurched a little to the
left when standing on
the left foot. He was
apyrexial and his pulse-
and respiratory rates
were normal.
Left thigh.— On its
antero-lateral aspect was
a large, smooth, tense,
fluctuant swelling about
7 by 5 in., which ex-
` 4 tended upward to the
; aoha MM o E iliac crest, outward to
FIG. 1.—Photograph taken after the great trochanter, and
excision of left cyst. The dis- inward to the femoral
coloration of the skin is due to vessels. It filled up the
Ha yine. space so defined and
projected beyond the
normal outline of the thigh by about 4 in. The overlying
skin was not attached to the mass and was normal in
all respects.
Right thigh.—There was a similar swelling in the corre-
sponding situation in the right thigh. This extended well
into the buttock, deep to the gluteus maximus, and fluctua-
tion was demonstrable between the swelling of the thigh
and of the buttock. The patient had not noticed the
swelling of the right thigh.
_ Hipjoints.—There was considerable limitation of
internal rotation of both joints with slight limitation of
flexion and abduction of the left joint. The lower limbs
were equal in length. No abnormality was discovered
on exami-
nation of
the spine or
of the rec-
tum, and
fluctuation
could not
be obtained
between
the swelling
of one thigh
and that of
the other.
Radio-
grams of
the hip-
joints and
femora
showed no
abnormal-
ity beyond
a small oval
area of
rarefaction
in the left
great tro-
chanter
(Fig. 2). A
radiogram
of the chest showed evidence of previous tuberculosis in the
form of densely calcified glands at both hila and dense
shadows in the upper third of the right lung field. There
was no evidence of present activity.
Operations.—The swelling of the left thigh was aspirated
and thick opaque yellow fluid containing cholesterol
crystals '`and a few polymorphs and lymphocytes was
obtained. It was sterile on culture and did not contain
tubercle bacilli, as was shown by a negative guinea-pig
inoculation with this fluid. On July 6th the left thigh
was explored and a large cyst adherent to the surrounding
structures, situated deep to the deep fascia of the thigh
and extending backwards deep to the anterior border of
the gluteus maximus, was dissected out. The main cyst .
communicated by a narrow neck with a small abscess
cavity in the great trochanter. This abscess cavity was
lined by smooth sclerosed bone and was filled with granu-
lation tissue. Cultures from the cyst fluid and from the
granulation tissue were sterile. The wound healed by
first intention. On July 30th the right thigh and
buttock were explored. An exactly similar cyst was found
situated deep to the gluteus maximus and extending
anteriorly between the tensor fascia femoris and the
vastus lateralis. Deep to the insertion of the gluteus
medius was a separate small abscess cavity lined with
granulations and lying over an area of bare bone about
3 in. in diameter. No connexion of the cyst cavity with
the hip-joint was demonstrable in either thigh. A portion
of the cyst wall excised from the right thigh was injected
into a guinea-pig, which 6 weeks later had developed
miliary tuberculosis.
Morbid histology.—The tissue excised consisted of the
cyst walls and the granulation tissue curetted from the
cavity in the left great trochanter. The cysts were iden-
tical in appearance both to the naked eye and on micro-
scopic examination. Each consisted of a tough, fibrous
wall about } in. thick, lined on its inner surface by yellow
caseous material which when washed away revealed a
granular surface like that of morocco leather. The outer
surface of the cysts was adherent to the surrounding
structures and had been separated from them by sharp
dissection.
On microscopic examination the granulations from the
abscess cavity in the bone were typical tuberculous
granulations. No bone trabecule were present. The
wall of each cyst was composed of three layers (Fig. 3).
(1) An outer layer of adult fibrous tissue adherent to
the surrounding structures. (2) A middle layer of
FIG. 2.—Radiogram of left great trochanter
showing area of rarefaction.
870
tuberculous granulation tissue. (3) An inner layer: of
caseous material. An unsuccessful search was made for
tubercle bacilli in the sections cut, but the nature of the
THE LANCET]
FIG. 3.—Microphotograph o Wiole thickness of cyst wall.
x 8.
lesion was proved by the positive guinea-pig inoculation
with material from the wall of the cyst.
The cystic swellings in the thighs were almost
certainly chronic abscess cavities arising from com-
paratively small bone lesions. The unusual feature
was the symmetry of the swellings which on first
sight gave the patient the appearance of having
some femoral deformity. This symmetry is explicable
on the supposition that the disease began in the
great trochanters if, as is probable, the initial bone
lesions were embolic in origin. This probability is
supported by the presence in the right lung of evidence
of an old tuberculous lesion from which the emboli
could have arisen.
The case belongs to that class of tuberculous
lesions in which a small bony focus is associated with
a large abscess in the surrounding soft parts, the
commonest example being caries of the spine, in
which a small lesion in one of the vertebral bodies is
associated with a large psoas abscess.
CASE OF STREPTOCOCCAL MENINGITIS
TREATED WITH PRONTOSIL
By I. Vrrenson, M.R.C.S. Eng.
AURAL SURGEON TO EAST HAM MEMORIAL HOSPITAL ;
G. Konstam, M.D., M.R.C.P. Lond.
PHYSICIAN TO EAST HAM MEMORIAL HOSPITAL: ASSISTANT
PHYSIOIAN TO WEST LONDON HOSPITAL
AND
IN a leading article in Tue LANCET (1936) and in
an annotation (1937) the importance of trying
Prontosil or its derivative p-aminobenzenesulphon-
amide in severe forms of streptococcal infection was
urged. This has prompted us to publish the follow-
ing case of hemolytic streptococcal meningitis
complicating acute otitis media, which was treated
with prontosil in addition to orthodox surgical
measures.
Although it is fully realised that no inferences can
be drawn from an isolated case, the favourable result
CLINICAL AND LABORATORY NOTES
[APRIL 10, 1937
might encourage others to test this chemothera-
peutic agent under similar circumstances. Available
statistics bear witness to the heavy mortality in those
cases of otitic meningitis in which the cerebro-spinal
fluid is infected with organisms, particularly
where they are sufficiently numerous to be seen in
films from the centrifuged fluid. Jory (1935) in
39 cases at St. Bartholomew’s Hospital of meningitis
complicating acute and chronic otitis media reported
11 in which the cerebro-spinal fluid contained hæmo-
lytic and non-hemolytic streptococci; 9 of these
patients died and 2 recovered. Gangl and Zange
(1935) collected 70 such cases, 16 of which contained
hemolytic and non-hemolytic streptococci in the
cerebro-spinal fluid ; 13 of these died and 3 recovered.
Neumann (1934) in 59 cases found streptococci in
the cerebro-spinal fluid in 16 instances; the propor-
tion of deaths to recoveries was as in the previous
series 13 to 3.
A boy aged 10} was admitted to the East Ham
Memorial Hospital on Nov. 13th, 1936, with a left-sided
otitis media of three weeks’ standing. For nine days
he had suffered from mucopurulent otorrhea without
pain or tenderness over the mastoid; the temperature
did not rise above 99:2° F. except on two occasions when
it was 100°. On the tenth day he suddenly developed
a temperature of 104:6°, without however any exacerba-
tion of his aural symptoms. A left Schwartze operation
was performed by one of us(I. V.) and an extensive osteitis
of the mastoid process with pus and granulations in many
cells was found. The lateral sinus was not exposed and
the lamina of bone covering it was apparently normal ;
the tegmen antri was removed over an area 6 mm. by 5mm.
and there was no evidence of extradural abscess; the
cells in Trautmann’s triangle as well as those in the apex
of the mastoid process were cleared out and the operation
was completed.
Seven days later the temperature became normal and
the wound was healing satisfactorily, the aural discharge
having ceased.
On the twelfth day after operation he woke up with
severe generalised headache, photophobia, vomiting, and
a temperature of 104:1°. Kernig’s sign with slight neck
rigidity was present and the ophthalmic disc margins were
blurred. At lumbar puncture the cerebro-spinal fluid
was under pressure and contained 3690 cells of which the
large majority were pus cells. Cocci were seen in films
and on culture they proved to be hemolytic streptococci ;
the protein content of the cerebro-spinal fluid was 80 mg.
per 100 c.cm.
On the same evening the mastoid wound was reopened
and Neumann’s operation for meningitis was performed ;
the posterior meatal wall was removed and the middle
fossa dura was widely exposed by the removal of the
tegmen tympani and antri and that part of the mastoid
bone in contact with the dura. The lateral sinus and the
posterior cerebellar dura were uncovered and finally
the superior angle of the petrous bone was removed. At
the termination of the operation the dura from both fossze
was seen to be tense and although it bulged into the
mastoid cavity it was not incised.
Nowhere was there macroscopic evidence of disease
of the meninges or extension of the osteitis. During the
following twenty-four hours he was delirious and by the
evening he had sunk into a deep coma. Lumbar puncture
was performed and 25 c.cm. of cerebro-spinal fluid which
was under increased pressure were drawn; this was
followed by general improvement. Three days later a
right external rectus paresis appeared but there was no
evidence of involvement of the other ear, and the diplopia
disappeared two weeks later. The papilledema at
first increased and remained for four weeks after operation
despite an amelioration of the symptoms. Convalescence
was interrupted by six days of continuous pyrexia and the
temperature became normal twenty days after the second
operation, Progress was thenceforward uneventful.
Post-operative treatment consisted in daily lumbar
puncture for thirteen days and the administration of
THH LANCET]
prontosil 10 c.cm. parenterally b.d. and 2 prontosil album
tablets orally b.d. The cerebro-spinal fluid became
sterile on the seventh day and the cells which at first
had numbered 3690 per c.mm. fell to 35 per c.mm. thirteen
days after the operation.
Although prompt operation will save a proportion
of such cases, the moribund condition of our patient
MEDICAL
ROYAL MEDICO-CHIRURGICAL SOCIETY
OF GLASGOW
A MEETING of this society was held on March 19th,
with Mr. GEORGE H. EDINGTON, the president, in the
chair. He showed a case in which the radial nerve
was operated on two years ago for
Traumatic (Fracture) Paralysis
A schoolboy, aged 14, was admitted to the Western
Infirmary on Jan. 23rd, 1935, with fracture in the
middle of the shaft of the right humerus, having
been knocked down by a motor-car a few hours
previously. Examination on the following day
showed marked musculo-spiral paralysis. The fracture
united and the boy was discharged in a splint. Two
months later the paralysis had not improved, and on
March 28th the radial nerve was exposed through a
lateral incision and found nipped between the frag-
ments of the bone. The nerve was divided and
freed above and below the fracture, and through a
medial incision the proximal part was displaced to
the front of the arm (as recommended by Stiles) and
sutured to the distal part under cover of brachialis
anticus. Recovery of power was very slow and when
the patient was seen towards the end of July, 1935,
there was little if any change; electrical testing
of muscles involved showed no response to faradic
and a weak response to galvanic current. When
seen early in October, 1936, he had fair use of hand
and arm. The limb was much thinner than its
fellow. Paralysis of extensor ossis metacarpi and
of primi internodii pollicis was noted. By mid-
February, 1937, power was greater; the boy was
able to play ping-pong but was doubtful of trying
tennis. If he tried manipulating a heavy object
he felt a strain at the wrist. Thumb paralysis
persisted, and extension of metacarpo-phalangeal
joint of index was not so complete as in the left hand.
Numbness was present down the radial side of second
metacarpal and index, and more slightly on adjacent
side of thumb and first metacarpal.
The points illustrated by the case were: (1) the
diagnosis of the precise cause of paralysis was not
made out before operation; (2) the slow recovery
of power; (3) the persistence at present date of
implication of deep extensors.
Mr, ALEXANDER MILLER discussed
Lesions of the Hip and their Treatment
showing lantern slides illustrating the primary and
secondary deformities encountered from lesions
in this region. He said that diagnosis was only
established in doubtful or early cases by careful
observation and followup. The classification adopted
was: (a) toxic arthritis, (b) tuberculous disease,
(e) infective arthritis (non-tuberculous), (d) pseudo-
coxalgia, (e) traumatic, (f) flail hip. The term
toxic arthritis was reserved for cases manifesting
the hip-joint syndrome which cleared up completely
following rest and extension. In treatment the
ROYAL MEDICO-CHIRURGICAL SOCIETY OF GLASGOW
[APRIL 10, 1937 871
the day after operation led one to expect a fatal
issue.
REFERENCES
Ganel, O., and Zange, J. (1935) Beitr. Hals-, Nas. u. Ohrenheilk.
Jory, N. (1935) Proc. R. Soc. Med. 28, 532. are
Lancet (1936) 2, 1339.
— (1937) 1, 211.
Neumann, H. (1934) Rev. Laryng., Paris, 55, 1.
SOCIETIES
relative values of manipulation, extra- and intra-
articular arthrodesis, and osteotomy were considered.
Mr. G. T. Mowat spoke on
Rapid Histology in Diagnosis
He discussed cases in which errors of diagnosis as to
malignancy had been made at the time of operation ;
in some cases radical procedure had been carried out
and subsequently proved to be unnecessary, in others
malignant tissue had been cut into, and an interval
had been allowed to elapse while a paraffin section
was being made, before adequate treatment was
carried out. The results obtained in the Glasgow
Royal Cancer Hospital from a system of quick
histology were described. In most cases definite
information was given, and in others an intelligent
lead was given to the surgeon. Routine paraffin
sections were made afterwards and in no case had
the diagnosis as to malignancy to be revised. The
system was found most useful in doubtful breast
cases, but was also used in the gastro-intestinal
tract and the oropharynx. In suspected carcinoma
of the body of the uterus, curettage scrapings were
successfully used for diagnosis. Methods used were
particularly (1) the frozen section, (2) Dudgeon and
Patrick method, and (3) the Ultropak illuminator.
The average time taken for diagnosis was five minutes.
The results left little doubt of the general efficiency
of the methods, or of the practical help given to the
surgeon,
Basal Metabolism in Hyperthyroidism .
Dr. A. B. ANDERSON discussed the relationship
of the basal metabolism rate (B.M.R.) to the clinical
signs of hyperthyroidism. In a series of 140 cases
of varied ages and both sexes which were clinically
hyperthyroid or suspected of hyperthyroidism, the
B.M.R. was estimated and compared with the occur-
rence of clinical signs: enlargement of the thyroid,
exophthalmos, tremor, tachycardia, sweating, and loss
of weight. The tentative conclusions reached were
that when enlargement of the thyroid is accompanied
by exophthalmos and any other of the clinical signs.
the B.M.R. will be high in nearly all cases. When
enlargement of the thyroid is not accompanied by
exophthalmos but all the other signs are present,
the B.M.R. will be high in nearly all cases, but when
only two or three signs are present the B.M.R. will
be normal in a number of cases. When enlargement
of the thyroid is present alone or with only one other
sign the B.M.R. will be normal. In tachycardias
without enlargement of the thyroid the B.M.R.
will be normal in nearly all cases.
WATERLOO HosPITaAL FOR CHILDREN.—At the
annual meeting of governors of this hospital it was
stated that if a traffic roundabout was made at the
junction of Waterloo-road, Stamford-street, and York-
road, part or the whole of the hospital site would have
to be used. The hospital has a surplus on the year’s
workings of over £5000 mainly owing to an increase in
legacies.
872 THE LANCET]
[APRIL 10, 1937
REVIEWS AND NOTICES OF BOOKS
Ions in Solution
By R. W. GURNEY, M.A.,
ciate in the University of Bristol.
Cambridge University Press. 1936.
10s. 6d,
THE development of the quantum mechanical
theory of the atom has led to important work on the
nature and reactions of ions in solution. Dr. Gurney
summarises, in condensed yet intelligible form, the
fruits of this work. If the book gives an impression
of being largely speculative, it must be remembered
that the approach is comparatively new and that
experimental research directly related to this approach
is at present little developed. It is unfortunate,
however, that the author has not taken more advan-
tage of the frequent opportunities offered to relate
his point of view to more old-established if by now
more barren ones. For example, the non-existence
in solution of certain metals, such as calcium, in a
lower state of ionisation (Ca+) than the normal
(Ca++), despite the predominance of the lower
states in ionised vapours, is one of the interesting
problems here raised. Dr. Gurney’s explanation in
terms of the ionisation energies of the solvated ions
and of the solvent is no doubt sound, but it is not
very helpful to dismiss as “irrelevant”? the non-
existence of salts in which calcium is monovalent.
In nearly all cases where a metal exists in more than
one state of ionisation in solution, corresponding
crystalline salts are known, and rarely is a metal
found in a crystal (even an anhydrous crystal) in a
state of ionisation which is not realisable in solution.
On the other hand, the discussion of the Debye-
Hiickel theory, though so brief as to be not entirely
accurate, is far better balanced than many much
fuller discussions which extend the theory in
some particular direction while leaving its basis
approximations unexamined.
The biggest recent advance dealt with is in that
part of electrochemistry which thermodynamics
cannot reach. The standard electrode potentials
and oxidation-reduction potentials of metals are
' discussed in relation to thermionic work functions
and energies of solvation. To the worker in the
Ph.D., Research Asso-
London :
Pp. 203.
biological and medical sciences, whose interest in `
ions is mainly in their permeability to membranes,
and their influence on colloidal dispersion and on
ionisation of weak acid groups in complex molecules,
the book is of no immediate practical value, because
‘quantum mechanics: has as wee little to say on these
problems,
Morphologische Pathologie
By Prof. Dr. WERNER Huercx, Director of the
Pathological Institute of Leipzig University. Leip-
zig: Georg Thieme. 1937. Pp. 818. R.M.52,
Prof. Hueck breaks away from tradition in the
arrangement of subject matter. There have been
truants before among text-books in pathology; for
example, MacCallum’s work is based on the idea that
all pathological changes are the result of some form
of injury; this attitude brings with it a liability
to teleological thinking. Prof. Hueck, being a strict
causalist, has taken the opposite point of view.
He discusses the whole of general pathology on a
purely morphological basis, and in fact the book
may be regarded as a continuation of Oertel’s “‘ Intro-
duction to Pathology.” It is interesting to find so
many problems approached from a logical standpoint
instead of from one which elevates heuristic ideas
to the level of final explanations.
The book is in two parts: the first, on general
principles, gives an admirable account of the poten-
tialities for differentiation of the mesenchyme and
its relation to pathology, and excellent chapters on
stone formation and tissue regeneration. The section.
on tumour formation is noteworthy for its com-
parison between the connective tissue tumours and
normal mesenchymal histogenesis; the absence of
any adequate account of the systematised blasto-
mata is disappointing. The second part of the book
deals with “ related morphological pathology,” which
is almost the same thing as what is usually known as
“ special pathology’; no attempt is made to men-
tion lesions in every organ, but a few of the more
important disease processes are discussed in detail.
For example, the account of pulmonary tuberculosis.
in its various forms, together with its complications—
tuberculous enteritis, miliary tuberculosis, and amy-
loidosis—is excellent; other sections worthy of
comment are those on disease of the heart and
arteries, the stomach, and the liver.
section reveals an interesting contrast between Ger-
man and Anglo-American teaching. Prof. Hueck
accepts without question the evolution of a sub-
acute hepatitis into a chronic stage, yet in nephritis
there is no suggestion that an acute nephritis may
pass through a subacute edematous stage before the
final uremic state; ‘ nephrosis’”’ and nephritis are
kept distinct, and focal nephritis is not mentioned.
A new book of such a revolutionary nature—
perhaps revivalistic would describe better a return
to the best teachings of ‘‘ cellular pathology ’’—is.
unlikely to maintain throughout a proper balance in
the allocation of space or to avoid omission of relevant.
facts. Here endocarditis is merely classed as simple,
verrucous, ulceropolypous, or fibrous with little con-
sideration of setiological factors; the account of
endocrine dysfunction in relation to constitutional
morphology is too short, and the chapter on leukosis
and anzmia is below the standard of the rest of this
stimulating book. We commend the instructive
diagrams, drawings, and photographs, and the lavish
use of colour printing.
Venereal Disease
Practical Methods in Diagnosis and Treatment. Third
edition. By Davin LEEs, D.S.O., M.B., D.P.H.,
F.R.C.S., F.R.C.P. Edin., F.R.S.E. Edited and
revised by RoBERT LEES, M.B., F.R.C.P. Edin.,
Assistant M.O. for V.D. to Edinburgh Royal
Infirmary and Edinburgh Corporation. Edin-
burgh: E. and S. Livingstone. 1937. Pp. 608.
15s.
THis good text-book on venereal disease has now
been brought up to date without having been enlarged.
The sections which deal with the clinical manifesta-
tions of syphilis contain many excellent photographs,
including some in colour, which are likely to be of
great value to those who seldom have access to this
type of clinical material. The views expressed on
treatment and on standards of cure are in the main
orthodox and are set out in a clear and practical
way. The detailed statement of recommendations
for treatment in all stages of syphilis are especially
to be commended. There are two unexpected omis-
sions. The important condition of metastatic iritis
This latter -
THE LANCET]
secondary to gonococcal infection is barely men-
tioned, and we. can find no reference to tricho-
monas vaginitis in connexion with the differential
diagnosis of vaginal discharges of inflammatory
origin, On most other subjects the information
given is full and complete.
It is unfortunate that some of the methods of expres-
sion are slipshod and ungrammatical. More careful
proof-reading would have excluded such lesser sources
of irritation as ‘“‘ prostrate gland.” These faults should
not be allowed to obscure the value of this compre-
hensive work in which sound theoretical knowledge
and wide practical, experience are combined.
- La vésicule biliaire et ses voies d’excrétion
Second edition. By M. Curray, Professeur agrégé
à la Faculté de Médecine de Paris; and I, PAVEL,
Maitre de Conférences à la Faculté de Médecine de
Bucarest. Paris: Masson et Cie. 1936. Pp. 860.
Frs.120. |
Ir is ten ‘years since this standard text-book on
diseases of the gall-bladder appeared, and the second
edition necessarily contains important changes.
-These concern particularly the physiology of the gall-
bladder and the mechanism of Oddi’s sphincter, the
ætiology of gall-stones, the mechanism of hepatic
colic, and the bacteriology of cholecystitis. For the
chapter dealing with the radiology of the gall-bladder
Dr. A. Lomon is responsible, and the reader will find
therein an excellent series of illustrations. A con-
siderable bibliography enriches each chapter, and there
is a full index of authorities as well as of subjects.
Studies in Cardiovascular Regulation
Lane Medical Lectures. By G. V. ANREP, M.D.,
D.Sc., F.R.S., Professor of Physiology, Medical
Faculty, Egyptian University, Cairo. London:
Humphrey Milford, Oxford University Press.
1936. Pp. 118. 10s. 6d.
In this monograph Prof. Anrep clearly describes
the many important advances recently made in
our knowledge of the way in which the heart exactly
adapts itself to the work demanded of it; of the
respiratory influence on the heart-rate; and of the
coronary blood flow. In a final chapter the blood
flow through skeletal and plain muscle is shown to
undergo during muscular contraction changes similar
to those in the coronary flow during the cardiac cycle.
Far from being the master of the circulation, the heart
is to-day regarded as its highly efficient servant, its
rate and output being dictated by a variety of reflexes,
the receptors of which are situated in the walls of the
cardiovascular system itself. Prof. Anrep gives an
interesting account of how, after much controversy,
the carotid sinus was recognised as an important
agent in the control of blood pressure and heart-rate.
With the aortic, and probably also the left ventricular
wall and the carotid body, the carotid sinus forms
the chief vaso-sensory area on the arterial side.
On the venous side, in the auricles and right ventricle,
are receptors which are held to have exactly opposite
effects. The complex effects of the impulses from
lung tissue and of central discharges from the respira-
tory centre on the cardiac rhythm are discussed
in detail. Their bearing on clinical problems is
not yet clear. The sections on the coronary blood
flow deal not only with matters of importance to the
physiologist, such as the effect of systole on
REVIEWS AND NOTICES OF BOOKS
[APRIL 10, 1937 873
the flow, but also many which directly concern
the clinician and cardiologist ; for example the rich
dual innervation of the coronaries, the reflex constric-
tion which occurs in them when the carotid sinus is
stimulated, the effects of certain drugs and the atypical
reactions when they are sclerosed. Prof. Anrep
has contributed largely to cardiovascular physiology.
His Lane lectures are a record of : his personal
observations, including those arising from important
experiments which he has been able to carry out in
Egypt on the human heart obtained soon after death.
1. Practical Physiological Chemistry
For Medical Students. By G. M. WisHart, D. P.
CUTHBERTSON, and J. W. CHAMBERS. Glasgow:
John Smith and Son, Ltd. (26, Gibson-street,
Glasgow, W.2). 1936. Pp. 125. 3s. 6d.
2. Laboratory Experiments in Physiological
Chemistry
By ARTHUR K. ANDERSON, Ph.D., Professor of
Physiological Chemistry, the Pennsylvania State
College. London: Chapman and Hall Ltd. 1936.
Pp. 234. 7s. 6d.
1. DESIGNED for use with a forty hours’ course in
practical biochemical work, this excellent little book
is eminently suitable for this purpose, being concise
and accurate. The omission of the estimations of
phosphate and sulphate in urine is regrettable, and
sodium hydrosulphite is preferable to ammonium
sulphide as a reducing agent in the study of the blood
pigments. This is an outstanding little book.
2. This may be described as the text-book interro-
gatory and local: interrogatory, because the reader,
instead of being told what the result of an experiment
should be, is questioned by the author on that very
point; local, because the reader is, for example,
exhorted to “ obtain from the instructor, in a dry
flask, the sample of vinegar to be analysed ” ; it is
possible that in other places than those familiar to
the atthor other customs may obtain, and the
instructor not be so well provided. In explanation
of the sentence (p. 46) “‘ by means of a clean graduate
add 240 c.c. of water to a beaker” it is a measuring
cylinder, and not the instructor, which is to be put
to use.
2
Physical Diagnosis
By Rarrn H. Mayor, M.D., Professor of Medicine
in the University of Kansas. London: W. B.
Saunders Co. 1937. Pp. 475. 21s.
Tus valuable text-book on physical diagnosis
embodies fifteen years’ experience in teaching by an
enthusiast for clinical medicine. Though the personal.
element is essential for teaching at the bedside it
can be tiresome and pedantic in print, but Prof. Major
is not guilty in this way ; his tone is not didactic and he
makes use of all the recognised authorities and recent
work with frequent quotations and extensive lists
of references. His admiration for the pioneers of
diagnosis leads him to quote their original des-
criptions in many places, but the emphasis is
fortunately not on the past; full credit is given to
such valuable advances as the X ray, the electro-
cardiogram, and the phonogram in explaining the
significance and the physical basis of signs. The
views expressed are on the whole in line with orthodox
British teaching, though as is natural where experi-
ence depends on local observation material points
of disagreement will be found; for example,
874 THE LANCET]
pathological findings in this country do not suggest
that the diagnosis of aortic insufficiency with a Flint
murmur is more often correct than that of the com-
bined lesion with mitral stenosis. The statement
that the wrist-drop in lead poisoning is due to a
paralysis of the ulnar nerve is of course merely a
careless error.
Though there can be few practitioners who would
not find interest in this work, and no teachers of
medicine who could not pick up a wrinkle or two
from it, it has two disadvantages from -the point
of view of the student for whom it is intended. First,
it is too long; aspects of disease other than physical
diagnosis might well have been left out, since they
could not be discussed adequately in the available
space. The benefit derived from learning the signs
necessary for a diagnosis of aortic stenosis for |
example is nullified if the student goes away with
the impression that it is caused equally commonly by
syphilis, arterio-sclerosis, and rheumatism. Secondly,
it is important that the student should know which
physical signs are nowadays regarded as significant
and reliable; this is not always made sufficiently
clear, and the historical emphasis may encourage the
seeker after strange signs who may miss dilated and pul-
sating veins in the neck when bending down in search
for Broadbent’s sign. On the other hand the many
excellent photographs, the helpful diagrams, and,
above all, the impulse of Dr. Major’s enthusiasm
may transmit to the student the thrill which will
send him to the bedside, there to look, listen, and feel
for himself.
Physical Therapeutic Methods in Oto-
laryngology
By ABRAHAM R. HOLLENDER, M.D., F.A.CS.,
Associate in Laryngology, Rhinology, and Otology,
University of Illinois College of Medicine. London :
Henry Kimpton. 1937. Pp. 442. 21s.
Dr. Hollender has had the help of ten collaborators,
but is himself responsible for the larger part of this
massive work. A preliminary section deals with the
physical characteristics of the various agents under
discussion and the apparatus used in their produc-
tion ; the main part of the volume is concerned with
the numerous diseases of the nose, throat, and ear
in which these methods may be employed, and is
followed by a few miscellaneous chapters. Among
the latter is one by Chevalier L. Jackson on endo-
scopy, and another on hearing-aids by Prof. Horace
Newhart which, although interesting, have little
bearing on the subject of physical therapy. Prof.
Francis Lederer has contributed to this part of the
book two chapters on neoplasms; in general he
favours diathermy, or electrodissection, but gives
no detailed description of the various forms of tumour
nor of the technique of their individual treatment.
This criticism may also be applied to his references
to treatment by radium and X rays, where details
of application and dosage are not discussed; of
` laryngeal carcinoma he merely says that radium has
proved to be an ineffective therapeutic agent.
It is difficult to decide what methods should be
included within the term of physical therapy. From
this book the galvano-cautery and all forms of spa
treatment and inhalation therapy are omitted. All
the methods here dealt with, except the use of radium,
involve the use of electrical apparatus, and include
such various procedures as ionisation, diathermy
in all its forms, short-wave diathermy, infra-red and
ultra-violet irradiation, and X rays.
NEW INVENTIONS
These new
[APRIL 10, 1937
methods, as opposed to older forms of treatment,
are advocated with a degree of enthusiasm which
some will think exaggerated ; notably where short-
wave radiation is hailed as ‘perhaps the most
important contribution since Roentgen’s epochal
discovery,” where diathermy is recommended for the
reduction of the inferior turbinals, and the galvano-
cautery is condemned because in unskilful hands it
may cause adhesions. A detailed table of contents
is provided, as well as a full index. The book contains
useful information on the treatment of a great variety
of diseases by these methods, and will be read with
interest by laryngologists.
Rural Health Practice
By Harry S. Mustarp, M.D., Associate Professor
of Public Health Administration, Johns Hopkins
University. New York: The Commonwealth
Fund; London: Humphrey Milford, Oxford
University Press. 1936. Pp. 603. 17s.
THE Local Government Act of 1929, by requiring
all future appointments of medical officers of health.
to be on a full-time basis, has inaugurated a new type
of expert in rural hygiene to whom Prof. Mustard’s
book will be most valuable. Such an expert should
have no difficulty in separating common ground from
that which represents differences between American
and British practices. In the United States also
part-time public medical officers, often appointed for
political or charitable reasons, are now giving place
to full-time experts having some security of tenure
of office and therefore the time and inclination to
make themselves expert in their particular branch
of medicine. This is the justification for this work,
which is compiled on original lines. Prof, Mustard
is one of America’s foremost hygienists and is almost
as well known in Europe as in the States as an
authority on rural hygiene—because he says he
has “ already made most of the mistakes which it is
possible for a rural health officer to make.” This
book is full of sound advice and is wittily expressed.
NEW INVENTIONS
A MODIFIED RECTAL BOUGIE
THE modified Wales’s rectal bougie here illustrated
is designed for the purpose of dilating high strictures
of the rectum. It is not safe in such a situation as
the upper end of the rectum to use rigid metal dilators,
or any form of dilator that cannot be passed through
the stricture under full sight. The bougie is made of
soft rubber in gradually increasing sizes and can be
passed through a large rectal speculum or preferably
an operating sigmoidoscope. The difficulty of using
soft rubber bougies in these circumstances is that they
buckle up, but this bougie has a hole reaching not
quite to the end into which a stylet can be passed to-
stiffen it, and to make it possible to guide it in the
desired direction. .
The bougie has been made for me by Messrs. Down.
Bros., Ltd., St. Thomas’s-street, London, S.E.
J. P. LOCKHART-MUMMERY, F.R.C.S. Eng.
Emeritus Surgeon to St. Mark’s Hospital for
Diseases of the Rectum.
THE LANCET]
THE LANCET
LONDON: SATURDAY, APRIL 10, 1937
PSYCHIATRY IN VOLUNTARY HOSPITALS
As part of its rebuilding scheme St. George’s
Hospital hopes to equip itself with a psychiatric
clinic of 50 beds. The idea of incorporating such
a clinic in an undergraduate teaching hospital
has such striking advantages that it is indeed
remarkable that it has not received effective
expression before now. Most of these hospitals
now have psychiatric departments ; but these are
concerned mainly with out-patients. From 1923
on the governors of St. Luke’s Hospital maintained
for a time two small wards for acute mental cases
at the Middlesex Hospital, but now in all the
London teaching hospitals taken together the
beds allocated to psychiatric cases add up to only
about a dozen, and even of these not all are adapted
to the reception of refractory or overtly psychotic
cases.
student has little opportunity to observe the full
course of mental illness. If he is sufficiently
interested to attend regularly the psychiatric
out-patients’ department he can see a sample of
mentally abnormal patients at perhaps weekly
intervals for a period of from three to six months ;
but this is a poor substitute for the opportunity
to observe them in a bed from the moment of
admission to that of discharge. The effect of the
existing system is that the student obtains his
impressions of psychiatry in heterogeneous ways.
As he imbibes his general medicine he will learn
how important is the psychological factor in
physical diseases; in the department of psycho-
logical medicine he can, if he wishes, familiarise
himself with the common neuroses ; in the habitués
and hangers-on in these departments he will make
acquaintance with the chronic neurotic and will
appreciate how complete can be the dependency
of such persons on doctors. He will see an
occasional psychotic case, referred to the depart-
ment for an opinion, or retained as an out-patient
if certification is not deemed necessary. But with
the psychotic requiring care and control he will
have very little contact except at periodic demon-
strations usually held at a place far removed
from the scene of his usual medical studies. Though
he may be expected to have a knowledge of the
psychoses sufficient to answer a few regularly set
questions in the final examinations, his attitude
after qualification can frequently be summed up
in the view that neurotic patients are a tribulation
and psychotic patients a class by themselves.
Of these he retains from a course of demonstra-
tions an impression comparable to that obtained
by a visitor from a series of visits to the Zoo.
In the field of neuroses, a practitioner’s reluctance
or incapacity to deal with the cases that come
under his care is reflected in the enormous waiting-
PSYCHIATRY IN VOLUNTARY HOSPITALS
In the course of his training the average
[APRIL 10, 1937 875
lists of organisations such as the Institute of
Medical Psychology; and in the field of the
psychoses there results from the existing system a.
popular conviction that mental illness carries a.
stigma which does not attach to physical disease,
and that certification is a kind of disgrace. To
this attitude of mind is attributable the change
of name of some well-known hospitals, for example
Hanwell Hospital becomes St. Bernard’s Hospital.
Even if a student is specially interested in
psychiatry, it is only after qualification that he
will be able to obtain a comprehensive first-hand.
experience of the total range of mental disorder.
As a part of such experience the neuroses and.
psychoses, between which a fundamental distinc-
tion is commonly and erroneously drawn, should
be studied simultaneously. Though admirable
facilities exist for such study at the Maudsley
Hospital, they have not hitherto been available
at the undergraduate teaching hospitals. In
the Scandinavian, most north European countries,
and in America the medical profession is more
effectively equipped to deal with mental illness
before qualification. A psychiatric clinic with
beds is usually incorporated with or closely
affiliated to the general hospital. The advantages
of this system are felt equally by the medical
profession and. by the public. The student is
familiarised in the clinic with the principles of
diagnosis and treatment of the psychiatric cases
potential or actual which he will encounter in
his later life; and the interests of the able and
ambitious student are directed to psychiatry
in which an opportunity is provided of obtaining
what we would call a house appointment at his
teaching hospital. The specialty is benefited by
obtaining recruits of good calibre and the needs
of the public are well catered for.
Many years ago the late Dr. JAMES COLLIER
organised a course of neurological demonstrations
at St. George’s Hospital which, since his death,
have been continued at fortnightly. intervals
by Dr. Antony Femina. These are not
confined to students of the hospital; indeed
they have been attended by large. audiences
from outside. For some months psychiatric
demonstrations have alternated with the sessions.
devoted to neurology and have been conducted
by Dr. DrEsmonp .CuRRAN, with the generous
assistance of the senior staff of the Maudsley
Hospital. It is a wise plan to provide a nucleus.
round which the department can expand when
facilities are available and to familiarise local.
doctors with the idea that expert consultants are
to hand. We wish the scheme every success.
and will watch its development with interest.
And it may be noted with gratification that an
anonymous gift of £5000 has already been received.
towards the cost and equipment of the department.
INFECTION THROUGH THE OLFACTORY
MUCOSA
Ir has lately been shown in America that.
susceptibility to infection with certain viruses can
be reduced or abolished by treatment of the
876 THE LANOET]
olfactory mucosa with solutions of tannic acid,
alum, or picric acid. It has been suggested that
this means might be of use in the prophylaxis of
poliomyelitis and possibly also of other infections
that gain entrance by the nose. In this con-
nexion it is useful to have a report by Dr. GEOFFREY
RakB? from the Rockefeller Institute. His object
was to learn how micro-organisms gained the
tissues when deposited on the olfactory mucosa and `
to this end he first studied the absorption of
prussian blue administered to mice intranasally.
The method is not a new one, having been used
for.a somewhat similar purpose by CLARK and
also by Oxitsky and Cox, and like them, RAKE
found that the absorption of the particles of dye
was extremely rapid. Within two minutes it was
seen in the lymphatics and blood-vessels of the
olfactory submucosa and had reached the sub-
arachnoid space. Apparently the pigment was
absorbed by more than one route. Some of it
passed inwards between the cells of the olfactory
mucosa, but the larger part was taken up by the
olfactory nerve-cells, from there to be dispersed
again to the surrounding tissues. This was clearly
brought out by experiments in which the mice
had been given a preliminary intranasal applica-
tion of 0'8 per cent. tannic acid, for in these animals,
although the dye reached the subarachnoid space
just as rapidly though in less amount, the olfactory
nerve-cells were almost devoid of prussian blue.
RAKE noted also in these treated mice that,
although they showed no nasal discharge during
life, when they were killed and examined a thick
exudate of mucus and leucocytes covered the
olfactory mucosa and turbinates and histological
sections revealed obvious signs of inflammation.
- Experiments with bacteria—the pneumococcus
and Bacillus enteriditis—showed that both these
pathogens reached the brain as rapidly as the
pigment, but that, unlike pigment, they travelled
between the cells and not via the neurones. This
observation explains previous work? showing that
intranasal administration of tannic acid to mice
confers no protection against pneumococci given
by the same route. In the case of viruses RAKE
found that a pantropic virus like that of equine
encephalomyelitis reached the brain just as quickly
as did pigment or bacteria, whereas strict neuro-
tropes like the viruses of St. Louis encephalitis,
louping-ill, and rabies took 24 hours to do so.
Presumably all four viruses were taken up by the
olfactory nerve-cells but the strictly neurotropic
ones were held there and passed slowly inwards to
the brain, whereas the pantropic equine encephalo-
myelitis virus, like pigment, left the olfactory
neurones and travelled to the brain by the more
rapid routes represented by the tissue spaces and
lymphatics.
The practical lesson of this work seems to be
that treatment of the olfactory mucosa with tannic
acid or similar preparations is likely to be most
. effective against a strictly neurotropic virus and
ineffective against bacterial invasion. It also
sounds a note of warning in that a very definite
l 1 Rake, G. W. (1937) J. exp. Med. 65, 303.
2 Cox, H., and Rake (1936) Proc. Soc. exp. Biol., N.Y .34, 716.
INFECTION THROUGH THE OLFACTORY MUCOSA.—VOX POPULI
[APRIL 10, 1937
inflammatory response resulted in the mouse from
the nasal instillation of tannic acid. This would
make one hesitate to advocate such a procedure in
man ; for repeated applications of these prepara-
tions are required to give protection and the risk
of producing chronic change resulting in an`
atrophic rhinitis cannot be excluded.
VOX POPULI
THE People’s League of Health, having made its
voice effectively heard for many years in support
of several good causes, has decided to add to their
number. It was in 1917 that Miss OLGA NETHER-
SOLE founded the League, and its achievements
were indicated at a luncheon recently given in
her honour? when Lord LEVERHULME foreshadowed.
an appeal to be launched at the Guildhall on
Thursday of next week at which the Lord Mayor of
London will preside. The essential purpose of the |
League has been the collection and distribution of
knowledge—knowledge based on scientific founda-
tion and presented in attractive form. The Safe
Milk campaign, with its inquiry as to the best
means of eliminating tuberculosis from milk-
yielding cows and as to the value of milk as food
for school-children, is the best known of the
League’s activities, but the League has been
invited to draw up a memorandum on the com-
position and description of foods, and it has
initiated a study of maternal mortality and mor-
bidity in codperation with nine metropolitan
hospitals. The League, while proposing to con-
tinue these campaigns and its activities as a
bureau of health mformation, is now propounding
eight other subjects in its new programme.
It has in prospect a centre for the practica
demonstrations of a scheme for the eradication of -
tuberculosis from dairy herds. It proposes to
develop a central almoner service where information
can be obtained about everything like child
welfare clinics, nurseries of various kinds, or the
adoption and boarding-out of children. It intends
to examine the conditions under which infants
and older children are received by foster-mothers.
It contemplates a survey of children under treat-
ment at orthopadic hospitals and other institutions
where surgical tuberculosis is treated. It hopes to
press upon the Government the value of compulsory
periodical medical and dental examinations of all
persons insured under the National Health Acts.
The position of the expectant mother under these
Acts is to be made the subject of inquiry. The
League has already emphasised the psychological
aspect of unemployment and considers the time
has come when no person should have scars left
on his mental and physical health simply as a
result of being unemployed. Finally the League
will continue to study all proposals, legislative
and otherwise, relating to the health of the people
and the circulation of information designed
to promote it. The appeal for £50,000 now
being made should meet with a ready response
in view of the League’s past record and present
intention.
1 See Lancet, Feb. 6th, p. $62.
THE LANCET]
[APRIL 10, 1937 877
ANNOTATIONS
A QUESTION OF NEIGHBOURLINESS
MANCHESTER is learning afresh the precept that
almsdoers should not let their left hand know what
their right hand doeth. One form of public benevolence
is the relief of pain and sickness by hospitals ; another
is the relief of unemployment by labour exchanges.
Manchester has a Royal Infirmary with a central
branch where two eminent honorary surgeons and a
resident staff do their best for very serious cases to the
number of 1300 to 1400 per annum. The Minister of
Labour, in spite of protests, has begun to erect
alongside this central branch a large building which
will deprive the patients of light and air, will cause the
wards to be overlooked from scores of windows, and
will collect in a narrow space at close range a crowd of
possibly 300 unemployed, not always perhaps the most
quiet and orderly of gatherings. The Minister is
doubtless not his own master. _He wants to find a
home for the divisional office for the North-West of
England, the Central Employment Exchange for
Manchester, and other departmental offices. His
Majesty’s Office of Works owns an empty space,
bought soon after the war, adjoining the central
branch of the infirmary. Naturally the Minister of
Labour wants the best site; naturally the Offce of
Works. has it available already. Between them
they can tell the Royal Infirmary that its patients
have been lucky all these years to look out upon
a vacant space, and that, whereas the central branch
is inconveniently situated and may some day have to
move, the new employment exchange will be a
permanent adornment of the city. What the Minister
of Health thinks of the dwarfing and obstructing of
the Royal Infirmary we have not been told. What
the medical board and the local medical officer of
health think about it we know. The Minister of
Labour has been assured on good: authority that
his building will make the central branch unsuitable
for in-patient accommodation and gloomy and
depressing for a casualty department. He has been
asked either to alter his building or to put it somewhere
else or to take over the Royal Infirmary’s building
and help the trustees to replace the 54 beds which
in that event would be lost. He replies that he has
considered all alternatives and has rejected them ;
he cannot wait any longer; the building must begin.
The dwellers in a peaceful part of the Thames
Valley lately learnt that a munition factory was to be
established in their midst. They protested success-
fully ; the department concerned gave way at the
eleventh hour in spite of having repeatedly stated
that no other place would do. Manchester has been
less lucky. The Minister of Labour could not change
his mind. Four years ago, with the obvious sympathy
of the Ministry of Health, Parliament passed an
Act to aid the fortunes of the Royal Infirmary.
To-day another Ministry, insisting firmly on its legal
rights, takes a step which will have the opposite
effect. The trustees of the hospital have put forward
a reasonable argument. The infirmary and the
employment exchange, they say, are alike public
services paid for out of public money. If the expen-
diture of the infirmary is not met from one set of
pockets, it must be met from another. If the
infirmary had in fact been the home of a Government
department conducting important research in health
matters, the Minister of Labour would have refrained ©
from neutralising its usefulness. If he now finds
himself destroying the value of Manchester’s only
central hospital, ought he not either to hold his hand
and change his plans or else help it to find proper
accommodation elsewhere ? i |
ANÆMIA AND THE PITUITARY
THE production of acute ulceration of the acid-
secreting area of the stomach of rabbits by injection of
massive doses of a posterior pituitary extract was first
described by Dodds and his collaborators! in 1934.
In a further communication? they discussed the
influence of large doses of pituitary extract on the
blood and suggested that the macrocytic anæmia it
induces may be due to increased blood destruction
and consequent regeneration, their findings leading
them to postulate a hormonal connexion between
the pituitary, the gastric function, and the blood.
On the assumption that the anæmia may be due to
blood dilution from the antidiuretic action of the
pituitary, Gilman and Goodman? have studied the
blood changes in rabbits resulting from large doses .
of the extract. They find that much dilution does
in fact occur—the hæmoglobin, the number of red
cells, and the plasma osmotic pressure being all
reduced—while cell destruction is sometimes super-
imposed upon it. The macrocytic anemia was
similar to that described by Dodds, but they attribute
it to the altered environment of the cells during
plasma dilution making them more fragile. In the
test-tube, the red-cell fragility was actually reduced
by lowering the plasma osmotic pressure, yet in-vivo
cell destruction was increased. All these changes
could be prevented by dehydrating the animals before
injection of the pituitary extract. McFarlane and
McPhail * have also produced anæmia by injections
of pituitrin into normal and hypophysectomised
guinea-pigs, but they did not investigate the anæmia
further. They state that they have failed to find
any hormonal connexion between the pituitary, the
gastric function, and blood formation.
PHYSICAL EFFICIENCY AND FATIGUE
As food is the ultimate source of energy it is not
remarkable that belief is perennial in the capacity
of this, that, or the other comestible to postpone
fatigue or increase muscular efficiency. Ever since
men have undertaken the special preparation com-
prehended as training, the part played by diet has
received exaggerated importance ; and although only
certain old-time restrictions now survive as a con-
cession to tradition, the belief persists to this day that
energy, stamina, strength, and endurance are directly
obtainable from selected foodstuffs. The menu of
any great athlete is minutely examined and as
minutely followed by ambitious youngsters, and the
more bizarre and heterodox the régime the greater
the appeal, The success of crews in the Boat Race
has on occasion been attributed to their “ training
on eggs”; oranges have likewise required a head-
line. Two years ago a professor of medicine assigned
to sugar in the training dietary the credit of the
repeated victories of Cambridge oarsmen. In the
circumstances it is surprising that nobody accused
the cunning Cantabs of having cornered all the glucose
1 Dodds, E. C., Noble, R. L., and Smith, E. R. (1934) Lancet,
2 — Hills, G. M., Noble, R. L., and Williams, P. ©. (1935)
Ibid, 1, 1099.
3 Gil (1937) Amer. J. Physiol.
iis unan, A., and Goodman, L.
‘McFarlane, W. D., and McPhail, M. K. (1937) Amer. J. med.
Sci. 193, 385.
>
878 THE LANCET]
in the country, so depriving the famous Oxford
marmalade of the little bit extra which might have
meant so much to those who endeavoured to uphold
the prestige of the University upon the Isis. The
latent possibilities in drugs, the mystery and the
magic, naturally invite still greater expectations
from such extremes as the simplest kitchen ingredients
and the most obscure secrets of native witch doctors.
At a recent meeting of the Berlin Medical Society
Prof. Helmut Dennig, director of the Moabit medical
clinic, claimed } an increase of physical capacity and
endurance by 30 to 100 per cent. from the adminis-
tration of natron, being bicarbonate of soda, to
hasten the elimination of acids, especially lactic acid.
The simplicity of the method recalls the remarkable
effect of delaying fatigue ascribed? to acid sodium
phosphate during the Jate war when this salt was
administered to the German storm-troops. Investi-
gations undertaken in America ° failed to confirm the
claim. Any advantage derived from the phosphate
was due to the increased sense of well-being or the
lessening of tiredness created by its stimulant action
- on the intestinal tract; there was no measurable
increase of muscular efficiency, nor was. the onset
of fatigue delayed. And this was confirmed by the
personal experience of a well-known physician-
athlete in this country. It is common experience
that in moments of stress the physical capability
may be increased to an extent hitherto unexpected —
and almost unbelievable. In everyday life there are
inhibitions which, acting like a governor, prevent
a maximal effort being put forth; any drug which
can diminish sensitiveness, paralyse the appreciation
of fatigue, and eliminate the faculties of judgment
and self-preservation might have the effect described
as doping in the case of race-horses. On the con-
tinent it seems to have been necessary to issue a
warning to athletes not to dope themselves.
DRAINAGE OF THE PERITONEAL CAVITY
THERE is something to be said for J. E. Jennings’s
contention * that so-called drainage of the abdominal
cavity is usually ‘“‘superstitious and ineffective
packing.” It is well established that none of the
ordinary methods gives anything approaching general
peritoneal drainage, but how far is this fact recog-
nised in practice ? Discussing Dr. Jennings’s paper,
Dr. W. B. Parsons of New York said that five
surgeons suddenly confronted with the problem
might be expected to give five different opinionsg
about the right way to drain an appendix or gall-
bladder, and as to why a drain is wanted in one
case and not in another. Since localised drainage is
alone possible, the indications for insertion of a
drain are definitely restricted. The most obvious
benefit to be gained is the formation of a ‘ path of
least resistance ” for localised infection, actual or
anticipated. Jennings holds that tubes or gauze
strips—the materials usually employed—irritate the
tissues, producing an exudate which at the same
time tends to block the drain and encourage walling-
off of the infection. Most drains act partly as packs,
and unless the infective process is localised, their
value as drains will be nil. In his opinion the indica-
tions for localised peritoneal drainage are, broadly
speaking, two. In the first place, drains may be
inserted at the end of operation to remove exudate,
blood, or bile collecting at the operation site, or to
serve as sentinels where a leak is feared at a line
1 Belfast Telegraph, March 18th, 1937.
2 Emden Schmitz and Meinicke (1921) Hoppe-Seyl. Z. 113, 10.
3 Publ. Hlth Wash. 1926, 29
Rep., : » 29.
‘4nn. Surg. January, 1937, p. 67.
VITAMIN-B DEFICIENCY AND THE HEART
[APRIL 10, 1937
of suture in a hollow organ. Secondly, they may be
used to remove infected exudate, such as pus, in
cases of localised peritonitis. Here the amount of
drainage that actually takes place through the tube
or gauze is slight, and the important effect of the -
drain is that a track is made down to an “ extra-
peritonealised ” cavity. The use of a material with
the minimum of irritation to the tissues will reduce
or prevent the formation of localising adhesions, and
such a material Jennings claims to have found in
raffia. Selected strands are chosen, cleared of
strangling fibres, washed in boiling soap and water,
cut into standard lengths, knotted in hanks of twenty
strands, and wrapped in muslin packages. Sterilisa-
tion is carried out on three successive days, and the
required strands are reboiled just before use. Raffia
has a capillary action and is very strong; it is also
smooth and inflicts the minimum of injury during
removal. Jennings has employed it for twenty years
and has found it especially useful where a drain is
required simply to remove an exudate, and where no
advantage can result from its acting as a pack.
VITAMIN-B DEFICIENCY AND THE HEART
HEART failure resulting from vitamin-B deficiency
has long been known in the East as an accompaniment
of beriberi and pellagra. An early view was that,
like the neurological symptoms, the heart affection
was secondary to a neuritis, the vagus nerves being
the site of the lesions. When in 1927 Wencke-
bach discussed this subject in our columns,’ he
suggested that the functional failure of the beriberi
heart was due to cdema of the myocardium. Weiss
and Wilkins 2 have now come to the conclusion that
similar deficiency states, accompanied by cardiac
disease, are not uncommon in the United States;
and they have been able to collect 97 cases, 12 of
which they observed personally. As evidence of
vitamin-deficiency they accepted polyneuritis, pella-
groid dermatitis, glossitis, and gastro-intestinal
disturbances, and a history of an inadequate diet.
The heart lesions associated with these conditions
could not be put down to other recognised factors,
and the symptoms and signs of such lesions improved
after administration of vitamin B. The circulatory
symptoms were variable ; but prominent among them
were dyspnea, regular tachycardia, palpitation, and
exhaustion. These, with excessive arterial pulsation,
loud sounds over the arteries, and a rapid circulation-
rate, are features that recall the circulatory changes
in goitre and also in some functional nervous dis-
orders. Such symptoms were found especially in
association with polyneuritis. Syncopal attacks,
exaggerated sensitivity of the carotid sinus, vaso-
motor collapse, and brachycardia in convalescence
were also observed and were regarded as signs of
nerve lesions. On the other hand, some of the
symptoms often encountered are more characteristic
of hypertensive and ischemic heart disease—for
example, gallop rhythm and congestive failure with
normal rhythm. Cardiac enlargement was usual and
changes in the electrocardiogram were rarely absent ;
these included low voltage, altered T waves, premature
beats, and occasionally auricular fibrillation. Histo-
logical studies on a few cases that came to autopsy
showed myocardial changes like those described by
Wenckebach, but these are held by Weiss and
Wilkins to be in no way specific. The treatment of
these cases is simple enough, consisting in rest and
1 Wenckebach, K. F. (1928) Lancet, 2, 265.
2 Weiss, S., and Wilkins, R. W. (1936) Trans. Ass. Amer.
Phys. 51, 341.
THE LANCET)
administration of vitamin B—if necessary giving the
crystalline B, by injection. Improvement was striking,
signs of congestion, for example, disappearing far
more rapidly than might be expected in other forms
of congestive failure; the electrocardiogram also
quickly regained its normal form. In animal experi-
ments such effects are even more remarkable, gross
electrocardiographic ‘changes seen in rats suffering
from vitamin-B, deficiency could be abolished within
twelve hours by an injection of crystalline B, (Zoll
and Weiss °). |
This paper by Weiss and Wilkins is of great interest,
and the six cases they record in detail would be hard
to explain in ordinary ways—except perhaps one, in
which the patient appears to have had hypertension.
Five of these six patients had alcoholic polyneuritis,
now regarded'as directly due to lack of vitamin B,,
and it is possible that inquiry into such cases in this
country, though now of course relatively rare, might
reveal significant cardiovascular disturbances.
JUDGMENT AND REASON
Dr. Hutchison’s little trilogy on the fundamental
principles of clinical medicine * has reached us in its
second edition. For the rounded felicity of their
style and the practical wisdom of their content his
essays are well worth re-reading. The preface puts
words into the reviewer's mouth: ‘“ although there
is nothing in them that has not been said often
before, there is also nothing in them that will not
bear saying again.” In the essay on diagnosis, we
read that this art involves the use of observation, of
knowledge, and of judgment, and by judgment is
meant an intuitive faculty of distinguishing the
relative importance of things. The use of reason
is not mentioned, which is a little discouraging
for those who labour in the faith that scientific
methods and scientific ways of thinking have much
to contribute to medicine. Not the most ardent
of them, however, can deny that medicine, as she is
practised, is still largely empirical. And there is
certainly the danger, which Dr. Hutchison would
guard against, that the art of dealing wisely with the
sick may be perverted by pseudo-scientific enthusiasms.
Most of us would be the better for turning over these
pages again, and a copy would not come amiss
as a gift for some medical student of our acquaintance
who may be approaching his final examination.
URETERO-INTESTINAL IMPLANTATION
EIGHTY years have elapsed since Simon made the
first attempt to divert the urine into the bowel,
and during these eighty years more than a thousand
such operations have been performed. Hinman and
Weyrauch,> who have written an elaborate account
of the methods used, complain that previous reviewers
have laid too little stress on the surgical principles
on which a satisfactory operation must be based.
An historical review can be of use to the surgeon of
to-day only if it teaches the way to implant ureters
more successfully than has been done in the past.
The. conclusions Hinman and Weyrauch themselves
reach are not altogether optimistic. They are left
“with a feeling of disappointment at the lack of
oe Zoll, P. M., and Weiss, S. (1936) Proc. Soc. exp. Biol, N.Y.
i Princi les of Diagnosis, Prognosis, and Treatment. Second
. LL.D., F.R.C.P
edition. y Robert Hutchison, M.D .D., F.R.C.P., Con-
sulting Physician, London Hospital and Hospital for Sick
Children, Great Ormond-street. Bristol :
John Wright and
Ropa. ULE; London : Simpkin Marshall. Pp. 53. 3s. 6d
s. 6d.
man, F., aog Weyrauch, H. M. (1936) Trans. Amer. Ass.
JUDGMENT AND REASON.—RESPIRATORY EFFICIENCY
_ disease the relation is closer.
[APRIL 10, 1937 879
improvement with the advent of newer methods and
greater experience. It would seem that every
surgical technique imaginable has been tried.”
Of the eleyen methods listed, submucous implantation
has given the best results; yet many questions
about it still require answers. What are the factors
that produce localised necrosis of the intestine or
perforation and tearing-out of sutures? Why is
anæmia, infarction, extensive necrosis, diffuse ureter-
itis, or dilatation of the ureter found at autopsy ?
Too often the answer to this will be failure on the
part of the operator to obey the simple well-known
rules of intestinal and ureteral surgery. The only
layers that are safe for suturing are the submucous
layer of the bowel and the adventitia of the ureter.
Sutures cannot penetrate the lumen of either without
danger. Their blood-supply cannot be disturbed
to any great extent; neither can they be unduly
bruised, twisted, or displaced. These are some of
the principles that must be followed if postoperative
accidents and complications are to be reduced.
Besides these problems of technique there are others
needing consideration, such as urinary sepsis. Some-
times varying degrees of pyelonephritis, or infected
hydronephrosis, are present before operation, and
experience shows that such conditions are often
favourable rather than otherwise, because they
favour immunity. The surgeon must needs consider
not only his surgery but the possibility of raising the
patient’s resistance to it.
RESPIRATORY EFFICIENCY
WORKERS in many centres continue the search for
an easy way of expressing the degree of efficiency
or failure of the respiratory apparatus. Kaltreider
and McCann: report investigations on patients
with chronic pulmonary disease, comprising estimates
of the ventilation, respiratory rate, tidal volume, |
oxygen consumption, and carbon-dioxide production
. during a standard form of exercise in 20 normal
subjects and in 28 patients with cardiorespiratory
abnormalities. They also correlated their results
with blood examinations and certain measurements
of the chest. From these they conclude that the
amount of dyspnoea is proportional to the expression
total ventilation .
ata aa They find that dyspnea is
experienced when this value is greater than 51, and
that excess of this figure at low levels of work is an
indication of pathological dyspnæœa. The maximum
minute-ventilation that can be maintained for 1}
minutes is only roughly proportional to the vital
capacity in normal subjects, but in chronic pulmonary
In their examination
of other suggested tests for respiratory efficiency,
Kaltreider and McCann make certain valuable
criticisms, as for example, that the “ventilation
equivalent for oxygen ” (the amount of ventilation
required per 100 c.cm. of oxygen absorbed) suggested
by Knipping, Lewis, and Moncrieff is not a good
index of the degree of dyspnoea since it varies from
person to person. The pulmonary reserve on the
other hand is held to be a useful measure of the
tendency to dyspnea. Normal subjects can increase
their resting minute-volume about ninefold, but
patients disabled by pulmonary fibrosis and’
emphysema could often increase their ventilation
only to about 60 per cent. of the maximum minute-
ventilation on moderate exertion. The basis of the
investigations has been the results obtained with
subjects harnessed to a closed spirometer, and in
1 Kaltreider, N. L.,and McCann, W.S., J. clin. Invest. January,
1937, p. 23.
88Q THE LANCET]
two other papers ? Lessen, Cournand, and Richards,
offer damaging comments on certain of the measure-
ments made of the respiratory gases in a closed-
breathing circuit. They show, for example, that
when a normal person breathes for several minutes
in a small closed circuit in which the oxygen con-
centration is steadily decreasing, a state of equilibrium
is reached and maintained in which the concentra-
tion of the nitrogen expired is less than that of the
nitrogen inspired. This is due to the progressive
increase in inspired-nitrogen concentration with.
each breath, to mixing of inspired air in the lungs
with air previously inhaled, and to the exhalation of
mixed samples. In the determination of residual
air volumes by quiet breathing, in a closed-circuit
apparatus, use of alveolar air samples, obtained
before and at the end of the breathing period, enables
a correction to be made for the inequality of con-
centrations of inert gases through the system. This
correction may amount to several hundred cubic
centimetres in normal subjects. In patients with
emphysema, with a poor distribution of tidal air and
hypoventilation through a large part of the pulmonary
air spaces, the errors may be even greater if the
residual lung volumes are determined by methods of
quiet breathing in a closed circuit. This fallacy of
what these authors call ‘‘ nitrogen lag ” is one demand-
ing serious attention, since it may well prove to be
one of the reasons why similar, but not exactly the
same, spirometric experiments in different centres
seem to give widely different results.
TUMOURS OF THE HAND
THE swellings other than acute infections that
may arise in the hand are discussed by M. L. Mason 3
(Chicago) with reference to origin and prognosis after
removal, Ganglia he regards as being probably due
to a gelatinous degeneration in the fibrous sheaths of
the tendons or joint capsules, and not to synovial
herniation as was previously held. Epidermoid cysts.
are attributed for the most part to implantation of
epithelial cells, while a few may develop from
congenital inclusions. Xanthoma is a tumour peculiar
to the extremities, whose origin is not settled. It
occurs as a firm slowly growing nodular mass, most
often on the volar surface of the thumb or finger.
The tumour is made up of lobules of yellow, orange,
brown, and grey tissue, bound together by septa,
and surrounded by a thin capsule. Microscopically
it is seen to be composed of giant cells, large round
cells, spindle cells, and foamy cells ; it does not recur
after complete removal. Fibromas and _ lipomas
in the hand behave as they do elsewhere in the body.
An interesting tumour is a telangiectatic granuloma,’
which follows infection in an abrasion. It bleeds
freely, and recurs if not completely excised. Subungual
melanoma and carcinoma are described, likewise
carcinoma arising in an irritative lesion, as after
burns, thermal and radiological, or chemical irritants.
The prognosis of these is bad. Chondromata are
common in the metarcarpals and phalanges. Angio-
mata of various types occur in the hand. A tumour
of recent recognition is called a glomus tumour,
arising under the nail bed, and sometimes elsewhere
‘in the hand. It is said to be developed from the
neuromyo-arterial glomus of Masson,‘ and is made
up of blood-vessels with thickened walls, the media
being replaced with epithelial cells, smooth muscle-
fibres, and myelinated and unmyelinated nerve-
* Lassen, H. C. A., Cournand, A., and Richards, D. W., Jr.,
Ibid., Dp. i and 9.
3 Sura. Gynec. Obstet. 1937, 64, 129.
“Masson, P. (1924) Lyon Chir. 21, 257.
TUMOURS OF THE HAND.—CANCER OF THE LUNG
[APRIL 10, 1937
fibres. When this tumour is removed complete it
does not recur.
Such detailed studies of regional surgery provide
a useful pathological background for guidance in
treatment.
CANCER OF THE LUNG
THE faint ray of hope that has flickered into the
prognosis of carcinoma of the lung made it a suitable
subject for the Silvanus Thompson lecture delivered
at the British Institute of Radiology’s congress last
December. This lecture, which we summarised at
the time, appears in full in the March issue of the
British Journal of Radiology. The lecturer was
Dr. A. C. Christie of Washington, and under the
head of diagnosis he makes it very clear that earlier
recognition is essential if treatment is. to have a
chance of success in more than a minute proportion
of cases. When a patient of 40 or over complains
of persistent cough with a small amount of sputum,
sometimes blood-stained and accompanied by
moderate dyspnea and pain, the suspicion of carci-
noma should at once be raised. Physical signs are
of little value, and in reaching a diagnosis there must
be careful correlation of information obtained by
various means of which the most important are
radiological and bronchoscopic. Once recognised,
there is now a possibility of complete eradication of
the growth and for this purpose total pneumonectomy
is tending to take the place of lobectomy. Although
it is at present applicable only in a small proportion
of cases, the fact that any cures are possible should
stimulate interest in early diagnosis to such an
extent that these operable cases cease to be such
rare exceptions. Radiation therapy has on the
whole been disappointing in lung cancer, and it must
be admitted that highly differentiated tumours in
this region‘ are almost completely radioresistant.
With less differentiated tumours Dr. Christie considers
the results more encouraging, especially when,
after careful localisation of the tumour, it is irradiated
through several relatively small portals.
A CONFLICT OF PHILOSOPHIES
A LITTLE book! written with obviously sincere
moral and religious convictions attacks what have
been called, and perhaps properly, the ‘“‘ pretentions ”
of science in the philosophical and moral fields.
In particular it attacks, on the one hand, the crude
materialism implied if not expressed in many popular
biological writings, and, on the other, the somewhat
patronising attitude taken towards theology in
modern books of cosmology and physics. One can
understand the irritation aroused by this attitude
in persons of a theological turn of mind whose
humanistic background stretches beyond Heisenberg
and Einstein to Spinoza and Jonathan Edwards.
It is not unreasonable to regard the “indeterminacy
principle ” as a device of the physicist to get himself
out of an awkward situation of his own making.
Stepping-stones have, before now, in science, been
mistaken for foundation-stones. The modern philo-
sopher-physicist might well feel some misgivings
that illustrations from ‘Alice in Wonderland ”’
come so glibly from his tongue. Even “ free-will”
theologians of the sterner sort will hardly appreciate
concessions that might equally be given as an excuse
2 The Philosophy of Religion versus The Philosophy of Science.
An exposure of the worthlessness and absurdity of some conven-
tional conclusions of modern science. By Albert Eagle, lecturer
in mathematics in the Victoria University of Manchester.
Printed for private circulation and obtainable through an book-
sellers from Simpkin Marshall Ltd. 1935. Pp. 352
THE LANCET]
for believing in any nonsense. Mr. Eagle is a trained
mathematician and physicist and as such is obviously
more at home in physics than in biology, psychology,
or economics. His attack on the relativity theory,
though it could no doubt be parried by an expert
relativitist, is at least a pungent statement of the
reactions of the ordinary man to the theory. The
main fault in this book is that the author attacks
too much and too wildly and the reader becomes
bewildered by his divagations through relativity
and indeterminacy, evolution and embryology,
psychology, capitalism, communism, and the rest.
A philosopher must not be blamed for exercising his
proper function as a critic of universal knowledge,
‘“ but it needs happy moments for this skill,” and
it is hardly work for the amateur. Mr. Eagle does,
however, succeed in reminding us how many slip-shod
philosophical notions reach the ordinary reader in the
form of “asides”? in popular scientific writings.
This is difficult to avoid as the ordinary reader craves
for general and sensational ideas and a sop must be
thrown to him from time to time. How far he is
misled, and how far it matters if he is, are nice
problems in the ethics of popular education. He
at least gets plenty of opportunity of hearing
both sides of the argument, even if the argument is
a bad one, and it is unlikely that Mr. H. G. Wells’s
fervent materialism will do him any more harm than
Sir Arthur Eddington’s light-hearted theology. In
other respects, he will be unquestionably the better
for such books as “The Science of Life” or ‘‘ The
Nature of the Physical World,” which after all were not
primarily written to teach him philosophy but to reveal
to him some of the wonders of modern discovery.
A NATIONAL FOOD POLICY
_ In his broadcast last week the Minister of Health
described the report of the Advisory Committee on
Nutrition as the most valuable document on the
subject yet issued, and went on to set out the action
he had already taken on it. He had, he said, that
day communicated with all the maternity and child
welfare authorities in the country asking them ‘to
review their arrangements for the supply of milk and
other protective foods to mothers and young children.
He deprecated the time-limits placed on the supply
of milk to expectant mothers and young children, and
suggested as a simple criterion the supply of sufficient
milk or other food whenever the provision is necessary
for the maintenance of the health of the mother or
young child. He had asked local authorities to
review the scales of income at present in force and
to frame them in such a way as not to render it
difficult for mothers to take advantage of the
authorities’ arrangements. Wherever possible the
milk-supply should be efficiently pasteurised, and
where this was not practicable the medical officer
of health should approve the source and quality of
the milk-supply. He regretted the abandonment in’
various places of the organised system of supplying
meals because of the difficulty in securing the
attendance of sufficient mothers or young children,
and expressed a hope that the successful solution of
the difficulty in certain large towns would be more
widely followed. The new Act, raising the block
grants to local authorities and redistributing the
grants so as to give a larger share to authorities
whose need was greatest, should, he thought, help
to do away with local hesitation on grounds of
financial stringency. Existing services deserved to be
more widely known and he emphasised the share
which the Ministry is taking in the autumn campaign
to make the services better known and more fully
A NATIONAL FOOD POLICY
[APRI 10, 1937 881
availed of. Finally he offered to discuss with repre-
sentatives or officers of the local authority any
difficulties in the way of a fuller realisation of the
committee’s recommendations.
WHAT IS OSTEOPATHY ?
OSTEOPATHY began as, and still is, an American
cult. The founder of the faith, Andrew Taylor
Still, was a remarkable man born in Virginia in 1828
and in 1874 the recipient, according to his own
account, of a divine revelation of the true science of
healing which he called osteopathy. What is osteo-
pathy ? Two doctors, Charles Hill and H. A. Clegg,
have tried to answer this and relevant questions in a
most readable book! The authors are perhaps
biased: they are doctors. Yet seeing that osteo-
pathy deals with human disease, and doctors are the
only class in the community. who can lay claim to
having studied the subject scientifically, that is no
drawback and the fact that neither of the authors
is engaged in medical practice ensures that their bias,
if it exists, is not due to fear of direct professional
rivalry. Their positions in the British Medical
Association give them a broad outlook on medicine
and a benevolently critical attitude towards their
brethren; and in addition to a scientific training
they have developed a more than usually wide
knowledge of the public and legal aspects of the
healing art. It is not their fault that the reader will
find a certain amount of confusion when he comes to
the part of the book where they try to give a
description of the cult; for Hill and Clegg are in the
same predicament as an artist trying to produce a
picture of a versatile chameleon: the beast changes
colour while you look at it. In the history of disease
there has been a progressive unfolding of the truth,
and even a “revolutionary” discovery in con-
nexion with a particular disease is found sooner or
later to harmonise with such earlier knowledge as
existed. But osteopathy, like the chameleon, appears
to change colour for protective reasons. Still believed
that all disease could be ascribed to displacements
of the spine, ribs, or hips. One would imagine that
he would have hailed the advent of X rays with
shouts of joy. Nota bit of it: no concerted attempt
was made to employ the new diagnostic weapon and
when it was found that osteopathic displacements
could not be demonstrated radiographically, and that
easily demonstrable displacements of the spine and
hips did not lead to other more remote diseases as
the osteopaths taught, the osteopathic “lesion ’? was
born, something much more subtle and elusive, to
replace the discredited ‘“‘ displacement.” It is a
remarkable and instructive fact that this nebulous
lesion found its way recently into the august seclusion
of our House of Lords. A Bill for the registration of
osteopaths was introduced in 1935, and after attaining
a second reading was referred to a Select Committee.
Although the subsequent investigation was expensive
‘and time consuming, the resulting exposure of the
osteopaths has done nothing but good. Dr. Hill
and Dr. Clegg allow the committee’s report to speak
for itself : it shouts condemnation. This, for example :
“The only existing establishment in this country
for the education and examination of osteopaths was
exposed, in the course of evidence before us, as being
of negligible importance, inefficient for its purpose,
and above all in thoroughly dishonest hands.”
Throughout the book, indeed, the evidence has been
1 What is Osteopathy? By Dr. Charles Hill, deputy medical
M
secretary, British oaoa Association; de uty Editor, British
Medical Journal; Dr. H. A. Clegg. London: J. M. Dent
and Sons. 1937. Pp. qin. 7s. 6d.
882 THE LANCET] ROCKEFELLER TRAVELLING FELLOWSHIPS.—FOOD AND EXERCISE
arranged with great precision, and the whole story
is told clearly and with engaging good humour. .
' A point remains for consideration. The fact that
osteopathy reached the House of Lords was due to
one thing—certain noble lords had been cured by
osteopaths, where, presumably, the doctors had failed.
This side of the question is examined, but one is left
with the impression that manipulation of the spine
(which in certain cases that drift to the osteopath
cannot fail to do good) as well as of other joints is
being regularly employed in suitable cases by members
of the medical profession. Yet too often still one meets
a patient who visited the bone-setter or the osteopath
after one or moré doctors had failed to relieve him,
and who was cured, This is not the place to discuss
the teaching of manipulative surgery (perhaps the
authors considered it outside the scope of their book),
but this important subject certainly has a claim to
more attention from medical students than, for
various reasons, it now receives.
A DIRECTORY OF LONDON MUNICIPAL
HOSPITALS
THE county of London having settled down to
another three years of hospital administration
undisturbed by thoughts of election, it is useful to
have for reference a handbook! prepared by its
hospitals and medical services committee. This
committee is responsible for 65 general and special
hospitals, a small-pox receiving station, and 9 insti-
tutions containing at the present time beds for sick,
healthy, and infirm inmates. The hospitals are
classified as 27 general, 1 for the chronic sick,
15 infectious, 6 children’s (sick and convalescent),
10 tuberculosis (including 4 for children only),
2 adult convalescent, 2 epileptic, 1 for ophthalmia
neonatorum and vulvo-vaginitis in children, and 1 for
maternity cases associated with venereal disease.
They contain some 38,500 beds, and the handbook
gives concise information about them all under six
headings, including an admirable hospital map of
the county. Primarily the information is for the
use of the managing committees, whose names and
time of meeting are set out for each hospital, but
there is a much wider circle which will welcome
such a conspectus of the hospitals as a whole, with
precise information about access, number of beds,
particular kind of work done with alterations in
progress or proposed, and the names and qualifica-
tions of heads of departments. On p. 90 of the hand-
book is an imposing list of the special units at the
L.C.C. general hospitals of which further details will
be found on p. 893 of our present issue.
ROCKEFELLER TRAVELLING FELLOWSHIPS
THE Medical Research Council announce that
they have been entrusted by the Rockefeller Founda-
tion of New York with £3000 annually, for three
years in the first instance, for the award of travelling
fellowships in medicine to candidates in the United
Kingdom. This generous benefaction renews an
arrangement which had been highly successful
during an earlier period, but which had latterly been
interrupted during a revision of the Foundation’s
general policy. These Rockefeller fellowships are
intended for graduates who have had some training
in research work in clinical medicine or surgery or
in some other branch of medical science, and are
likely to profit by a period of work at a chosen centre
? London County Council: A Handbook of General and
Special Hospitals and Ancillary Services. 1936. London:
P. S. King and Son. No. 3245. Pp.168. 1s. 6d.
“reached £102,839.
[APRIL 10, 1937
in the United States or elsewhere abroad before
taking up positions for higher teaching or research
in this country. Five or six fellowships will be avail-
able annually, and applications for the academic
year 1937-38 will be invited in May. It is of interest
to recall an analysis which was made, at the end of the
previous ten-year period, of the positions occupied
by the 70 men and women who had completed their
tenure of Rockefeller fellowships awarded by the
Council. This showed that 12 were professors in
universities, that 36 others occupied whole-time
positions for teaching and research, and that a further
16 held part-time appointments of the same kind.
FOOD AND EXERCISE
Many people little disposed to listen to discussion
of the principles governing nutrition or the best means
of promoting physical culture take a lively interest
in talk of food and exercise, Lord Horder was wise,
therefore, in using concrete example and homely
simile in a suryey ! introductory to a series entitled
“Towards National Health ” to be broadcast on
Monday evenings during April, May, and June.
Proper food, decent shelter, ample fresh air, a chance
of doing work, a reasonable amount of leisure, and room
for play: these, Lord Horder declared, are the
means of health, and governments, central and -
local, can see to it that no section of the community
lacks them. He dismissed the man who talks about
the “secrets of good health” as either a crank
or one who has something to sell, and showed how
easily science can be prostituted to business ends.
On the other hand, health is more than a balanced
resistance to stresses. It implies the possession
of some kind of purpose or passion, be it a lofty
one or a low one. Lord Horder’s conviction of the
need for fostering zest for life if health is to be main-
tained led him to plead for exercise without exercises,
though he does not minimise the value of sergeants
and instructors in correcting faults of posture or
gait. Just as natural and appetising foods are better
for us than artificial and doctored foods, so, he holds,
natural and enjoyable forms of exercise are better
for us in every way than drill and physical jerks.
Future talks will be concerned with various aspects
of nutrition and on May 24th they will be linked
to a second part of the series by an account of
the relation of physical culture to nutrition and to
other aspects of national health.
1 The Listener, April 7th, 1937, p. 655.
—
UNIVERSITY COLLEGE ; HOSPITAL, LONDON.—It was
announced at the annual meeting of governors of
this hospital that all the new extensions were in full
working order and almost all the pay beds occupied.
The centenary appeal made in 1935 for £300,000 has now
The number of patients is increasing
and general accounts show a deficit of over £5000, which
will probably be increased by the burden of interest
charged in connexion with the private patients’ wing.
Special efforts are being made to facilitate the admission
of emergency cases.
EASTBOURNE EAR, NOSE, AND THROAT HOSPITAL.—
The Marquess of Hartington was elected president of
this hospital at the annual meeting on March 24th, in
succession to the late Sir John Maitland. Legacies and
gifts strengthened the financial position during 1936,
and as the number of patients was increasing year by
year—306 in-patients and 2178 out-patients had been
treated during the last twelve months—it was hinted that
the governors were contemplating the erection of a hospital
on two floors in a quieter neighbourhood.
THE LANCET |
[APRIL 10, 1937 883
PRINCIPLES OF MEDICAL STATISTICS
XV—GENERAL SUMMARY AND
CONCLUSIONS*
In the preceding sections I have endeavoured to
make clear to the non-mathematically inclined
worker some of the technique that the statistician
employs in presenting and in interpreting figures. The
major part of that discussion has been directed to
two basic problems :—
(1) The “ significance,” or reliability in the narrow
sense, of a difference which has been observed between
two sets of. figures—be those figures averages,
measures of variability, proportions, or distributione
over a series of groups; and
(2) The inferences that can be drawn from a
difference which we are satisfied is not likely to be
due to chance,
A Secure Foundation for Argument
The discussion of the first problem led to the
development of tests of “significance ’’—the standard
errors of individual values, the standard errors of
the differences between values, and the y? test.
The object of such tests is to prevent arguments
being built up on a foundation that is insecure owing
to the inevitable presence of sampling errors. Medical
literature is full of instances of the neglect of this
elementary precaution. Illustration is hardly
necessary but I may, perhaps, give a quotation from
an article published while I was preparing this
section for the press: ‘a mere list of the treatments
which have been tried in thrombo-angiitis obliterans
would be of formidable length and there is little
point in mentioning many of them—they have only
too often fallen by the way after an introduction more
optimistic than warranted by results” (Lancet,
1937, 1, 551). This general summary may well be
written round that problem of clinical trials.
In general, worker A, who is at least careful enough
to observe a control group, reports after a short
series of trials that a particular method of treatment
gives him a greater proportion of successes than he
secures with patients not given that treatment, and
that therefore this treatment should be adopted.
Worker B, sceptically or enthusiastically, applies the
same treatment to similar types of patients and has to
report no such advantage. The application of the
simple probability tests previously set out would have
(or should have) convinced A that though his treat-
ment may be valuable, the result that he obtained
might quite likely have been due to chance, He
would consequently have been more guarded in his
conclusions and stressed the limitations of his data.
If, however, the test satisfied worker A that the
difference in reaction that he observed between his
two groups was not likely to be due to chance, then
there comes the second, and usually much more
difficult, problem. Were his two groups of patients
really equivalent in all relevant characteristics
except in their differentiation by mode of treatment ?
This question immediately emphasises the importance
of the initial planning of clinical trials with some
new treatment or procedure, a point which was
discussed in the first of these articles. The simple
probability tests are not rules merely to be applied
blindly at the end of an experiment, whether that
* In Sections IV and X I discussed the meaning and use of
the atandard deviation and the coefficient of correlation. I have
been asked to show how in practice these two statistical values
are calculated. I propose to do this in two further sections
which will follow this concluding summary.
experiment be well or badly carried out. Certainly
they can tell us in either case whether certain
observed results are likely or not likely to be due to
chance; equally certainly they can tell us nothing
beyond. that. But if the trials are ‘well-planned
then we can with reason infer that the “ significant ”
difference observed between the groups is more likely
to be due to the specific treatment than to any other
factor, for such other factors are likely to be equally
present in both groups in the well-planned test.
If the trials are badly planned, in the sense that the
groups to be compared are allowed to differ in various
important respects as well as in treatment, then we
can infer nothing whatever about the advantages of
the specific treatment. The time to reach that very
obvious conclusion is not at the end of the experi-
ment, when time, labour, and money have been spent,
but before the experiment is embarked upon. To
argue at the end of a badly planned experiment that
the statistical method is not applicable is not reason-
able. The statistical method (like any other method)
must fail if it has to be applied to faulty material ;
but faulty material is often the product of a faulty
experiment. Much thought, in fact, must be given
to the devising of a good experiment, of really effective
clinical trials, and the statistical aspect must be
borne in mind from the start.
The Problems of Clinical Trials
With methods of treatment the main questions
to be settled are usually these :—
(a) How can the patients be effectively allocated
to the two groups which are to be compared—which
we can refer to as the treated and control groups.
(b) What criterion or criteria can be used as evidence
of the effects of treatment.
(c) On how many patients will the trials have to
be made to give reliable results.
The answers to these questions will, naturally,
vary with the particular case at issue, but there
may be some advantage in discussing them, briefly
in general. |
(a) ALLOCATION TO GROUPS
By the allocation of patients to the two groups
we want to ensure that these two groups are alike
except in treatment. It was pointed out in the first
section that this might be done, with reasonably
large numbers, by a random division of the patients,
the first being given treatment A, the second being
orthodoxly treated and serving as a control, the third
being given treatment A, the fourth serving as control,
and so on, no departure from this rule being allowed.
It was also pointed out that this method could be
elaborated, the groups being made equal in such well-
defined characteristics as age and sex, and then
randomly composed in other respects (and, of course,
more than one form of treatment could be brought in).
While the treatment to be tested has only an empirical
-basis—as it must have before it has been adequately
tried out—there can be no serious moral objection
to this procedure, though practical difficulties of
administration may well arise. On the other hand,
once there is evidence that one treatment gives
better results than another (even though the evidence
is slender) the moral problem becomes acute. One
cannot treat human beings like laboratory animals
and to withhold from a patient.a treatment which
is likely to benefit him is impossible. All the more
important, therefore, is it to secure reliable evidence
of the effects of a form of treatment before that
884
position arises. In the early days of a new treatment
there are also likely to be some workers who regard
it favourably, and others who distrust it. If a random
division of patients is objected to, or is administra-
tively impossible, it should be possible at this stage
to make comparisons between similar types of patients
to whom worker A is giving the treatment and worker
B is not. For example, in the treatment of pulmonary
tuberculosis by collapse therapy there are physicians
who now believe that an artificial pneumothorax
should be induced at an early stage ; there must have
been, and no doubt still are, many patients of similar
types to whom that treatment has not been applied,
who would serve as an effective standard of
comparison. The difficulty is that usually any one
worker’s field of observation is too limited to give a
convincing result, while a prolonged period of
observation of each patient is also a necessity and
difficult to secure. Organisation is required so that
patients may be classified on a uniform system, and
the results collated and judged by identical criteria.
In the long run it is probable that useless forms of
treatment will be discarded and the good will survive,
but it may be an unfortunately long run which
carefully controlled trials would have effectively
shortened. j
The advantage of recording limited data.—Even
the smallest amount of data has its advantage, if
collected on some uniform system and clearly defined.
In some instances it is only by the accumulation of
such data that an answer to a problem can be reached.
For example, there is some evidence that epidemics
of milk-borne and water-borne enteric fever differ
in the sex- and age-incidence of the persons attacked,
the former attacking women and children—the larger
consumers of milk—with proportionately greater
frequency. The problem cannot be settled by the
evidence from any one epidemic; it requires the
accumulation of data from a series of epidemics of
the two types. The field of obseryation of any one
worker is insufficient, but if uniform data of the sex
and age of patients are systematically collected and
published reliable evidence will eventually be reached.
The problem of classification—In that particular
instance the criteria for classification of patients,
namely, age and sex, are simple ; in grouping types of
patients, given or not given a specific form of treat-
ment, the task may be very much more difficult. No
purely objective criteria may be available and
subjective factors, variable from one worker to another,
may enter in—for instance in classifying patients with
cancer or pulmonary tuberculosis to the stage of
disease. Can any system in each case be devised
which with any worker ensures that like is being put
with like, at least in. broad categories? It is often
said that it cannot be done, that particular problems
are not susceptible to statistical analysis because
patients cannot be efficiently classified before and
after treatment. It is true that there are sometimes
very serious difficulties in making such objective
classifications but these difficulties must be faced
if the problem is important. Can a clear-cut answer
be reached in any other way to the fundamental
questions ‘‘is this treatment of value, of how great
a value, and with what types of patients?” In
the large majority of cases it is dificult to see how
it can. Even if the treatment is not of general
value but of apparently great benefit in relatively
rare isolated cases, satisfactory evidence of that
must le in statistics—viz., that such recoveries
(however rare) do not occur with equal frequency
amongst equivalent persons not given that treatment.
Sooner or later the case is invariably based upon that
THE LANCET)
PRINCIPLES OF MEDICAL STATISTICS
\
[APRIL 10, 1937
kind of evidence, but in the absence of planned
trials it is often later rather than sooner. If it be
maintained merely in general terms that a particular
type of patient fares much better under such-and-
such a form of treatment, then two queries arise.
If the patient can be thus defined as of this particular
type why cannot he be classified and compared with
the patients of similar type not specifically treated ?
To reach the conclusion that he has benefited from
treatment he must have been compared at least
mentally with his untreated prototype, and the
conclusion is itself based upon statistical though
unrecorded evidence. The difficulty does not seem
to lie, in that case, in classifying (for the clinician
has done that in drawing his conclusion) but rather
in the small field of observation of any one worker
and in the lack of organised trials in the earlier
days of a form of treatment. It may of course be
said with truth that no two patients are alike in all
respects ; but if that is a logical objection to classifica-
tions it is equally a logical objection to treating any
patient on the basis of past experience. In medical
statistics, moreover, we are not usually comparing
the reactions of individuals but of broadly similar
groups of individuals, and in comparing randomly
chosen groups, or groups representative of a type,
we can reasonably presume, if the groups are fairly
large, that the distribution of unknown characters
which may influence the issue is likely to be equivalent.
(b) ASSESSMENT OF THE RESULTS OF TREATMENT
The second query that arises from our general
statement is how much better do the patients fare
under the particular form of treatment? How can
the advantage be qualitatively or quantitatively
assessed ? For that purpose the criterion of success
or failure must be defined, and clearly the more
objective it can be made the better it will be.
criterion must, of course, vary with the problem.
It is useless to use the survival-rate as an index with
a disease that has an extremely low fatality-rate.
Speed of recovery may be an appropriate test in one
case, incidence of complications in another, absence
of remission in a third, structural change in yet
another, and so on. The choice of criterion and the
way in which it is to be measured or defined are
inherent in the question at issue and an essential
part of the planning of the experiment, the clinical
trials, or whatever is under discussion. The way in
which it is to be recorded, the means of securing
uniformity if different, workers are involved, and the
steps to be taken to avoid the omission of necessary
items of information, must all enter into this plan
in its initial stages. Team-work is often requisite
and in that team I suggest (at the risk of being accused
of over-emphasising the importance of my own
subject) the medical statistician ought to be repre-
sented. His inclusion should have two advantages. He
should be able to advise on the statistical aspects of the
inquiry at its inception, and secondly, and equally
important, he will learn at the start the details of the
problem, the difficulties of solving it, and the factors
that may complicate it. If his task is only to come
in at the end, merely to make a technical analysis,
he may be faced not only with material that is not
capable of answering the questions posed but also
with material which he may imperfectly understand,
having had no previous association with it, and
therefore be liable to misinterpret.
(c) THE NUMBERS REQUIRED
Finally a question very frequently put to the
statistician relates to the size of the sample that is
The .
THE LANCET]
necessary to give a reliable result. To that there
is usually no simple answer. If two groups are to
be compared, a treated and a control group, then the
size of the sample necessary to ‘“‘ prove the case”
must depend upon the magnitude of the difference
that ensues. 3 |
If, to take a hypothetical example, the fatality-rate
(or any other selected measure) is 40 per cent. in the control
group and 20 per cent. in the treated group, then by the
ordinary test of ‘“‘ significance ” of the difference between
two proportions, that difference would be more than is
likely to occur by chance with 42 patients in each group
(taking twice the standard error as the level). In other
words, with those fatality-rates we should have to take
at least 42 patients in each group to feel at all confident
in our results. If there were 50 patients in each group and
20 died in the control group and 10 in the specially treated
group that difference is (on the criterion of “ significance ”’
adopted) more than would be likely to occur by chance.
If, on the other hand, the improvement was a
reduction of the fatality-rate from 40 to 30 per
cent. we should need at least 182 patients in each group.
If we had 200 in each group and 80 died in the
one and 60 in the other, that difference is more than
would be likely to occur by chance. Finally, if the
fatality-rate was only 4 per cent. in the control group and
2 per cent. in the treated group we should require as
many as 600 patients in each group to be able to dismiss
chance as a likely explanation. With that number in
each group there would be 24 and 12 deaths, and a
difference of this order on smaller numbers might well be
due to chance. (In such a case the fatality-rate, of course,
might not be the best measure of the advantages of the
treatment.)
The determination of the numbers required is
based, it will be noted, upon the difference observed
between the groups. In practice we often do not
know what that difference is likely to be, until at
least some trials have been made. There can be no
answer given in advance to the question “ how many
observations must be made.” Unless there is some
indication from past experience as to the kind of
difference that may result, or unless we can argue
on a priori grounds, we must confess ignorance of the
numbers required to give a convincing result.
Common Sense and Figures
Apart from these problems of the errors of sampling,
much of my discussion of the interpretation of figures
has centred, it will have been noted, not so much on
technical methods of analysis but on the application
of common sense to figures and on elementary rules
of logic. The common errors discussed in previous
sections are not due to an absence of knowledge of
specialised statistical methods or of mathematical
training, but usually to the tendency of workers to
accept figures at their face value without considering
closely the various factors influencing them— without
asking themselves at every turn ‘“‘ what is at the
back of these figures ? what factors may be responsible
for this value? in what possible ways could these
differences have arisen?” That is constantly the
crux of the matter. Group A is compared with
Group B and a difference in some characteristic is
observed. It is known that Group A differed from
Group B in one particular way—e.g., in treatment.
It is, therefore, concluded too readily that the
difference observed is the result of the treatment.
To reject that conclusion in the absence of a full
discussion of the data is not merely an example of
armchair criticism or of the unbounded scepticism
of the statistician. Where, as in all statistical work,
our results may be due to more than one influence,
there can be no excuse for ignoring that fact. And
AN ORTHOPZEDIC NURSING CERTIFICATE
[APRIL 10, 1937 885
it has been said with truth that the more anxious we
are to prove that a difference between groups is the
result of some particular action we have taken or
observed, the more exhaustive should be our search
for an alternative and equally reasonable explanation
of how that difference has arisen.
It is also clearly necessary to avoid the reaction to
statistics which leads an author to give only the
flimsiest statement of his figures on the grounds that
they are dull matters to be passed over as rapidly
as possible. They may be dull—often the fault
lies in the author rather than in his data—but if
they are cogent to the thesis that is being argued
they must inevitably be discussed fully by the author
and considered carefully by the reader. If they are
not cogent, then there is no case for producing, them
at all. In both clinical and preventive medicine,
and in much laboratory work, we cannot escape from
the conclusion that they are frequently cogent, that
many of the problems we wish to solve are statistical
and that there is no way of dealing with them except '
by the statistical method.
(ene Ope eT EEL,
A. B. H.
AN ORTHOPÆDIC NURSING
CERTIFICATE
THERE are at the present time in this country
some thirty orthopædic hospitals most of which issue
certificates of proficiency to their nursing staff
on completion of their training. These certificates
lack uniformity and offer no accepted standard when.
applications for other posts are being considered.
The Central Council for the Care of Cripples, which,
since its inauguration in 1920, has acted as a coördinat-
ing body in matters concerning the welfare of cripples,
now proposes an orthopædic nursing certificate based
on a uniform syllabus. In consultation with the
principal orthopedic hospitals a scheme for such
a certificate has been drawn up and the rules and
syllabus have been issued in pamphlet form! by
the Council. The certificate will be awarded as the
result of tests held at the end of the first and second
years of training respectively, but probationer nurses
who have passed the preliminary State examination
will be exempt from the earlier test. The first, which
includes anatomy, physiology, hygiene, and practical
nursing, both written and oral, will be taken at the
training hospital in May or November. The second
test on orthopedic conditions and their nursing will
be taken partly at the hospital, but for the practical
and oral portion examinees will generally be asked
to attend at a centre—London, Bristol, Newcastle,
or Birmingham—again in May or November. General
State-registered nurses will be allowed to sit for the
final examination at the end of one year’s training.
The entrance fee will be 10s. 6d. for the first test and
one guinea for the second. There are five ortho-
peedic surgeons on the executive committee of the
Central Council one of whom, Mr. E. S. Evans, has
acted as chairman of the subcommittee which drew
up the scheme. Dame Agnes Hunt, who is president
of the Council, expresses the hope that every ortho-
peedic hospital which offers training to probationers
will adopt the certificate, so that its possession may
be generally accepted as evidence of sound training
in the elements of orthopedic nursing. It is proposed
to hold the first examination in November, 1937.
1 From the secretary of the Council, 34, Eccleston-square,
London, S.W.1. 2d., post free.
886 THE LANCET]
SPECIAL ARTICLES
[APRIL 10, 1937
replaced and the thumb flexed. The pipette is held
MICRO-CHEMICAL METHODS OF
BLOOD ANALYSIS
By E. J. Kine, M.A., Ph.D. Toronto
READER IN PATHOLOGICAL CHEMISTRY IN THE UNIVERSITY OF
LONDON AT THE BRITISH POSTGRADUATE MEDICAL SCHOOL
G. A. D. HastEwoop, M.Sc., Ph.D. Lond.
ASSISTANT IN PATHOLOGICAL CHEMISTRY AT THE SCHOOL ;
G. E. DEetory, B.Sc. Lond.
LABORATORY ASSISTANT IN PATHOLOGICAL CHEMISTRY
AT THE SCHOOL
AND
THE methods of blood analysis here described have
proved their usefulness in research and routine
laboratory work. Some of the methods are modifica-
tions of published procedures, while others are new.
A.—PROCEDURES FOR WHOLE BLOOD
Micro-chemical methods of blood analysis are
particularly useful in investigations which require
the taking of frequent samples of blood. Determina-
tions on capillary blood, as compared with venous
blood, are less inconvenient to the patient, who
usually objects to numerous and elaborate veni-
punctures, and are less laborious for the investigator.
A puncturing apparatus or a Hagedorn needle,
together with a supply of capillary blood pipettes,
is much easier to keep and to use than a supply of
sterilised syringes and needles.
The accuracy of the micro-methods is usually
beyond question, and biochemical methods carried
out on small quantities of capillary blood have given -
at least as consistent and as accurate results as the
larger scale procedures from which they usually
sprang. The advantage of being able to omit any
anti-coagulant substance in the taking of the sample
needs no comment. The sample can be measured
in most capillary blood pipettes with a high degree
of precision ; and the possibility of obtaining abnormal
proportions of cells and plasma when sampling an
improperly mixed specimen of venous blood (a potent
source of error not often appreciated) is avoided.
The level of some substances in arterial blood is
different and of greater physiological significance
than the level in venous blood. This is notably so
in the case of glucose. Arterial blood glucose is
best estimated in capillary blood, which gives the same
value.
The micro-methods described have been developed
' primarily for use with capillary blood, but they are of
course applicable to samples of venous blood.
TAKING OF BLOOD
Blood may be taken from a puncture on the ear or
finger, but the most convenient place to obtain
capillary blood is probably from the thumb over
the bed of the nail. The part is wiped clean with a
little ether or spirit and a stab of 1 to 2 mm. deep is
made by means of a puncturing apparatus or Hagedorn
needle. A piece of soft rubber tubing or of gauze
is wrapped fairly tightly about the thumb above the
knuckle. On flexing the thumb a free flow of blood
is usually obtained. If the blood does not come
easily, the rubber is released and the hand shaken in a
downwards direction. This operation will ensure an
adequate amount of blood when the tourniquet is
horizontally with its point in the drop of blood
issuing from the stab wound. The blood is allowed
to run in exactly to the 0:2 c.cm. mark. The pipette
is then wiped, and the blood allowed to run into a
15 c.cm, conical centrifuge tube containing water
or isotonic sodium sulphate solution, and by alternate
blowing and sucking the pipette is washed several
times with the solution.
I.—Estimation of Urea in Blood
Urea represents about 50 per cent. of the non-
protein nitrogen of the blood. Normally there are
between 20 and 40 mg. of urea present per 100 c.cm.
High values are found in conditions associated with
impaired renal function—particularly in chronic
nephritis, but also in some cases of acute nephritis,
prostatic obstruction, cardiac failure, &c.*
PRINCIPLE
The sample of blood is digested with urease, and
the urea thus converted into ammonia. After
removal of proteins, the colour produced by the
ammonia with Nessler’s reagent is compared colori-
metrically with the colour produced under the same
conditions with a standard ammonium chloride
solution,
Direct nesslerisation does not lead to the production
of cloudiness in the case of protein-free filtrates from
unlaked blood. This is due to the fact that the
sulphydryl substances glutathione and ergothioniene,
which produce turbidities with Nessler’s reagent
because of the insolubility of their mercury salts,
are confined to the cells and do not appear in the
filtrate, as is the case with filtrates of laked blood.
Filtrates of unlaked blood have the further advantage
that no ammonia is contributed to the determination
through the action of the arginase of the red cells
on the arginine contained in most commercial
preparations of urease (see Addis 1928). The use of
zinc hydroxide as deproteinising reagent eliminates
a small amount of turbidity producing substance
contributed by most preparations of urease.
METHOD
0:2 c.cm. of blood is added to a centrifuge tube
containing 3-2 c.cm. of isotonic sodium sulphate
solution,
A “knife point’? (about 20 mg.) of Jack Bean meal
is added, and the whole stoppered with a rubber
bung, mixed, and incubated at 37° C. for 20 minutes.
0-3 c.cm. of zinc sulphate solution and 0:3 c.cm. of
0-5 N sodium hydroxide are added to precipitate the
proteins, and the mixture is centrifuged. 2 c.cm.
of the supernatant fluid represent 0:1 c.cm. of blood.
2 c.cm. of the clear supernatant are treated with
5 c.cm. of water and 1 c.cm. of Nessler’s reagent.
The solution is compared in a colorimeter ł with a
“ high ” or “low” standard made up with 2 c.cm.
or 5 c.cm. of the standard ammonium chloride
solution (0:01 mg. of nitrogen per c.cm.), 5 c.cm.
* No attempt is made to give a complete statement of the
amounts of the various substances present in diseased conditions
nor to discuss their significance. Brief mention is made only of
those clinical conditions in which abnormal] values are most
commonly encountered.
+A micro-colorimeter or micro-attachments (cups and
plungers) for an ordinary Duboscq are necessary for this and
other colorimetric procedures. Micro-cups and plungers can
now be obtained as interchangeable attachments for almost all
the makes of colorimeters commonly in use.
THE LANCET]
or 2 c.cm. respectively of water, and 1 c.cm. of
Nessler’s reagent. The colorimetric comparison is
facilitated by the use of a blue light filter (see section C).
CALCULATION
(1) “Low ” standard : | .
= Reading of standard , 9. 100 , 9.
Blood- | Reading of test x 0°02 x 01 x 2°14
urea * _ Reading of standard ,. 4o-g
~ Reading of test
(2) “ High ” standard :
— Reading of standard : 100 .
Reading of test ee a
Reading of standard x 107
= Reading of test
N.B.—1 mg. of nitrogen = 2°14 mg. of urea.
*mg./100 c.cm. blood.
Blood-
urea *
SOLUTIONS
Nessler’s reagent.—As described in Peters and Van
Slyke’s “Quantitative Clinical Chemistry,” Baltimore, 1932,
vol. ii, p. 532, and in Beaumont and Dodds’s ‘‘ Recent
Advances in Medicine,” 8th ed., London, 1936, p. 391.
Standard ammonium chloride solution (containing
0-01 mg. of nitrogen per c.cm.).—153 mg. of pure
ammonium chloride are weighed out and dissolved in
water. The volume is made up to 100 c.cm. 25 c.cm.
of this solution with 10 c.cm. of N sulphuric acid are
diluted to 1 litre with distilled water.
Isotonic sodium sulphate.—30 g. of crystalline sodium
sulphate (Na,SO,.10 H,O) are dissolved in water and made
to 1 litre. 7
Zine sulphate-——10 g. of crystalline zinc sulphate
(ZnSO,.7 HO) are dissolved in water and made to
100 c.cm.
II.—Estimation of Non-Protein Nitrogen
The non-protein nitrogen containing substances of
blood are urea (10-20 mg. N), uric acid (1-2 mg. N),
creatinine (0:5-1 mg. N), amino-acid nitrogen (6-8 mg.),
and substances such as glutathione and ergothioniene
(5-10 mg. N per 100 c.cm. of blood). The normal
range of non-protein nitrogen (N.P.N.) is from
25-40 mg. per 100 c.cm. Increased values are found
in the conditions showing a high blood-urea.
PRINCIPLE
The proteins of laked blood or plasma are pre-
cipitated by trichloracetic acid. Part of the filtrate
is digested with sulphuric acid until all the nitrogen
is converted into ammonium sulphate. The ammo-
nium salt is estimated colorimetrically with Nessler’s
solution ; excess of which is used for the test in order
to neutralise the sulphuric acid and give an alkaline
medium.
METHOD
0:2 c.cm. of blood (or plasma) is pipetted into
3-2 c.cm. of water or isotonic sodium sulphate solution.
Proteins are precipitated by the addition of 0:6 c.cm.
of trichloracetic acid. The tube is stoppered and
thoroughly shaken. After five minutes the mixture
is filtered.
1 c.cm. of the filtrate (=0-05 c.cm. of blood or
plasma) is evaporated in a test-tube with 0-5 c.cm,
of 30 per cent. sulphuric acid until the liquid turns
dark and white acid fumes are evolved. The cooled
liquid is then treated with 1 drop of hydrogen
peroxide (99-100 vols.), to destroy any coloured
products, and boiled for 4 minutes. To the cooled
solution are now added 5 c.cm. of water and 3 c.cm.
of Nessler’s solution. The colour produced is com-
pared in the colorimeter with the “low” or “ high ”
standard used in the determination of blood-urea,
MICRO-CHEMICAL METHODS OF BLOOD ANALYSIS
[APRIL 10, 1937 887
OALCULATION
(1) “ Low ” standard :
— Reading of standard ; 100
Reading of test ma 0°05
Reading of standard x 40
= Reading of test
(2) “ High ” standard :
~ Reading of standard ` 9.95 x 100
N.P.N.* ( Reading of test v'ud 7
peels _ Reading of standard , 19
— Reading of test
* In mg./100 c.cm. of blood or plasma.
N.P.N.*
SOLUTIONS
Nessler’s reagent, and ammonium chloride standard
as described for urea (A.I.).
Trichloracetic acid.—25 g. are dissolved in water and
made to 100 c.cm. |
30 per cent. sulphuric acid.—30 c.cm. concentrated acid
are allowed to run slowly and with shaking into about
60 c.cm. of distilled water in a 100 c.cm. volumetric flask.
The mixture is cooled to room temperature, made to the
mark, and mixed.
III.—Estimation of Uric Acid in Blood
Uric acid is normally present to the extent of
2-4 mg. per 100 c.cm. of blood. In gout and in
certain conditions of renal impairment high values
are found.
PRINCIPLE
Blood in isotonic sodium sulphate solution is treated
with a phosphotungstic acid reagent. This precipi-
tates the proteins, and on addition of sodium cyanide
to the supernatant liquid, the excess of phospho-
tungstic acid reagent produces a blue colour with
uric acid present. The colour is compared with that
given by a standard solution of uric acid. The
blood must not be laked, as interfering substances,
such as glutathione and ergothioniene, would be
liberated from the cells.
METHOD
0-2 c.cm. of capillary blood is pipetted into 3:2 ¢.cm,
of isotonic sodium sulphate in a 15 c.cm. centrifuge
tube. 0-6 c.cm. of Folin’s (1934) uric acid reagent
is added. The tube is stoppered, its contents mixed
gently by inversion, and immediately centrifuged.
2 c.cm. of the supernatant liquid (= 0:1 c.cm. of
blood) are treated with 1 c.cm. of sodium cyanide-
urea reagent. At the same time a mixture of 1 c.cm.
of the uric acid “blood” standard (=0-004 mg.
uric acid), 0-7 c.cm. of distilled water, and 0:3 c.cm.
of Folin’s reagent is treated also with 1 c.cm. of
sodium cyanide-urea reagent. The two tubes are
placed in a boiling water-bath for 5 minutes, cooled,
and the solutions compared colorimetrically.
Reading of standard , 4
™ Reading of test
*mg./100 c.cm. of blood.
CALCULATION
— Reading of standard , 9.99 100
Uric Reading of test Ne 0°
acid *
SOLUTIONS
Isotonic sodium sulphate as under blood-urea (A.I.).
Sodium cyanide-urea reagent.—5 g. of sodium cyanide
and 20 g. of urea are dissolved in water, and the volume
made to 100 c.cm. The urea prevents clouding during
the determination.
Folin’s (1934) uric acid reagent.—(1) Preparation of
molybdate-free sodium tungstate: a solution of 250 g.
of sodium tungstate in 500 c.cm. of water is treated with
5 N hydrochloric acid until neutral to litmus paper. The
888 THE LANCET]
solution is saturated with hydrogen sulphide, and allowed
to stand 24 hours. It is then treated with 400 c.cm. of
absolute alcohol, added gradually with constant shaking.
The mixture, after standing for a further 24 hours, is
filtered, and the precipitate washed with 50 per cent.
alcohol and dissolved in 375 c.cm. of water. 0-5 c.cm.
of bromine is added, and the mixture boiled gently until
the excess bromine is dispelled. Sodium hydroxide
solution (40 g. per 100 c.cm.) is now added to the hot
solution until the latter is alkaline to phenolphthalein.
The cooled solution, filtered if necessary, is treated with
200 c.cm. of absolute alcohol, and allowed to stand for
24 hours. The white crystals are filtered off and dried
in a desiccator.
(2) Preparation of reagent: 100 g. of molybdate-free
sodium tungstate are treated gradually with a solution
of 30 c.cm. of “‘syrupy’”’ phosphoric acid (89 per cent.)
in 150 c.cm. of water. The mixture is boiled gently
under reflux for 1 hour, decolorised as above with a drop
of bromine, cooled and diluted to 500 c.cm.
Stock uric acid standard (Folin) (= 1 mg. per ¢c.cm.).—
1 g. of uric acid is placed in a 1-litre flask. 0-6 g. of lithium
carbonate is dissolved in 150 c.cm. of cold water. The
carbonate solution, filtered if necessary and warmed to
60° C., is added to the flask containing the uric acid, which
is warmed under the hot tap. The warm mixture is
shaken for five minutes, cooled at once under the tap, and
treated with 20 c.cm. of formalin (40 per cent. solution
of formaldehyde) and enough water to fill half the flask.
A few drops of methyl-orange are added, and then gradually
with shaking, 25 c.cm. of N sulphuric acid. The solution
should turn pink when 2-3 c.cm. of acid remain to be
added. The mixture is now diluted to 1 litre, mixed and
stored in the dark in a stoppered bottle, when it will
keep almost indefinitely.
Uric acid “ blood ” standard (= 0-004 mg. per c.cm.).—
2 c.cm. of the above “stock” standard solution are
diluted with water and 1 c.cm. of 40 per cent. formalin
to 500 c.cm. This solution should be made up fortnightly.
IV.—Creatinine in Blood =
PRINCIPLE
Creatinine gives a red colour with alkaline E
of picric acid (Jaffé’s reaction). A similar colour is
also given by blood (and plasma) filtrates. It is
not certain that the colour in this case is due to
creatinine, but the substance which may thus be
estimated as blood “ creatinine ” is of some clinical
importance. Calculated as “‘ creatinine’? the normal
values are 1—2 mg. per 100 c.cm. of blood. In advanced
renal failure enhanced values may be found.
METHOD
0-2 c.cm. of blood is added to 1-4 c.cm. of isotonic
sodium sulphate solution. 0-2 c.cm. of zine sulphate
solution and 0:2 c.cm. of 0:5 N sodium hydroxide
are added, and the tube is stoppered and shaken.
The mixture is centrifuged, and 1 c.cm. of the clear
supernatant fluid (=0-1 c.cm. of blood) is used as
‘“ test’? solution (see Somogyi 1930).
For normal blood a “‘ standard ” solution is made
by diluting 1 c.cm. of the creatinine ‘“ blood”
standard described below, with 4. c.cm. of water.
The ‘test’? solution and 1 c.cm. (=0-001 mg. of
creatinine) of this ‘‘standard”’ solution are then
treated at the same time with 0-5 c.cm. of freshly
‘made alkaline picrate solution (see below). After
not more than 15 minutes the solutions are compared
in the colorimeter, using a blue-green light filter, such
as Ilford’s spectrum blue-green (see section C).
CALCULATION
Reading of standard 100
Blood Reading of test eae STs | vI
“ creatinine ” * Reading of standard , 1.9
= Reading of test
* mg. per 100 c.cm. blood.
MICRO-CHEMICAL METHODS OF BLOOD ANALYSIS
[APR 10, 1937
In cases where a raised blood “ creatinine ” is found or
expected, stronger. ‘‘ standards ” may be made by using
larger quantities of the ‘‘ blood standard,” and diluting
these as before to 5 c.cm. with water. In general the
calculation becomes :—
Blood — Reading of standard x 0:001 x 199. 100
“ creatinine ” J Reading of test Eis : OL
where C is the number of c.cm. of “‘ blood ” standard used
in the 5 c.cm. of ‘‘ standard ” solution.
Preparation of solutions.—Isotonic sodium sulphate,
10 per cent. zinc sulphate, and 0:5 N sodium hydroxide
as under blood-urea (A.I.).
Creatinine ‘‘ stock” standard (containing 1 mg. of
creatinine per c.cm.).—1-602 g. of pure creatinine zinc
chloride are dissolved in N/1Q hydrochloric acid solution,
and the volume made up with the N/10 acid to 1 litre.
Creatinine “blood ”’ standard (0-005 mg. per c.cm.).—
5 c.cm. of the above ‘stock ” standard are treated with
10 c.cm. of N/10 hydrochloric acid and the volume made
up with water to 1 litre.
Alkaline picrate solution.—Five parts (by volume) of
a saturated aqueous solution of pure picric acid, contain-
ing about 15 g. picric acid per litre, are mixed with 1 part
(by volume) of 10 per cent. sodium hydroxide.
Note.—The picric acid may be purified by recrystallisa-
tion from glacial acetic acid. It must be of such purity
that when 10 c.cm. of a saturated aqueous solution are
treated with 5 c.cm. of the 10 per cent. hydroxide, the
colour (determined in the colorimeter) of the alkaline
mixture so formed is not more than twice as deep as that
of the saturated picric acid solution.
V.—Inorganic Phosphate
The blood of normal adult persons contains 2-3 mg.
per 100 c.cm. (expressed as P) of inorganic phosphate.
In conditions involving an acidosis, such as is often
found in nephritis, the amount present may be
definitely raised. The amount of phosphate present
in the blood of children, where bone formation is not
yet complete, is at a higher level—usually of about
5 mg. per 100 c.cm. In rachitic conditions the figure
is lowered.
PRINCIPLE
The inorganic phosphate of a deproteinised filtrate
of the blood is coupled with molybdate, and the
yellow phospho-molybdate is reduced to give a blue
substance. The amount of blue colour produced
in the solution is directly proportional to the amount
of phosphate present.
_ METHOD
0:2 c.cm. of whole blood or plasma is pipetted
into 3-2 c.cm. of water or isotonic sodium sulphate
and treated with 0-6 c.cm. of 25 per cent. trichlor-
acetic acid. The mixture is shaken well, and after
5 minutes filtered through a small paper. 2 c.cm.
of the clear filtrate (= 0-1 c.cm. of blood or plasma)
are treated at the same time as 2 c.cm. of the dilute
standard phosphate solution (=0-004 mg. P) with
0-3 c.cm. of the ammonium molybdate solution
followed by 0:2 c.cm. of the reducing agent (amino-
naphtholsulphonic acid). The contents of the tubes
are gently shaken between each addition, and the
colours are read after 10 minutes in a colorimeter
(King 1932). ,
CALCULATION
— Reading of standard 100
= Reading of test x D00 X TI 01
$
Blood phosphate”) _ Reading of standard „ 4
~ Reading of test
*mg. P/100 c.cm. of blood.
SOLUTIONS
Trichloracetic acid solution.—As under non-protein
nitrogen (A.II.).
Ammonium molybdate.—5 g. of ammonium molybdate
are added to a mixture of 75 c.cm. distilled water and
THE LANCET]
MICRO-CHEMICAL METHODS OF BLOOD ANALYSIS
[APR 10, 1937 889
15 c.cm. of concentrated sulphuric acid in a 100 c.cm.
volumetric flask. The mixture is shaken until dissolution
is complete, and cooled to room temperature. The
solution is then made up to 100 c.cm. and mixed.
Reducing agent.—0-2 per cent. aminonaphtholsulphonic
acid. 0:2 g. of the 1:2:4-acid, 12 g. sodium metabi-
sulphite, and 2-4 g. crystalline sodium sulphite are dissolved
by shaking with enough water to make 100 ¢.cm. If the
solution does not filter clear it should be left overnight
and filtered again. A fresh solution should be prepared
every two weeks.
Standard phosphate—A stock solution is made by
dissolving 2-194 g. of pure potassium dihydrogen phosphate
(KH,PO,) in 500 c.cm. in water. This solution contains
l mg. P per ccm. A dilute standard solution is made
by diluting 2 c.cm. of the stock solution to 1 litre with water.
1 c.cm. of this solution contains 0-002 mg. P. Both
solutions should be kept saturated with chloroform to
prevent any bacterial growth, which might cause a loss
of inorganic phosphate,
VI.—Cholesterol in Blood
Total cholesterol in the blood of normal persons
may be present in amounts varying from 120 to
230 mg. per 100 c.cm. The amounts present in blood
may be raised in severe diabetes, biliary obstruction,
and in some forms of nephritis (particularly the
nephrotic type). Low values are found in severe
anemia.
The method recommended is that described in
detail by Sackett (1925).
VII .—Glucose
Harding’s (1932, 1933) modification of the Schaffer
Hartmann method. This method gives “‘ true sugar
values ” as opposed to total reducing substances
when applied to filtrates of unlaked blood.
PRINCIPLE
The “sugar” in whole blood is a mixture of
glucose, present mainly in the plasma, and nitrogenous
reducing compounds (chiefly glutathione) in the
corpuscles. It is possible to exclude the corpuscles
by mixing the blood with isotonic sodium sulphate
solution, in which the corpuscles remain intact.
A determination of the reducing power then becomes
equivalent to an estimation of glucose alone. For
normal (fasting) individuals values of 65-90 mg.
per 100 c.cm. are found,
METHOD
0-2 c.cm. of blood is added to 3-2 c.cm. of isotonic
sodium sulphate. After 4 minutes’ standing to
allow diffusion from the cells, 0:3 c.cm. of zinc sulphate
solution and of 0-5 N sodium hydroxide are added. tf
The mixture is shaken and then centrifuged.
2 c.cm. of the supernatant liquid (=0:1 c.cm.
of blood) are treated with 2 c.cm. of the mixed
copper reagent in a wide (# in.) test-tube. A
“ blank ” is prepared with 2 c.cm. of distilled water
and 2 c.cm. of reagent. Both tubes, stoppered lightly
with cotton-wool, are placed in a boiling water bath
for exactly 10 minutes.. They are then cooled at
once under the tap. To each is added 2 c.cm. of
1 per cent. potassium iodide and 2 c.cm. of N sulphuric
acid. After standing 1 minute the contents of each
tube are titrated with N/200 sodium thiosulphate.
One per cent. soluble starch (made up in water or,
better, in saturated phenol red solution) is used as
indicator. The titration figure of the test solution
is subtracted from that of the “ blank.”
ł If the sugar determination cannot be made immediately, it
is advisable to keep the blood in an isotonic sodium sulphate
containing fluoride and thymol—see solutions.
CALCULATION
1 c.cm. N/200 thiosulphate = 0°116 mg. glucose.
The c.cm. of thiosulphate given by the difference
between the “‘ blank” and ‘‘ test ” titrations is equivalent
to the amount of glucose present in the ‘‘ test.’ Hence—
c.cm. N/200 thiosulphate x 0°116=mg. glucose in 2 c.cm.
filtrate (i.e., in 0°1 c.cm. blood).
And, therefore—
c.cm. N/200 thiosulphate
x 0'116 x 100
ol
i.e., c.cm. of N/200 thio
sulphate x 116
\ = mg. of glucose/100 c.cm. blood.
B: = mg. of glucose/100 c.cm. blood.
If the blood-sugar value thus obtained is greater than
400 mg./100 c.cm., the determination should be repeated,
using as test solution a mixture of 1 c.cm. of filtrate and
l c.cm. of water. The result then obtained is multiplied
by 2.
SOLUTIONS
Isotonic sodium sulphate containing fluoride and thymol
to prevent glycolysis—100 mg. of sodium fluoride and
10 mg. of thymol are dissolved in 100 c.cm. of the 3 per
cent. sodium sulphate. 10 per cent. zinc sulphate; and
0:5 N sodium hydroxide as for blood-urea (A.I.).
Copper reagent.—Solution A: 13 g. copper sulphate
crystals are dissolved in water and the volume made up to
1 litre.
Solution B is made by dissolving: 24 g. rochelle salt
(sodium potassium tartrate), 40 g. anhydrous sodium
carbonate, 50 g. sodium bicarbonate, 36°8 g. potassium
oxalate, and exactly 1-4 g. potassium iodate separately
in the minimum quantities of water at room temperature.
The solutions are then mixed and the volume made up to
1 litre,
The ‘‘ copper reagent ” is a freshly made mixture of
exactly equal volumes of solutions A and B.
Note.—Only purest analytical chemicals should be
used in making up the above reagent. When preparing a
fresh copper reagent, it is advisable to check it against
a solution of pure glucose.
B.—PROCEDURES FOR PLASMA
I.—Plasma Proteins
The total quantity of protein in blood plasma
varies in normal individuals from approximately
6 to 8 g. per 100 c.cm. Plasma protein is divided
into two main fractions: globulin and albumin.
Globulin includes fibrinogen. Normally the approxi-
mate amounts of the proteins in plasma are albumin
3-4-6-0 g. per 100 c.cm.; globulin (excluding
fibrinogen) 1-5-3:0 g. per 100 c.cm.; fibrinogen
0-2-0-4 g. per 100 c.cm. Where there is decrease of
plasma protein—e.g., through proteinuria or mal-
nutrition—the albumin is chiefly affected, and there
is often av reduction of the albumin-globulin ratio
(normally 1-3-4:0). A reduction of this kind is
characteristic of nephrosis. An increase in the
globulin, especially fibrinogen, may accompany
inflammatory conditions.
PRINCIPLE
Oxalated plasma diluted with isotonic sodium
chloride is used for estimation of total protein.
Another portion of the diluted plasma is treated with
calcium chloride, and the fibrin clot removed. A
further (fresh) sample of plasma is treated with
saturated sodium sulphate solution, which precipitates
the “ globulin,” and the filtrate is used for estimation
of “albumin.” For total protein, and “ albumin,’
the protein is precipitated with zinc sulphate and
sodium hydroxide, the precipitates and the fibrin
clot being then digested with sulphuric acid and
hydrogen peroxide. The protein nitrogen is estimated
1
890 THE LANCET]
MICRO-CHEMICAL METHODS OF BLOOD ANALYSIS
[arri 10, 1937
colorimetrically, as ammonium sulphate, with Nessler’s
solution. The nitrogen figures multiplied by 6-25
give the approximate protein values, which are
expressed as grammes per 100 c.cm. of plasma.
METHOD
(A) Total protein.—o-2 c.cm. of plasma (from
oxalated blood) in a 10 c.cm. volumetric flask is
diluted to 10 c.cm. with isotonic (0-9 g. per 100 c.cm.)
sodium chloride. 0:2 ccm. of this solution
(= 0-004 c.cm. of plasma) is pipetted into 4 c.cm.
of water in a Pyrex centrifuge tube. 0-1 c.cm. of
zinc sulphate and 0:1 c.cm. of 0:5 N sodium hydroxide
are added with mixing, and the precipitate is centri-
fuged down.
When the supernatant liquid has been carefully
decanted, the inverted tube is drained on a filter
paper. 0-5 c.cm. of 30 per cent. sulphuric acid is
added, together with a small piece of porous pot.
The mixture is gently boiled until blackening occurs
and white acid fumes appear. One drop of hydrogen
peroxide (99-100 vols.) is added to the cooled solution,
and boiling continued for 4 minutes. To the cold
colourless solution are added 5 c.cm. of water and
3 c.cm, of Nessler’s solution. The colour is compared
with a standard prepared from 5 c.cm. of the standard
ammonium chloride solution (containing 0:01 mg.
of nitrogen per c.cm.), 2 c.cm. of water, and 1 c.cm.
of Nessler’s solution.
CALCULATION
Reading of standard ; 00
Reading of test ue x04
Reading of standard 5 ;
= Reading olte? a0
* g./100 c.cm. of plasma.
(B) Fibrin.—To another 5 c.cm. (=0-°1 c.cm. of
plasma) of the solution of plasma in isotonic sodium
chloride, placed in a narrow tube, is added 0-1 c.cm.
of calcium chloride solution. The mixture is kept
at 37° C. until clotting occurs. The fibrin is carefully
collected on a thin glass rod, pressed to remove
liquid, washed with water, and dropped into a test-
tube for digestion. This, and also the colorimetric
estimation, is carried out exactly as in the case of
total protein.
6°25
1000
Total
protein (A) *
CALCULATION
` — Reading of standard . 100 6'25
Í Reading of test x 0°05 X eT * FOUN
Fibri .
rin (B) | _ Reading of standard ~ 005 x 6'25
— Reading of test
* ¢./100 c.cm. of plasma.
(C) “ Albumin.” —0-2 c.cm. of plasma is placed
in a 5 c.cm. volumetric flask. The volume is made
up to 5 c.cm. with a saturated solution `of sodium
sulphate. The mixture is kept at 37°C. for 3 hours
and is then filtered through a fine filter paper.
0-2 c.cm. of the filtrate (Œ= 0-008 c.cm. of plasma)
-is placed in 4 c.cm. of water in a Pyrex centrifuge
tube and the protein precipitated with zinc sulphate
and sodium hydroxide, drained, digested, and
estimated as ammonium sulphate exactly as in the
case of total protein,
CALCULATION
í = Reading of standard , 9.9, x 100 6°25
“ Albumin ”’ í Reading of test O'UUR 1000
(
C) * Reading of standard 29 .
| = Reading of test eee eee
D-* = Total protein — fibrin + “albumin ”
“ globulin ” | = A — (B + O0)
* g./100 c.cm. of plasma.
Note.—A blue filter may be used with advantage in
this colorimetric comparison (see section C).
SOLUTIONS
Thirty per cent. sulphuric acid, Nessler’s reagent, and
standard ammonium chloride as for urea and non-protein
nitrogen (A, I. and II.). .
Calcium chloride.—2:-5 g. per 100 c.cm. in water.
Saturated sodium sulphate.—22-2 g. of anhydrous sodium
sulphate (Na,SO,) dissolved in warm water and made to
100 c.cm. The solution is kept at about 37° C.
II.—Bilirubin ©
Normal blood contains small amounts of the yellow
pigment bilirubin.§ These quantities may be greatly
increased in various types of jaundice.
PRINCIPLE
The plasma is treated with diazotised sulphanilic
acid, with the addition of ammonium sulphate and
alcohol] to precipitate the protein. The red colour
produced was originally compared colorimetrically
against a standard solution of bilirubin, treated with
diazotised sulphanilic acid. This is, however,
difficult to obtain pure, and various artificial ‘‘ per-
‘manent standards’’ have been devised. The most
satisfactory is that containing methyl-red (o0-carboxy-
benzene-azo-dimethylaniline—2-9 mg. per litre at
pH 4-63) in sodium acetate buffer. The colour of
this solution accurately matches the colour obtained
when 0-1 mg. of bilirubin is treated with the diazo
reagent in a final volume of 25 c.cm.
METHOD
1 c.cm, of plasma is treated in a centrifuge tube with
0-5 c.cm. of diazo reagent ||, 0:5 c.cm. of saturated
ammonium sulphate, and finally 3 c.cm. of absolute
ethyl alcohol. The mixture is stoppered, thoroughly
mixed, allowed to stand for a few minutes, and filtered.
Under these conditions the dilution of the plasma
closely approximates to 1 in 4, allowance being made
for the volume of the precipitate and for the change
in volume when alcohol is added to water. The
colour of the clear filtrate is compared with the
standard mentioned above (= 0-1 mg. of bilirubin
in a volume of 25 c.cm.) (Haslewood and King 1937).
CALCULATION
- _ Reading of standard , y., , 4 , 100
EE 3 ; x 0I x= x
Reading of test : 25 1
_ Reading of standard ,, 4.6
Reading of test
*mg./100 c.cm. plasma.
It is frequently found that brownish or purplish tints
produced in the reaction make colorimetric comparison
with the artificial standard difficult. These extraneous
colours (probably due to traces of substances other than
bilirubin which react with the diazo reagent) may be
eliminated by the use of a coloured light filter (see
section C).
The green filter (Ilford spectral green } in. diameter is
an appropriate type) is placed over the eye-piece of the
colorimeter and the reading made against the artificial
standard. The adjustment is then made in a green
field whose two halves are of exactly the same quality
of colour, and differ only in intensity. The reading is
taken in the usual way.
SOLUTIONS
Stock standard methyl-red solution.—0-29 g. of pure
methyl-red is dissolved in glacial acetic acid and the
volume made to 100 c.cm.
Bilirubin *
§ There is no generally accepted range of norma] values for
blood bilirubin. Research in progress suggests that the normal
values determined by this method fall within the range 0'1 to
1°3 mg. per 100 c.cm. of Paonia, with the majority of the values
within the limits 0:3 to 0:8 (Vaughan and Haslewood 1937).
il If the diazo reagent is carefully ‘‘layered’’ above the
plasma, and the tube allowed to stand for a few moments, a
positive “ direct ’’ reaction (if present) may be seen at the liquid
junction.
: ld
THE LANCET]
MICRO-CHEMICAL METHODS OF BLOOD ANALYSIS
[APRIL 10, 1937 891
a Ne
Methyl-red standard (2:9 mg. per litre at pH 4-63).—
1 c.cm. of the above standard is placed in a litre flask,
together with 5 c.cm. of glacial acetic acid. Water is
added, and 14:4 g. of crystallised sodium acetate are washed
into the flask. When dissolution is complete, the volume
is made to 1l litre with water.
The diazo reagent.—This is made by mixing two solutions
A and B.
Solution A is made by dissolving 1 g. of sulphanilic
acid in 250 c.cm. of N hydrochloric acid, and making the
volume to 1 litre with water.
Solution B contains 0:5 g. of sodium nitrite in 100 c.cm.
of aqueous solution. ;
The diazo reagent mentioned above is made freshly
before use by mixing 0°3 c.cm. of solution B with 10 c.cm.
of solution A.
III.—Plasma Phosphatase
PRINCIPLE
The estimation of phosphatase depends upon
measuring the amount of hydrolysis which takes
place when the enzyme is allowed to act on a suitable
substrate—an ester of phosphoric acid (such as
phenyl phosphate) under standard condition. The
amount of phosphate or phenol so liberated may be
taken as the measure of the amount of enzyme
present. The phenol is more conveniently determined
than the phosphate, and three times as much phenol
as phosphorus is set free. The hydrolysis is carried
out at the optimum pH of 10 for 15 minutes. The
results thus obtained agree very closely with those of
the method of King and Armstrong (1934), of which
this is a modification,.and with the method of Jenner
and Kay (1932). The results are expressed in arbitrary
“ units ” of phosphatase activity.
the blood of normal individuals contains 5-10 units
per 100 c.cm. of plasma. Great increases are found
in cases of generalised bone disease and obstructive
jaundice. Infective and toxic jaundice show smaller
increases.
METHOD
Test—In a conical centrifuge tube are placed
4 c.cm. of buffer ‘substrate. The tube is allowed
to remain in a water-bath at 37°C. for 5 minutes.
Without removal of the tube from the bath, exactly
0-2 c.cm. of plasma (which must be cell-free) is
added and mixed. The stoppered tube is allowed
to remain in the bath exactly 15 minutes. At the
end of this time 1-8 c.cm. of dilute phenol reagent
are added and the mixture centrifuged or filtered.
Control.—In another tube are placed 4 c.cm. of
buffer substrate. 0:2 c.cm. of plasma, and at once
1-8 c.cm. of dilute phenol reagent are added, and the
mixture centrifuged or filtered.
4 c.cm., of filtrate from the test and control solutions
are pipetted into test-tubes. 1 c.cm. of 20 per cent.
sodium carbonate is added, and the tubes replaced
in the water-bath for 5 minutes to bring up the
colour.
Comparison.—The solutions are compared in the
colorimeter with a standard made up at the same time
by taking 4 c.cm. of standard-phenol-solution-and-
reagent and 1 c.cm. of 20 per cent. sodium carbonate.
The tested solution is placed on the left-hand side
of the colorimeter and set at 30 mm. The standard
is placed on the right-hand side and the colours
matched. The use of an orange or red filter will be
found to increase the ease of colorimetric comparison,
particularly with weak solutions (see section C).
CALCULATION
The phosphatase activity of a plasma is expressed as
units per 100 c.cm. and is numerically equal to the mg.
of phenol which would be set free from the phenyl
By this method
phosphate under the standard conditions by 100 c.cm.
of plasma. Thus :— l
Units of phosphatase per 100 c.cm. =
mg. phenol per 100 c.om. ° mg. phenol per 100 c.cm.
plasma in test TAVIEN plasma in control.
The number of mg. phenol in 100 c.cm. of plasma in
the test and in the control is found by the equation :—
Reading of standard 6 , 100 -
“Reading of “ teat” x strength of standard x A x 02
With the unknown solution set at 30 mm. and the
strength of standard = 0:04 mg. this equation can
eee tandard 6 100 |
Reading of standar . 6 100
Dan x O04 XX Ta
All figures in the above equation cancel out, making
it equal to “ Reading of Standard.”
More simply then :—
Units of phosphatase per 100 c.cm. =
Reading of standard , Reading of standard
against the test MANUS against the control.
SOLUTIONS
1. Buffer substrate—M/200 phenyl phosphate in M/20
sodium carbonate—M/20 bicarbonate buffer. 1:09 g.
di-sodium phenylphosphate, 5:3 g. anhydrous sodium
carbonate, and 4:2 g. sodium bicarbonate are dissolved
in water and made to 1 litre. The mixture is preserved
in a well-stoppered bottle with a few drops of chloroform,
and kept in the ice-chest when not in use.
2. Phenol reagent of Folin and Ciocalteau.—As described
in Peters and Van Slyke’s ‘ Quantitative Clinical
Chemistry,” vol. ii, p. 665, and Beaumont and Dodds’s
“ Recent Advances in Medicine,” 8th ed., p. 403. This
reagent is diluted 1 in 3.
3. 20 per cent. sodium carbonate (w/v).—20 g. of
anhydrous sodium carbonate are dissolved in warm water
and made to 100 c.cm. This solution is preserved in a
warm place, otherwise the sodium carbonate tends to
crystallise out.
4. Stock standard phenol (100 mg. per 100 c.cm.).—
1 g. pure crystalline phenol is dissolved in, and made
up to 1 litre with 0-1 N HCl.
5. Diluted stock standard phenol (10 mg. per 100 c.cm.).—
Made by a suitable dilution of (4). (This keeps for at
least three months in the ice-box.)
6. Standard-phenol-solution-and-reagent (1 mg. phenol
per 100 c.cm.).—5 c.cm. of diluted stock standard (10 mg.
per 100 c.cm.) and 15c.cm. diluted phenol reagent are made
up with water to 50 c.cm. This solution should be made
freshly for use, but will keep several days if preserved in
the ice-chest.
IV.—Plasma Chloride
The blood plasma of normal persons contains from
560-620 mg. of chlorides (per 100 c.cm. expressed
as NaCl). A decreased plasma chloride may occur
in febrile conditions, particularly pneumonia, Addi-
son’s disease, and in cases of gastro-intestinal dis-
turbances associated with vomiting or with diarrhea.
PRINCIPLE
The method is based on the reaction
NaCl + AglIO,->AgCl + NalIO,
Silver iodate in ammoniacal solution is added to the
deproteinised filtrate of blood or plasma. The
excess of silver iodate, together with the silver
chloride formed, is precipitated by the addition of
acid, leaving in solution an amount of soluble iodate
equivalent to the amount of chloride originally
present. After the addition of potassium iodide,
the amount of iodine set free from this soluble iodate
is determined by titration with thiosulphate.
METHOD
0-2 c.cm. of plasma is added to 1 c.cm. of water.
0-4 c.cm. of zine sulphate solution and 0-4 c.cm. of
0-5 .N sodium hydroxide are added and thoroughly
mixed, The mixture is then centrifuged. 1 c.cm.
892 THE LANCET]
of the supernatant liquid (= 0-1 c.cm. of plasma) is
treated with silver iodate reagent (0:5 c.cm.) and,
after mixing, with 2 N sulphuric acid (0-5 c.cm.).
The mixture is shaken and filtered through a small
fine paper. 1c.cm. of filtrate (= 0-05 c.cm. of plasma),
with the addition of 1 c.cm. of 1 per cent. potassium
iodide, is titrated with 0-005 N sodium thiosulphate,
with starch as indicator (Haslewood and King
1999);
CALCULATION
Chloride (as mg. NaCl/100 c.cm. of blood) = 97:5 x titre.
SOLUTIONS
Preparation of silver iodate reagent.—Silver iodate is
prepared by mixing equimolecular solutions of silver
nitrate and potassium iodate. The precipitate is filtered,
washed with distilled water, dried in vacuo, and preserved
inthe dark. 2g. ofthe dried solid are dissolved in 100 c.cm.
N ammonia. Both silver iodate and its ammoniacal
solution appear to decompose slightly when kept, with
liberation of soluble iodate. Immediately before a
series of determinations, therefore, 5 c.cm. of the stock
(2 per cent.) ammoniacal silver iodate are acidified with
2 N sulphuric acid (5 c.cm.) and centrifuged. The
supernatant fluid is discarded and the iodate redissolved
in 5 c.cm. of fresh N ammonia.
C.—PHOTOMETRIC MEASUREMENT WITH
THE ORDINARY COLORIMETER
Photometric measurement of the intensity of
colour in a solution is preferable, for analytical
purposes, to colori-
metric comparison
with standard solu-
tions. More accu-
rate measurement
of the colour is
possible, and inter-
ference by extrane-
ous colours—a
source of frequent
trouble in colori-
metry—can be
avoided. Photo-
meters are, how-
ever, expensive,
and most labora-
tories are already
equipped with
colorimeters of the
Duboscq type. By
the use of light
filters and neutral
grey screens it is
possible to make
photometric
measurements
with the ordinary
Duboscq colori-
meter. By placing
the light filter on
A—>500mu 600 700
\ YELLOW
A [Lf | [sca
AT ROR
SOLUTION
a
COLORIMETRIC READING (nm) OF SOLUTION
N
O
20
Y
3z s $ 8 Š D & the top of the eye-
S SSÜ piece, and using
9 $ daylight or arti-
X > ficial illumination,
E curves of standard
solutions (neutral grey screens,
spectral filters). Yellow solu- T The spectra) filters
tion : nesslerised ammonium of Messrs. Ilford Ltd.
chloride solution (strong urea are appropriate for the
standard) ; neutral screen, purpose. A set of 8
density 0°75. Red_ solution: gelatin spectral filters,
bilirubin standard, 0'l mg. in mounted in glass (grade
25 c.cm. (Haslewood and King “A?” glass, 2 in. di-
1937); neutral screen, density ameter, is suitable),
0°50. ‘Blue solution: uric acid can be obtained
covering the visible
standard ; neutral screen, density
0°50. spectrum.
MICRO-CHEMICAL METHODS OF BLOOD ANALYSIS
‘Read. of test against grey screen
` Haslewood,G.A.D.
[APRIL 10, 1937
virtually monochromatic light is obtained. Neutral
grey screens serve as standards of light absorp-
tion.** The neutral screen is placed on the
left-hand rack of the colorimeter, and the rack
screwed up till the screen is against the bottom
of the plunger. The coloured solution is placed in the
right-hand cup and its depth is adjusted until
the two fields appear equal, This depth gives the
measure of the light absorbed by the solution, which
is equal to that absorbed by the neutral grey screen.
The absorption will vary for lights of different wave-
length as given by the different filters. With the
filter showing maximum absorption the reading
(millimeters of solution) will be minimum; and
the depths of two different solutions of the same
coloured substance should be in inverse ratio to
the strengths of the solutions. Generally speaking
absorption will be found to be maximum for red
solutions in the green or blue-green, and conversely,
green solutions will show maximum absorption in the
red. Blue and violet solutions are maximally absorb-
ing in the yellow, orange, and red; and yellow
and orange solutions in the blue and violet.
The grey screen of an appropriate density, together
with the light filter showing maximum absorption,
may be used as a permanent standard for any colori-
metric method. It should be calibrated against
the coloured solution of known strength—the
“ standard ”? ; and the general equation for calculating
the result for an unknown solution—the “*‘ test ”—
then becomes :—
Read. of std. against grey screen
x Conc. of std. = Conc. of test.
When comparison of an unknown solution with a
known standard of the same substance is made,
using the light filter showing maximum absorption,
the accuracy of matching is increased; and inter-
ference by other contaminating colours is minimised
because they are not maximally absorbing for light
of the wave-length being used.
REFERENCES
Addis, T. (1928) Proc. Soc. exp. Biol. Pe ea 25, 365.
Folin. O. (1934) J. biol. Chem. 106,
11.
Harding. V.J., and Downs, C. E. (1933) Ibid, 101, 487.
— Nicholson, T. F. Grant, G. A., Hern, G. and Downs,
C. E. (1932) "Trans. R. Soc. Canad. 3rd series, 26 (v), 33.
„and King, e: J. (1937) Biochem. J.31,in press.
a 936) Ibid, 30, a
o H. D., and Kay, H. D. (1932) Brit. J. exp. Path. 13,22.
King, E. J. (1932) Biochem. J. 26, 292.
— and Armstrong, A. R. (1934) Canad. med. Ass. J. 31, 376.
Sackett, ee E. (1925) J. viol. Chem. 64, 203.
Somogyi, M. (1930) Ibid, 87, 339.
Vaughan, J., and Haslewood, G. A. D. (1937) to be published.
** For example, Ilford neutral grey screens of 0°25, 0°50,
and 0°75 aeaee These should also be obtained mounted
in glass (grade ‘‘ A ”); 1 in. is the most suitable diameter.
WEMBLEY HosPITAL.—The demands upon this
institution are very heavy and ever increasing, and an
extension scheme has been prepared which will cost
£28,000. A nurses’ home and more accommodation
for women and children will be provided.
WOMEN IN SovIET Russta.—The central] statistical
department of the State Planning Commission of the
U.S.S.R. announces that in 1936 the number of women
employed at the factories, in agriculture, transport,
trade, public catering, health protection, education, &c.,
was 8,492,000, forming 34 per cent. of the total number
of employed workers. There were 15,338 women scientific
workers and 42,353 women doctors—a little less than
half the total doctors in the country. The number of
welfare centres for mothers and infants grew from 2475
in 1928 to 3945 in 1936, and during the same period
the number of maternity beds increased from 32,773
to 48,250.
THE LANCET]
SPECIAL UNITS OF THE L.C.C. HOSPITAL SERVICE
x
[APRIL 10, 1937 893
SPECIAL UNITS OF THE L.C.C.
HOSPITAL SERVICE
A FEATURE of the hospital organisation of the
London County Council is the segregation of certain
types of cases requiring special treatment, so as to
allow of this treatment being under the control of
teams of consultants skilled in the various specialties.
The advantages are obvious:
results in a large number of cases is clearly of more
value when these are under unit control, with
accessory factors, such as nursing personnel, kept
constant; multiplication of consultants and of.
equipment is avoided; and the reservation of a
number of beds in one hospital for the same type
of case enables the resident staff, both medical and
nursing, to become specially skilful in its treatment.
Brief accounts of the work of these special units
during the past year may be read in the Annual
Report of the London County Council, 1935 (Vol. IV,
Part ITI, Public Health—Medical Supplement to the
Report of the Hospital Services !),
The puerperal fever unit at the North-Western
Hospital was in the charge of Dr. A. Joe, with Dr.
Hilda Davis as assistant medical officer and Dr.
J. M. Wyatt as consultant obstetrician; 184 cases
were treated during the year, of which 156 were of
uterine sepsis and associated complications with
11 deaths; the fatal cases are subjected to detailed
analysis. Urinary infections complicated 42 out of
_ the 156 cases of uterine sepsis. Towards the latter
part of 1935 5 cases of B. colt infection were treated
with mandelic acid when they had passed the acute
febrile stage; in all the urine became sterile after a
period of between 7 and 17 days.
A report on the radium centre for carcinoma of
the uterus at the Lambeth Hospital supplies a very
detailed table showing the cases of carcinoma of the.
cervix or corpus treated during each year from 1928
to 1934, divided into stages and differentiated between
those confirmed histologically and those not confirmed.
This table and the comments on propaganda on
p. 92 merit serious attention. The gynecological
surgeon to this centre is Mr. Arnold Walker, with
Sir Comyns Berkeley as consulting gynecological
surgeon. —
Mr. George Stebbing, the surgeon specialist, Dr.
P. Berry, Dr. T. M. Robb, and Mr. L. H. Clark as
physicist, report on the radiotherapeutic clinic at the
Lambeth Hospital. During the year under review
567 new patients were placed on the records of this
clinic. A number of patients who had already had
treatment by surgical operations or by radiotherapy
elsewhere and had tumours at a very advanced stage
were not included among these 567 cases, as they
were deemed unlikely to respond favourably, though
palliative treatment was expected to make them
much more comfortable. The results obtained are
set out in tables which show the crude survival-rate
up to five years for those treated in 1930, and since
special attention is paid by the clerical staff and a
lady almoner to following up patients it seems likely
that these will yield very valuable statistical material
in a few years. An account of the method of following
up is instructive,
One of the most successful is the plastic surgery
unit at St. James Hospital, under Sir Harold
Gillies, Mr. T. P. Kilner, and Mr. A. H. McIndoe.
During the year ended Dec. 31st, 1935, 274 patients
1 London: P. S. King and Son. L.C.C. No. 3254. Pp. 162. 5s.
the comparison of
were admitted, some of whom had come from as far
as Scotland, Wales, and Devon. The classified list
of cases treated shows a great number of operations
for facial scars and nasal fractures. Cleft lips and
palates also figure largely. Skin grafts of every
description have been used, by far the greater number
being Thiersch grafts. Interest has been aroused by
the promising results obtained in the surgical treat-
ment of active lupus; and it is most encouraging to
find that repair of cleft palate in infancy has resulted
in such perfect results. that the children seen years
later are found to speak normally without speech
training. |
Sir Leonard Hill reports on the arthritte unit at
St. Stephen’s Hospital. A method of treatment is
being tried in the rheumatoid type of arthritis which
consists in lavage of the joint combined with syno-
vectomy at an early stage of the disease. This
gives an opportunity to Mr. Timbrell Fisher and Dr.
G. H. Eagles to study early histological changes in
the synovial membrane and in the joint fluid. Dr.
Claude Elman is investigating the results of gold
therapy in the treatment of chronic infective arthritis.
Two thoracic surgery untis have been established,
one at St. Andrew’s Hospital and one at St. James
Hospital. A great number of operations are being
carried out on cases of chronic pulmonary tubercu-
losis. The operations done included thoracoplasty,
phrenic evulsion, thoracoplasty and division of
adhesions, and apicolysis. Dr. J. W. Linnell,
working at St. Andrew’s with the late Mr. H. P. Nelson,
also dealt with cases of intrathoracic new growth,
lung abscess, and empyema. The only unsatis-
factory results reported were in cases of tuberculous
empyema and pyopneumothorax. Despite repeated
irrigation and aspiration and intercostal drainage in
secondarily infected cases, the efforts to prepare
them for thoracoplasty have been disappointing.
Of 5 cases of chronic non-tuberculous empyema, on
the other hand, 3 were complete successes; and of
8 cases of abscess of the lung 6 recovered, and this is,
as the authors say, a highly satisfactory proportion
in such a serious malady. The importance of good
team-work and, in particular, of highly skilled
nursing is emphasised by the medical superintendent
of St. Andrew’s. Mr. A. Tudor Edwards, working
with Mr. R. C. Brock and Mr. L. O’Shaughnessy,
reports on the second year’s work at St. James
Hospital. Amongst 153 operations performed there
were 27 thoracoplasties and 47 operations for acute
empyema and 19 for chronic empyema.
A goitre clinic has been in existence at New End
Hospital since 1932. Cases are transferred to this
clinic from the Council’s hospitals and about a third
come from outside the L.C.C. area. The patients are
encouraged to attend the clinic at intervals after
their operations and an effort is made to keep in
touch with them by questionnaires. The majority of
the 100 patients treated in 1935 were suffering either
from primary Graves’s disease (40 cases) or from
thyrotoxic goitre (46 cases); 104 operations were
‘performed, the majority under a combination of
avertin, local infiltration and gas-and-oxygen, and
there were no deaths. The consulting staff are Sir
Thomas Dunhill, Mr. Geoffrey Keynes, and Dr.
Linnell.
Dr. A. F. R. Dewar gives an interesting account of
the running of the diabetic clinic at St. George-in-the-
East Hospital and of the principles observed in the
control of glycosuria in patients of different age-
groups. The avoidance of the danger of hypo-
glycemia in the school-child by the administration
of
894 THE LANCET]
daily of insulin in several small doses is considered.
In the middle aged—i.e., those whose ages range
from 45 to 60—the difficulty has not been so much
in control of the main diabetic symptoms as in
prevention of degenerative lesions, particularly of the
nervous and cardiovascular types. Fibrositis is also
an urgent problem. A high blood-sugar is not regarded
as the prime factor responsible for these degenerative
changes. Dr. B. A. Young, in reporting on the
diabetic clinic at St. Peter’s Hospital, discusses the
relative importance of urine analysis and of blood
analysis in controlling the treatment. He says that
at his clinic it is the practice to endeavour to keep
the blood-sugar within normal limits in younger
patients. In the older patients urine analysis is
often sufficient. In diagnosis, blood-sugar estima-
- tions are,. of course, necessary. Self-administration
of insulin is taught wherever possible. If the patient
cannot be taught, a responsible relative is often
available. St. Peter’s Hospital have been fortunate
in having the coöperation of the East London Nursing
Society who have administered insulin and helped
in the education of the poorer diabetics. The higher
carbohydrate diet combined with the low fat diet
advised by Watson and Wharton has been successful
in trials at St. George-in-the-East.
A congenital syphilis unit, with residential treat-
ment for the children, at St. John’s Hospital is under
the supervision of Dr. David Nabarro, Twelve new
cases have been admitted during the year, 9 boys
and 8 girls, and there were 11 readmissions, all girls.
Dr. Nabarro reports that the progress made by the
children is good and fully justifies the provision of
residential accommodation. His only regret is that
so few of the admissions are of infants under the
age of 2-3 months, for it is when started at this
early age that treatment is most likely to result in
cure. Even better results are obtained by treatment
of expectant mothers. |
The urological unit at St. Mary Abbots Hospital
comprises two wards, male (28 beds) and female
(25 beds). Under the auspices of the Medical Research
Council the effect of Hombreol on prostatism is —
being studied. The number of cases has been small
owing to the fact that before any research can be
carried out the patients must be free from urinary
infection, It is stated that the results as far as can
be ascertained have not been satisfactory. A
follow-up department has been established for
prostatectomies and stricture cases; patients from
other hospitals may attend this clinic for dilatations.
A total of 165 operations were performed during
1935, and the report of the medical superintendent,
Mr. James Carver, shows that a great variety of
genito-urinary diseases are dealt with. Curiously
enough, amongst 248 admissions there were only
2 cases of tuberculosis of the kidney and none of
tuberculosis of the testis. Urinary infection accounts
for 83 admissions, stricture of the urethra for 18,
and enlargement of the prostate for 26. The other
cases cover a wide field. :
Mr. D. A. Beattie reports on the fracture clinic at
Fulham Hospital. He emphasises the importance of
segregation of these cases on admission to hospital.
The two wards available at Fulham are equipped
with special power points for the use of portable
X ray plant and with fracture-beds of the Meurice
Sinclair type, that can be tilted by means of pulleys
fixed to the ceiling. By collecting the cases in one
ward the training of the nursing staff is made much
easier and more efficient. In treatment of out-
patients ambulatory plaster methods are employed,
UNITED STATES OF AMERICA.—SCOTLAND
[APRIL 10, 1937
and every fracture case that has been treated in
hospital attends. The senior member of the massage
department is always present to ensure the closest
possible coöperation between the surgeons and the
masseuses. The records are kept in a filing system
that renders them easily accessible at any time.
The patient’s notes are filed with the X rays in one
envelope inscribed with his name and number. A
viewing-box forms part of the equipment. The
average number of patients attending the weekly
sessions of the clinic vary between 38 and 45. In
addition to fracture cases, all orthopedic patients of
the out-patient type and any out-patients referred
for massage treatment are kept under observation at
the clinic,
UNITED STATES OF AMERICA
(FROM AN OCCASIONAL CORRESPONDENT)
THe American Foundation Studies in Government
published on April 5th its report on medical care in
the United States.1 This report is significant both as
a contribution to the science of government and as
a presentation of the serious thought of the profession
most concerned upon the urgent social problem of
providing ‘‘ adequate ° medical care to the people.
The work of organisation, of review, and of com-
pilation involved in this study must have been
tremendous. Wealth alone could not have accom-
plished it. The Foundation has been well served by
research workers with both imagination and ability.
The report is based on some 5000 letters from more
than 2000 carefully selected physicians located in all
parts of this country. It represents the views of
individuals rather than of organisations. At the
same time anonymity has been preserved in order
that the facts and arguments presented may stand on
their own authority. The reader is obliged to rely
upon the Foundation for the verification of state-
ments, but he will probably be willing to do so both
on account of their general reputation and the
evident competence displayed in the preparation of
this report. English readers may find it difficult to
appreciate how greatly American readers might be
affected by the publication of names in this very
controversial discussion.
This study does not ‘‘ prove” anything. It was
not intended to do so. What it must do is to promote
thought, broaden understanding, and dissolve pre-
judice. Incidentally it will be a “source” book for
sociologists and serious students of government in
universities all over the world. For the problems
with which it deals are by no means peculiar to these
United States.
SCOTLAND
(FROM OUR OWN CORRESPONDENT)
DISCOVERER OF ETHER ANESTHESIA
A MEMORIAL to Crawford Williamson Long,
American discoverer of ether anesthesia, was unveiled
in the library of the Royal College of Surgeons,
Edinburgh, last week. The memorial is a plaque
which has been presented by the Southern Society
of Clinical Surgeons, U.S.A., in appreciation of their
reception in Edinburgh during their visit in 1936.
Dr. Long (1815-78) made his discovery at Jefferson,
` 1 American Medicine: Expert Testimony Out of Court.
The American Foundation Studies in Government, 565, Fifth-
avenue, New York City. 1937. Pp. 1500 (2 vols.). $3.50 for
both volumes.
THE LANCET]
Georgia, on March 30th, 1842. Mr. L. B. Wevill,
F.R.C.S.E., who was introduced by the president
of the College, pointed out that this remarkable
discovery was made by an unknown young general
practitioner working in a small country town. The
effect of inhaling nitrous oxide or ether was at the -
time used by itinerant chemists to cause amusement.
Long observed that during these frolics the subjects
of the experiment did not complain of pain when
they injured themselves. He therefore proposed
to a certain Mr. Venable, one of his patients, who
required to have a wen removed, that here might
be a way to have the operation done painlessly.
On March 30th, 1842, this experiment was carried
out with complete success.
POST-GRADUATE TEACHING
The syllabus for post-graduate teaching in Edin-
burgh has just been published. Apart from the usual
summer courses, arrangements are being made for
an intensive eight weeks’ medical course to be held
next autumn. There will be four hours of coérdinated
teaching each day during the course and special
facilities for the study of clinical methods and ward
work,
IRELAND |
(FROM OUR OWN CORRESPONDENT)
MEDICAL ATTENDANCE ON THE CIVIC GUARD
A FEW weeks ago Mr. Ruttledge, Minister for Justice,
received a deputation from the Council of the Irish
IRELAND.—THE SERVICES
\
[aPrit 10, 1937 7895
Free State Medical Union to hear their views on the
method ordinarily employed for the appointment
and remuneration of medical attendants to the Garda
Siochana in country districts. It was pointed out to
the Minister that when a vacancy occurred in the
position of medical attendant to the Garda it had
become the custom for an officer of the Force to
invite the medical practitioners in the neighbourhood
to tender for the post, stating the fees they would be
willing to accept for the several services rendered.
The practitioner who was willing to accept the
smallest fees was usually appointed. The Minister,
without admitting that the deciding point was the
size of the fees demanded, recognised that the present
method was unsatisfactory, and promised to endeavour
to alter it. The matter was raised again in the Dáil
last week in the debate on the estimates by Dr.
R. J. Rowlette, who had called attention to it
previously two years ago. He also commented on
the fact that the State did not supply a full medical
attendance to members of the Garda, but only what
might be called a ‘general practitioner’’ service.
If a guard had to seek the advice of a specialist or
to enter hospital he must do so at his own expense.
He suggested that a guard should not be in a worse
position than a soldier as regards the care of his
health by the State. There should be an efficient
medical service provided by the State for its servants.
The Minister, in reply, stated that the question of
remuneration was the subject of communication
between his Department and the Department of
Finance, and he hoped for a satisfactory result.
THE SERVICES
ROYAL NAVAL MEDICAL SERVICE
Surg. Comdr. R. L. G. Proctor to President for course.
Surg. Comdrs. J. S. Elliot and L. S. Goss, O.B.E.,
retire at own request with rank of Surg. Capts.
Surg. Lf.-Comdrs. T. W. Froggatt to St. Angelo for
R.N. Hosp., Malta; J. J. Keevil to Leander and lent to
N.Z. Division for three years; and E. J. Mockler to
Ganges.
Surg. Lts. W. W. Simkins to Furious ; and T. McCarthy
to Drake for R.N.B., and to Centurion (on commg.).
Surg. Lts. for Short Service: G. L. Hardman (St.
George’s Hosp.), J. F. Meynell and W. S. Parker (Man-
chester Univ.), and W. B. Teasey (Queen’s Univ., Belfast).
Surg. Lts. (D) H. Bradley-Watson to Pembroke for .
R.M. Infirmary, Deal; and S. R. Wallis to Royal Sovereign.
W. G. Smith and E. B. Mackenzie to be Surg, Lts. (D).
ROYAL NAVAL VOLUNTEER RESERVE
Surg. Lts. F. T. Land, promoted to Surg. Lt.-Comdr.,
and G. C. Martin, transferred from List 1 of the Mersey
Division to List 2 of the London Division.
Proby. Surg. Lt. J. K. Sargentson to Ramillies.
ARMY MEDICAL SERVICES
The War Office announces that Col. G. G. Tabuteau,
D.S.O., late R.A.M.C., has been promoted to the rank of
Major-General with effect from April Ist, and will continue
in his present appointment as Deputy Director of Medical
Services, Northern Command. ,
Major-General Tabuteau received his medical education at
the Royal College of Physicians and Surgeons, Dublin, and
entered the R.A.M.C. in 1905.. He was promoted Lt.-Col.
in 1928, Brevet.-Col. in 1932, and Col. in 1934. He served in
France and Belgium during the Great War, and in addition to
receiving the D.S.O. was twice mentioned in dispatches. He
also served in Waziristan (1921-24) and in Burma (1930-32),
being mentioned in dispatches for the latter service and receiving
the brevet rank of Col. |
Maj.-Gen. FitzG. G. FitzGerald, C.B., D.S.O., K.H.S.,
late R.A.M.C., is placed on half-pay under the provisions
of Art. 500, Royal Warrant for Pay and Promotion, 1931.
Col. A. Dawson, O.B.E., late R.A.M.C., retires on
ret, pay.
Lt.-Col. H. Gall, from R.A.M.C., to be Col.
Lt.-Col. A. N. R. McNeill, D.S.O., from R.A.M.C., to
be Col.
ROYAL ARMY MEDICAL CORPS
Majs. to be Lt.-Cols.: R. H. Alexander, M.C., R. W.
Galloway, D.S.O., W. Frier, and F. G. Flood, M.C.
REGULAR ARMY RESERVE OF OFFICERS
_ Maj. C. M. Rigby, having attained the age-limit of
liability to recall, ceases to belong to the Res. of Off,
SUPPLEMENTARY RESERVE OF OFFICERS
Lt. R. L. Walmsley to be Capt.
ARMY DENTAL CORPS
Maj. J. H. W. Fitzgerald, having attained the age for
retirement, is placed on ret. pay.
‘Short Service Commissions.—Lts. to be Capts.:
R. Walker, D. V. Taylor, and D. S. Wilson.
ROYAL AIR FORCE
Wing Comdr. B. F. Haythornthwaite to R.A.F. Station,
Calshot, for duty as Medical Officer.
Squadron Leader C. G. J. Nicolls to R.A.F. Station,
Gosport, for duty as Medical Officer. i
Flight Lt. O. S. M. Williams to Princess Mary’s R.A.F.
Hosp., Halton.
Flying Ofir. R. F. Courtin to R.A.F. Depôt, Uxbridge.
DEATHS IN THE SERVICES
The death occurred on March 14th at Southsea of
Lieut.-Colonel RoBERT Gate, D.S.O., R.A.M.C., retired.
Born in August, 1887, he was a son of the late Mr. Parnell
Gale and was educated at Glasgow University and
graduated M.B., Ch.B. Glasg. in 1909. He entered the
R.A.M.C, in the same year, became captain in 1913, and
major in 1921. From 1911 to 1914 he was in civil employ-
ment in Egypt, and then served during the European war
to 1918, being mentioned thrice in dispatches and created
-= D.S.O. in 1915. In 1934 he was Deputy Assistant Director
of Medical Services, Northern Command, at York. In
1915 he married Lora, daughter of the late Mr. R. F.
Alexander of Glasgow, and leaves a son and daughter.
896 THE LANCET]
[APRIL 10, 1937
GRAINS AND SCRUPLES
Under this heading appear week by week the unfettered thoughts of doctors in
various occupations. Each contributor is responsible for the section for a month ;
his name can be seen later in the half-yearly index.
FROM A TADDYGADDY
Il
“Of his works there ts no end... .” The man who
wrote that was thinking of us as we were more than
two thousand years ago: the ordinary plodding day
in day out G.P.s of his time. We don’t seem to have
changed much. We still are slaves of the night bell
and the inconsiderate friends of the patient who
never think of sending till after hours. He was an
observant chronicler. Did he not go on...?
_“ From him is peace over all the earth... .”
Our remote predecessors knew enough to carry with
them always a few opium pills, or their equivalent, so
that, once disturbed, they would not get a second
message on the same night from the same restless
patient. Yet was he thinking merely of the comfort, or
discomfort, of the doctor? Assuredly not. That
writer, Jeshua Ben-Sira, thought many wise thoughts
and, fortunately, wrote them down. When he
wrote about us and peace he was thinking—can we
doubt it 1—of the part other wise men might take
in ensuring it. Is it arrogant if we, the doctors of
to-day, claim to be numbered with the wise ? We
may not have any very great store of book-learning—
in our student days we were compelled to the study
of books that were hardly books at all in the proper
sense; but if we are not wise it surely is our own
fault. We are thrown, whether we like it or not,
into the intimate company of men and women of all
sorts. If we do not learn wisdom from them we shall
learn it nowhere.
* x
“ From him is peace... . Why not? The states-
men talk of war and preparations for war. That way
come death and destruction. We are doctors. Our
job is the prevention of death, when possible: the
alleviation of suffering. Actually we are, or should
be, at variance with the statesmen in so far as they
consider war inevitable. But are we? And now,
somebody will say, I am becoming political. Maybe.
But I am content to walk with Ben-Sira. He also
was political; but he knew how to write. And he
was always on the side of righteousness. Somehow
I cannot help feeling that if we doctors would we
could do a vast deal in the direction of fostering
world peace. In our time we have seen so much of
the personal effects of war. Potentates pay cere-
monial visits to hospitals where they are shown the
more presentable cases and say the appropriate
things. We see the men who, owing to the activities
of flying bits of jagged hot metal, or of noxious
gases, are no longer capable of controlling their more
unpleasant functions. We know, from personal
observation, that war means something even more
horrifying than a patch of country littered with
corpses: it means here and there an assembly of
men, still alive, but no longer men as men were
meant to be. Do the statesmen—it matters little
whether they are, or are not, dictators—ever think
of those half-men ?
* x
What about that old time sentence, “From him
is peace over all the earth ?” Has it any meaning
for us? We, do not let us forget this, are members
of a corporation that is international as no other
corporation except the Catholic church is international
To a doctor any other doctor is as he is—just a doctor.
We have no secrets we will not share. If you or I,
English doctors, happen to stumble on something
that will help matters in the struggle with—shall we
say, the common domestic cold in the head {—we
pass it along as quickly as the postal authorities will
permit to the uttermost parts of the earth. We are
no more respecters of narrow nationalism than were
the wandering scholars of the days of faith. They
tramped from university to university, from monas-
tery to monastery, from bishop’s palace to bishop’s
palace, swapping manuscripts, gossip, and ideas.
So is it with us, with this exception—we do not have
to tramp. And yet, in spite of all our heaven-given
opportunities, we are content to let our power run to
waste.
* * *
It was another Hebrew who wrote: ‘ Wisdom
went forth to make her dwelling-place among the
children of men, and found no dwelling-place. Wisdom
returned to her place, and took her seat among the
angels.” It is not surprising that he wrote thus.
Between his time and the time of Ben-Sira his country
had been a battlefield for a couple of hundred years.
Ben-Sira had looked forward. That later writer
looked back. And we... in what direction do we
look—we, the doctors of this much later age %
* * %
My working life has been spent in and about back
streets ; and long before it began I wandered in and
out of the homes of the poor with my father, who
was essentially a poor man’s parson, As a child I
numbered many old women among my friends.
There was one who lived in a single room with a
parrot and, during the proper season, a great card-
board box in which silkworms grew fat on a diet of
lettuce leaves until they shut themselves up in
cunningly spun prisons of gleaming silk. She and I
shared a secret hope—that some day we should
gather a pound of yellow silk thread, for then we should
be paid a whole sovereign. We never did. Once I
found that old woman in a state of dire distress.
She had upset her cardboard box, and the silkworms
were loose in her bed. However, I collected them
for her and all was well. There was another old
woman who had as sole companion a bantam hen.
She used to give me bantam’s eggs which were
served up for my breakfast in a wooden egg-cup
decorated with a picture of the Crystal Palace given
me by another old woman. And this very evening
an old woman, very poor: she lives in a single
room in an alms-house—has come to see me because
she has a sore-throat. That is unusual, As a rule
when she comes it is to press upon me a bottle of
home-made wine of her own brewing. And the point
of all that personal chronicle is just this, that all
these old women were friendly. They asked no
more than that they might be at peace with every-
body else. And is it not so generally? In back
streets people quarrel one with another. There are
family feuds. But let trouble happen along—the
feuds are forgotten, are put on one side. Mrs. Jones
will sit up all night with her enemy Mrs. Smith, and
THE LANCET]
then go off to her work next morning without turning
a hair. Forty years in and about back streets have
shown me something of the inherent friendliness of
people.
Æ% * *
Is it surprising that I, an ordinary average G.P., a
Taddygaddy, fail entirely to understand why it is
the statesmen seem to think war inevitable ? I have
gone about my business for many years in quarters
that were terribly overcrowded, but very seldom
have I heard any suggestion from the people living
there that they shall go and seize by force more
roomy quarters. The governing people of Europe
would be horrified if the common people did that.
Yet they have no hesitation in doing it themselves.
They call it “ expansion.” In furtherance of their
policy they employ any sort of devilish device that
comes to hand. They burn and blister and blow up
any who have the temerity to get in their way, and
leave us to do what we can in the way of repair. We
can do something for the burned and the blistered,
but those effectively blown up are beyond our power
to help.
* * *
World politics, to every experienced Taddygaddy,
must seem entirely mad. The one remedy that may,
even yet, be effectual is ridicule. The statesmen of
Europe seem to have forgotten how to laugh. But
PANEL AND CONTRACT PRACTICE
[APRIL 10, 1937 897
we have not forgotten. A Taddygaddy, an ordinary
G.P., who has forgotten how to laugh is no longer a
Taddygaddy. He has become no more than a medical
man—a tradesman hawking his wares in hope of
profit: just that, and no more than that. We have
not arrived there yet. We still are a profession that
takes no heed of national boundaries. To us it matters
not at all whether another doctor be French, or
German, or Jap, or English. We do not ask a sick
man to produce his passport before we offer our
services. All we ask of the foreign doctor is that he
shall help: of the foreign patient that he shall
accept.
x% * *
We have our ideals, They are, very largely, the
ideals of the mediæval church which took small
stock of narrow nationalism, preaching—even when
it did not practise—international brotherhood. The
church had this, at least, a common language. The
clerk, wherever he went, could talk to fellow-clerk.
That made for international unity, so far as the clerks
were concerned, We, the doctors of the world, may
go further if we will, We have no common language,
unfortunately. We no longer express ourselves in
Latin, as did that great pathologist, Shattock, not
so long ago. But we have this in common with all
doctors—sympathy of aim. Cannot we urge that
upon the politicians? They might ... they might,
see what it is we are getting at.
PANEL AND CONTRACT PRACTICE
Black-coated Workers
THe text of the Widows’, Orphans’, and Old Age
Contributory Pensions (Voluntary Contributors) Bill,
1937, was issued on March 23rd. Health and pensions
insurance have been so interlocked hitherto that it
is not surprising that some practitioners have
wondered whether the Bill may bring into medical
benefit persons who have previously been excluded.
This is not so. The purpose of the Bill is simply to
extend the benefits of voluntary insurance for widows’,
orphans’, and old age pensions to persons with
small incomes, whether working on their own account
or not, who have not the qualification of insurable
employment required under the present scheme.
The persons now rendered eligible for pensions will
include ministers of religion, shop-keepers, farmers,
dressmakers, and music teachers. Its provisions
will give them no claim for medical, sickness, or
disablement benefit. The scheme not being com-
‘pulsory the full pension will be dependent upon the
payment of a certain number of contributions ;
if the average falls below that number the rates of
pension (normally those provided under the Con-
tributory Pensions. Act of 1936) will be reduced.
Applicants for admission to insurance must have
been resident in Great Britain for at least ten years ;
their income at the time of application must not exceed
£400 a year for men, £250 for women, and in either case
up to half may be unearned. For the first year
applicants not exceeding 55 years of age at the
commencement of the scheme will be admitted, at
ls. 3d. per week if insured for all benefits or 10d.
a week for widows’ and orphans’ pensions only.
Women initial entrants will be insured for old age and
orphans’ pensions for 6d. a week. After the first
year applicants must not be more than 40 years of
age at the date of application and their contributions
will vary in accordance with their age at entry.
The main qualifying conditions for a pension are
as follows.
For a widow’s or orphan’s pension.—l04 weeks of
insurance and payment of 104 contributions since the
date of entry into insurance. |
For an old age pension.—Continuous insurance for
at least ten years immediately prior to attainment of the
age of 65, and payment of 260 weekly contributions.
Full pensions will be paid only if there is an average
of at least 50 weekly contributions per annum
throughout insurance,
Mixed Partnerships
Dr. A. resigned from an insurance committee's
list in the hope of securing an appointment as head
of a department for psychological treatment, to
which his having an insurance practice would have
been a bar. He transferred his insured patients to
another member of his firm, two of whom were
under agreement with the committee. Dr. A. wished
to attend insured persons on behalf of his partners
but the committee were of opinion that it is undesir-
able for the partner of an insurance practitioner
not to be under contract to treat insured persons,
inasmuch as misunderstandings and abuses might
arise from the treatment of insured persons by a.
non-insurance practitioner. The committee made
a further point: his partners might call Dr. A.
in as consultant, when he was not the best specialist.
for the purpose, because his fees would form part of
the firm’s income. The matter was referred to the
Ministry of Health which replied thus :
“... the Minister of Health is advised that there is no
legal objection to the partner of an insurance practitioner
not being under contract with the insurance committee,
and the Minister has no information which would lead
to the conclusion that such a partnership is undesirable
as tending to lead to misunderstanding and abuse... .
the Minister sees no ground on which exception could
be taken to the giving of treatment outside scope by the
non-insurance partner .. . . if an insurance prac-
titioner refers one of his patients to his non-insurance
partner for treatment outside the scope of an insurance
practitioner’s obligations . . . no case could lie against
898 THE LANCET]
PUBLIC HEALTH
4
[APRI 10, 1937
him unless it were shown that he had not faithfully dis-
charged his duties . ... if the non-insurance partner had
the necessary qualifications for undertaking the treatment,
the fact that some other practitioner might be better
shirt would not necessarily indicate _ non-compliance
. with the requirements of Clause 9 (1).”’
The Insurance Acts Committee has recently had
under consideration a communication from a pro-
vincial panel committee raising the question of
partnership between a practitioner who is doing
insurance work and one who is not. The question
had arisen because of a suggestion from the insurance
committee concerned that the partner with the
private practice only should agree not to charge
fees to his partner’s insured patients. In 1934 the
annual panel conference referred to the I.A.C. a motion
by Lancashire in the following terms :
“ That in the opinion of this conference an arrangement
whereby an insurance practitioner has any partnership
with a doctor who is not on the medical list is prejudicial
to the observance of the regulations governing insurance
practice and must of necessity conduce to abuses in the
matter of receipt of fees by insurance peacutionsrs from
patients on their lists.”
The J.A.C.’s view was that any abuses which could
be attributed to such a partnership occurred so
seldom as not to demand a special regulation, and the
1935 conference concurred in this view.
PUBLIC HEALTH
1936 in Scotland
` DETERIORATION rather than improvement in the
health of Scotland during 1936 is shown by the
report of the Department of Health just issued.
The infantile mortality-rate rose from 77 in 1935
to 82, which compares very unfavourably with
England’s rates (57 and 59 respectively). Maternal
mortality fell from 6:3 to 5-6 per 1000 live births,
but even the latter rate is higher than it ought to be.
The slight rise in the general death-rate, from 13-2
to 13-4, and the slighter increase in tuberculosis
mortality can be put down to epidemic prevalence of
influenza. The history of infectious disease in Scot-
land in 1936 was not sensational, though the biennial
epidemic of measles was sharper than usual; there
was an unusual- amount of poliomyelitis in autumn
in south-east Scotland, and several small outbreaks
of paratyphoid occurred, especially in the west. As
in the rest of Britain and most parts of Europe,
diarrheal diseases (including the typhoid and dysentery
groups) were more prevalent in 1936 than for many
years.
The Scottish Office provides an annual report on
the health of insured persons, which is the most
reliable of the meagre reports on morbidity available.
We read that it is “ disappointing that the completion
of a quarter of a century of National Health Insurance
leaves the incidence of incapacitating sickness so
high .. . at eleven days per insured person per annum
and the figure is not declining.” But in two places
attention is called to the higher standard of health
demanded, which causes employees to go off work
earlier and more frequently and to return to work
later than they did in the past. To what extent this
leads to better health is one of the chief medico-
social problems before us at present. Attention is
called to the increase in chronic incapacity not
attributable to the increased age of the population
and an alleged increase in deaths from rheumatic
heart disease amongst the young. ‘“‘ Year after year
at least 1000 lives are lost from this type of heart
mischief in Scotland.” Housing in Scotland is
notoriously bad, but it is astonishing to read that
overcrowding is six times as common as it is in
England. The paragraph on housing gives the
impression that the Department attributes much of
the avoidable ill health of Scotland to bad housing.
A chapter on food-supply opens by describing a
milk-feeding experiment on school-children in England
and Scotland. A third of the children were given
daily a third of a pint of pasteurised milk, another
third were given two-thirds of a pint of pasteurised
milk, and the remaining third were given two-thirds
of a pint of raw milk.: No difference was detected
between the pasteurised and raw-milk groups, but
the two-thirds pint children did better than the
one-third pint. ` The milk-in-schools scheme, similar
in Scotland to what it is in England, is having the
same history. After the first spurt there was a big
reduction in the numbers of school-children paying
for the milk, though recently the tide has turned and
there is a slight increase. The reasons assigned for
what must be considered a partial failure of the
scheme can be divided into excuses that should be
ignored and grievances that should be remedied.
The latter are three in number: novelty worn off ;sx
mid-morning milk spoils the appetite for dinner ;
parents resent paying for what some can obtain
free, The first is the most important. The milk-
in-schools scheme was introduced to foster the habit
of milk-drinking, but so far its success in that
direction has been poor, for the habits of the people
are not to be changed in a few months. It is necessary
to make the milk-in-school a more intimate part of
education if it is to engender a permanent habit of
milk-drinking. If eleven-o’clock milk were called an
aperitif instead of a milk ration it might increase and
not diminish appetite for the midday meal! In any
case the drink can be retimed. From Dundee comes
the admirable suggestion to give the ration between
9 and 10 o'clock because “it would be of benefit to
such children as had had only a scanty breakfast.”
There is general agreement that a third of a pint of
milk is insufficient, and a growing tendency to give
more of it free.
An Epidemic and the Public
In the late summer of last year there was an
outbreak of typhoid fever in the Bournemouth
district in the course of which 523 cases were notified
to the sanitary authorities of Bournemouth, Poole,
and Christchurch, and 41 deaths occurred. Com-
plaint was made in the local press against the local
authorities that they had not taken the public into
their confidence at a sufficiently early stage. There
was in fact a suggestion that an endeavour had been
made to conceal from the public the true facts about
the outbreak. At the request of all the parties con-
cerned, Judge Cotes-Preedy held a private inquiry,
the report of which was issued on Tuesday. In his
view, once the situation was established, there was no
endeavour on the part of the authorities to conceal
the true facts about it; he thought the officials
would have acted unwisely if they had sponsored
the announcement in the press of an existing epidemic
directly suspected cases had appeared. It was common
knowledge, he remarks, that sporadic cases of typhoid
frequently occur and the difficulty of diagnosis
called for caution, if only for the reason that a hasty
announcement might determine the flight of people
carrying the disease to all parts of the country.
THE LANCET]
[APRIL 10, 1937 899
CORRESPONDENCE
- OVER-TREATMENT OF GONORRHG@A
To the Editor of THE LANCET
Str,—I beg to endorse the views given by Mr.
Nicholls in your issue of March 20th, writing as_one
who has lived in that dark and uncritical world to
which he refers, having held posts in venereal disease
clinics for over twenty years.
I gave evidence before a subcommittee of a V.D.
hospital more than two years ago, and directed
attention to some of the points raised by him, but
do not know with what result. If the total number
of attendances rather than the total number of
patients is to be regarded as a criterion of good work,
and monetary grants are apportioned accordingly,
this system appears to call for the most searching
investigation.
Among various types of cases which occur to my
mind are those that are treated regularly over long
periods by prostatic massage and posterior irriga-
tions, usually carried out by orderlies. In a large
proportion of these cases the patient complains only
of a slight morning urethral moisture, and notices
threads in the urine; cultures and films continually
taken show only diphtheroid bacilli and staphylo-
cocci, the prostate exhibits no gross abnormality, and
the urethra appears normal on urethroscopy. Why
are these cases condemned to protracted treatment,
with the risk of disastrous psychological reactions ?
Again, irritation of the prostate by posterior irriga-
tions and massage during the early weeks of gonor-
rhea is, in my opinion, mainly responsible for the
cases of acute prostatitis and epididymitis that are
so frequently recorded... A prostate treated with
respect and sonsidetation will, as a rule, give no
serious trouble in the course of the disease. All
experience goes to show that the efficiency of any
V.D. clinic depends in great measure upon systematic
liaison with various departments of a hospital, of
which the genito- “urinary one is manifestly inter-
dependent. -
As Mr. Nicholls points out, it is difficult to under-
‘stand why gonorrhea should be “wedded to
syphilis” and why an expert knowledge of either
disease provides any guarantee whatever of a like
standard of efficiency in dealing with the other. It
seems obvious that the syphilis department of a
V.D. clinic should be divorced from the gonorrheal
one; the director of the former having special
experience in dermatology, cardiology, and neurology,
and that of the latter in genito-urinary surgery and
gynecology.
Procedure in regard to the segregation of V.D.
cases from others is another matter which demands
urgent attention. For example, the psychological
effects on a man suffering from a non-gonococcal
urethritis and prostatitis (now recognised as a common
condition) when condemned to make use of the
same cubicle and apparatus as a V.D. patient can be
left to the imagination. The female V.D. department
is, in my opinion, in still greater need of reorganisa-
tion. My experience has convinced me that. this
part of the clinic tends to become a “ sifting ” depart-
ment for a variety of conditions—such as laceration
of the cervix following childbirth, prolapse, and
mycotic diseases of the vulva and vagina—owing to
the fact that, under the present system, a patient
complaining either of vaginal discharge and irritation,
or of painful and frequent micturition, is customarily
referred to a V.D. department. This procedure,
~
I submit, not only involves a total disregard of the
patients’ feelings but also makes them reluctant to
seek advice, l
Some twenty years have elapsed since an inquiry
relating to venereal disease was last held in this
country. In view of the fact that the London County
Council are to expend no less than £55,000 on V.D.
clinics in London during the coming year, it seems
reasonable to suggest that the time has now arrived
for the holding of another inquiry for the purpose of
assuring the public that the organisation of these
clinics is such that the money provided is being
expended in the best interests of public health.
I am, Sir, yours faithfully,
A. MALCOLM SIMPSON.
Wimpole-street, W., April 5th. .
WHO INVENTED THE IDEA OF TARRING
ROADS ?
To the Editor of THE LANCET
Sæ,—In reply to the query raised by “ A Rusticating
Pathologist’? in Grains and Scruples of March 20th,
the tarring of roads would seem to have been invented
by Sin and Death when they thus treated their
causeway across Chaos from Hell to the newly
created World (“ Paradise Lost,” Bk. X). The work
of consolidating the materials with asphaltic slime
appears mainly to have been done by Death, which
suggests that the alleged increase of cancer of the
lungs in recent times may perhaps be due, not to the
dusty roads of thirty years ago, but to the widespread '
use since then of so notorious a carcinogenic substance
as tar. I am, Sir, yours faithfully,
New College, Oxford, April 2nd. R. S. CREED.
To the Editor of THE LANCET
. SIR, —In your issue of March 20th “ A Rusticating
Pathologist” begins his article with the statement :
“ No one that I have asked has been able to tell
me who invented the idea of tarring roads. It was a
great discovery, worth a peerage and a fortune as
well as the preservation of a name,...” It may
interest you to learn that it was Dr. Guglielminetti,
a Swiss by origin born in Monthey (Valais), who in
1900 in Montecarlo made the first experiments with
tarring roads. As a doctor he was greatly impressed
by the dust nuisance and this led him to his discovery.
In the French automobile press Dr. Guglielminetti
has been appraised as le père goudron.
I am, Sir, yours faithfully,
Basel, March 31st. A. L. VISCHER,
ATHLETICS FOR WOMEN
To the Editor of THE LANCET
SIR, —Your reviewer (March 27th, p. 760) of the
“ British Encyclopædia of Medical Practice ’’ dislikes
my (apparently) old-fashioned prejudice against
violent exercise for women. Any such objections
proceed from a variety of reasons: some perhaps
merely a matter of taste, some affording legitimate.
scope for difference of opinion. It may be true, as
your reviewer submits, that a large number of women
condemned to childlessness seek an outlet for their
energies in athletics, although one may speculate
whether some preferable form of sublimation might
not be selected. But when he adds that my
(presumed) contention that the habit of taking
strenuous exercise makes for difficult labour is quite
unsupported by evidence, he implies that he has
900 THE LANCET]
the unanimous support of obstetricians and gynszco-
logists. A considerable number of eminent obstet-
ricians have assured me that they are fully convinced
of the disadvantageous influence of violent and
strenuous exercise from their point of view. From
my point of view there are other direct and indirect
consequences of the strain of intense competition
against which I particularly inveigh.
I am, Sir, yours faithfully,
Brook-street, W., March 30th. ADOLPHE ABRAHAMS,
COLOUR PERCEPTION TESTS
To the Editor of THE LANCET
Srm,—In a moderately illuminated spectrum the
number of colours seen by different people varies
from six to two. The brightest portion of the
spectrum is between wave-lengths 57 and 614, and
from there the brightness appears to shade into the
dark red and violet constituting as it were two areas
of brightness, a central very bright area within a
larger bright area. The colours in the former are
pale greenish yellow, yellow and orange red, whereas
the green and red in the larger area are saturated
and distinct.
Trichromics and dichromics confuse red, green,
yellow, and white signal lights. The only property
common to these colours is brightness and the
difference in brightness apparently enables colour-
blind persons to differentiate colours from each other.
If this is correct, then mistakes should start in the
brightest portion of the spectrum in the earlier
varieties of colour-blindness and be more and more
pronounced till total colour-blindness is reached—
and this is exactly what occurs. The trichromic, the
first stage of dangerous colour-blindness, when asked
to map out the fullest extent of red will stop short
of orange and declare he can see yellow (or white),
and when asked to do likewise with this colour will
map out an area extending from orange red into a
yellow-green and declare it to be monochromatic
yellow or white, whereas it contains pale red, orange,
yellow, and pale green colours. This area corresponds
to the brightest portion of the spectrum. He does,
however, recognise the more pronounced red and green
colours of the spectrum on either side of his mono-
chromatic area. With a lantern examination the
same person, if shown similar pale red, green, and
yellow colours, will be unable to distinguish them
because colours of this saturation and brightness
come within his confusion area; but he will not
confuse saturated reds and greens which are outside
it. This confusion of colour corresponds to the extent
of altered colour perception, increasing to a point
where it reaches the stage of dichromatism.
Dichromics, when asked to map out the fullest
extent of red, will map out an area extending right
into blue and consider it red or yellow, and this area
‘will be found to correspond to the larger area of
brightness. As this area contains definite red and
green colours with a lantern examination, they will
mix up saturated red, green, and yellow colours. To
the dichromic there is no difference between red and
yellow; he is apt to call a yellow-green red. The
totally colour-blind see only a bright area of varying
shades of intensity. Looking at the full spectrum,
dichromics see a white space of varying size between
the red and violet.
There is apparently a definite balance between
saturation and brightness on which the recognition
of colour depends, and if this balance is upset then
brightness gets the upper hand, bright red appears
as yellow and violet as blue, giving rise to the
COLOUR PERCEPTION TESTS
[APRIL 10, 1937
so-called yellow and blue sensation. There is not
really an increased sense towards yellow and blue;
these colours merely appear brighter. In all colour
perception tests these facts should be borne in mind.
When carrying out book tests care must be taken to
make the examination in a bright light to bring out
the confusion effect ; otherwise varying results will be
obtained with the same person by different examiners.
I am, Sir, yours faithfully,
C. E. R. NORMAN,
Chief Medical Officer, South
Trichinopoly, March 13th. Indian Railway.
THE ÆTIOLOGY OF PELLAGRA
To the Editor of THE LANCET
Sır —May I call your attention to an error and a
misconception in the report in your issue of April 3rd
(p. 811) of my contribution to the discussion on
nutrition and its effect on infectious diseases which
took place on March 24th at the Royal Society of
Medicine. The experiments with pigs referred to
were carried out in collaboration with Dr. T. A.
Birch, not Bird, and Sir Charles Martin in the
department of animal pathology at Cambridge.
They were devised to study the nutritive defects of
maize in the hope of throwing light on the ætiology
of pellagra. On a diet of maize supplemented with
pure casein the pigs soon ceased to grow and suffered
from diarrhea. This was apparently due to the
combined effect of an intestinal infection and the
defective diet, but it was not my intention to convey
that the “intestinal condition’? resembled that
found in human pellagra.
I am, Sir, yours faithfully,
HARRIETTE CHICK,
Lister Institute, London, S.W., April 5th.
IMMUNISATION OF MEN—AND ANIMALS
To the Editor of THe LANCET
Sm,—I read with considerable interest your
annotation in last week’s number on vaccination
against African horse-sickness, and as a Houyhnhnm
I was touched by the solicitude shown by your race
for the less fortunate members of mine. This concern .
for the welfare of beings other than themselves has
always seemed to me to be one of the traits which
argues that the human race will some day emerge
from its present state to something like what we
Houyhnhnms would call civilisation. My brother,
who has always taken a more cynical view than I of
human endeavour, made the remark that had the
horses been black instead of being of good British
blood, African sickness could have done its worst
without attracting much attention. But I pointed
out to him that at any rate in large-scale commercial
undertakings painstaking and praiseworthy efforts
are made by the management to prevent tuberculosis
and pneumonia from incapacitating or exterminating
the native labour force. I had, indeed, been reading
your annotator’s comments with unqualified gratifica-
tion until I came to the final paragraphs where after
detailing the various dangers and mishaps to horses,
which might attend vaccination with neurotropic
vaccine, he casually remarked that “ these considera-
tions are of minor importance.”
So much depends upon the point of view! I confess
that both my mane and my tail bristled at your
annotator’s remark, I could have to some extent
understood it had he been referring to the immunisa-
tion of human children. I find modern human litera-
ture too depressing to read extensively, but from what
THE LANCET]
little I read and from what I hear from correspon-
dents of my own people in different parts of the
world I gather that humankind has definitely made
up its mind that it is the State not the individual
that matters. Of this I have nothing to say. I am
liberal enough to believe that the human species,
and even such backward members of it as Russians,
Germans, and Italians, know their own business best.
But I should like to make it clear that the principle
has never been admitted in Houyhnhnm philosophy
and to this we are inclined to ascribe the culture,
peace, and happiness of our society. So far as horses
are concerned it must be allowed that their very
origin was in the freedom of the unlimited steppes
where the family rather than any larger social
caucus was the fundamental unit. To an equine it
would never appear a sufficient justification of mass
immunisation that some other equine’s offspring was
saved if it were at the expense of ‘‘ unfortunate
results ” of immunisation affecting his own offspring.
It may not be known to your readers that although
immunisation methods have been introduced to a
limited extent among the Houyhnhnms, they are
only adopted after certain formal preliminaries. If
a case has been made out in the laboratory for the
procedure, our doctors are permitted to make trial
upon themselves. _ If this is satisfactory (and there
are any doctors left) volunteers who are told exactly
how things stand are asked for and inoculated. The
results on these are handed over to one of the most
responsible officers of our State—the Lord Chief
Statistician. With us this dignitary’s opinions are
as valued, his judgments are as binding, and his
jokes as highly appreciated as with your own Lord
PARLIAMENTARY INTELLIGENCE
[APRIL 10, 1937 901
Chief Justice. If his opinion is unfavourable the
perpetrators of the false immunisation are severely
punished and this perhaps explains why immunisa-
tion has never been so popular with us as with you.
If, on the other hand, his opinion is favourable he
affixes his seal and the countersign “fiat” (an
abbreviation for fiat experimentum not for fiat lex,
as might be expected from human precedent). The
fiat, with the relevant data but without further
remarks, is then promulgated throughout our
Commonwealth and any parents who choose may .
bring their foals to be injected. There is, of course,
no compulsion and that essentially human activity—
propaganda—is entirely unknown among us. It is
one of the advantages of being a Houyhnhnm that the
steppes are wide and grass is cheap, and if we don’t
like society or its ways we can always lump it.
Mark you, I am not denying the general principles
expressed in your annotation. I wish merely to
point out that though they may be applicable to
many species of beings, including yourselves, they are
repugnant to what I would with due modesty call
“ horse sense.” The classical human historian of
my people (may his great soul rest in peace !) wrote
also, you will remember, a constructive little pam-
phlet called “‘A Modest Proposal’ for eating Irish
children, which it has always seemed to me deals
admirably with the human aspect of the case. But
you will say that “ Ireland isn’t England and never
was,” and although I find myself unable to subscribe
to many human opinions, I have, in this instance,
to admit that you are probably right.
I am, Sir, yours faithfully,
April 4th. A HoUYHNHNM.
PARLIAMENTARY INTELLIGENCE
NOTES ON CURRENT TOPICS
THE House of Commons reassembled on Tuesday,
April 6th, after the Easter recess.
The Special Areas (Amendment) Bill was read a
second time.
QUESTION TIME
TUESDAY, APRIL 6TH
The Duties of Coroners
Mr. Epwagrps asked the Home Secretary whether, in
view of statements recently made by coroners which
seemed to be outside the function of a coroner, he would
now consider expediting action on the report of the
departmental committee which deplored the tendency
of coroners to make animadversions on the character and
conduct of individuals.—Sir JoHn Smon replied: I am
not sure what particular statements the hon. Member
has in mind, but I fear there is no prospect of an oppor-
tunity being found during the present session for any
legislation on the subject of coroners. I do not think
there is any action which can conveniently be taken
meanwhile to deal with particular recommendations
included in the committee’s report: but I have no doubt
coroners have noted the recommendation in the report
on the point to which the hon. Member refers.
Viscountess ASTOR: Can the right hon. gentleman
assure us that some action will soon be taken? Will
he bear in mind that it was because of the action of
coroners that the committee was set up and that a good
many people are beginning to think that the committee
was just so much eye-wash ?
Sir Joun Smon : I do not think that the hon. Member
can take that view. The committee reported earlier in
the year. It is not always possible to legislate immediately
when a committee reports. But I would certainly agree
with the committee in deprecating animadversions
unnecessarily made in the course of an inquest which
reflect on persons who are not in the court and who have
no means of reply.
Recruits Below Standard
Miss Warp asked the Minister of Labour whether he had
examined the Aldershot experiment in connexion with
recruits below the required standard for acceptance
in the Army; and whether he could make use of the
satisfactory results in the sphere of unemployed men
who were in need of health services.—Mr. ERNEST BROWN
replied: The results of the experiment are now being
examined by my department with a view to seeing whether
they point to the need for any modifications in the treat-
ment of unemployed men applying for a course of training.
Medicine Stamp Duties
Sir ROBERT BIRD asked the Chancellor of the Exchequer
(1) whether he was aware of the great anxiety felt by those
members of the Pharmaceutical Society engaged in trade
over the recommendations in the report of the Select
Committee on Medicine Stamp Duties; and whether
it was his intention to introduce legislation implementing
the recommendations wholly or in part; and (2) what
steps he intended to take for terminating the loss to the
revenue consequent upon the avoidance of the payment
of medicine stamp duties disclosed in the report of the
Select Committee on Medicine Stamp Duties.—Mr.
CHAMBERLAIN, Chancellor of the Exchequer, replied :
I can assure my hon. friend that due weight will be given
to all relevant considerations in connexion with the
committee’s report, but I regret I am unable, at present,
to make any further statement on the matter.
——————
CLATTERBRIDGE ISOLATION HosPITAL.— A new
nurses’ home and a cubicle block were opened on
March 22nd at this hospital by Major Green, chairman
of the Wirral Joint Hospital Board. The scheme cost over
£14,000 and the nurses’ home has accommodation for 26.
902 THE LANCET]
[APRI 10, 1987
OBITUARY
CHARLES COLEY CHOYCE, C.M.G., C.B.E.,
F.R.C.S.
Prof. Choyce, formerly surgeon to University
College Hospital and director of the surgical unit
there, died in the hospital on Friday last. He had
been ill for a considerable time and had retired
from all his professional positions.
Charles Coley Choyce was born in Auckland, New
Zealand, and educated at the University of New
Zealand, where he graduated as B.Sc. in 1896. He
proceeded to Edinburgh for his professional training
and graduated in medicine in 1901, proceeding later
to the M.D. degree, while in 1905 he obtained the
diploma of F.R.C.S. Eng. He held resident appoint-
ments at the Leicester Infirmary and the Dread-
nought Seamen’s Hospital, of which institution he
was medical superintendent for three years; later
he was surgeon to in-patients at the Albert Dock
Hospital and assistant surgeon to the Dreadnought,
while he also acted as out-patients’ surgeon at the
Royal Northern Hospital, At the outbreak of war
he was appointed consulting surgeon to the Egyptian
Expeditionary Force, with the temporary rank of
colonel, A.M.S.; he took charge of a large con-
valescent hospital for officers, and his services were
recognised at the close of the war, when he was
made C.B.E. and C.M.G. Shortly afterwards he
was appointed professor of surgery in the Univer-
sity of London with the chair at University College,
while he became director of the surgical unit at
University College Hospital.
We owe to Mr. A. J. Gardham the following appre-
ciation of Prof. Choyce’s work and influence: “ Prof.
Choyce came to University College Hospital in
January, 1920, as first director of the surgical unit,
a post which he held until his retirement in October,
1935. The post which he was asked to fill was not
an easy one: it called for new ideas, for persistence,
and for an ability to handle men and things with
firmness and tact. All these Choyce had, and by the
ungrudging use of them he built up the surgical unit,
carried it through its early troubles, and was able,
when the time came, to hand it over to his successor
as an established institution. It is probably true to
say that by the time he came to University College
Hospital he felt that his primary interest was in
medical education. This interest he followed actively
after failing health had curtailed his clinical activities,
and it will be as a great teacher and as a charming
and courteous personality that Choyce will live in
the minds of those who passed through his hands in
these years. It was never Choyce’s aim to be a
figurehead, His contacts with his colleagues and his
juniors were essentially personal, and he was per-
fectly equipped to hold a post which by its very
difference from that held by other members of the
honorary staff enabled him to act as a connecting
link between them. He was never happier than
when some surgical or administrative problem led
to a friendly meeting of his colleagues in his office.
For students he had an almost royal memory, both
for faces and character, and it was not for nothing
that he was often referred to among them as ‘Papa’
Choyce. His geniality however was never sufli-
ciently indiscriminate to include the lazy or the
inefficient, and his judgment of men was much more
penetrating and critical than he allowed it to appear.
The student who worked well in the surgical unit
wards, however unobtrusively, secured thereby a
wise and helpful friend for as long as he had need
of him, The shirker, and most particularly the
shirker who laid himself out as he thought to attract
the favourable attention of the professor, found ‘a
stern critic beneath the genial exterior.
“ There can be no one who has acted as Choyce’s
assistant in any capacity who does not wish to
praise him as a master. Once an assistant had gained
the confidence of the professor he was left to work
out his own lines of thought and action, secure in
C. C. CHOYCE
the knowledge that his judgment would be backed by
his chief in public, even if it were wisely and gently
criticised in private. He believed that his function
was to train men who would be capable of thinking
and acting for themselves when the time came, and
consequently his advice was seldom given unless
sought. Choyce was sometimes criticised for his
apparent inaction in relation to his assistants, and
although it is perhaps still too early to judge com-
pletely how wise it was, many of those who learned
to seek his advice and profit by it are now inde-
pendent surgeons and teachers who remember their
early training with gratitude.
‘““Choyce’s literary activities are well known
wherever surgery is practised and the English
language understood. Only one who has shared
them to some extent can understand the labour
which went into the production and re-editing of
‘The System.’ Nothing but the best was good
enough for this book. Choyce rightly felt it to be
the standard by which English surgery is judged in
many places where it is read of rather than seen, and
he was proud of the responsibility which this threw
on his shoulders. Personal surgical experience and
knowledge which he had in abundance were useful,
but not enough. In addition, he had the faculty,
born of a very wide association with the leading men
of his time, of knowing where to go for what he
needed, This, combined with never-failing tact and
THE LANCET]
unremitting labour, produced the work of which he
was so justly proud. Although it was the best
known of his works, ‘The System’ was by no means
the only one, and everything with which he had to
deal, either as author or editor, received the same
meticulous attention.”
Mr. E. K. Martin writes: “ When Choyce first
came to University College Hospital after the war
he was a comparative stranger to its staff and an
unknown quantity to the students. The whole-time
units were just starting in an artificial atmosphere
with determination towards their immediate success
and doubt as to their ultimate validity. The men
returning from the war regarded the intrusion of
women into the school with feelings of heat rather
than warmth. In the emotional tension of 1919,
and within the limited horizons of a medical school,
Choyce was a monument of kindly permanence.
He was confident in his ideals and he liked to help
his fellow-men. In this sense, ‘men’ included
women, and his encouragement did much to widen
the openings available to them in the hospital
Sympathy with youth was so natural to him that,
within a few years of his joining U.C.H., he became
the recognised confidant of anyone who wanted to
talk over or seek advice on the current problems of
his life. The annual residents’ play never omitted a
sympathetic caricature of ‘Papa’ Choyce. On com-
mittees he was a counsellor of moderation and a
mediator between differences of opinion.. His excep-
tional capacity for the working out of detail has a
permanent memorial in several of the recent buildings
and reconstructions at U.C.H: This same grasp of
detail, combined with wide knowledgeandagentle power
of persuading other people to fall in with his plans,
made his ‘System of Surgery’ the most successful
text-book of its type in the English language His
surgical work was characterised by a wide know-
ledge of established procedure and a sound judgment
of the men whom he had seen at work.”
A friend and colleague of 30 years’ standing
writes: ‘‘C, C. Choyce was a man with many friends
and no enemies; just the man to edit a System
of Surgery, for he could manage his team without
the whip ; just the man to run a surgical unit, for he
had no selfishness, no personal vanity, and no axe
to grind. He was a sound surgeon, of good judg-
ment, with no fads or fancies; a sane teacher. His
influence on those he taught will spread through
the next generation as a healthy leaven.”’
Throughout most of his time at U.C.H. Prof.
Choyce’s health precluded much work in the operat-
ing theatre, but with characteristic optimism he made
of this disability, which he so greatly regretted, an
opportunity for the encouragement and education of
his successors. The courage and equanimity with
which he faced the troubles which ill health threw
upon him in his later years was the admiration of all
who knew even a part of what these were. He was
61 years of age at the time of his death.
Prof. Choyce married the daughter of Mr. F. C.
Dobbin at Chislehurst, who survives him with a
daughter and son.
ALEXANDER CORSAR STURROCK, M.D. Edin.,
M.R.C.P. Lond.
THE death occurred at Eccles, near Manchester, on
March 27th of Dr. Alexander Sturrock, consulting
physician to the Salford Royal Infirmary, and well
known in the neighbourhood as a sound general
physician .especially well equipped in connexion with
OBITUARY
[APRIL 10, 1937 903
mental disease. A son of the late Mr. George
Sturrock of Linlithgow, he was educated at the
University of Edinburgh, where he took his degree
in arts in 1892, secured a Vans Dunlop scholarship,
and graduated as M.B., C.M. with first-class honours
in 1896. On proceeding to the M.D. degree two
years later he obtained the gold medal. Having
held resident appointments at the Grimsby Hospital
and the Manchester Royal Infirmary, he started in
general practice in Eccles, and in 1906 took the
diploma of M.R.C.P. Lond. During the war, with a
commission in the R.A.M.C., he acted as physician
to Sir Henry Norman’s hospital at Wimereux ;
later he served for two years at Salonica, was men-
tioned in dispatches, and retired with the rank of
major. He now engaged in consultant work at
Manchester and was appointed physician to the
Salford Royal Hospital. Here he displayed his
practical interest in mental disease, organising an
out-patients’ department at Salford in connexion
with the county mental hospital at Prestwick.
Dr. Sturrock occupied an important social position,
was a county magistrate, and an active politician
with Conservative views. He was 65 years of age
at the time of his death. .
JOSEPH PEREIRA GRAY, M.D. Brux., M.R.C.S.
THE death of Dr. Joseph Pereira Gray, who died
on March 13th in his sixty-ninth year, removed a
much respected and well-known figure from the
city of Exeter, in which he had practised for forty
years. .
Dr. Gray studied medicine at Charing Cross
Hospital, London, and at Brussels, taking the
M.R.C.S. Eng., L.R.C.P. Lond. in 1894 and
the M.D. degree of the University of Brussels,
with honours, in 1903. He was a prominent figure
in Exeter public life, holding the appointments of
police surgeon, medical officer to the City Hospital
and the Exeter Children’s Home, medical officer to
the Southern Railway, and visitor of Licensed Houses
under the Lunacy and Mental Deficiency Acts.
He was an honorary surgeon to the Exeter Dispensary
for twenty-five years, serving on the committee on
numerous occasions, and later being elected consulting
surgeon. He was keenly interested in ambulance
work, being the first surgeon to the Exeter City
Division of the St. John Ambulance, which was
founded in 1901, and remained its surgeon for very
many years, obtaining the long service medal, and
being elected honorary life member, lecturer, and
examiner to the St. John Ambulance Association.
A man of untiring energy and with an attractive
personality, he had a very large general practice,
his chief characteristic being an unfailing kindliness,
especially to his poorer patients.
GILBERT COCHRANE, M.B. Glasg.
THE death occurred recently at Birmingham
General Hospital of Dr. Gilbert Cochrane, who had
been M.O.H. of the Bromsgrove urban district for
the last ten years.
He received his medical education at the University
of Glasgow where he graduated in medicine in 1923.
He held resident appointments at the Staffordshire
General Infirmary and the Consumptive Sanatoria,
Bridge of Weir, and settled in practice at Bromsgrove
in 1926, when he was appointed M.O.H. of the
‘Bromsgrove urban district and medical officer for
the Bromsgrove, Droitwich, and Reddich joint
isolation hospital. He was also medical officer
to the Bromsgrove school and surgeon to the local
904 THE LANCET]
cottage hospital. The early termination of Dr.
Cochrane’s professional career is a distinct loss to
Bromsgrove and the district. His colleagues on
the staff of the Bromsgrove cottage hospital
recognised the soundness of his coöperation there,
while his work at the isolation hospital was highly
thought of by his authority. As M.O.H. of the
enlarged Bromsgrove district his duties were carried
out in a conscientious manner and marked by a
high standard of efficiency.
GEORGE HERBERT SPENCER, M.R.C.S. Eng.
Dr. G. H. Spencer, who died at his home at New-
castle after a brief illness on March 24th, practised
MEDICAL NEWS
[APRIL 10, 1937
on Tyneside for over thirty years, first at Wallsend
and afterwards at Newcastle. Born at Austerfield,
near Doncaster, he received: his medical training at
the London Hospital, and qualified with the English
double diplomas in 1900. He held resident appoint-
ments at the London Hospital and the Tynemouth
Infirmary, and was then appointed surgeon to the
Hospital for Sick Children at Newcastle-on-Tyne.
Having previously held a commission in the R.A.M.C.
(T.A.), he commanded the military hospital at
Catterick camp during the war with the rank of
lieut.-colonel, R.A.M.C. In the Tyneside he secured
by skill and personal popularity a large connexion.
He was 67 years of age at the time of his death, and
leaves a widow and two children.
MEDICAL NEWS
Royal College of Surgeons of England
On Monday next, April 12th, at 5 r.m., Mr. Philip
Wiles will deliver his Hunterian lecture which was post-
poned. He will speak on postural deformities of the antero-
posterior curves of the spine. Two Arris and Gale lectures
will be given by Dr. John Beattie at the same hour on
Wednesday and Friday, April 14th and 16th. His subject
will be the anatomical and physiological relations of the
hypothalamus and pituitary gland.
Society of Apothecaries of London
The May examinations for the diploma of the mastery
of midwifery will be held on Tuesday, Wednesday, and
Thursday, May 18th, 19th, and 20th, instead of on the
dates previously announced.
University of Aberdeen
At a graduation ceremony held on March 31st the hon.
degree of LL.D. was conferred on Mr. Naughton Dunn,
surgeon and lecturer in orthopedic surgery in the Uni-
versity of Birmingham. The diploma in public health
was conferred on Robert Fraser and S. T. G. Gray.
University of Dublin
At recent examinations at the School of Physic, Trinity
College, the following candidates were successful :—
FINAL MEDICAL EXAMINATION FOR M.B., B.OH., B.A.O.
Part I
Therapeutics and Pathology.—Myer Herman, G. E. Nevill
(first-class honours); F. D. F. Steede, Isabella M. Dorman
(second-class honours) ; Thaddeus Fallon, F. H. Counihan,
Deborah Bloom, Bernard Kernoff, H. M. Buchanan, M. F. X.
Slattery, J. L. Mans, J. W. Cathcart, T. W. Hanna, Jack Morris,
Nathan Marks, and Mary Conyngham.
Part II
Medicine. —William Hayes, H. F. Sloan, O. M. Harrison,
Sterling Tomlinson, G. K. Donald, R. W. Duncan, C. S!
Flood, Rebecca M. k. Pik e, H. M. Carson, end F J. B. Convery.
Surgery. — Eileen D. Maunsell, J. G. Steinbock (second-class
honours); P. J. Mullaney, Cecil Mushatt, G. C. Retz, S.
Toole, F. 3. B. Coney J. G. Cunningham D. J. H. Douglas,
P. L. van Aardt J. Reeves, Jobn McQuillan, and Max Levy.
Midwifery. —E. i. Cotas G. N. MacFarlane, M C. Brough,
R. E. Taylor, H. J. Walker (first-class honours); W. T. Kenny,
. E. Gillespie, Stella M. Coen, C. G. Reilly,
Charles Cunningh am, J. A. Strong, Jasmine Taylor, F. C.
MacFetridge (second-class honours); M. C.
Warnock, F. A. Hanna ra ae aga Pollock, Jack
Freedman, D. G. Harrison, Grace M . Wild Drury,
Patricia oe J. Conway, J. G. Nixon, J. B. e, S G. Heaton,
J. H. itchell, J. R. Steen, Ronald Brass, C. M.
Ludlow, ‘and Samuel Rubin.
D.P.H.
Part I.—T. A. Austin, Emily M. Booth, H. W. Dalton, and
Mary S. Miller.
D.G.O.
Koppel Tatz, M. M. Kriseman, Amin Wassef, and V. D.
Lespinasse.
Part II.—H. J. Eustace.
University of Sheffield
At recent examinations the following candidates were
successful :—
FINAL EXAMINATION FOR M.B., CH.B.
Part II and III.—Margaret G. Bell (with first - class honours) ;
Ronald W. Elliott, Sigmund Schutz, David Sata Ian B.
Sneddon (with second-class honours); Sydney R Adlington,
George K. Burton, Harry Cullumbine, Sa’dallah Khalil, Arthur
Naylor, Morris J. ’Pivawer, and George E. Robinson.
D.P.M.
Prof. Archibald Young and Dr. J. G. McCutcheon
have been appointed deputy lieutenants of the county of
the City of Glasgow.
University of Birmingham
Five William Withering lectures on nutrition and
nutritional disorders will be given at the University
during April and May. The first lecture will be given by
Prof. W. N. Haworth, D.Sc., on April 22nd, the next
two by Prof. J. C. Drummond, D.Sc., on April 29th and
May 6th, and the last two by Prof. L. G. Parsons on
May llth and 13th. All the lectures will be at 4 P.m. in
the medical faculty buildings, Edmund-street, and members
of the medical profession and students are invited to attend.
Institute of Medical Psychology
Twenty lectures on psycho-physical adaptation will be
given at the Institute on Thursdays at 3 p.m. by Dr.
Hugh Crichton-Miller and at 4.30 r.m. by Dr. Cedric
Shaw from April 22nd to June 24th. Further information
may be had from the educational secretary of the Institute,
Malet-place, London, W.C.1.
British Health Resorts Association
Next Saturday, April 17th, this association will hold
a conference at Skegness. The first discussion will are on
Industry and the Health Resort, to be opened by Mr
A. L. Peterson, speaking as an employer, followed by
Mr. Ernest Bevin and Dr. L. P. Lockhart. The second
will be on Games, Sport, and Sea-bathing in relation
to Health, and the speakers will be Sir Kaye Le Fleming,
Dr. R. Cove-Smith, and Dame Louise McIlroy. The
association, whose secretary is Dr. Alfred Cox, may be
addressed at 199, Piccadilly, London, W.1.
St. George’s poepital: :
ment
The treasurers of the hospital have received an anony-
mous gift of £5000 towards the cost of buildings and
equipping a psychiatric department in the new hospital.
In a letter accompanying the gift, the donor says,
“ St. George’s Hospital deserves active public support in
its decision to establish a large-scale psychiatric clinic.
The benefit to patients, staff, and students of making such
a clinic part of a general hospital cannot be too strongly
stressed.”
Mothers’ Clinics
The: annual Spring Ball in aid of the Mothers’ Clinics
will be held at Claridge’s Hotel on Tuesday, May 18th.
Dr. Marie Stopes, founder in 1921 of the Mothers’ Clinics,
will be chairman, and among other members of the com-
mittee and patrons are Mr. Lloyd George, Mrs. Stanley
Baldwin, the Duchess of Atholl, Miss Lilian Braithwaite,
Dr. Harriette Chick, Lady Bertha Dawkins, and Sir Alfred
Knox. The tickets are £2 2s. each, and may be obtained
from Dr. Marie Stopes, Norbury Park, Dorking, Surrey ;
Mrs. Stallard, 108, Whitfield-street, W.1; or from
Claridge’s Hotel. They cover the cost of the dinner and
the buffet, which will be running during the dancing.
A cabaret and sideshows have been arranged.
a New Psychiatric Depart-
THE LANCET]
MEDICAL NEWS
[APRIL 10, 1937 905
Mr. Philip Franklin has been elected hon. vice-
president of the American Institute for the Deaf-Blind.
Auxiliary Royal Army Medical Corps Funds
The annual meeting of the members of the funds will
be held at 5.15 p.m. on Friday, April 23rd, at 11, Chandos-
street, London, W.
Royal Institution
On Friday, April 16th, at 9 p.m., a lecture will be given
at the institution, 21, Albemarle-street, London, W.,
by Mr. T. Macara, F.1.C., who will speak on science and the
conservation of food.
Queen’s University Club, London
The spring dinner of this club will be held in the
Dorchester Hotel on Thursday, April 22nd. Further
information can be obtained from the secretaries, 101,
Harley-street, W.1. |
University of London Medical Graduates Society
The annual dinner of this society will take place in the
new buildings of the University at Bloomsbury, on
Thursday, May 6th, at 7.45 p.m. The guests of honour
will be Mr. H. L. Eason, Vice-Chancellor of the University,
and Mr. W. Girling Ball, dean of the faculty of medicine.
The annual general meeting of the society will be held
before the dinner at 7 P.M. in the University. The society
may be addressed at 11, Chandos-street, W.1.
Ophthalmological Lectures at University of Glasgow
A short course of lectures will be given at 5 P.M. on
Tuesdays from April 20th to May 18th at the Tennent
Memorial Building, Church-street, Glasgow. The lectures
will deal with leading symptoms in ophthalmology and the
lecturers will be Prof. A. J. Ballantyne, Dr. Chesar
Michaelson, and Dr. John Marshall. All interested
are invited.
Preventive Pediatrics |
The Association Internationale de Pédiatrie Préventive,
which is the medical section of the Save the Children
International Union, has deferred till September its annual
conference which was planned to take place in Rome this
Easter. The reason is that the International Child Welfare
Congress, which was to have met in Rome at Easter, has
been postponed to September. The secretary of the
association may be addressed at 15, rue Lévrier, Geneva.
National Association for the Prevention of Tuber-
culosis
The King has consented to become patron, and the
Duke of Kent president, of this association, which was
founded by King Edward VII, as Prince of Wales, in
1898. The chairman is Sir Robert Philip, who fifty
years ago established in Edinburgh the first tuberculosis
dispensary in the world.
The twenty-third annual conference of the association
will be held in Bristol from July lst to 3rd. The chief
subjects for discussion will be propaganda and publicity
methods ; preventive institutions with particular reference
to open-air schools; and the equipment and activities
of a tuberculosis dispensary. Further information may
be had from the acting secretary-general of the association,
Tavistock House North, Tavistock-square, London, W.C.1.
Fellowship of Medicine and Post-Graduate Medical
Association
F All-day courses during Apriland May will be as follows:
neurology, at the West End Hospital for Nervous Diseases
(April 19th: to 24th); proctology at the Gordon Hospital
(April 26th to May Ist); and psychological medicine,
at the Maudsley Hospital (April 26th to May 29th).
Afternoon courses will be given in dermatology at the
St. John’s Hospital (May 3rd to 29th), and in thoracic
surgery at the Brompton Hospital (May 24th to 29th).
Week-end courses will be held in infants’ diseases at the
Infants Hospital, (April 24th and 25th), in cancer at the
Royal Cancer Hospital (April 24th and 25th), in chest
diseases at the Brompton Hospital (May 8th and 9th),
in physical medicine at the St. John Clinic and Institute
of Physical Medicine (May 22nd and 23rd), and in children’s
diseases at the Princess Elizabeth of York Hospital
(May 29th and 30th). Further information may be had
from the Secretary of the Fellowship, 1, Wimpole-street, W.
Sheffield, 6995 beds were rated at an average of £1°51.
A Congress on Hormones
The Journées médicales internationales de Paris will be
held from June 26th to 30th under the patronage of the
Revue médicale française. The subject for discussion will
be the biological, clinical, and therapeutic aspects of
hormones. Prof. Paul Carnot will preside, and the
secretary-general is Dr. Godlewski.
National Institute of Industrial Psychology
After considering what steps should be taken to cope
with the increasing work of this institute, the council
has appointed Mr. T. G. Rose, M.I.Mech.E., general
director. He will collaborate with Dr. C. S. Myers, F.R.S.,
the principal, who will retain the position held by him since
the institute opened 16 years ago. The address is Aldwych
House, Aldwych, London, W.C.2.
King’s College Hospital
During the evening service at 5.30 P.M. on Sunday,
April 18th, a plaque will be unveiled in King’s College
Hospital chapel to the memory of Dr. Harold Wiltshire,
formerly one of the physicians to the hospital. At the
same service the endowment of a bed in memory of Mr.
Albert Carless, who was actively associated with the
medical school and hospital for nearly 40 years, will
be offered by his wife. The address will be given by
his friend, the Rev. Howard Banister, vicar of Wallington,
Surrey.
Progress of Cremation
In the annual report presented to the Cremation Society
recently it is stated that whereas ten years ago there
were 16 crematoria with 2877 cremations the numbers
last year were 33 and 11,289 respectively. The society,
whose headquarters are at 23, Nottingham-place, London,
W.1, conducts propaganda in favour of cremation and
makes arrangements for registration of the desire to be
cremated, and for assurance against the cost. The Inter-
national Cremation Congress is to be held for the first
time in England this autumn, meeting in the Guildhall,
London, from Sept. 24th to Oct. 2nd. The National
Association of Cemetery and Crematorium Superinten-
dents holds its twenty-second annual conference at Torquay
from June 28th to July Ist.
Rate Burdens on Hospitals
Emphatic protests against the crushing burden of rates
on voluntary hospitals, coupled with appeals from the
various institutions for a system of differential rating,
were made at the recent annual meetings of the Brighton
hospitals. It was stated at the court of governors of the
Royal Sussex County Hospital, the largest hospital in
the town, that 5s. in every £ received in subscriptions
had to be paid away in rates, and the other institutions
had similar experience in 1936 in proportion to their
size. At the annual meeting of one of the hospitals, the
mayor defended the position by stating that the law
forbade the authorities to do anything in the way of
differential rating. Brigadier-General d’A. C. Brownlow,
chairman of the governors of the Royal Sussex County
Hospital, replied to this statement by giving figures
regarding the rating of hospitals in other parts of the
country, and asked for an explanation of the difference.
He found, he said, that the 1656 beds in Sussex hospitals
were valued at an average of £7:13. In the adjoining
counties, including Canterbury, Tunbridge Wells, Guild-
ford, Winchester, Portsmouth, and Southampton, 1574
were rated at £3:64 per bed. Further afield, at the large
hospitals of Bristol, Birmingham, Hull, ope ie ae
18,
the chairman said, showed that some rating authorities
had found a way of giving preferential treatment to their
voluntary hospitals. Replying to a suggestion that the
corporation be asked to return the rates in the form of
an annual donation, if it were impossible to reduce the
assessment, he said the authorities had power to contri-
bute to hospitals up to 1:3d. in the £. The governors had
never asked the corporation to make such a donation,
and it had never been volunteered. He added that he
believed Portsmouth returned the whole of the rates in
the form of a grant.
906 THE LANCET]
VITAL STATISTICS.—APPOINTMENTS ,— VACANCIES
[APRIL 10, 1937
William Julien Courtauld Hospital, Braintree
The maternity ward of this hospital is to be given up
and used as a general ward. If £1500 is subscribed by
the end of June the president of the hospital, Mr. W. J.
Courtauld, will then build a RAERD wing to take ten
patients.
Kettering Hospital
A scheme has been inaugurated at Kettering to provide
hospital treatment for residents earning from £250 to £500
a year who contribute annually from £2 to £3. The sum
of £6000 has just been left to the hospital by Miss Walker.
Evesham Hospital
The committee has secured the land which adjoins
this hospital to allow of necessary extensions. The work is
increasing and a new out-patient department, casualty
ward, and ophthalmic clinic are needed. They will only
be part of a comprehensive development of the hospital.
Merseyside Hospitals Council
At the annual meeting of this council Lord Cozens-
Hardy stated that there are now 300,000 contributors
and the -voluntary hospitals and institutions received
from it £90,000 more than they obtained from the Saturday
and Sunday funds before the council was started. It is
hoped that with improving trade prospects it may be
possible to ask contributors for another penny a week and
thus bring the income up to £250,000.
INFECTIOUS DISEASE
IN ENGLAND AND WALES DURING THE WEEK ENDED
MARCH 27TH, 1937
Notifications —The following cases of infectious
disease were notified during the week : Small-pox, 0 ;
scarlet fever, 1530; diphtheria, 966; enteric fever,
20; pneumonia (primary or influenzal), 1181 ;
puerperal fever, 27; puerperal pyrexia, 99 ; cerebro-
spinal fever, 28; acute poliomyelitis, 3; acute
encephalitis lethargica, 7;
continued fever, 1 (Salford) ;, dysentery, 14;
ophthalmia neonatorum, 95. 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 April 2nd was 3345 which included: Scarlet
fever, 871; rater 1 1011; measles, 41; whooping-cough,
542 ; puerpera fever, 11 mothers (plus 7 babies) ; : encephalitis
lethargica, 282 ; poliomyelitis, 1 At St. Margaret’s Hospital
pee were 16 babies (plus 7 mothers) with ophthalmia neona-
orum.
Deaths.—In 122 great towns, including London,
there was no death from small-pox, 1 (0) from enteric
fever, 9 (1) from measles, 3 (1) from scarlet fever,
33 (7) from whooping-cough, 27 (3) from diphtheria,
48 (2) from diarrhoea and enteritis under two years,
and 98 (17) from influenza. The figures in parentheses
are those for London itself.
Derby re porved the only death from enteric fever. Hull
and Wolverhampton each had two deaths from measles. Fatal
cases of whooping-cough were scattered over 19 great towns ;
Liverpool had 4. Fatal diphtheria was reported from 18 great
towns—B ham 3, Burnley, Liverpool, Newcastle-on-Tyne,
and Wolverhampton each 2.
The number of stillbirths notified during the week
was 259 (corresponding to a rate of 43 per 1000
total births), including 40 in London.
polio- encephalitis, 1;
Appointments
JoRY, PHILIP, M.B. N.Z., F.R.C.S. Eng., Ear,
eg oron to the St. John Clinic, London.
F. . Eng., Medical Superintendent at the
neton and District Hospital.
PALIN, ANTHONY, B.M. Oxon., F.R.C.S. Edin., Hon. Assistant
Surgeon to the Bristol Eye Hospital.
PAYNE, R. VAUGHAN .Chir. Camb., F.R.C.S. Eng., Surgeon
to the Maidenhead Hospital.
SMITH, Ross, Ch.M.Sydney, F.R.C.S. Eng., Orthopsedic
Surgeon to the Royal Victoria and West Hants Hospital,
Bournemouth.
WALKER, V. R., M.B. Glasg., D.P.H., Medical Officer of Health
for Lowestoft.
WESTERMAN, ARTHUR, M.D. Aberd., Medical Officer to the
Mercers’ School, Holborn.
Porody mg Surgeons under the Factory and Workshop Acts:
G. LEVIcK (Bungay, Suffolk) and Dr. G. W. MAY
Ware, Hertfordshire).
Nose, and
V acancies
For further information refer to the advertisement columns
ave Royal ee ee Hosp.—Second Res. M.O.,
at rate o:
Baghdad, Royal College of Medicine—Prof. of Pathology
and Prof. of Bacteriology, each £150 a month.
Bangor, Caernarronshire a Anglesey Infirmary.—Sen. and
Jun. H.S., 8150 and £100 respectively.
Barnet, Victoria Cottage Hospital.—Children’s Physician.
urgeon. Also Gynecologist.
Parnaeu. Beckett Hosp.—Res. Surg. O., £300.
Barnstaple, North Devon Infirmary. — Res. M. O., at rate of £150.
Bath, Royal United Hosp.—H.S. to Ear, Nose, and Throat
Dept., at rate of £150.
Battersea ’ Borough Council's Maternity Hosp., Wandsworth
Common, S.W .—Res. M.O., at rate of £150.
Bedford County Hosp.—Second H. S., at rate of £150.
e nei Canwell Hall Babies’ Hosp. —Res. M.O., at rate of
Birmingham, Coleshill Hall. —Res. Asst. M.O., £350
Birmingham, tee road Hospital.— Jun M.O., at rate of £200.
Birmingham, Maternity and Child ed Dept .—Three Temp.
.O.’s, each £10 per week.
Bootle General Hosp.—H.S., at rate of £150.
Bournemouth, Royal National Sanatorium.—Med. Supt., £800.
Also Res. Asst. M. O., £200.
pradfora, City Sanatorium, Grassington.—Asst. M.O., £175.
radjord, Re Royal Eye and Ear Hospital..—H.S., £1
Bn Royal Alexandra Hosp. for Sick Children. —H. S., £120.
Burton-on-Trent General Infirmary.—H.8., £150.
Cardiff Royal Infirmary.—H.S. to Ophth. ‘opt, at py of £80.
Chester, Barrowmore Tuberculosis Sanatorium ‘and Settlement,
Great Barrow.—H.P., at rate of £150.
Chesterfield and North Derbyshire Royal Hosp.—H.S. to Ophth.
and Ear, Nose, and Throat Dept., at rate of g- D
Chichester, Royal West Sussex Hosp. fe un. eH S., £125.
Connanghd Hosp., Walthamstow. oe » at ata ‘ot, £100.
, Guest Hosp.—Second H.S.,
Bashers. Princess Alice Hospital. sa H.S., £15
Edgware, Redhill County Hosp.—Asst. Pathologist, aa,
Edinburgh Royal Infirmary. me u: Asst. Radiologist, £250.
Glasgow Eye Infirmary.—Res. £150.
Grimsby and District Hosp.—J Ta Sr S., £150.
Guildford, Royal Surrey County Hosp. ~~ Asst. Pathologist, £500.
Hampstead General and N.W. London Hosp., Haverstock Hill,
N.W.—H.S., at rate of £100.
Harrogate Clinical Laboratory.—Clinical Pathologist, £450.
Harrogate, Royal Bath Hosp.—Res. M.O., £156.
Hastings, Royal East Sussex Hosp.—Sen. H.S., at rate of £200.
Hertford ‘County Hospital.—Sen. H.S., at rate of £200
Hosp. for Diseases of the Skin, Blackfriars, S.E. —Pathologist.
Also Clin. Assts.
Hosp. for Sick Children, Great Ormondad-street, W.C.—Out-patient
Med. Reg., £175.
Hove General Hosp. —Jun. Res. M.O., £120.
Huddersfield Royal Infirmary.—Two HS.’ s, each at rate of £150.
Ilford Borough.—Res. M.O. for Maternity Home, £350.
Kettering and District General Hosp.—Res. M.O. and Second Res.
M.O., at rate of £175 and £125 respectively.
Lancashire County Council.—Consultant Obstetrician, £1000.
Leigh Infirmary, Lancs.—Jun. Res. H.S., at rate of £150.
Lincoln County Hosp.—Jun. H.S., at rate of £150.
Liverpool Sanatorium, Delamere Forest, Frodsham.—Sen. Asst.
to Med. Supt., £350.
London County Council.—Asst. M.O.’ s, Grade I, £350. Also
Asst. M.O.’s, Grade II, £250.
mae J oboe Hosp., Stepney Green, E.—Asst. Anesthetist,
$
Macclesfield General Infirmary.—Second H.S., at rate of £150.
Manchester, Ancoats Hosp.—Radiological Officer, £300.
Manchester, Baguley Sanatorium.—Res. Jun. Asst. M.O., £250.
Mar a wean Hall Hosp. for Children. —Deputy Med.
up
Manchester Royal Infirmary, &c-—Travelling Scholarship in
Medicine, £300. Also Scholarship in Pathology, £75.
Metropolitan Hosp., Kingsland-road, &.—Sen. and Jun. H.P.’s
and H.S.’s. Also Cas. O: and Res. Aneesthetist, ‘each at
rate of £100.
Ministry of Heaul Whitehall, S.W.—Temp. Serologist, at
Hosp., Gower-street, W.C.—Hon. Asst.
National Temperance Hosp., Hampstead-road, N.W.—H.P., at
rate of £100.
Newurk General Hosp.—Res. H.S., £175.
Newcastle-upon-Tyne, Royal Victoria Infirmary.—Hon. Surgeon.
Newcastle-on-Tyne, Wooley Sanatorium, near Hexham.—aAsst.
Northwood, Mount Vernon Hosp —H. a At rate of £150.
Norwich Isolation Hosp.—Res. M.O.,
Noy. Norfolk and Norwich Hosp. easy S. to Spec. Depts.,
Nee en General Hosp.—H.S.to Spec. Depts. and Res. Cas.
each at rate of £150
Ocean O77 gach £c., Central Pacific. —Asst. M.O., £500
Qtaham, Boundary Park Municipal Hosp. —Res. A. M. O., at rate
20
Plymouth, Prince of Wales's Hosp., Devonport.—Jun. H.S., at
rate of £120.
h and Southern Counties Eye and Ear Hosp.—HS.
£150.
Portsmouth Royal Hosp.—H.8., at rate of £1380.
E rnea Keatrice Hospital, Earl's Court, S.W.—Med. Reg.,
guineas
Princess Louise Kensingten Hosp. for Children, St. Quintin-
avenue, 1’.—Hon. Radiologist.
THE LANCET]
Queen’s Hospital for Children, Hackney-road, E.—H.S., at rate
of £100. Also Clin. Asst. for Med. Out-patient Clinics,
5s. per attendance.
Reading, Royal Berkshire Hosp.—hH.S., Cas. O., also H.S. to
Spec. Depts., each at rate of £150.
Rochester, St. Bartholomew’s Hosp.—H .S., at rate of £150.
Rotherham Hosp.—Hon. Aneesthetist.
Royal Chest Hosp., City-road, E.C.—Res. M.O., at rate of £150,
also Med. Reg., £50.
Royal College of Physicians, Pall Mall East, S.W.—Prophit
Scholar, £400.
Royal Free Hosp., Gray's Inn-road, W.C.—Asst. Physician to
or of Physical Medicine. Also Res. Asst. Pathologist,
50.
Royal Naval Medical Service.—M.O.’s.
Royal Northern Hosp., Holloway,'N.—H.S., at rate of £70.
Royal Waterloo Hosp. for Children, &c., W aterloo-road, S.E.—
Res. Cas. O. and H.P., at rate of £150 and £100 respectively.
Salisbury General Infirmary.—Res. M.O., £250.
Sheffield Children’s Hospital.—HH.S., at rate of £100.
Sheffield, Jessop Hosp. for Women.—U.S., at rate of £100.
Sheffield Royal Hosp.—Clin. Asst. to Ophth. Dept., £300.
Sheffield University, Dept. of Bacteriology.—Asst. Bacteriologist
and Demonstrator, £500.
Shrewsbury, Royal Salop Infirmary.— Res. H.P., at rate of £160.
Siepney Metropolitan Borough.—Deputy and Asst. M.O.H., £750.
Sunderland Royal Infirmary.—Cas. O., £150. Also two H.S.’s,
each £120.
Surrey County Council Mental Hospital's Service.—Jun. Asst.
Convalescent Homes,
M.O.’s. each £350.
Parl-wood.—Res.
M.O., at rate of £200.
Swanley, Kent, Hosp.
Swansea, Adelina Patti Hosp.—H.P., at rate of £150.
Swansea General and Eye Hosp.—Cas. O., at rate of £150-£175.
Swindon Borough.—Deputy M.O.H. and Asst. School M.O.,
£600.
Taunton and Somserset Hosp.—H.S., at rate of £100.
Torquay, Torbay Hosp.— H.P. and H.S., each £175.
Victoria Hosp. for Children, Tite-street, S.W.—Cas. O., at rate
i of £200.
Wallasey, Victoria Central Hosp.—Jun. H.S., £150.
West Bromwich, Hallam Hosp.—H.P., at rate of £200.
Wesen Ophthalmic Hosp., Marylebone-road, N.W —Jun. Res.
D, 6100.
Westminster Hosp., Broad Sanctuary, S.W.—Asst. M.O. in
X Ray and Electrical Dept.
Whitechapel Clinic, Turner-street, E.—Asst. Pathologist, £500.
Wickford, Essex, Runwell Hosp.—Asst. Res. Physician, £350.
Winchester, Royal Hampshire County Hosp.—H.S., at rate of
£125
Wolverhampton Royal Hosp.—H.S.’s, each at rate of £100.
Woolwich and District War Memorial Hosp., Shooter’s Hill, S.E.—
H.P.and H.S., each at rate of £100.
York Dispensary.—Res. M.O., £175.
The Chief Inspector of Factories announces vacancies for
Certifying Factory Surgeons at Newport (Monmouth),
Edgware (Middlesex), Paisley (Renfrew), Kilbride (Renfrew),
and St. Austell (Cornwall).
Medical Referee under the Workmen’s Compensation Act
1925, for the Dewsbury, Leeds, Otley, and Wakefield
County Court Districts (Circuit No. 14). Applications
should be addressed, the Private Secretary, Home
Whitehall, London, S.W.1, before April 26th.
e Medical Diary
Information to be included in this column should reach us
én 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, April 12th.
United Services. 4.30 P.M. Annual General Meeting.
Surg. Commander J. C. Souter: Fungus Infection
of the Skin of the Feet.
TUESDAY.
Psychiatry. 8.30 P.M. Dr. C. P. Symonds:
Disorder following Head Injury.
FRIDAY.
Physical Medicine. 3.30 P.M. (St. John Clinic and
Institute of Physical Medicine, Ranelagh-road, S.W.)
ue General Meeting. 4.30 P.M. Demonstrations
and cases.
Obstetrics and Gynacology. 8P.M. Mr. Everard Williams :
Infection in the Cervix Uteri. Dr. R. A. Wilson (New
York): Prevention of Asphyxial Death in the New-
born (with film)
Radiology. 8.30 P.M. Dr. Courtney Gage and Dr. S.
Cochrane Shanks: Lesions and Special Methods of
Investigation of the Alimentary Tract. Dr. R. BS.
Paterson and Dr. G. B. Bush will also speak.
Office,
Mental
BRITISH INSTITUTE OF RADIOLOGY, 32, Welbeck-
street, W.
THURSDAY, April 15th.—8 P.M., Dr. M. H. Jupe: The
Reaction of the Bones of the Skull to Intracranial
Lesions. ,
HARVEIAN SOCIETY.
THURSDAY, April 15th—8.30 P.M. (26, Portland-place, W.),
Dr. John Taylor: Some Causes of Sudden Death—
Common and Uncommon—from the Medico-Legal
Standpoint.
HUNTERIAN SOCIETY.
MonpDAY, April 12th.—8.30 P.M. 2 Sarr a Restaurant,
Cheapside), Annual General Meeting. Dr. L. Haden
Guest: Air-raid Precautions.
MEDICAL DIARY
[APR 10, 1937 907
SOCIETY FOR THE STUDY OF INEBRIETY.
TUESDAY, April 13th.—4 P.M. (11, Chandos-street, W.),
Dr. John Dent: The Environmental Factors in the
Causation and Prevention of Alcoholism.
NORTH LONDON MEDICAL AND CHIRURGICAL
SOCIETY, Royal Northern Hospital, Holloway-road, N.
FRIDAY, April 16th.—9.15 P.M., clinical evening.
PADDINGTON MEDICAL SOCIETY.
TUESDAY, April 13th.—9 P.M. (Great Western Royal
Hotel, Paddington), Dr. T. O. Hunt: The Abdomina!
Quartette (Colon, Appendix, Stomach, and Gall-
bladder).
SOUTH-WEST LONDON MEDICAL SOCIETY.
WEDNESDAY, April 14th.—9 P.M. (Bolingbroke Hospital,
Wandsworth Common), Mr. Claud Mullins: Marriage,
the Doctor, and the Police-court.
LECTURES, ADDRESSES, DEMONSTRATIONS, &c.
ROYAL COLLEGE OF SURGEONS OF ENGLAND, Lincoln’s
Inn-fields, W.C.
MonDay, April 12th.—5 P.M., Mr. Philip Wiles: Postural
Deformities of the Antero-posterior Curves of the
Spine. (Hunterian lecture.)
WEDNESDAY and FRIDAY.—5 P.M., Dr. John Beattie:
The Anatomical and Physiological Relations of the
Hypothalamus and Pituitary Gland. (Arris and
Gale lectures.)
BRITISH POSTGRADUATE MEDICAL SOHOOL, Ducane-
road, W. i
MONDAY, April 12th.—2.30 P.M., Dr. ©. W. Buckley:
Arthritis.
WEDNESDAY.—Noon, clinical and pathological conference
(medical). 2.30 P.M., r. ray: Diagnosis of
Malignancy. 3.15 P.M., clinical and pathological
conference (surgical). 4 P.M., Mr. J. E. H. Roberts:
Surgery of the Chest. 4.30 P.M., Dr. W. E. Gye:
Experimental Cancer Research. ;
THURSDAY.—Noon, clinical and pathological conference
(obstetrical and gynæcological). 2.30 P.M., Dr. Duncan
White: Radiological Demonstration. 3.30 P.M.,
; K. Henry: Demonstrations of the Cadaver
of Surgical Exposures. 3.30 P.M., Mr. Wilfred Shaw :
Irregular Uterine Heemorrhage.
FRIDAY.—2 P.M., operative obstetrics. 3 P.M., department
of gynecology, pathological demonstration. ;
Daily, 10 A.M. to 4 P.M., medical clinics, surgical clinics and
operations, obstetrical and gynæcological clinics and
operations.
WEST LONDON HOSPITAL POST-GRADUATE COLLEGE,
Hammersmith, W.
Monpbay, April 12th.—10 a.M., Dr. Post: X Ray Film
Demonstration, skin clinic. 11 A.M., surgical wards.
2 P.M., operations, surgical and gynæcological wards,
medical, surgical, and gynecological clinics. 4.15 P.M.,
Mr. Arnold Walker: Breech Presentations.
TUESDAY.—10 A.M., Medical wards. 11 A.M.,surgical wards.
2 P.M., operations, medical, surgical, and throat
clinics. 4.15 P.M., Mr. Hamblen Thomas: Rhinitis,
including Hay-fever.
WEDNESDAY.—10 A.M., children’s ward and clinic. 11 A.M.,
medical wards. 2 P.M., gynescological opora: ani,
medical, surgical, and eye clinics. 4.15 P.M., . Gibb :
Demonstration of Eye Cases.
THURSDAY.—10 A.M., neurological and gynecological
clinics. Noon, fracture clinic. 2 P.M., operations,
medical, surgical, and genito-urinary and eye clinics.
FRIDAY.—10 A.M., medical wards, skin clinic. Noon,
lecture on treatment. 2 P.M., operations, medical,
surgical, and throat clinics. i
SATURDAY.—10 A.M., children’s and surgical clinic. 11 A.M.,
medical wards. ez
The lectures at 4.15 P.M. are open to all medical practitioners
without fee.
FELLOWSHIP OF MEDICINE AND POST-GRADUATE
MEDICAL ASSOCIATION, 1, Wimpole-street, W.
MONDAY, April 12th, to SATURDAY, April 17th.—RovYal.
EYE HOSPITAL, St. George’s-circus, S.E., afternoon
course in ophthalmology.—Wed. and Thurs., plastic
surgery course at various hospitals.—PaRK HOSPITAL,
Hither-green, S.E. Sat. and Sun. course in infectious
diseases.—These courses are open only to members
of the Fellowship.
NATIONAL HOSPITAL FOR DISEASES OF THE HEART,
Westmoreland-street, W.
TUESDAY, April 13th.—5.30 P.M., Dr. T. F. Cotton:
Some Clinical Aspects of Myocardial Disease.
HOSPITAL FOR SICK CHILDREN, Great Ormond-street,
WwW
.C. `
THURSDAY, April 15th.—2 P.M., Dr. Reginald Lightwood :
Interpretation of Splenic Enlargement. 3 P.M., Dr. A.
Signy: Modern Aspect of Diphtheria. | -
Out-patient clinics daily at 10 a.m. and ward visits at 2 P.M.
aia ele FOR EPILEPSY AND PARALYSIS, Maida
ale, W.
THURSDAY, April 22nd.—3 P.M., Dr. Wyllie: Demonstration.
ST. JOHN CLINIC AND INSTITUTE OF PHYSICAL
MEDICINE, 42, Ranelagh-road, S.W. ;
FRIDAY, April 16th.—4.30 P.M. Demonstrations of cases
by members of the visiting staff.
MANCHESTER ROYAL INFI ARY.
TUESDAY, April 13th.—4.15 P.M., Dr. A. Ramsbottom :
Infections of the Gall-bladder.
FRIDAY.—4.15 P.M., Mr. R. L. Newell: Demonstration
of Surgical Cases. .
GLASGOW POST-GRADUATE MEDICAL ASSOCIATION.
WEDNESDAY, April 14th.—4.15 P.M. (Lock Hospital),
Dr. David Watson: Venereal Disease in Women.
908 THE LANCET]
[APRIL 10, 1937
~ NOTES, COMMENTS, AND ABSTRACTS
MUSIC IN THE FACTORY
(BY AN OCCASIONAL CONTRIBUTOR)
IN tackling seriously the subject of boredom in
industrial workers the Industrial Health Research
Board?! has undoubtedly come to gripswith one of the
major problems of modern life for here, at bottom,
lies the secret of strikes, revolutions, wars and the
rumours of wars. The bulk of humanity have had
to sell their birthright for a mess of pottage and
no wonder they have proved fractious and dis-
contented bargainers. The replacement of crafts-
manship by mass production has bereft many of the
individuality which was a sufficient compensation
for poverty. The carver of Chippendale chairs or
the moulder of Chelsea figures had probably to work
long, hard and for little gain, but he had also the
never-failing satisfaction of seeing his own work and
of knowing that it was good.
The investigations dealt with in a recent report
on boredom in repetitive industry are conceived
on the simple lines no doubt essential in the pre-
liminary study of such a complex problem as this.
The subjects of the investigations were four groups of
factory girls working at chocolate packing, cracker
making, and ‘‘ tying small blocks in calico.” These
jobs are no doubt deadly dull, but not more so than
those which engage the majority of factory workers.
A short questionnaire was devised, the answers to
which were calculated to give some general idea of the
psychological reactions of the worker to her work.
The outcome of the inquiry can be anticipated, but
it is none the less pitiable. Of 355 workers, only
3 per cent. expressed no sign of boredom, 33 per cent.
were slightly affected, 38 per cent. experienced a
moderate degree, and 26 per cent. suffered severely.
Temperamental differences accounted for a good deal
of variation in the amount of boredom suffered, and,
understandably enough, the more intelligent type of
worker suffered most severely. It is possible that
women, who look elsewhere than in hired work for
the fulfilment of their lives, suffer more than men,
but many of them have their day-dreams for com-
pensation. Men on the other hand are more given
to kicking against the pricks and they shoulder their
burden knowing it will stay with them while health
and life last. The writers of the report study many
causes of discontent among workers. Questions of
promotion, security, supervision, wages, hours of
work, &c., have all their contributory effects, but the
radical remedies for these are matters too inflammable
to be the subject of official reports. The investigators
make, however, one valuable positive contribution
to the prevention of boredom in industry. They
found that gramophone records played at chosen periods
during the day had a marked alleviating effect on the
symptoms. Almost all the workers, we are told,
“ responded to the music by an increased output.”
The average increase in output while the music was
actually being played was 6'2 to 11°3 per cent.
An inquirer of another age might well wonder why
the ingenuity of psychologists could not have devised
a more delicate test for human contentment than
an increased output of chocolate boxes, but we are
in a century when the still small voices of humanity
are liable to be drowned in the clash of machinery and
the rattle of cash registers. Music the antidote to
misery—an old theme with ever new application !
The caged linnet sings away its captivity. The
chain gangs and the galley slaves sang their rhythmic
1 Fatigue and Boredom in Repetitive Work. By S. Wyatt
and J. N Langdon (assisted by F. G. L. Scott). Medical
Research Council: Industrial Health Research Board. Report
No. 77. H.M. Stationery Office. 1937. Pp.77. 1s. 3d
catches as they strained and sweated. The old
mariners found their shanties helped them to weigh
the anchor and to endure their hardships. The
negroes in the cotton fields, no doubt, increased their
output in bales with their plantation songs and the
Volga boatmen who, if music and elementary
geography go for anything, lived a hard and bitter
life, probably got a 10 per cent. increase in speed by
singing their stirring boat-song. But now when
division of labour is an inexorable law and the
discipline of the factory has advanced beyond that
of the chain gang, the music too is no longer
e oyal ‘but must be provided by mechanical
evices.
There is music like the Liebestod from- Tristan
or the last movement of the Fifth Symphony which
must be received head between hands and in semi-
coma, The investigators who, no doubt, had share-
holders to consider made no experiments with this
ind of music. Of the types they tried “light
orchestral music ”?” seems to have had least effect
and this we take as welcome evidence that our factory
girls, though sore beset, have still sturdy souls. It
was the youthful and stimulating music which goes
by the name of “ jazz ” or ‘‘ rhythm ” that was found
to be the best antidote to boredom. ‘‘ It is generally
agreed ” say our investigators gravely, ‘‘ that rhythm
induces a pleasant emotional effect which acts as a
more favourable background for production.”
But we should like to have more precise details as
to the nature of the successful music. The investi-
gators give the impression that a studious and
sheltered life may have made them insensible to the
finer distinctions of rhythmic music. It is not
enough to classify their records as waltzes, one-
steps, or fox-trots. There are fox-trots and fox-
trots, and dance bands and dance bands, and of this
an industrial psychologist could convince himself
if he compared the incomes of the “ kings of jazz.”
Is the output as great with the music of Duke
Ellington as with that of Irving Berlin? We can
imagine shuffling chocolates to Ellington’s neolithic
measures, but not packing them, The astute psycho-
logists of Radio-Normandie seem to find that the
Blue Danube and the Lily of Laguna, old as they are,
have a specially potent effect in helping mothers of
families through their daily chores and in keeping
them diligently dosing their children with vitamins,
laxatives, and. antacids. The Blue Danube may
suit the mangle yet fail with “ tying small blocks in
calico.” There is obviously a field for further inquiry
here and the services of Mr. Charles Cochrane,
Mr. Ambrose, or Mr. Roy Fox might be advan-
tageously codpted for the investigation.
But, when all is said, this question of boredom
in the modern world is a desperately serious and
important affair and well worth the continued
attention of the Industrial Health Research Board.
There is much to be done and it is satisfactory to
see that a good start has been made. The medical
man, himself a worker who, whatever his misfortunes,
rarely knows boredom, may well be moved, by the
picture given in this report of the soul under the
industrial system, to see, as it were, the naked nerve
touched by the experimenter’s probe. But lest he
look back too regretfully to the simple life of the
old world, let us quote from another observer as
impersonal as the writer of government reports and
infinitely more callous :—
‘“ ,. certains animaux farouches, des mâles et des femelles,
répandus par la campagne, noirs, livides et brûlés du
soleil, attachés à la terre qu’ils fouillent et qu’ils: remuent
avec une opiniatreté invincible: ils ont comme une voix
articulée ; et quand ils se lévent sur leurs pieds, ils mon-
trent une face humaine; et en effet, ilssont des hommes.”
And there were no gramophones, radios, cinemas,
or football pools under the old régime.
THE LANCET]
1
NOTES, COMMENTS. AND ABSTRACTS
[APRIL 10, 1937 909
NOISY MOTOR VEHICLES
IN 1934 the Minister of Transport set up a Depart-
mental Committee to advise him on the measures
that should be taken to alleviate noise from motor
vehicles. The Committee, of which Mr. G. W. C.
Kaye, D.Sc., of the National Physical Laboratory is
chairman, embarked on a programme of research on
all classes of mechanically propelled vehicles both
under normal conditions and under somewhat extreme
conditions of misuse. In pursuance of this pro-
gramme, an elaborate series of tests were undertaken
by the National Physical Laboratory.
The Committee has issued three reports in all.
In the first two, published in 1935 and 1936, newly
manufactured vehicles of all classes came up for
review, and the Minister was recommended to con-
sider the advisability of setting up a standard of
noise to which all such vehicles should conform
under certain specified conditions of test. In terms
of the new unit of loudness, the standard suggested
was 90 phons at a distance of 18 feet sideways from
the vehicle or 25 feet to the rear. This is, in point
of fact, a very moderate demand and one to which
the majority of motor-cars already conform, while
other vehicles, including sports cars and lorries, can
readily be made to do so. Motor-cycles present
greater difficulties, but the industry is already trying
to overcome them; and to give it breathing-space,
the Committee proposed that motor-cycles should be
allowed 5 phons’ grace for a period of two years.
The third report of the Committee, which has just
been issued by His Majesty’s Stationery Office (1s.),
deals with “ old ” or ‘‘ used ”? vehicles on the road.
Loudness measurements have been conducted under
@ variety of conditions on some 600 vehicles typical
of ‘the chief types. The results fall within the limits
70 to 105 phons, the latter value corresponding to
that of a noisy road drill. The Committee now
propose that the noise limit on the road should be
95 phons, which is roughly equivalent to the noise
in a tube train, the relevant tests being identical
with those suggested for new vehicles. It is proposed
that this limitation of loudness should apply at first
only to vehicles registered after an appointed day,
but that two years thereafter it should apply to
vehicles of any age. |
It is clear that the modest requirements suggested
by the Committee in its several reports would, if
given effect, achieve its first objective of suppressing
the outstanding noise pests on the road. In the
future the industry, which is free to solve its problems
in its own way, should not only be able to meet the
proposed noise limits with comparative ease, but
should enable the limits to be lowered as time goes on.
The Committee, which was given a difficult task,
has earned the thanks of those who wish to create
acoustical decency on the roads. At the Minister’s
request it is now investigating the noise of motor-
horns, so as to advise him whether action might
usefully be taken to abolish the more offensive types.
GUIDANCE TO CAREERS
AN exposition of the methods of vocational guid-
ance ! designed for the layman should dispel any
fears about the limitations of cut and dried scientific
method as a means of estimating the complex poten-
tialities of the adolescent. Applicants for vocational
guidance are not, as is popularly supposed, guided
on the results of a few isolated tests. The results
of the test material (which is in itself exceedingly
varied) are in each case considered in conjunction
with extensive reports from parents, teachers, and
in some instances from the child himself. Personal
interviews are given, and the report finally produced
1 Tho Handbook of Vocational Guidance. By C. A. Oakley
B.Sc. Eng., Ed.B., Scottish Divisional] Director of the Nationa
Institute of Industrial Psychology ; and Angus Macrae, M.A.,
M.B., lately Head of the Vocational Guidance Department of the
Institute. London: University of London Press. 1937.
Pp. 337. 108. 6d.
aims at constructive advice with regard not only to
the candidate’s ability, but to his health, financial
circumstances, and personal inclinations. The reader
is left with the conviction that vocational guidance
is still and perhaps always will be less a science than
an art—half intelligent interpretation of given facts
and half sympathetic understanding. The first part
of the handbook explains test material and methods
of testing, grouped under tests for special ability.
This is followed by a chapter given up to the detailed
analysis of the cases of John Jones and Elizabeth
Brown. ‘These standard cases do much to explain .
the methods followed by the National Institute of
Industrial Psychology, but could with advantage be
shortened in presentation. The section on occupa-
tional requirements should prove useful to advisers
on careers, and the tables of qualities and abilities
required in various careers (which are plotted against
the average scholastic level at the school certificate
stage—16 to 17 years) are of special interest.
It is a difficult task to present a vast body of
highly specialised knowledge in a form which the
average layman can understand and digest. More
careful attention to the plates would have added to
public interest; those included provide “close-ups”
of vocational guidance officers and children being
tested but do not really make the test material clear.
In a future edition simple diagrams or photographs
of the test boards in surface view would be welcome
additions. There is, however, plenty of absorbing
detail in the text, which is full of information.
THE STAYPUT BED SUPPORT
THE support here illustrated is primarily a sub-
stitute for the pillow tied under the knees of a
patient in Fowler’s position. It is also said to
be useful in nursing a gynecological, heart, or
eye case and after confinement. It consists of
a stout but light metal
frame, over which is
fitted a square pad
of spongey Dunlopillo
rubber. The edges of
the frame and the weight
of the patient are gener-
ally enough to prevent
the support from slip-
ping down the bed, but
if needed there are linen
bands which can be
clipped to the bed-
frame. When not
required for the sitting
position the support
may be used as a pillow, foot-rest, or arm-rest, or
the pad when detached itself makes a comfortable
pillow. Both the frame and the pillow can be disin-
fected but each has a cloth cover that can be quickly
removed for washing.
The Pappo is made by the Stayput Bed Support
Co., 47, High-street, Camden Town, London, N.W.
A CLASSICAL MANUAL ON CHILD WELFARE
MANY years’ work at the pioneer infant welfare
centre opened at the St. Marylebone General
Dispensary in 1906 gave Mrs. Langton Hewer the
experience embodied in a little book! which has
now reached its twenty-first edition. Being herself
unable to undertake the work of revising this edition
Mrs. Hewer has handed it over to Dr. Sophia Friel
(also connected with the Marylebone Welfare Centre)
who has successfully brought it up to date without
materially altering its original character. Much
information is packed into its 167 pages, and advice
can here be found on most matters germane to
——
1 Our Baby: For Mothers and Nurses. 21st edition. By
Mrs. J. Langton Hewer, S.R.N., C.M.B., late hospital ward sister.
Revised by Sophia Seekings Friel, M.D., B.S., D.P.H. Bristol :
John Wright and Sons, Ltd.; London: Simpkin Marshall Ltd.
1936. Pp.167. 2s. 6d.
910 THE LANCET] NOTES, COMMENTS, AND ABSTRACTS.—BIRTHS, MARRIAGES AND DEATHS [APRIL 10, 1937
mothercraft ranging from the onset of pregnancy to
the character training of toddlers. It is essentially a
ractical book and the author does not theorise,
ut in places it is perhaps too complicated and full
of alternative suggestions for the average mother or
child’s nurse; but monthly and welfare nurses, for
whom also presumably it is written, will not find.
this a defect. In the chapter on infant feeding it is
surprising that whereas such things as peptonised
feeding are described in some detail no mention is
made of lactic acid milk. Excellent emphasis is
_ laid upon the importance to the infant of fresh
moving air and the correct balance of rest and
exercise. The last few chapters are devoted to a
discussion of childish ailments, accidents, and illnesses,
and contain much sound advice. There is a chapter
dealing with the care of infants in the tropics, a short
bibliography, and a good index.
We are informed that nearly two hundred thousand
copies of this book have been sold; it remains one
of the best of its kind. ;
MEDICAL ACTIVITIES FOR LAY READERS
THE increasing popular demand for superficial
knowledge on various topics fostered by certain
organs of the press and not altogether discouraged
by the B.B.C. has produced a spate of small books of
which a typical example is one entitled Science
Fights Death.: Herein the progress and problems of
modern medicine are thinly though not inaccurately
discussed in non-technical language. Bacteriology
and infectious diseases, parasitology, virus diseases,
the endocrines, plastic surgery, industrial and blood
diseases, and the cancer problem are some of ‘the
things touched upon; the author is to be forgiven
if he has chosen the more cheerful and dramatic
themes, for it is well known that laymen are always
more interested in the potentialities of a subject than
in its limitations. Moreover, the doctor lured,
however unwillingly perhaps, at a dinner-party to
talk about his job, might do worse than take this book
as a model of how to ‘ put over ” snippets of informa-
tion in a manner calculated not to bore the casual
listener.
NEW PREPARATIONS
ACROSONE.—The advantages claimed for this
antiseptic are that it is neither poisonous, irritating,
nor corrosive, giving a relatively clear solution in
water and having a Rideal-Walker coefficient of 13.
It is slightly oily, and this discourages adhesion of
dressings to wounds. For the sterilisation of instru-
ments immersion in a 20 per cent. solution for ten
minutes is said to suffice. The use of Acrosone is
also advised for cleaning septic wounds, for vaginal
douching, for sterilisation of hands and skin, for
rinsing ulcerated mouths, and for treating cutaneous
sepsis. It is made by James Woolley Sons and Co.,
Ltd., Victoria Bridge, Manchester 3. è
BILRON is a mixture of iron and bile acids in the
form of ferric bile acids. It is soluble in alkaline
solution, but almost insoluble in water and acid
media, and it may therefore be taken by mouth
without special enteric coating. Its administration
is suggested wherever stimulation of secretion of
bile is desired—e.g., in dyspepsia due to hepatic
insufficiency and in some forms of constipation and
of migraine—and also during surgical drainage of the
biliary tract. The manufacturers of Bilron (Eli
Lilly and Co., Ltd., 2, Dean-street, London, W.1),
refer to unpublished observations by Kohlstaedt and
Rosenak on the usefulness of iron bile salts in cases
of cholecystitis without stones. The product is
sold in 5-grain Pulvules (filled capsules).
. SOLUSEPTASINE, a product of Pharmaceutical
Specialities (May and Baker) Ltd., Dagenham, is
disodium p (y phenylpropylamino) benzenesulphon-
1Science Fights Death. By D. Stark Murray, B.Sc., M.B..
Ch.B. London: Watts and Co. 1936. Pp. 149. 2s. Gd.
‘in 5 per cent. solution and recommended
amide- a, y-disulphonate. It is supplied in ADDU
y the
makers for intravenous or intramuscular injection
in the treatment of severe streptococcal infection.
VITEOLIN is the name now given by Glaxo
Laboratories Ltd. (Greenford, Middlesex) to their
wheat-germ oil extract. They have issued a booklet
entitled ‘‘ Vitamin E” which gives an account
of the clinical use of this vitamin especially in the
treatment of repeated and threatened abortion. The
extract is described as a twenty-five-fold concentra-
tion of the vitamin E in wheat-germ oil, and it is
put out in 3-minim capsules.
ORHEPTAL.—E. Merck, of Darmstadt, have pre-
pared a new tonic for use in cases of secondary
anemia, during convalescence and in conditions
of weakness and loss of tone. Besides a concentrated
liver extract, it contains ferric ammonium citrate,
cupric chloride, tincture of nux vomica, sodium and
manganese glycerophosphate, caffeine, and small
quantities of quinine, bitters, alcohol, and syrup.
It is obtainable in this country from Savory and
Moore Ltd., 61, Welbeck-street, London, W.1.
A pamphlet on ‘‘ Ovarian Hormones in Clinical
Practice ’’ is issued by Boots PuRE Druga Co., LTD.
(Nottingham). It gives particulars of the Boots
preparations of cestrone benzoate (Ovostab) and
corpus luteum hormone (Luteostab) and illustrates
the use of these substances by quotations from
published papers.
WANTED, A CASE OF BILIARY FistTuLa.—M.D.
ABERD., who is investigating the effect on the liver
secretion of various medicinal waters, would be glad
to find a case of biliary fistula willing to undergo such
a test. All expenses would be paid.
Births, Marriages, and Deaths
BIRTHS
AIRD.—On April 4th, at Blackpool, the wife of Dr. J. Wilson
Aird, of a son. l
BLAcK.—On April 1st, 1937, at Leeds, to Stella, wife of George
Black, F.R.C.S., of 26, Park-square, Leeds—a son. l
CONSTAD.—On April 3rd, at Welbeck-street, W., the wife of
Dr. Victor Constad, of a daughter.
DANNATT.—On March 24th, at the Middlesex Hospital, W.,
the wife of Mr. R. M. Dannatt, F.R.C.S. Eng., of a son.
HARTLEY.—On March 29th, at Rye, Sussex, the wife of Dr. J. L.
Hartley, of a daughter.
JAMES.—On March 25th, the wife of T. G. Iûtyd James, F.R.C.S.,
of a son.
JOHNSTONE.—On April 2nd, at Leicester, the wife of Mr. A. S.
Johnstone, F.R.C.S. Edin., of a daughter.
McCONNEL.—On April 2nd, -at Welbeck-street, W., the wife
of Dr. R. W. McConnell, Wendover, Bucks, of a son.
TURNER.—On March 23rd, at Bracknell, Berks, the wife of
Dr. Ronald Turner, of a son.
; MARRIAGES
BETTLEY—SANDERS.—On March 31st, at St. Peter’s, Croydon,
F. Ray Bettley, M.D., of Croydon, to Mary Stewart, only
child of Robert Stewart Sanders, formerly of Purley.
BOWES—WHITTON.—On March 31st, at the Church of the
Annunciation, Bryanston-street, W., Robert William
Wallace Bowes, M.A., M.R.C.S., of Diss, Norfolk, to Olga
Mary Whitton, M.Com. (Vict.), Seymour-street, London,
LANGTON—WHITE.—On April 3rd, at St. Mary’s Church,
Scarborough, Peregrine Stephen Brackenbury Langton,
M.B., Medical Superintendent of the Royal Earlswood
Institution, Redhill, Surrey, to Vera Dennis White, youngest
daughter of Mr. F. A. White, of Scarborough.
DEATHS
Brisco-OWEN.—On March 24th, Ella Gertrude Brisco-Owen,
L.M.S.S.A.
N.B.—A fee of 7s. 6d. is charged for the insertion of Notices of
Births, Marriages, and Deaths.
THE LANCET]
[APRIL 17, 1937
ADDRESSES AND ORIGINAL ARTICLES
POSTURAL DEFORMITIES OF THE
ANTEROPOSTERIOR CURVES OF THE
SPINE *
By Pamir Writes, M.S. Lond., F.R.C.S. Eng.
ASSISTANT ORTHOPÆDIO SURGEON TO THE MIDDLESEX
HOSPITAL, LONDON
THE generally accepted views of the physiology
of the neuromuscular system, so far as they concern
posture, have undergone considerable modification
of recent years. Before discussing them, however,
it is necessary to emphasise a fact that should be a
commonplace—the ligaments play no part at all in the
normal regulation of posture. Over a hundred years
ago Delpech (1828), a French orthopedist, drew atten-
tion to this fact, but its general acceptance has been
very slow. The function of ligaments is to limit the
extremes of movement, and no loss of stability need
occur when they are absent, as may be seen after
complete excision of the capsule of the hip-joint.
The function of skeletal muscles is to cause move-
ment and to maintain posture, but an individual
muscle-fibre is capable only of one thing, the develop-
ment within itself of a state of tension. Its behaviour
when the tension develops depends on conditions
external to itself. If there is no resistance to its
movement, the fibre contracts. If there is resistance
which it is unable to overcome, movement is absent,
or minimal, and the contraction is said to be
“ isometric.” The former process is used in making
movements, the latter in maintaining posture.
Individual fibres appear to follow the “all or none”
law, so the power exerted by a whole muscle is pro-
portional to the number of fibres in action. This
in turn depends on the. external resistance to be
overcome and the rapidity of the movement;
consequently for the maintenance of posture the
number of fibres required at once may be very small,
Each muscle-fibre, or small group of fibres, is
separately supplied by motor nerves which can trans-
mit impulses of only one type and in one direction.
For the purpose of maintaining posture, muscular
power, and therefore the number of fibres in use at
once, is comparatively small, so that continual change
of contracting fibres can occur, and fatigue is reduced
to a minimum, This is clearly shown in records of
the action currents which are produced during the
active contraction of a muscle. A fine double
electrode is inserted into the substance of the muscle ;
the current is amplified, made visible by means of
a cathode ray oscillograph, and photographed on
a moving film. The currents are of a moderately
small order, and only such as are produced by muscle-
fibres in the immediate neighbourhood of the electrode
are detected. Dr. C. A. Keele, of the department of
physiology at the Middlesex Hospital Medical School,
has been kind enough to assemble the apparatus and
cooperate in making a number of observations.
In Fig. 1 are records of action currents in the central
portion of the gluteus medius. When the leg was
supported so that the muscle was completely relaxed
action currents were absent, or only occasionally
recorded (above). When the subject was standing
with both feet on the ground so that the muscle was
engaged in maintaining normal upright posture,
contractions were fairly frequent but not absolutely
* A Hunterian lecture delivered before the Royal College of
Surgeons of England on April 12tb.
regular (middle). During active muscular contraction,
violent activity is recorded (below).
The process of maintaining posture requires the
balanced contraction of the muscles on each side of the
joint concerned—that is, in the upright position,
nearly every joint in the body. The regulation of this
complicated process is entirely a function of the
central nervous system. It is brought about mainly
TAY e iN Bia
sp i i i
POARTA "A Y
i A yf ms y Wit n i}
yi
ah
| weil High.
phe Be
k
a ae a2 @ @2 @ 2m A
a & A
FIG. 1.—Action currents of central poron of gluteus medius.
Above: leg supported and muscle fully relaxed. Middle:
standing still with legs 6 in. apart. Below: standing on
one leg
by means of unconscious reflexes which coördinate
afferent impulses from the muscles, joints, eyes, ears,
and skin.
A permanent change in habitual posture is not
maintained by the muscles on one side of the joints
concerned contracting more strongly whilst those
on the other side are more relaxed. This process
only causes the movement by which the new posture
is reached. Once it is reached, all that is necessary
to maintain it is a change in the length at which
the muscles must remain, and the power required
may be no greater than before. To keep the muscles
habitually at this changed length is obviously a
function of the central nervous system and involves
the conditioning of a new reflex which regards a
new muscle length as normal.
The requirements for a good posture in an otherwise
healthy body are adequate muscles and correctly
conditioned reflexes. The muscular power required
to maintain posture is so small that it is unusual
for muscular weakness alone to be the cause of
postural deficiency. In a large proportion of cases
the error lies in the postural reflexes, and it is to this
that attention has chiefly to be directed. It is
perhaps permissible to compare the state of affairs
to that in a pianola. When a record of a given
pattern is passed through the instrument, a particular
tune is played, but it is subject to the conscious
modulations of the player by means of the speed and
volume controls. Any fault in the record will be
reflected in the tune and can be remedied only by
altering the record; conditions in the body are
much the same. Temporary modification of posture
can be obtained by conscious control, but any
permanent change must be associated | with an
alteration in the postural reflexes; increasing the
size and power of the muscles alone will have no
effect.
Q
912 THE LANCET]
Etiology
The causes which lead to the development of faulty
postural reflexes, or to a change from good to faulty
reflexes, are little understood. There must be many
factors concerned, more than one of which are likely
to be present in any case.
A great number of postural deformities commence
in late childhood and adolescence, during periods
of rapid growth. The bones and muscles are then
increasing in Jength and the central nervous system
is continually being called upon to modify its postural
reflexes. This adjustment is likely to be interfered
with by any upset in general well-being. There
are many ways in which this can be brought about ;
at the present time a common one is undernutrition.
Toxemia from some chronic infection is another
factor which may play its part, and one which is
itself greatly aggravated by undernutrition.
It is doubtful if heredity is concerned in the etiology
of those cases falling within the definition of postural
deformities, but it is probably of importance in
certain of the fixed deformities which cannot be
corrected by voluntary muscular effort, for example,
those ‘‘ malignant ” cases of pes cavus or of scoliosis
which tend to recur or to progress in spite of every
treatment.
It has been the custom of surgeons for many
years to blame the immediate surroundings of the
patient, such as vicious school furniture and types
of clothing, for the onset of some deformities. Some
have even gone so far as to suggest that “ one-sided ”
occupations, like violin-playing and the use of a
side-saddle in horse-riding, are sometimes responsible
for scoliosis! No logical explanation of the mode of
action of such mechanical factors has been brought
forward and it is difficult to believe that they are
of any great importance. A child who is determined
to sit. badly will do so at any desk—it would be far
more rational to blame a boring lesson that fails to
hold his attention.
A normal posture can only be assumed when the
higher parts of the brain are intact, so it 1s reason-
able to suppose that any disturbance in the normal
functioning of the brain can interfere with the develop-
ment of postural reflexes. It is obvious that posture
is subject to conscious modification, and, by analogy,
it might be expected to be influenced by unconscious
cerebral processes. There is a growing tendency
to explore the psychogenic factors underlying disease
processes of many sorts. The investigation of this
subject is fraught with the greatest difficulties, and
there are many pitfalls in the way of the interpretation
of any findings. Sometimes, however, it does seem
possible to make a direct correlation between the
psychopathological findings and the physical condi-
tion, and certain cases of postural deformity provide
excellent examples.
Bankart has said ‘‘ to diagnose a scoliosis, look at
the child’s back ; to find its cause, look at the mother’s
face.’ The general truth of this observation is
apparent to everyone, and, moreover, it is quite
rational to expect that any psychological maladjust-
ment will be reflected in the postural habits. The
most extreme case of the association of an abnormal
psychological state with an abnormal posture is seen
in “ neurasthenia,’”’ using the word in its narrow sense
of a particular functional nervous disorder. It
occurs in both adults and children, and the picture
is very distinctive. The patient is flabby in both
body and mind: Mentally he is tired, bodily he
has given way to gravity and has sagging jaw and
eyelids, tilted pelvis, and flat feet. The mental and
MR. P. WILES: POSTURAL DEFORMITIES OF THE SPINE
[APRIL 17, 1937
physical conditions go together and any attempt to
change the physical condition, until such time as the
psychological adjustment has been improved, usually
leads to disappointment.
Other but less clearly defined groups are to be
found amongst children and adolescents. In the
“ anxiety states ” the general picture is of a hyper-
‘sensitive, alarmed child, not infrequently subject to
nightmares and often with a stammer. Physically
he tends to have flat feet, knock-knees, and round
shoulders, a position of fear; but, in contrast to the
**neurasthenic,” his muscles are tense rather than
slack. Again, the “‘ obsessional” child may show
queer habits of gait and posture, often asymmetrical,
which are impossible to explain except in association
with the psychological condition.
To sum up, there are a number of factors concerned
in the ætiology of postural deformities. The most
important are undernutrition, rapid growth, and
psychological maladjustment. Undernutrition alone
may provide sufficient cause by undermining the
general health, both physical and mental. In
other cases it develops during a period of rapid growth
in people who are emotionally disturbed, and
consequently are unable to make satisfactorily the
adjustments in their postural reflexes that are
necessary to meet the needs of growth. In a further
class, exemplified by the “ neurasthenics,” the
psychological attitude is directly reflected in the
posture. I do not maintain that nearly everybody
with a postural deformity is a “‘ neurotic.” I
suggest rather that, in far more cases than is usually
suspected, there is some psychological maladjust-
ment that interferes with the development of correct
reflex postural habits. The maladjustment is often
only temporary, and, when it has corrected itself, the
postural habits also are readily corrected.
Pelvic Inclination
Deviation of the curves of the spine from what has
come to be regarded as normal is of more than
cosmetic importance. It reduces the mechanical
efficiency of the back so that it is more readily
fatigued and more liable to strain. It is therefore
important to have accurate knowledge of the normal
arrangement, and some method of mensuration
more accurate than the usual one of judging by
eye is desirable. Direct measurements have proved
notoriously unsatisfactory because of the difference
in the thickness of the fleshy and fatty coverings and
of the actual lengths of the spinous processes. The
ideal method of measurement would be to take
radiograms of the standing patient with a tube at
6 ft. and a plate large enough to cover the pelvis
and most of the spine. A suitable X ray apparatus
is in existence, but, as it is not available in this
country even for research work, the method is at
present of no value for routine use.
Since it is impracticable to measure the spinal
curves directly, attention has been turned to an
indirect method. The spine is attached to the pelvis
at the lumbosacral junction, so that any movement
of the pelvis will cause a corresponding movement of
the fifth lumbar vertebra. ‘The habitual posture
of the pelvis therefore determines that of the fifth
lumbar vertebra, which in turn must affect the
posture of the whole lumbar spine. Hence measure-
ment of the inclination of the pelvis should give an
estimation of the curve of the lumbar spine.
The inclination of the pelvis has never been
measured satisfactorily in the living subject. Reynolds
and Lovett (1910) say they believe it to be impossible
to measure its variations with sufficient accuracy
THE LANCET]
` MR. P. WILES : POSTURAL DEFORMITIES OF THE SPINE
[APRIL 17, 1937 913
to be of value, but they give no indication of the
methods they have tried. Most estimations have
been on the cadaver, but several workers, notably
Prochownick (1882), have attempted it on the living
subject by rather elaborate means.
I have devised a simple method of measuring the
pelvic inclination, which I believe is of sufficient
accuracy.
fixed object give readings accurate to 1° with different
observers. Repeated measurements of the pelvis
of the same people on ‘different occasions gave a
variation of + or — 2°, This wider variation is
accounted for by a slight difference in posture on the
different occasions, and it is not present if the person
stands still whilst several observations are made.’
The instrument (Fig. 2) has been made for me by
Messrs. Down Bros., Ltd. It consists essentially of
a pair of external callipers with a vertical plate fixed
at the hinged end in such a way that it is always in
a plane at right angles to the plane of bisection of the
callipers. The plate is graduated in degrees, and a
plumb-line suspended so that the inclination to the
horizontal can be read directly from the scale.
The points taken for measurement are the upper
border of the symphysis pubis in front, and the level
of the posterior-superior spines behind. This posterior
level was chosen, rather than the fifth lumbar spine,
i Ms. rae >
` PN
zs } Sree 5% =
- M ne aS
FIG. 2.—Pelvic inclinometer.
because the latter is much broader and often difficult
to palpate accurately. No mention of posture is
made to the subject unless the one adopted is
obviously forced. The posterior-superior spines are
palpated and a pencil mark made on the skin at this
level in the midline, The blades of the callipers are
held one in each hand with much the same sort of
grip as a pencil is held when writing. The upper
border of the symphysis is palpated with the middle
finger of the right hand, and the point of the right
Measurements of the inclination of a’
blade adjusted to touch this point. The left blade
is placed on the mark already made posteriorly.
Finally, the graduated plate is made parallel with the
a ng and therefore vertical, and a reading is
made. |
Lovett (1931) quotes the figures for the pelvic
inclination obtained by various investigators in the
S SSS Goes See ESsSeae
6 20 FSR AS E P E =e
lala) es ea ee ee a AL E el T =
S is EA ==
q SEA E SEE os
SERRE ERASE ===
SS EA il os
8 ee RN = N E
>X SE ee ee R T FENT
ne a ee oe EN]
37 35 33 31 29 27 25 23 21 19
Pelvic inclination in degrees
FIG. 3.—Pelvic inclination of adults.
vie Males (interrupted line)
average 31°.
Females ((continuous line) average 28°.
last century as ranging from 41° to 65°. He says
that all the figures are adjusted to give the inclination
of the true conjugate of the pelvis, which he defines
as the line joining the lumbosacral junction to the
upper border of the symphysis. However, Ten
Teachers’ Midwifery (1935) defines the true conjugate
as the line joining the centre of the promontory of
the sacrum to the nearest point on the surface of the
symphysis. The planes in which these two lines
lie differ by some 10°, so it is difficult to use Lovett’s
figures as a basis for comparison. Prochownick
(1882) has adjusted his figures to give the inclination
of the plane of the “‘ pelvic inlet” and this differs
from both the above planes.
The older workers were interested in the inclina-
tion of the pelvis from the point of view of the
mechanics of parturition. Since this is not now thë.
only interest, and since the inclination of the true
conjugate can only be measured directly by radio-
graphy, I suggest that this plane should no longer
be used as the standard. Subsequent mention
in this paper of the inclination of the pelvis will
refer to the angle between the horizontal plane and
the plane of the lines joining the posterior-superior
spines to the symphysis pubis. :
The pelvic inclination has been measured in a
consecutive series of ‘“‘ normal’ adults. The women
were mostly nurses and massage students, aged 18 to
30 (average 21). The men were from a Y.M.C.A.
training class, and medical students, aged 17 to 50
(average 23). The figures are given in the Table
and the frequency with which the various inclinations
occurred is shown in graphic form in Fig. 3.
Table showing Pelvic Inclination
Average. Range.
93 men 31° 37°~19°
137 women .. 28° 38°~18°
It was necessary to discover to what extent the
shape of the lumbar spine would correlate with the
pelvic inclination. With this in view, a note was made
in every case of the appearance of the back, as judged
by eye, and of the degree of lordosis, so far as it could
be measured, This was done by dropping a plumb-
line from the most prominent vertebra, and measuring-
the distance in inches from the plumb-line to the
sacrum and the point of maximum lumbar convexity.
914 THE LANCET]
It was found that these measurements were almost
useless as a guide to the shape of the spine. The
appearance, however, was of much greater value
and correlated well with the pelvic measurement.
The normal curves of the spine must vary a certain
amount from individual to individual, and it is very
difficult to define them. Moreover, if a person is
leading an ordinary life and is free from symptoms, `
it is difficult to say that any small deviation from
an arbitrary standard is abnormal. The standard
here adopted is one in which the body is well “ set ”
as judged by the eye, and in which a vertical line in
the plane of the mastoid process passes through the
middle of the shoulder- and hip-joints, towards the
front of the knees, and well in front of the ankles
(Fig. 4). By this standard, 56 per cent. of the men
and 46 per cent. of the women in this series were
classed as having normal curves and normal posture,
The pelvic inclination in the men ranged from 34°
to 26°, with an average of 31°, and in the women
from 33° to 23°, average 29°. Individuals classified
as having a lumbar lordosis invariably had an
increased pelvic inclination, and those with a flattened
lumbar spine had a decreased inclination. A change
in inclination also occurred in those who leant back-
wards or forwards at the hips and yet had normally
curved spines, and in certain other abnormalities of
posture. This will be discussed more fully under
types of postural deformity.
It is usually said that the posture and spinal
curves vary with the type of body build. With
a view to studying this point, the type of each person
examined was recorded. The classification used
was normal, sthenic, asthenic, and dysplastic. The
standard of normal was again an arbitrary one and
really amounted to the mean between sthenic and
asthenic. Individuals with a sthenic lower body
and asthenic thorax, or vice versa, were described
as dysplastic. These types have been carefully
correlated with
the rest of the
data. No par-
ticular type of
posture or
spinal curves
could be found
corresponding
to the body
types. The
average angle
- of pelvic in-
clination of
each type
closely ap-
proximated to
the general
average,
The pelvic
inclination is
rather smaller
in the early
years of life
than in the
adult. This is
as might be
expected dur-
ing develop-
ment from the
flexed intra-
uterine posi-
tion to an up-
right posture.
An attempt
FIG. 4.—Norma] posture. A line has been
drawn through the mastoid process
parallel to a plumb-line included in the
original photograph.
MR. P. WILES : POSTURAL DEFORMITIES OF THE SPINE
{APRIL 17, 1937
Pelvic inclination in degrees
45 67 8 9 10 Il
Age in Years
2 B>
FIG. 5.—Pelvic inclination of children. Males = continuous
line. Females = interrupted line. i
has been made to follow this change statistically,
but difficulties were experienced in obtaining
access to a sufficient number of children. The edu-
cation committee of the London County Council
kindly gave me permission to attend the routine
medical examinations of children under their
control, These examinations are made at approxi-
mately the ages of 4, 7, 11, and 13 years, and twenty-
five children of each sex at each of these ages were
measured. The results are given in Fig. 5 and
suggest that there is a steady increase in pelvic
inclination up to the age of 11 when the adult level
is reached,
Muscular Control
The pelvis is balanced on the femora, so that its
angle of inclination (and consequently the curve
of the lumbar spine) depends on the posture of the
hip-joints. The muscles controlling the hips are
therefore responsible for determining the pelvic
inclination. In the upright position the thighs are
the fixed points from which these muscles act
so that contraction of the flexors (the iliopsoas
and rectus femoris) will increase the inclination,
and contraction’ of the extensors (the glutei and
hamstrings) will decrease it.
Investigation of muscle action by means of their
action currents has brought out two points concern-
ing the glutei that are of importance, It is commonly
stated—e.g., Quain’s Anatomy (1923)—that the gluteus
maximus is not used in ordinary walking movements
to any great extent. This could not be confirmed.
The muscle participated in producing full external
rotation of the hip and in every movement involving
extension, including tilting backwards the pelvis.
The glutei medius et minimus are primarily abductors
of the hip but they are also extensors and, by their
central and posterior portions, they are external
rotators.
The three glutei function in life as one unit and as
part of the extensor group of muscles that maintain
the upright position. Their combined action on the
hip can produce extension, abduction, and external
rotation ; but the thigh or pelvis is moved according
to which is the fixed point. Postural increase in the
THE LANCET]
MR. P. WILES : POSTURAL DEFORMITIES OF THE SPINE
[APRIL 17, 1937 915
lengths of these muscles will therefore result in forward
tilting of the pelvis and internal rotation of the legs.
The latter is of considerable importance in the
ætiology of flat feet.
The action of the rectus abdominis is often mis-
understood because it can be seen to contract
synergically with the glutei when the lumbar spine is
flattened. From this it is often argued that the
rectus, and not the glutei, is tilting the pelvis back-
' wards, and consequently remedial workers pay great
attention to it in cases of lordosis. However, such
an action is impossible because there is no fixed
point above from which it can pull.
If the rectus abdominis could be made to contract .
alone, it would clearly approximate the sternum to
the symphysis pubis and flex the lumbar spine. The
part of the body actually moved would depend
on which was the fixed point; either the pelvis
would be tipped backwards or else the thorax bent
forwards. When standing upright the thorax is
the least fixed and must therefore be the part to
move. If it were desired to fix the thorax and move
the pelvis, the only muscles that could do so would
be the erector spine ; but consider what must happen
if the rectus and the erector spine contract together.
These muscles are bridging the gap between two
bony boxes which are joined by a curved flexible
rod, Their simultaneous contraction can have only
one effect, to move the thorax bodily nearer to the
pelvis and increase the lumbar curve (Fig. 6). The
rectus abdominis can therefore have little effect
on the inclination of the pelvis when standing erect.
Its action (in addition to that of retaining the
abdominal contents) is to flex the lumbar spine.
The erector spine control extension of the spine.
The range of movement is largest in the lumbar
region, where there is a large and powerful mass
of muscle to raise the trunk from the flexed position.
In the dorsal region the range of movement is very
much smaller ; the erector spine is much less powerful,
but there are other muscles which assist it. The
lordosis
type I
FIG. 7.—Types of postural deformity.
Flat back sway back roundback round back
dorsal curve is flattened appreciably with every
inspiration, and for this the muscles of respiration—
the diaphragm, intercostals, &c.—are largely respon-
sible. These muscles must therefore codperate
FIG. 6.—Simultaneous contraction of the rectus abdominis
and the erector spins must increase the pelvic inclination,
in maintaining normal posture, and also in recover- —
ing from a “slack” position, in which there
is a slight increase in the dorsal curve, to a good
posture.
The weakest part of the extensor mechanism of
the spine is in the upper lumbar and lower dorsal
regions. The mass of the erector spine is getting
smaller, and the change of curve from concave to
convex is taking place, making it mechanically a
vulnerable spot. Loss of tone in the extensors will
allow the whole weight of the upper part of the
body to come on to the spine and produce one of
the commonest deformities, a dorsolumbar kyphosis
(Fig. 10). In the early stages the deformity can
be straightened by the action of the erector spine.
Later on, however, it seems that the ligaments become
contracted, and sometimes the vertebrae
become wedge-shaped, so that active
correction is no longer possible.
To summartse—the inclination of the
pelvis is controlled almost entirely by
the muscles surrounding the hip-joints.
The abdominal and spinal muscles have
little direct effect on the pelvis; their
action is to keep the body upright,
whatever the pelvic ‘inclination, by
varying the curves of the spine.
TYPES OF DEFORMITY
It is essential for the maintenance of
the upright position, whatever abnor-
mality of posture may be present, that
the centre of gravity of the whole body
should fall somewhere within the area
occupied by the feet. This limits con-
siderably the possibilities of postural
variation, and analysis shows that only
two components contribute to make
up the majority of cases. Firstly, there
is nearly always an alteration in the
pelvic inclination, which may be
increased or decreased. Secondly, there
may, in addition, be a dorsolumbar
kyphosis. These two variables combine
to produce four distinct groups which
are adequate to classify the majority
of cases. (In the following, ‘‘ normal
spine ”' means one which has no
type H
916 THE LANCET]
intrinsic error: and whose curves become normal
when the pelvic inclination is corrected.)
Forward tilt of f normal spine lumbar lordosis.
pelvis plus dorsolumbar kyphosis «. ; sway back.
Backward tilt f normal spine flat back.
of pelvis plus \dorsolumbar kyphosis . round back.
In the ensuing account of the Tna of postural
deformity the pelvis is taken as the starting-point
for description; not because it is necessarily the
causal factor, but because it is the base on which the
column of the spine is supported. The problem then
becomes largely the mechanical one of explaining
how the centre of gravity is adjusted (Fig. 7).
A theoretical explanation of the production of the
= deformities is given for the sake of convenience,
but it is not suggested that it is the actual manner
in which they arise during life. The process is one
of gradual ‘‘slumping,” rather than of separated
movements.
LUMBAR LORDOSIS
The mechanism of the production of lordosis can
be visualised as follows. First the pelvis is allowed
to tilt forwards, and with it the whole trunk. Then
the centre of gravity is restored by bending backwards
in the lumbar region and increasing the concavity
(Figs. 7b and 8). The mastoid line bears much the
same relation to the large joints in the corrected and
uncorrected positions. The spine is pretty well
balanced, so the erector spine have little work to
do and can share in a general slump of the anti-
gravity muscles, thus permitting a slight increase in
the dorsal curve.
The condition is often referred to as kypho-lordosis,
but the increase in the dorsal curve is slight and
unimportant. The dorsolumbar curves in the
corrected and uncorrected positions were recorded
in a number of cases with malleable metal strips.
The strips were then outlined on papers which could
be superimposed to show the amount of change.
The change
is surpris-
ingly small
in the dorsal
region, and
the kyphotic
appearance
of the dorsal
spine in such
cases is
partly . due
to the exag-
gerated
curves above
and below.
Tracings of
photo-
graphic
reductions
are shown
in Fig. 9.
Internally
rotated legs
and valgus
feet are very
commonly
present in
cases of lor-
dosis, as in
all other
deformities
in which
there is an
FIG. 8.—Left : lordosis. Right: pomeccven by
decreasing the pelvic inclinat
MR. P.-WILES : POSTURAL DEFORMITIES OF THE SPINE
“the tilted.
[APRIL 17, 1937
increased pelvic inclination. The feet can only be
corrected after the general posture and the rotation
of the femora has been altered (Wiles 1934).
The pelvic inclination has been measured in 24
‘female patients undergoing treatment for lordosis. The
average angle was 39°, with a
range of 34° to 41° (average
for normal women 28°).
= he clinical picture in a
typical case is one of a
forward tilted pelvis, in-
creased lumbar and dorsal
curves, shoulders drooping
and head poked forwards,
internally rotated legs and
¿| valgus feet. The dominating
é feature, however, is the pel-
i vis; the rest of the deform-
j ities are secondary to it.
| This has often been demon-
strated when examining un-
treated cases. The patient
has been shown how to use
the glutei to restore the
pelvic inclination to normal
and the posture of the trunk
has at once returned almost
to normal.
Treatment, so far as it is local at all, should be
directed. chiefly to the glutei. To concentrate on
the abdominals, as some workers tend to, can achieve
FIG. . 9.—Showing
small change in
spine in two cases of
lumbar lordosis (see
text).
little by itself because these muscles play only a
secondary part in this deformity.
SWAY BACK
This name originated in America for a postural
type which seems to be very common there, Analysis
along the lines already indicated shows it to consist
of a forward tilted pelvis in association with a dorso-
lumbar kyphosis. The degree of kyphosis is often
quite small, really no more than a flattening of the
upper part of
the lumbar
concavity.
However, even
this amount is
sufficient to
prevent. the
spine com-
pensating to
pelvis by a
general in-
crease in
the curve of
the lumbar
region, as
occurs in the
previous type.
Instead, the
centre of
gravity is
restored to a
stable posi-
tion by bend-
ing the spine
sharply back-
wards in the
lower lumbar
region (Figs.
7d and 10). In
this position,
sway back. Right: de-
creasing the pelvic inclination improves
the posture but cannot remove the
dorsolumbar kyphosis.
FIG. 10.—Left :
THE LANCET]
the legs are in-
clined slightly
forwards at
the ankles so
that the pelvis
projects for-
wards. The
mastoid line
passes well
behind the
great tro-
chanters and a
plumb-line
from the most
- prominent part
of the dorsal
convexity falls
behind the
sacrum. Inter-
nally rotated
legs and valgus
feet are com-
monly present,
and not infre-
quently there
is a total sco-
liosis as well.
In the cases
examined, the
average in-
clination of
| the pelvis was
FIG. 11.—Left: round back, Type 1. 37°,
ht : the pelvic inclination is in d Toa Tango
e pelvic inclination is increase . ° o
but the back is still abnormal. being 35°—41°.
The dorso-
oe lumbar region
of the spine is only occasionally sufficiently
mobile to allow active correction by the erector
spine. As a rule, there is such limitation of
movement that the deformity is not even cor-
rected when a wedge is placed under the upper
lumbar spine and the patient lies limply across
it. The limitation of movement is sometimes due
to structural changes in the vertebre, which can
then be shown by X rays to be wedge-shaped.
From the point of view of treatment, sway back
differs from simple lordosis in that correction of the
pelvic angle does not enable the spinal curves to be
restored to normal, Treatment has therefore to be
directed at first to increasing the mobility of the spine
—one of the most difficult problems of postural
correction.
FLAT BACK
Flat back is just as ‘much a postural deformity
as any of the other conditions discussed. The pelvis
is abnormally flat and the spine is flattened in
compensation. Such cases, however, are seldom,
if ever, sent to orthopedic departments on account
of their posture, and adolescent patients are rarely
seen in remedial clinics undergomg treatment for
flat back. -People with flat back come under ortho-
pædic observation later in life complaining of back-
ache, sacro-iliac strain, or other troubles of a
mechanical nature. By this time the spine is too
stiff for any change of posture to be possible, and
only symptomatic treatment can be given. A
great many of these complaints could be prevented
if only parents and school medical: officers could
be brought to realise that a “lovely straight
back ” is not necessarily ideal and could be per-
suaded. to’ send such cases for treatment during
childhood,
MR. P. WILES: POSTURAL DEFORMITIES OF THE SPINE
[APRIL 17, 1937 917
ROUND BACK
This name has been adopted for a rather less
clearly defined group of cases in which a decreased
pelvic inclination is associated with a dorsolumbar
kyphosis. The
centre of
gravity is
stabilised by
mechanisms of -
two different
types. In type
1, which gives
the name to
the group, the
trunk is bent
forwards in
the lower
lumbar region
obliterating
what is left
of the lumbar
curve. The
legs are in-
clined slightly
backwards at
the ankles so
that the pelvis
is displaced re-
latively back-
wards and the
great tro-
: FIG. 12.—Left: round back, Type 2.
chan ter is Right : increasing the pelvic clina.
behind the tion improves the posture but cannot
mastoid line remove the dorsolumbar kyphosis.
(Figs. 7e and
11). The mechanism in type 2 is very similar
to that in sway back. The legs are inclined forwards
and the trunk backwards causing a lower lumbar
angulation ; the great trochanter is in front of the
mastoid line (Figs. 7f and 12).
The treatment of this group presents just the same
problems as sway back—the diffculty of restoring
the upper part of the lumbar concavity.
DORSAL KYPHOSIS
There is a group of cases of kyphosis affecting
principally the dorsal spine that was at one. time
regarded as being postural in origin. Recently,
however, such cases have been shown to be associated
almost invariably with disease of the intervertebral
disks and the epiphyses of the bodies of the vertebræ.
These cases, therefore, do not fall under the heading
of postural deformities.
Treatment
Before embarking on the treatment of postural
deformity, inquiry, should always be made into its
cause. In cases in which there is no mechanical
cause, the factors discussed under etiology have to
be considered. Especially is the question of under-
nutrition worth attention ; to give remedial exercises
to an undernourished patient is only adding to his
troubles. When no other cause is forthcoming,
investigation should be made into possible psycho-
logical factors. This involves inquiry into the
psychological make-up of the patient and his home
conditions. In any case of doubt, or when the
problem of emotional readjustment is beyond easy
solution, it is advisable to obtain the assistance of a
medical psychologist. It is of little use to expect
a patient to codperate in remedial work when he is
918 THE LANCET]
trying to grapple with an emotional problem which is,
te him, of much greater importance.
The treatment of postural deformities falls into
three stages. Firstly, restoring sufficient mobility
to enable correction to be made; secondly, acquiring
voluntary control over the movements that produce
correction; and thirdly, the establishment of new
reflexes that will maintain permanently the correct
posture. Any good system of remedial work deals
with all three stages simultaneously ; they are only
separated here for discussion.
Mobility is limited to an extent sufficient to prevent
correction of the deformity in only a proportion of
cases, This is of importance particularly in the
dorsolumbar kyphosis of sway back, and the limitation
of extension of the hips in some cases in which the
pelvic inclination is increased. There are three
causes of the loss of mobility, one or more of which
may be present in any case. -
(1) Structural changes in the shape of the bone;
(2) Contracted ligaments; and
(3) Shortened muscles.
A structural change in the shape of the bones occurs
in some cases of dorsolumbar kyphosis. It is
impossible to restore the shape of the bones by any
remedial measures. Indeed it is doubtful if any of
the most drastic corrective machinery used by
orthopedic surgeons has any effect on it. The object
of remedial work in structural cases is to develop
such compensatory curves as will give the greatest
mechanical. and esthetic advantage.
Contracted ligaments and joint capsules may be
found preventing correction of dorsolumbar kyphosis
or limiting extension of the hips in cases with increased
pelvic inclination. The stretching of contracted
ligaments, as of any other fibrous tissue, is a matter
of difficulty. Forced passive movements, either with
or without an anesthetic, result in tearing the liga-
ments and do more harm than good.. The most
effective method of stretching them at all rapidly
is prolonged traction. Head suspension is therefore
very valuable when dealing with contractions affecting
the spine and, if carefully supervised, is well tolerated
by patients.
extreme range and repeated frequently may be of
some assistance in stretching ligaments, but care
must be taken to see that the movements are not
too violent and to ensure that they are localised to
the affected region.
“ Shortened muscles” probably play a part in
hindering correction of most deformities that are
at all severe. The process of increasing the length
of muscles is often referred to as muscle-stretching.
This is hardly the right word to use because, so far
as is known, muscle-fibres cannot be stretched—they
have to be made to relax more fully. This is not
merely an academic point, but a practical one which
directly affects treatment. The normal physiological
response of a muscle to stretching is contraction,
and the harder it is stretched the more strongly it
contracts. Therefore, passively stretching a muscle
calls into action this “stretch reflex” and makes
the muscle contract more. The passive stretching
of muscles with the idea of lengthening them is a
procedure that should be abandoned; it can do no
good, and, if carried to an extreme, it will do harm.
The lengthening of a muscle can be achieved by
getting it to relax more fully. A muscle relaxes
reflexly when its antagonist contracts, but, when a
“ free” movement is made—that is, one without
any resistance to it—the muscle does not relax
completely ; it mamtains enough tone throughout
MR, P. WILES : POSTURAL DEFORMITIES OF THE SPINE
Active movements carried to their
[APRIL 17, 1937
the movement in order to keep the joint under control,
and it will go on contracting even when the extreme
of movement is reached. However, when a move-
ment is made against resistance, the muscle is enabled
to relax
more fully
because con-
trol of the
joint is
obtained by
means of
the pressure
between the
resistance
and the
contracting
muscle.
Hence, to
stretch a
muscle, its `
antagonist
must be
made to
contract
against re-
sistance and
continue to
work against
the resist-
ance when
the extreme
of move-
ment has
beenreached.
Thus, if the
flexors of
the hip are contracted, the appropriate exercise is to
extend one leg backwards against gravity whilst
keeping the trunk vertical, in the manner of the
“ battement derrière ” of the Classical Ballet (Fig. 13).
Backward bending from the hips is useless because
the movement is made by gravity with the flexors
contracting strongly to control it.
Voluntary control over the movements that correct
a postural deformity is easily taught when adequate
mobility is present. In those cases in which mobility
is limited at the commencement of treatment, control
is learnt automatically whilst mobility is acquired.
In cases where the pelvic inclination is increased, the
glutei are the correct muscles to restore it to normal.
The glutei are the principal extensors of the hips
and tilting backwards the pelvis is exactly the same
movement as extending the hips. Patients should
not be told to “ draw the stomach in” or they will
use the abdominals. They should be given some
such order as to “tuck their tails under them,”
and then be watched to see that they really are using
the glutei. Some patients tend to use the hamstrings
for tilting the pelvis ; this can be prevented by making
the movement in the kneeling position so as to reduce
the power of the hamstrings.
The establishment of new postural reflexes is the
final aim of all remedial treatment. It is just here
that so many systems, including that officially
recognise@ in this country, show their greatest weak-
ness. They are mainly concerned with strengthening
muscles and increasing mobility, and make but little
effort to teach the patient how to hold the new posture.
Remedial work requires ‘“‘ postural fixation” not
“ postural change,” so, when it is possible to make a
voluntary correction, exercises that move the parts
of the body principally concerned can do no good,
Exercises must be directed towards keeping those
FIG. 13.—The correct movement to encourage
extension of the hip and spine.
THE LANCET]
parts as still as possible whilst the rest of the body
is moved. Thus the patient is taught to keep a good
posture during every variety of movement.
It would be out of place to attempt to describe
here any particular remedial system that will fill
the criteria set out. It requires but little ingenuity
to invent one once the principles are understood.
I am concerned mainly to emphasise that it is not
movement, but absence of movement, of any given
part that is essential for the establishment of a
postural reflex. Success or failure of treatment
depends.on the extent to which the coöperation of the
patient is obtained. During the remedial class it is
only possible to teach the patient how to get into the
, new posture and how to hold it under a variety of
conditions. The establishment of an unconscious
reflex that will hold the new posture permanently
is only possible if the patient continues to try after
the class is over, and it can never be done if, as soon
as he is out of the room, he just drops back into
the old posture. For treatment to be successful
the patient really must want to be cured and make
up his mind to succeed. The personality of the
teacher, and his ability to win the patient’s confidence
and keep his interest, is of just as great importance
as a knowledge of remedial technique.
Summary
1. The regulation of posture is a function of the
central nervous system which determines the length
at which the muscles are habitually held; the
strength of the muscles is of less importance.
2. The importance of rapid growth, undernutrition,
and psychological factors in the etiology of postural
deformities is emphasised.
3. A new instrument is described for measuring
the pelvic inclination. This angle in “normal”
adult males averages 31°, and in females 28°, In
children it is somewhat less, but it increases up to
11 years of age when the adult level is reached.
4. The pelvic inclination is regulated by the
muscles surrounding the hip-joint, and not by the
trunk muscles.
5. Deformities are classified on the basis of their
two principal components—variation in pelvic inclina-
tion and the presence or absence of a dorsolumbar
kyphosis—into four types: (l) lumbar lordosis ;
(2) sway back; (3) flat back; (4) round back.
6. Final correction of a deformity can only be
made by establishing new postural reflexes. This
can never be done by movement, but only by absence
of movement, therefore exercises must be designed to
keep still the parts of the body concerned.
It is a pleasure to thank Prof, Samson Wright for per-
mission to work in the department of physiology at
the Middlesex Hospital medical school, and also the
honorary staff'of the Royal National Orthopedic Hospital
for allowing me to examine a number of their patients.
I also wish to express my indebtedness to Sir Frederick
Menzies and the London County Council for permission
to attend the medical examinations of elementary school-
children, and to Mr. Paul S. Newby, director of physical
training at the Central Y.M.C.A., and Miss E. M. Prosser,
sister-in-charge of the massage department of the
Middlesex Hospital, for their kindness in procuring me
normal subjects for measurements of pelvic inclination,
and to the many subjects themselves, whose great patience
has made this work possible.
REFERENCES
Delpech, J. (1828) De l’Orthomorphie par rapport à lespéce
humaine. Paris.
Lovett, R. W. (1931) Lateral Curvature of the Spine. Phil-
adelphia, p. 25.
(Continued at foot of next column)
`
MR. J. W. RIDDOCH : PRURITUS ANI
[APRIL 17, 1937 919
PRURITUS ANI*
By JoHn W. Rippoca, M.C., M.B.,
F. R.C.S. Edin.
HON. SURGEON TO THE MIDLAND HOSPITAL, BIRMINGHAM
THE sensation of itching, like pain, is a protective
: function of the body. Pain causes various reflex
acts while itching leads to scratching or rubbing to
remove such things as insects which have a harmful
effect on the organism. Pain is transmitted by the
autonomic as well as the cerebro-spinal nervous
system, but itching is carried by the somatic nerves
alone as only these supply the parts where itching is
biologically useful. If, however, scratching is unlikely
to do good, itching must be regarded as pathological
and worthy of the name pruritus. It is apt to occur
more frequently about the various body orifices than
elsewhere, no doubt to get rid of excess discharge,
and at two of these, the anus and the vulva, it not
infrequently becomes pathological and so severe as
to acquire the status of a syndrome or even an
actual disease.
Anal irritation of minor degree occurs in a con-
siderable proportion of cases of internal hæmorrhoids
and other local abnormalities, but the term pruritus
ani denotes a condition where irritation is relatively
severe. In it the symptoms are often worse at night
soon after retirement to bed, and they may seriously
interfere with sleep. Sometimes there are inter-
missions when the irritation is in comparative abeyance
and the patient may think he has got over the worst
of his trouble only to be sadly disillusioned by the
next attack. Carlyle could not have known of this
disease when he said that the greatest pleasure in life
is to scratch the part that itches, for the patient gets
little relief from his efforts. The sensation is described
in such terms as smarting, tickling, burning, pricking,
and it is situated in the lower end of the anal canal,
the anal verge, and a variable extent of the peri-anal
region. The affected skin may be surprisingly normal
in appearance, but it is usually thickened and some-
what sodden—a change described as lichenification
—and often shows superficial cracks radiating from
the anus. Superimposed on this, scratching and
formidable remedies may have grafted a traumatic
dermatitis, and though septic infection is thus intro-
duced it is curious to note that inguinal adenitis
rarely if ever occurs (O’Donovan 1936).
JEtiology |
There must be few diseases that have been ascribed
to so many causes as pruritus ani. Lord Horder
(1935) has said “it is the merest tyro who supposes
that ... local pruritus (is due) to local causes. I am
quite sure that pruritus ani... may be of entirely
general origin.” On the other hand, Lockhart-
Mummery (1915, 1934) has long believed that a
local cause is present in all cases, but that in some
our knowledge is insufficient to recognise it. It is
agreed that anal pruritus may be caused by local
*A paper read before the Midland Medical Society on
Feb. 3rd, 1937.
(Continued from previous column)
Prochownick, L. (1882) Arch. Gynaek. 19, 1.
Quain’s Elements of Anatomy (1923) London, vol. iv., part 2,
p. 224.
Raynolds. E; and Lovett, R. W. (1910) J. Amer. med. ASS.
Ten Teachers’ Midwifery (1935) London, p. 230.
Wiles, P. (1934) Lancet, 2, 1089.
Q2
920 THE LANCET] —
conditions that give rise to a discharge, such as
fissure, fistula and infected anal crypts, and proctitis,
colitis, and ulcerative diseases of the bowel. It is
likely that threadworms produce itching in this way.
Internal hzmorrhoids and polypi may induce a
seepage of mucus by excess of secretion or by allowing
it to escape by prolapsing into the sphincters and
preventing their closure. Scarborough (1933) believes
that all cases arise in such a manner and can be
cured by removal of the cause but his claim is |
unique.
There is no doubt in the minds of a colleague and
myself that mucus can cause anal irritation as we
have produced it on ourselves by its application, but
it is probable that some sensitivity must be present
as well, for it is not uncommon in some rectal con-
ditions to see the peri-anal skin moist with mucus
or other discharge without causing symptoms. Dirt,
excessive local sweating, and pediculi may cause
irritation but can easily be recognised. Bacterial
and fungus infections have been put forward as
causes but have not found acceptance.. Where a
careful search has failed to reveal any local abnor-
mality distant lesions have been blamed, especially
gynecological abnormalities; conditions of urinary
obstruction such as stricture, prostatism, and stone
in the bladder; and cholecystitis and diseases of
the liver. In the absence of these, focal sepsis, gout,
rheumatism, and diabetes are commonly mentioned,
though with what justification I am unable to say.
The fact that attacks may be brought on by tea,
coffee, and alcohol, and in some people by cheese,
fish, strawberries, &c., has added allergy to the list
of causes, and lastly, and perhaps inevitably, the
disease is often regarded as a neurosis.
In order to escape from this diagnostic maze
some classification is necessary and I propose to
distinguish between those cases due to a discharge
and those which are not. I regard cases associated
with a discharge, and cured by its removal,, as cases
of exogenic dermatitis. In them the rash and irrita-
tion tend to pass backward in the natal cleft and
forward on to the scrotum owing to the spread of
the offending secretion in the directions of least
resistance, and though in some of these cases the
irritation may be severe, in the majority it is com-
paratively mild. True or idiopathic pruritus ani is
however a separate disease; it may occur in a
severe form with little, if any, alteration in the naked-
eye appearance of the skin; when it is coincident
with an exogenic dermatitis it persists after the
latter has been cured; it has a pathology of its own
which is not, as is commonly supposed, the result
of scratching; it may have superimposed on it a
traumatic dermatitis due to scratching or irritant
applications, but when this has cleared up after
suitable treatment the pruritus remains; and it
occurs in the complete absence of abnormalities in
the anorectal region as judged by recognised
standards and also in the absence of any general
disturbance of health.
The sensation of irritation arises in the epidermis
for, as pointed out by O’Donovan (1936), irritation
ceases if ulceration occurs. It is due to minor but
more or less rapid changes in tension (Bunch 1912),
such as are caused by the burrowing of the Icarus
scabiei or when tight garments are suddenly dis-
carded. It is a feature of whealing and Sir Thomas
Lewis (1927) mentioned itching when a wheal was
caused by freezing the skin and no irritant was
introduced from outside. It occurs in many skin
diseases and in these cedema of the epidermis is
commonly found, and it is reasonable to assume that
MR. J. W. RIDDOCH : PRURITUS ANI
[APRIL 17, 1937
where the circulatory balance is upset, as it is in
cdema, abnormal variations in tension are apt to
occur and irritation is likely to arise. _
In this paper I hope to show that idiopathic
pruritus ani is caused by œdema of the peri-anal
skin following on stasis in the external hemorrhoidal
veins; in other words, it is due to external piles.
Histology
As regards the microscopic appearances of pruritus
ani Crawford (Haskell and Smith 1936) regarded
them as essentially those of a low-grade inflammatory
process with proliferative changes. He found much
thickening of the epidermis, dilatation of the super-
ficial blood-vessels and lymphatics, extensive infiltra-
tion of white cells, usually small lymphocytes, and
fibrosis in the deeper layers of the cutis with oedema
superficially. Montgomery (Rankin, Bargen, and
Buie 1932), reporting on 5 cases, gave similar findings
but believed that the changes resembled those of
neurodermatitis and urticaria rather than inflamma-
tion. Further, it is important to note that in
comparing cases of normal naked-eye appearance
with those where frank change was present he found
the microscopic appearances differed in degree only
and not in kind.
With the help of Dr. Whitelaw and Dr. Felix
Smith I have examined sections from 6 cases; 5 of
these presented various degrees of lichenification,
but one showed no such alteration. In all there were
changes similar to those described by Crawford and
Montgomery. The epidermis was thickened, in
some parts to twice its normal depth, and showed
various degrees of acanthosis. @Œdema was evidenced
by swelling of the prickle cells and poor staining of
their nuclei, and by the fact that the intercellular
channels were more evident than in normal skin.
Some thickening of the horny layer was usually
present and in one case this was very marked. In
the cutis there was dilatation of the blood-vessels,
especially the veins, and obvious cdema shown by
separation of the connective tissue fibres and poor
nuclear affinity for stain. The lymphatic vessels were
also dilated. There was usually some lymphocytic
infiltration of the papille and the subpapillary
layer, most marked round, the vessels, but this feature
was very variable, being absent in some parts of the
sections (see Figure). An occasional eosinophil was
seen in one section only.
It might be said that the lymphocytic infiltration
suggests the presence of an irritant factor, but it is
not a very pronounced feature except in one case
and is hardly noticeable in some areas of the sections.
Also in three normal specimens of peri-anal skin
examined a certain number of lymphocytes were
seen, Their presence in any number is not a
characteristic of the disease and the essential change
is one of edema. Such oedema, as elsewhere in the
body, can be produced by local venous stasis. It
is, I think, reasonable to assume that in the earliest
stage of the pathological change. pruritus has not
manifested, itself, but the threshold to irritation is
lowered ; the skin is in a prepruritic state.
Effect of Venous Stasis
Let us now see how the theory of venous stasis
agrees with the clinical manifestations and the
therapeutics of the disease. A dramatic feature
in the symptomatology is the fact that a patient
who is free of symptoms during the day may be
attacked by intolerable itching soon after getting
into bed. He gets up and applies his favourite
powder or ointment and relief sooner or later follows.
THE LANCET]
He goes to bed again and again the itching starts.
He may find that the only way he can obtain sleep
is to spend the rest of the night in a chair. The usual
explanation that all itching is worse at night because
one is warmer in bed and the mind is not occupied
is hardly adequate. In the erect position the pressure
of the valveless portal system is conveyed to the anal
veins and when the patient lies down this pressure
ceases and there is a sudden drop in tension in the
peri-anal veins which is transmitted to the skin of
the area. This would account for the great exacerba-
tion that occurs at night, and the same train of
events is seen in varicose eczema of the legs.
` MR. J. W. RIDDOCH: PRURITUS ANI
[APRIL 17, 1937 921
Neurosis is merely of interest because the neurotic
complains more bitterly of his symptoms than the
normal person, and, if he has no disease to show to the
uninitiated the poor fellow gets little sympathy.
Clinical Findings
The skin in the lower end of the anal canal and its
vicinity is normally very thin and thrown into folds
only a millimetre or two in width. In cases of
pruritus ani the folds are much wider and the skin
is felt to be thicker than normal when picked up
between the finger and thumb owing to cedema
even when no other change is present. When an
B
A. Normal peri-anal skin: note density of staining. (x 80.)
B. Pruritus ani: showing pallor of dermis and epidermis due to odema.
(x 80.)
C. Severe pruritus ani. The papille are flattened out and there is a polypoidal formation with great increase in thickness
of the keratin layer and epidermis. (x 20.)
As regards the part played by gynecological condi-
tions inflammatory affections will cause general
congestion of the pelvis, and pelvic tumours may
interfere with the venous return in both the superior
hemorrhoidal and internal iliac veins and so cause
anal congestion and stasis. A similar result will be
brought about by the increased intra-abdominal
tension involved in the straining of urinary obstruction,
and affections of the liver by congestion or by
mechanical means will react unfavourably on all the
radicles of the portal system including the anal veins.
The effect of certain foods in sensitised individuals
is explained by the fact that the ingestion of any
substance that acts on the skin vessels will lead
to changes of tension in that structure, and though
these changes may not be sufficient to cause any
sensation in normal areas they may produce itching
in a prepruritic zone such as has been adumbrated.
Allergy is thus accounted for. Slight rises in
temperature produced by focal sepsis would act in
a similar manner and the effect of alcohol is also
explained in this way. The conception of a pre-
pruritic state also helps us with regard to the action
of tea and coffee in starting attacks as caffeine
facilitates the reception of sensory impulses (Cushny
1924).
I will not attempt to explain the supposed
importance of gout, rheumatism, and diabetes ;
as previously stated they are often mentioned,
but their relationship to pruritus ani is open to
doubt and Lockhart-Mummery (1915) has said he
has never seen a bad case due to diabetes.
anoscope is inserted and slowly withdrawn past
the mucocutaneous junction the skin below this line
forms large bulges through which the bluish colour
of the enlarged underlying veins is often apparent.
Treatment
Turning now to the effects of treatment, Morley
(1916) noted that pruritus ani sometimes cleared
up after the injection treatment of quite small and
symptomless internal piles. I have confirmed this
on many occasions and would go further and say that
benefit may be obtained by similar injections in the
complete absence of any sign of internal hemor-
rhoids. This treatment acts by destroying the veins
of the internal hemorrhoidal plexus and relieving
back pressure on the external hemorrhoidal veins.
It is not surprising, however, that the results of such
treatment vary as the anastomosis between the two
plexuses is not constant and the external plexus
has connexions with the systemic veins. :
Most operations are based on that of Sir Charles
Ball (1905) which was devised to cut all the sensory
nerves to the affected part. An essential part of the
procedure is to undermine the skin of the anal canal
to above the mucocutaneous line. Lockhart-Mummery
(1934) speaks well of this operation and states that
though sensation returns in 4-6 weeks the pruritus
is cured in most cases. It is stated that the skin
operated on must be rendered completely anesthetic.
In six recent cases I have made a curved incision
on each side of the anus and undercut the skin of the
anal canal to just above the mucocutaneous line,
a
922 .THE LANCET]
taking special care to destroy the veins; extensive
undermining was avoided as far as possible and
sensation was not completely lost. In five cases the
pruritus disappeared, and the skin became normal in
appearance in a short time.
reappeared after only 14 days, but it yielded to sub-
cutaneous sclerosing injections and, I regard this
failure as due to faulty technique. From these
results it would appear that complete section of the
nerves is not necessary for cure, as far as one can
judge at this stage, and here I would point out that
it is impossible to carry out Ball’s operation without
destroying many if not all of the underlying veins.
Sir Frederick Wallis (1911) believed pruritus ani
was due to some lesion at the mucocutaneous junction
and he excised this along with the skin of the lower
part of the anal canal. He claimed good results
from this operation but again it is impossible to carry
out the procedure without excising the neighbouring
veins.
The subcutaneous injection of alcohol, dilute
hydrochloric acid, and other substances was intro-
duced, as a substitute for operation to destroy nerves
but the beneficial effects claimed can be explained,
in a similar manner. Solutions of anzsthetics in
oil will stop the itching temporarily and allow a
scratch dermatitis to subside, but they also will tend
to strangle the veins by causing fibrosis.
As far as external applications are concerned they
may be very important in the treatment of patients
who have become sensitised to some superadded
infective skin condition, and in these cases the
coöperation of a skin specialist is often necessary ;
but in the treatment of the true idiopathic form the
value of such remedies is belied by the very numbers
that have been recommended. Radioactive mud,
colon lavage, vaccines, ionisation, artificial and
natural sunlight, &c., may, I think, be placed in the
same category and their lack of value in treatment
is easily understood, in the light of the theory presented.
The claims put forward on behalf of Röntgen rays
are usually moderate, but they appear to have some
curative value and the explanation of this may be a
destructive effect on the blood-vessels.
Conclusion
In conclusion, I believe that the severest form
of pruritus ani and the occasional itching found in
association with internal piles are merely different
degrees of the same condition and that the under-
lying cause is cedema of the skin due to venous stasis.
If I have not convinced you I can at least say that
I have found this view to be a useful working
hypothesis.
I wish to express my indebtedness to Dr. W. Whitelaw
for his interest in-the pathological side of the work and for
preparing the photomicrographs.
REFERENCES
Ball, C. let Brit. med. J. 113.
Bunch, J - L. (1912) Dto 89, 357.
Crawford, quoted by Haskell, B., ‘and Smith, C. D.
(1936)
AmE med. Ass. 106, 1248.
Gusin, R. (1924) arr and Therapeutics, London,
Horder, T. (1935) Lancet, 87.
Lewis, T. (1927) The Siod Vessels of the Human Skin and
their Responses, London,
Locihert Murie ery, J.P. (1915) Dait. med. J. 291.
— 9 Diseases of the Rectum and Coles, London,
43.
Morley, A. gs. ore Lancet, 1, 617.
O’Donovan, W. J. (1936) Practitioner, 136, 148.
Montgomery, quote d by Rankin, F. W., Bargen, J. A.,
and Bule, A. (1932) The Colon, Rectum, and Anus,
London, p. 609"
Scarborough, R. A. (1933) Ann. Surg. 98, 1039.
Wallis, F. (1911) Practitioner, 87, 417.
@
In one case the pruritus.
DR. O. SCHEEL: TUBERCULIN REACTIONS AND RADIOLOGICAL FINDINGS [APRIL 17, 1937
COMPARATIVE STUDY OF
TUBERCULIN REACTIONS AND
RADIOLOGICAL FINDINGS
By O. ScHEEL, M.D.
PHYSICIAN TO ULLEVAAL HOSPITAL, OSLO, NORWAY
THERE is still no agreement as to where we are to
fix the limit dividing positive from negative tuberculin
reactions and as to which technique should be used,
in particular whether Pirquet or Mantoux. During
recent years in Norway we have regarded the Pirquet
reaction, by the scarification method, as positive
when induration measures 2 mm, or more after
48-72 hours; the Mantoux reaction is considered
positive when induration measures 10 mm. or more
after 48-72 hours. In France also the Pirquet
téchnique is employed as a rule. In Sweden, Den-
mark, and England,.on the whole, the Mantoux test
is preferred and most workers fix the limit between
positive and negative reactions lower than we do.
Thus D’Arcy Hart fixes the minimum for a positive
Mantoux reaction, after 48—72 hours, at “an area of
erythema or erythematous infiltration ’’ whose greatest
diameter is 5 mm.; he uses up to 10 mg., and on
occasion 100 mg., of tuberculin. Arborelius considers
a second Mantoux test with 1 mg. tuberculin as
positive when there appears after 48 hours a definitely
palpable induration and an area of erythema measur-
ing at least 5 mm. by 5 mm. Thus both these
observers fix the minimum for positive reaction lower
than we do and think our method too insensitive,
with the result that we obtain too few positive
reactions among healthy subjects—viz., approxi-
mately 50 per cent. at twenty years of age, while
Arborelius obtains 85 per cent. and D’Arcy Hart,
from twenty-one years of age, 95 per cent.
Now it is generally agreed that on the whole we
can distinguish between pronounced tuberculin-
positive individuals and completely tuberculin-
negative individuals, which corresponds to infected
and uninfected individuals. But the dividing line
between these two groups is difficult to determine,
for two reasons: on the one hand there are the
false reactions which are due to non-specific sub-
stances in the tuberculin, especially when more than
1 mg. of tuberculin is injected; on the other hand,
the reaction may fail because of insufficient dose,
faulty technique, or for other reasons. I have dis-
regarded in the following the anergy which is seen,
for example, in certain diseases and among the aged,
for it has no interest in connexion with this material
which consist of young healthy subjects.
In order to fix the limit between positive and
negative reactions all observers argue from certain
characters of the definite positive and definite
negative reactions—viz., the size of the reaction,
its mode of development in the course of the first
few days, and the result of repeated tests with the
same or increasing doses. But in this way evidence
is sought in that which is to be proved; this is the
case, for example, if we regard the Mantoux test as
the reliable one and compare the various Pirquet
responses with that of the Mantoux test. This mode
of reasoning involves a logical ctrculus vitiosus in
which that which is to be proved is used as argument in
the chain of reasoning : both argument and conclusion
are links in the same chain, the tuberculin reaction itself.
In order to break this vicious circle it is therefore
necessary to control the tuberculin reactions by facts
obtained from an independent source of evidence.
~
THE LANCET]
I may first reiterate the fact that with our Pirquet
technique we always find a higher tuberculous
morbidity among the Pirquet-negative than among
the Pirquet-positive when both groups are exposed
to infection. This corresponds to the known experi-
mental finding that an initial infection with tubercle
bacilli in animals has a more serious outcome than a
later ‘‘ superinfection ’’ with small doses of tubercle
bacilli, With our Pirquet technique, therefore, we
distinguish on the whole two different immuno-
biological groups, but this control is not sufficient to
draw any exact line between infected and uninfected.
THE INQUIRY
In an attempt to determine with more certainty
this limit between positive and negative, I have
compared the tuberculin reactions with the simul-
taneously obtained radiological findings in 1697
students. The great majority of the material is
derived from the university tuberculosis clinic at
Oslo, where the radiological diagnosis is made by the
radiological department of the State Hospital; all
the students are radiographed. The tuberculin tests
have been carried out and interpreted by various
doctors from my department at Ullevaal Hospital,
but the same procedure is always followed. All
those examined were healthy, without previous
history of tuberculous disease and not vaccinated
with BCG.
851 STUDENTS REGARDED AS TUBERCULIN-NEGATIVE
. — o D : he i
4 | Z8 | we |a
= ~~ S = ag "oj A 0
S | #2 | AS | 2884
| E= Ay o a chee
% % %
Fiancee. Gunna 585] 4:3 | 12 | or,
Doubtful Diack or Mantoux. ; 139 4'3 0 0
Two Pirquet tests, 0 mm 65 3'1 0 0
Single praua test, 0—1 mm. 62 6'5 1'6 3°2
8 que neg. :
2nd reac. : Mantoux 1-9 mm. 63 4°8 0 0
846 STUDENTS REGARDED AS TUBERCULIN-POSITIVE
Ist: Pirquet, 0 mm.
2nd reac.: Mantoux 10 mm. "VE ga | 62 2°5 0
(or Pirquet positive) J l
Pirquet, 2 ` si 40 0 0 0
es 3 Da a5 Ra 61 3°3 3°3 13°1
on ; mm. aoe 98 6'1 4'1 12°2
5 mm. or more 566 4°2 6'9 16°2
“isi: Pirquet neg. r ere
d reac.: Mantoux \ 89 3°4 1°2 1°2
10—40 mm.
reac. = reaction.
We see from the accompanying Table that the
851 students whom we have regarded as tuberculin-
negative fall into four groups.
(1) First tuberculin test by Pirquet method and second
test by Mantoux method give no » measurable induration
after 48 hours.
(2) Doubtful reactions: first test (Pirquet) may be
doubtful or feeble positive, 1-2mm. induration; later
Mantoux test negative or the later Mantoux test may give
1-9 mm. induration (in some cases 10 mm. or more, but
a further reaction is then negative).
(3) Two successive Pirquet reactions negative.
(4) A single Pirquet test with 0-1 mm. induration as
result.
In 846 students whom we have regarded as
tuberculin-positive there is, first, a group in whom
the first test (Pirquet) is negative, the second test
(Mantoux or, in a few cases, Pirquet) is positive.
In the remaining groups only a single Pirquet test
has been made and the reactions have been 2, 3,
DR. O, SCHEEL : TUBERCULIN REACTIONS AND RADIOLOGICAL FINDINGS [APRIL 17, 1937
923
4, 5 mm. or more (induration). In some cases giving
a Pirquet of 2 mm. a Mantoux test has been
carried out.
In the two groups, tuberculin-negative and
tuberculin-positive, I have also indicated by asterisks
the results of a second test (Mantoux), the
induration measuring 1-9 mm. in the negative
group, 10-40 mm. in the positive group. Among
these last, 89 in number, 62 gave induration measuring
only 10-20 mm. The Mantoux tests are always
carried out with tuberculin dilutions supplied in
sealed ampoules (1/10 c.cm.=—1 mg.); these are
opened after the lapse of some days or weeks, on
occasion some months. A freshly prepared dilution
of tuberculin gives as a rule a slightly more powerful
reaction, but, according to comparative tests we
have recently made, the difference is not great.
I have now grouped these tuberculin-positive and
tuberculin-negative individuals according to the
radiological findings. Three groups have been
considered.
(1) Changes in the pleura, usually diaphragmatic
adhesions, sometimes thickening over the apex, but
without changes in lung or hilus.
(2) Shadows in the lung fields, in some cases with
changes in the pleura, but without calcification.
(3) Deposits of calcium in lung tissue or glands, in these
there may be in addition pleural and lung shadows.
These radiological changes are distributed in the
folowing way among those we have regarded as
tuberculin-negative and tuberculin- positive respec-
tively :—
The purely pleural changes appear with approxi-
mately equal frequency among tuberculin-negatives
and positives, 0-6-5 per cent. The purely pleural
changes are therefore clearly not of tuberculous
ætiology but must be due to non-specific affections
such as, for example, bronchopneumonia. The
distribution of pleural changes which are combined
with lung or hilus changes is not revealed in the
Table.
The pure lung shadows without calcification,
presumably corresponding to a deposition of fibrous
tissue, are distinctly more frequent among the
positive (0-6-9 per cent.) than among the negative
(0-1-6 per cent.); they may obviously be due to
non-specific lung infiltrations but are more frequently
a sign of a healed tuberculous process.
Calcified foci occur, though rarely, among the
definite tuberculin-negative (0-7 per cent.), which is
not surprising ; there are other causes of calcification
besides tuberculous—e.g., calcified lung emboli,
intra-alveolar ossification ; in pneumonia also there
may occur necrosis of lung tissue, leading to abscess
formation, and presumably also in glands; and
where there is necrosis the conditions necessary for
calcification are always present. In the group who
received only a single Pirquet test, with negative
result, there appear also two cases showing calci-
fication ; but here the numbers are so small that we
must not lay much stress upon the percentage—
3-2. We do not know either what result would
have been obtained by a repeated Pirquet test on |
these subjects.
In the group which we have regarded as tuberculin-
positive we find calcified foci with much greater
frequency, but only when the Pirquet test has given
an induration measuring 3 mm. or more. The fre-
quency of calcified foci in these groups varies from
12-2 to 16-2 per cent. These figures represent only
a fraction of the calcified foci actually present ;
thus Frimann-Dahl and Waaler, by radiography of
200 excised lungs from autopsy material extending
| 924 THE LANCET]
over all ages, found calcification shadows in 71 per
cent. Even though the frequency of calcified foci
in our material is thus much less, we nevertheless
find calcified foci in the positive groups approxi-
mately twenty times as frequently as among the
purest negative group. This frequent calcification is
therefore obviously an index of tuberculous infection,
and this infection is revealed by a Pirquet reaction
of 3 mm, or more.
On the other hand, we have no calcification
shadows in two of the groups of our material which
we have regarded as tuberculin-positive—namely,
(1) those in whom the first Pirquet reaction is negative
while the second test, Mantoux or Pirquet, is positive,
and (2) those in whom the first Pirquet test gives a
reaction measuring 2 mm. This finding strongly
indicates that at any rate the great majority of
these feeble tuberculin reactions do not correspond to
tuberculous infection.
If we consider in particular those cases (indicated
by asterisks in the Table) where the second test—
a Mantoux test—has given a more or less pronounced
reaction after a negative response to the first Pirquet
test, we find only a single case with calcification.
According to this it appears doubtful whether the
Mantoux test performed after a negative or doubtful
Pirquet test has any significance or is at all neces-
sary. We must, however, qualify this conclusion in
two ways. Firstly, a second tuberculin test can
probably reveal a tuberculous infection if the reaction
be sufficiently powerful, even though the first test
was negative. In most of our cases the second
reaction was of moderate extent, and we can there-
fore neither confirm nor deny the possibility of a
“ sensitisation ” effect, but must regard it as possible.
Secondly, we do not regard our figures as of universal
application; it would seem that other Norwegian
observers have found calcification in association with
doubtful or negative tuberculin reactions more
frequently than we have, and we are unable to decide
whether this divergence is due to any difference in
interpretation of tuberculin reactions or radiological
appearances. Our radiological control applies there-
fore chiefly to the tuberculin technique we have
employed among healthy subjects at about 20 years
of age.
A clinical case, recently observed, appears to
support our view.
A nursing probationer, on enrolment at Ullevaal
Hospital, gave on two successive occasions (each with
two scarifications) a completely negative response to the
Pirquet test (Sept. 5th-7th and 7th-9th, 1936). A third
tuberculin test by the Mantoux method, with 1 mg.
tuberculin (Sept. 9th-llth) gave a reaction with 12mm.
erythema and 10mm. induration. She began work in
the tuberculosis wards on Dec. 22nd, 1936. On Jan. 26th,
1937, she developed erythema nodosum and a Pirquet
test on Feb. 25th now gave a vesicular reaction with
25 mm. erythema and 10 mm. induration. A radio-
gram taken on Feb. 26th showed a small isolated opacity
in the left infraclavicular region and the blood sedimenta-
tion rate on Feb. 28th was 44mm. in 1 hour. There can
be little doubt that this patient’s Mantoux reaction,
showing 10mm. induration, was non-specific, and that
the erythema nodosum was evidence of a primary infection.
CONCLUSION
When by any method of investigation we wish to
draw a line between two biological groups or condi-
tions, such dividing line is always more or less arbi-
trary ; in reality there will be some overlapping of
the two groups in the region of the dividing line.
We should therefore rather reckon with a dividing
zone than a dividing line, but in practice it may be
DRS. I. W. ROWLANDS AND A. 8. PARKES : ANTI-GONADOTROPIC SERUM
[APRIL 17, 1937
necessary to draw a sharp line, and, in our material,
this line should therefore lie between 2 and 3 mm.
induration after the first Pirquet test; a repeated
tuberculin test does not as a rule appear to reveal
any additional infected individuals unless it gives a
very powerful reaction. All this applies to human
infection, which is, practically speaking, the only
type existing in Norway.
It therefore appears that in our Norwegian student
material, so far from obtaining too few positive
reactors as our critics assert, we have included too
many.
INHIBITION OF THE
GONADOTROPIC ACTIVITY OF THE
HUMAN PITUITARY BY ANTISERUM
By I. W. ROWLANDS, Ph.D.
AND
A. S. PARKES, Sc.D. Camb., F.R.S.
(From the National Institute for Medical Research,
| London, N.W.3)
THE prolonged injection of thyrotropic or gonado-
tropic extracts of ox anterior pituitary tissue into
laboratory animals leads to their becoming gradually
insensitive to the stimulating action of the extracts
and may even cause a condition of hypopituitarism
such as is found after hypophysectomy (Collip 1934).
This result was originally ascribed to exhaustion of
the responding gland, but in 1934 Anderson and
Collip showed that the blood-serum of an animal
chronically treated with thyrotropic extract would
protect a second animal from the effect of the extract.
The same thing was afterwards shown for gonado-
tropic extracts. These remarkable observations,
subsequently confirmed by other workers, have
opened up wide fields of research.
The mechanism of the production of the anti-
thyrotropic and antigonadotropic substances is not
understood. It may be said definitely that their
site of origin is not the responding gland, since
Oudet (1937) has recently shown that antithyrotropic
activity can be evoked in the thyroidectomised
rabbit. Probably no endocrine organ is involved.
A recent attempt (Sulman 1937) to associate the
phenomenon with Abderhalden’s ‘“‘ protective fer-
ment ” does not appear promising. The most probable
explanation is that the active substance or grouping
is linked with a protein having antigenic properties
and that the production of antihormone activity is
an immunological reaction. If so, by analogy with
thyroglobulin, further work may lead to the separation
of the prosthetic group from the protein and to the
production of active but non-antigenic preparations.
The antibody theory is supported by the fact that the
activity of the antisera can be concentrated in the
globulin fraction—Thompson (1937a) states that all
the activity appears in the pseudoglobulin fraction of '
the antiserum, but this may vary with the species
of the donor. The theory is further supported by
Thompson’s observation (1937b) that the continued
injection of sheep pituitary extract into a sheep does
not lead to its serum acquiring the power to neutralise
the action of the extract on another animal, by
Twombly’s failure (1936) to find antihormone activity
in the serum of a woman chronically injected with an
extract of human urine of pregnancy, and by Katzman,
Wade, and Doisy’s analogous work on the rat (1937).
THE LANCET]
These results agree with our own experience, and
almost exclude the possibility that ‘‘ antihormones,” of
the kind produced experimentally, play any part
in the maintenance of the endocrine balance of the
normal animal. It is as yet uncertain what degree
of zoological relationship, between the species from
which the extract is made and the chronically. injected
animal, is compatible with “ antihormone”’ forma-
tion. Apparently, a wide divergence may be required,
since ox pituitary extract does not seem to evoke a
strong response in a sheep, or pig pituitary extract
in a goat.
There are other aspects of the specificity problem,
such as species specificity and source specificity, in
the effectiveness of antisera. It is known that sera
of animals immunised to ox or sheep pituitary
extracts will inhibit gonadotropic extracts of the
pituitaries of several different species, but the full
range of effectiveness has not yet been investigated.
Sources of gonadotropic extracts include pituitary,
human urine of pregnancy, human placenta, and
equine pregnancy serum. It is likely that considerable
immunological specificity will be shown between the
substances from these different sources. Thus, anti-
serum to extract of human urine of pregnancy is not
effective against ordinary pituitary extracts, while
antiserum for ox pituitary is only partially effective
against extract of human urine of pregnancy (Row-
lands 1937). Antiserum to gonadotropic extract of
pregnant mare serum appears to be only partially
effective against other types of gonadotropic substance
(Thompson and Cushing 1937). One of us (I. W. R.)
has examined the interaction of many antisera and
gonadotropic extracts and the results will form the
subject of a detailed report.
For clinical application it is important to produce
antisera capable of neutralising human thyrotropic
and gonadotropic substances. Fluhmann (1935) was
able to obtain serum from a number of rats immunised
to human pituitary, but such a technique would be
impracticable on a large scale, and the problem is
to find what antisera, capable of being produced in
bulk, are effective against the gonadotropic or thyro-
tropic substances of human pituitary. We have not
yet been able to prepare sufficient amounts of human
thyrotropic extracts to test antithyrotropic sera, but
it is hoped to do so eventually. Human pituitaries,
however, prove to have high gonadotropic activity
and a comparatively small number have provided
adequate material for quantitative experiments.
It has been found that rabbit antisera to ox and
horse gonadotropic extracts are at least partially
effective against the gonadotropic activity of human
pituitaries, but this fact is at present only of academic
value, since extracts of ox and horse pituitaries are
highly impure, available only in limited amounts,
and doubtfully antigenic in animals large enough to
provide adequate amounts of serum. Clinical possi-
bilities are, however, suggested by the experiments
described below, which show that serum from an
animal immunised to gonadotropic extract of human
urine of pregnancy will obliterate the gonadotropic
effect of human pituitary extract on test animals.
METHODS
Antiserum to gonadotropic extract of human urine
of pregnancy was prepared by subcutaneous injection
of a 40 kg. goat with 10 mg. rising to 20 mg. (1000-
2000 rat units), daily of Pregnyl for five months.
The response of the immature rat ovary, as judged
by weight, was used to measure the activity of the
Pregnyl and the effectiveness of the antiserum.
Groups of ten rats (40-50 g.) were given five daily
DRS. I. W. ROWLANDS AND A. S. PARKES: ANTI-GONADOTROPIO SERUM [APRIL 17, 1937 925
injections, and killed 24 hours after the last one.
The antiserum and the Pregnyl, when given simul-
taneously, were injected on opposite sides of the
animal, The ovaries were weighed after fixation in
Bouin’s fluid, The ovaries weigh 10-12 mg. without
treatment; a total of 0-25 mg. of Pregnyl caused
increase to about 35 mg., which is slightly less than
the maximum average size (40 mg.) obtainable in
this period by urine of pregnancy extracts (Deanesly
1935).
_ When the goat had been injected for three months,
0-0125 c.cm., of the antiserum was capable of inhibiting
that amount of urine of pregnancy extract required
to give 35 mg. rat ovaries. Assuming the goat to
have had 1:5 litres of serum, its total antigonadotropic
power equalled 30 g. of Pregnyl—i.e., about 20 times
the amount administered over the three months.
It has been found (unpublished data) that this anti-
gonadotropic activity can be quantitatively recovered
in the globulin fraction of the antiserum.
EXPERIMENTAL RESULTS
The anti-Pregnyl serum known to inhibit gonado-
tropic material from pregnancy urine was tested
against placental gonadotropic extract and found to
be effective. The crucial test against human pituitary
Weight of ovaries (mg)
w Aa ony OQO
O ÒO Oo O Q O O
N
oO
r=)
0 0025 0-05 0-075 0-1
Equivalent of whole serum ( c.cm)
Capacity of anti-Pregny] serum to inhibit the gonadotropic
activity of a constant dose of 3 mg. desiccated human
anterior pituitary tissue.
gonadotropic extract was then carried out. In a
preliminary experiment on oestrous rabbits, a saline
extract of 10 mg. of fresh human pituitary caused
ovulation in every one of a batch of ten rabbits.
The same amount given with 2 c.cm. of the anti-
Pregnyl serum failed to cause ovulation in any of _
ten rabbits of another group. In an experiment on
immature rats a saline extract of 25 mg. of human
pituitary caused hypertrophy of the ovaries to an
average of 70 mg. in a group of ten rats, while one
of 20 mg. given with 0:5 c.cm. antiserum failed to
alter the average weight, which was normal at 10 mg.
It was decided, therefore, to construct a dose-
response curve for the power of the anti-Pregnyl
serum to inhibit human pituitary gonadotropic
substance. For this purpose a mixed batch of
acetone desiccated pituitaries was prepared. A total
dose of 3 mg. of this powder suspended in distilled
—_—_ ee eee eee eee a
1 The pituitarics used were from three accident cases, two
males and one female, with ages ranging from 64 to 66 years.
Such pituitaries are about three times as potent as those from
people under 45.
) |
926 THE LANCET] MR. J. C. HODGSON :
REGIONAL ILEITIs : CROHN’S DISEASE
[APRIL 17, 1937
water, given over five days to a group of ten rats,
was found to produce a very strong response (90 mg.
ovary weight). The same dose, together with varying
amounts of the globulin fraction of the antiserum,
was then given to further groups of rats. From the
results shown in the accompanying Figure it can be
seen that a total dose equivalent to a little over
0:05 c.cm. of the original antiserum inhibited the
total activity of the 3 mg. of human pituitary. The
weight of the average human anterior pituitary after
acetone desiccation is about 50-70 mg. so that
1 c.cm. of the antiserum would inhibit the whole of
the gonadotropic activity of one human pituitary.
It is impossible to say what the relation may be
between content and output of gonadotropic sub-
stance in the human pituitary, but it is known that
antiserum may be effective against the secretions of
an animal’s own pituitary (Parkes and Rowlands
1936, Rowlands 1937), and the above results indicate
a strong probability that the gonadotropic activity
of the human pituitary in situ might be inhibited by
adequate amounts of the anti-Pregnyl serum and
that a temporary, differential, serological ‘‘ hypo-
physectomy ” might be performed.
DISCUSSION
The interest of the above results lies in the possi-
bility of successfully treating hyperpituitarism. The
preparation of highly active extracts of ovary, testis,
and pituitary may make it possible to deal adequately
with conditions resulting from the hypofunction of
these glands, but the hope of dealing with hyper-
function by endocrine therapy has seemed less good.
Now, however, it seems that excessive secretion of
the gonads or pituitary might be treated by passively
immunising human subjects against their own
pituitary hormones. Such a procedure would have
great advantages over surgical interference in that
the duration of the effect could be regulated, and the
obliteration of pituitary activity would be differ-
ential. The serum described above would neutralise
only gonadotropic substances, but further research
-may make available selective antisera for the thyro-
tropic and possibly other pituitary secretions.
SUMMARY
Prolonged treatment of a goat with urine of preg-
nancy extract (Pregnyl) resulted in its serum
acquiring the power to neutralise, in test rats and
rabbits, not only the effect of the original antigenic
extract but also the gonadotropic activity of human
anterior pituitary.
The activity of the serum was such that 1 c.cm.
would inhibit the gonadotropic power of a whole
human pituitary.
Our best thanks are due to Dr, P. Hartley who prepared
the globulin fraction of the serum; to Major G. W. Dunkin
who undertook the immunisation of the goat; and to
Dr. Dorothy Russell who kindly obtained the human
pituitaries. We are also indebted to Organon Labora-
tories Ltd. for the generous supply of Pregnyl.
REFERENCES
Anderson, E. M., and Collip, J. B. (1951) Lancet, 1, 76.
Collip, J. B. (19: eh J. Mt lee Hosp. 1, 28
Deanesly, R. (1935) Quart. J. Pharm. 8, 651.
Flubmann, C. F. (1935) Proc. Soc. exp. Kiol, a 32,
Katzman, P. A., Wade, N. J., E) Sorio-
crinology, 21, 1.
Oudet, P. (1937) "C.R. Soc. Biol. Paris, 123, 1180.
Parkes, 6 S.,and Rowlands, I.W. (1936) J. ' Physiol. 88, 305.
Rowlands, I. W. (1937) Proc. roy. Soc. B. 121, 517.
ulman, F. (1937) J. exp. Aled. 65, 1.
Thompson, K. W. (1937a) Proc. Soc. exp. Biol., N.Y. 35, 640.
— (1937b) Ibid, p. 634.
— and Cushing, H. (1937) Proc. roy. Soc. B. 121, 501.
Twombly, G. H. (1936) Endocrinology 20, 311.
and Doisy, E
REGIONAL ILEITIS: CROHN’S DISEASE
By Joun C. Hopeson, M.D. Edin.
HONORARY SURGEON TO ASHFORD HOSPITAL, KENT
THE reading of an article on Crohn’s disease (Hurst
1936) has been illuminating in the reconsideration
of a diagnosis made seven years ago.
In 1932 Crohn of New York drew attention to a
not uncommon intestinal condition looked upon in
the past as a hyperplastic tuberculosis of the lower
ileum and cecum. He described the clinical picture
and demonstrated that it was definitely not tuber-
culous. The morbid anatomy is that of an inflamma-
tion of the terminal ileum which may spread to the
cecum; the affected segment becomes thick and
cdematous and rigid, and this is followed by fibrosis
and progressive diminution in the lumen of the rigid
bowel. In the inflammatory phase adhesions and
fistulae may develop, and although microscopically
giant cells are found, yet no tubercle bacilli have
ever been discovered and animal inoculation is
negative. The clinical picture is one of progressive
- obstruction of the small intestine.
Since then numerous papers have appeared in
America on the subject (e.g., Rosenblate, Goldsmith,
and Strauss 1936, and Koster, Kasman, and Stein-
field 1936) but the condition is only becoming
recognised in England. Cases have recently been
recorded by Dickson Wright (1935), Edwards (1936),
Barbour and Stokes (1936), and Jackman (1934).
A good account has been published in Holland by
Snapper, Pompen, and Groen (1936), but Crohn’s
disease is apparently still unrecognised in other
parts of the Continent.
Seven years ago a man aged 61 came under my
care suffering from intestinal obstruction and |, at
operation the provisional diagnosis of an inoperable
carcinoma invading the ileum and proximal cecum
was made. A lateral anastomosis was performed
“to tide the patient over.” He rapidly improved,
put on 2 st. in weight, and did a labourer’s work and
was lost sight of. Recently he came under my care
again, suffering from a perforated duodenal ulcer,
from which he is now recovering.
Hurst’s paper had just. been digested and this
recently acquired knowledge, with fresh radiographic
evidence, suggests that Crohn’s disease was the
probable diagnosis. A brief résumé of the case is
therefore given in the belief that it may be useful to
others who may meet with a similar condition.
CASE-HISTORY
For 18 months the patient, aged 51, had complained
of attacks of pain in the lower right segment of the
abdomen. These attacks lasted about a week, often
passed off for a few weeks. The pains were griping and
accompanied by distension—he became “ blown out.”
His bowels alternated between constipation and diarrhea,
but especially the former, and castor oil was the only
medicine which would help him. Occasionally he vomited,
his appetite was poor, and he had lost weight.
He was admitted to hospital, and the operation notes
state: ‘* Partial obstruction due to a bloodless band over
the cecum, and partial volvulus from this. Appendix
removed and band cut; nothing else abnormal found.”
After this operation he had five months’ freedom from all
symptoms. Unfortunately they returned, and twelve
months later he came under my care. The pains had
occurred more frequently, especially about one hour
after meals, and in the right iliac fossa. His appetite
had become poor; he was afraid to eat because of the
pains food caused, and he had lost about 2 st. in the last
year, and actually 1 st. in the last six weeks. For the
THE LANCET |
last six months his constipation had wholly disappeared,
and he had instead three to four diarrheic motions per
day. He vomited occasionally, he had never been
jaundiced, and he had never passed blood.
Examination.—A thin anzmic patient, with abdomen
distended in centre and flanks, Umbilicus stretched and
bulging ; visible peristalsis present of the small intestine
type with loud rumblings; some rigidity in right loin;
no mass felt; abdomen very resonant; occult blood +.
Mild pyrexia present,
Radiography.—‘‘ Great dilatation of the small intestine
indicating an obstruction of the lower ileum and ileocecal
valve.” Unfortunately this plate was destroyed so no
comparison is now possible.
Operation.—A large inoperable mass was found invading
the terminal ileum and adjacent cecum and the diagnosis
of carcinoma was made. The naked-eye appearance
did not suggest tuberculosis. The ileum above this was
very greatly distended almost to the diameter of the normal
stomach ; the mesentery was thickened and the mesenteric
glands enlarged. A lateral anastomosis was made between
the cæcum and the ileum above the growth. Recovery was
uninterrupted.
At the recent operation the cecal area could not be
palpated for adhesions, and his general condition made speed
imperative. Further radiography shows ‘‘ some remaining
dilatation of the small intestine : anastomosis satisfactory :
filling defects in the terminal ileum and proximal cecum.
WEST LONDON MEDICO-CHIRURGICAL SOCIETY
4
[APRIL 17, 1937 927
amounting to the ‘string sign ’—a thin irregular linear
shadow running through the filling defect.” This string
sign is described as very characteristic of the disease.
DISCUSSION
Crohn’s disease seems to be the correct diagnosis
in this case. The treatment usually advised in this
_ condition is total excision of the affected segment,
since the disease tends to spread if not eradicated,
but this case suggests that simple short-circuiting
is sufficient in certain cases, and should be seriously
considered when the infiltration of the mesentery
renders total excision dangerous.
My thanks are due to Dr. E. Scott who did the
radiological work in this case.
REFERENCES
Barbour, R. F., and Stokes, A. B. (1936) rears 1, 299.
Crohn, B. B. (1934) Amer. J. Dig. Disorders, 1,'97.
Edwards, H. C. (1936) Trans. med. Soc. Lond. 59, 87.
Hurst, A. F. (1936) Practitioner, 137, ee
Jackman, W. A. (1934) Brit. J. Surg.
Koster, E., Kasman, L. P., and Stenier. w (1936) Arch. Surg.
Rosenblate, H. Goldsmith, A. A., and Strauss, A. A. (1936)
. Amer. at Ass. 106, 1452.
Snapper, J., Pompen, A. W. M. . and Groen, J. (1936) Ann. Méd.
Wright, A. D. (1935) Trans. med. Soc. Lond. 58, 94.
MEDICAL SOCIETIES
WEST LONDON
SOCIETY
A MEETING of this society was held on April 9th, Mr.
N. F. Srnciar, the president, being in the chair, when
a SCURMoN oA ogden Death
was opened by.Dr. B. T. Parsons-SmituH. He said
that as a general rule the cause of a sudden death
could only be a matter for speculation until a post-
mortem examination had been made, but that some-
times the patient's previous medical history might
afford valuable evidence; circumstantial evidence
might be enough to justify a reasonably safe opinion
when, for instance, death followed a massive hæmor-
rhage in a patient known to have been suffering from
an aortic aneurysm or if it followed hæmorrhage after
operations or obstetrical accidents. Chronic disease
did not necessarily explain sudden death ; Sir Wiliam
Osler had said: ‘‘ It may seem paradoxical but there
is a truth in the statement that persons rarely die
of the diseases with which they suffer.” In cases of
sudden death, a post-mortem examination should be
deemed necessary however convincing the circum-
stantial evidence. The speaker then discussed those
cases in which the death was incidental to natural
causes—i.e., when an acute or chronic disease
ended fatally in a sudden and unexpected fashion.
According to Glaister 1 per cent. of all deaths from
natural causes were sudden, and statistical evidence
associated most of these with varying types of cardio-
vascular disease. The risk of sudden death was great
in such conditions as aortic valve disease, specific
aortitis, angina pectoris, coronary atheroma, and
myocarditis, both acute and chronic; the sudden
asystole had been attributed to vagal inhibition, but
Lewis doubted whether permanent asystole could be
produced in that way. Sudden death was nowadays
associated with ventricular fibrillation, which might
develop in all types of human heart disease, notably
in digitalis toxemia, now fortunately less common
than it once was. Fibrillation was also thought to
be the immediate cause of sudden death following
MEDICO-CHIRURGICAL
straightforward fainting or vasovagal seizure, and
was probably the explanation of the fatalities which
sometimes followed trivial accidents, sudden shocks,
and painful stimuli.
Hemorrhage, arterial embolism, and thrombosis
were foremost among the vascular accidents which
might have immediately fatal results. Pulmonary
emboli deserved special mention because of their
frequency and high fatality-rate; those coming
from venous clots probably were more often fatal
than not, while the relatively small emboli from
intracardiac sources, unless complicated in some
other way, were seldom fatal. Emboli of the major
circuit, which arose most often from infective endo-
carditis and failure of the left heart, might lead to
sudden death, commonly by entering the cerebral
or coronary arteries; fatal results had also been
recorded from their entering mesenteric and supra-
renal vessels. Thrombosis, apart from embolism,
might cause sudden death when it occurred in the
heart or brain.
Dr. EDWIN SMITH, coroner for the western district
of London, said that coroners often found that post-
mortem examinations had been carried out too
inadequately to ascertain the cause of death; for
instance, sometimes the coronary or cerebellar
arteries had not been looked at. Neglect to open the
stomach might lead to the concealment of important
evidence; for example, in one case recalled by
Dr. Smith of sudden death during anesthesia the
anesthetist had reason to be grateful to the patho-
logist who found 2 Ib. of figs in the stomach. Other
examples of inadequate autopsy were: a seamstress
while quietly at work had died suddenly ; the doctor
had reported death as due to a fractured skull
and suggested she had hit her head against.a wall
as she walked to work. On further inquiry the
fracture was found to have been made at autopsy
and death had been due to a stroke. In another case
a small handkerchief, rolled up at the back of the
pharynx, had not been found at autopsy and only
came to light in the dissecting-room.
Dr. Smith thought a distinction should be made
between deaths due to an anesthetic and those
occurring while under aw anesthetic. The legal
928 THE LANCET]
ROYAL SOCIETY OF MEDICINE: SECTION OF PSYCHIATRY
[APRIL 17, 1937
compulsion to notify a coroner of a sudden death
was on the registrars and.there was no law compelling
a doctor to report the cases direct to the coroner.
In practice, however, the coroner came to expect
doctors to report direct to him cases which were bound
to come to his notice. The mental state was some-
times very important in determining sudden death,
for example in people with hardened arteries who had .
to make an after-dinner speech. Dr. Smith mentioned
that he did not accept acute gastritis as a cause of
death without amplification. In his district the
registrars were required to report such certificates
to him at once in order that the underlying cause of
the gastritis should be ascertained. In conclusion
he described the case of a man found dead in a cottage
which had been struck by lightning; about half an
hour before the storm a man, known to have been on
bad terms with the dead man, had been seen leaving
the cottage. The jury solved a difficult problem
by a verdict that the man had died “from a visita-
tion from God under suspicious circumstances,”
Dr. T. SKENE KEITH had analysed the last 800
cases of sudden death investigated by him and had
found the following percentages from various causes :
cardiovascular disease 60; pulmonary disease ő;
diseases of the intestine 2:5; diseases of the central
nervous system 1:5; renal disease 0:5; special
conditions 6; stillborn 0:5; external agencies 21,
For statistical purposes sudden death should be
defined, and he would define it as a death which so
surprised the doctor that he was not prepared to sign
a certificate or when a certificate so surprised the
registrar that he did not accept it or when death so
surprised the patient that a doctor had not been called
in. Deaths from surgical operations came under
three headings: In the first group the patient had
not the strength to stand a necessary operation either
because the operation was too severe, for instance
an abdomino-perineal excision, or because the
patient was already too reduced, as in advanced
acute peritonitis. In the second group death was
due to surgical misadventure. Those of the third
group were due to status lymphaticus, a condition
repeatedly declared dead but one which Dr. Keith
believed to exist; it was certainly found far more
frequently among children dying under an anæs-
thetic than among those dying from road accidents.
Deaths from external injuries included those from
birth injuries which were nearly always due to
tentorial tears ; these seemed to be found as often after
natural and easy labours as after difficult and forceps
deliveries. Dr. Parsons-Smith had said how much
the doctor might miss the aid of autopsy in diagnosis ;
the pathologist might miss still more the doctor’s
contribution of the history. The number of cases
coming to autopsy in which the doctor was to blame
was remarkably small; mistaken diagnosis was not
so uncommon. The pathologist was not absolutely
infallible ; just as it was much harder to diagnose
a fault in a car that would not start than in one that
was running badly, the pathologist was up against
the difficulty of lack of function. He could only say
that he had seen similar appearances before and that
they were compatible with cessation of life. While a
definite opinion could usually be given on coronary
occlusion or atheroma, it was much harder to decide
whether myocardial degeneration was a cause of
death ; Dr. Keith was in the habit of looking in the
stomach of these cases just to make sure. Ventricular
fibrillation was a comfortable explanation as it allowed
any heart to die at any time; it only shifted the
burden of proof on to someone else. Death in heart
cases was apt to be so.sudden that at the Heart
Hospital it was unusual for the resident medical -
officer to get to the bed in time.
Dr. G. S. HOVENDEN mentioned four cases of death
in the puerperium, two of which he had signed up
as due to air embolism and two to pulmonary
embolism ; he had been unable to decide which
was the cause. l
Mr. H. L. ATTWATER had been struck by the
comparative. frequency of sudden deaths during
comparatively trivial operations.
Mr. G. B. WoopD WALKER had recently come across
a museum specimen of a ruptured aneurysm ot the
circle of Willis which had occurred in a window-cleaner.
The pathologist had established that the rupture had.
occurred before the man had fallen off his ladder ;
the specimen had impressed upon him the importance
of post-mortem examination especially in these days
of compensation. |
Mr. J. KEMBLE thought that patients dying on
the operating table and those dying of post-operative
pulmonary embolism were alike in being of the sub-
thyroid type; sudden death of this kind was not
so common among patients who had had pre-operative
thyroid therapy.
Dr. GERALD SLOT pointed out the difficulty a
pathologist had in coming to any conclusion about
the state of the lungs after artificial respiration had
been carried out for, say, half an hour. He had
recently examined the body of a woman, found with
a lysol douche beside her, in whom death had occurred
without intracervical interference; such deaths
were apparently quite common although douching
in other circumstances was without risk. Coronary
thrombosis, one of the commonest causes of sudden
death in adult men, apparently occurred much more
often than it used to do. Dr. Slot spoke of the
difficulty presented by the increasing number of
undetectable poisons and the desirability of having
a panel of medico-legal experts to perform autopsies.
Mr. LEVY, speaking as a barrister, complained that
doctors would use terms incomprehensible to the
magistrate, lawyer, and jury.
Dr. Parsons-SMITH, in reply, said the apparent
increase in coronary thrombosis was due to its better
recognition.—Dr. EDWIN SMITH said both the use
of and the objection to medical terms were reason-
able; he told how at an inquest on a man who had
been shot in the sternum, the foreman of the jury
had concluded that the man must have been
running away.—Dr. SKENE KEITH, in reply to
Dr. Hovenden, said that the distinction between
air and pulmonary embolism could have been made
by autopsy. `
ROYAL SOCIETY OF MEDICINE
SECTION OF PSYCHIATRY
AT a meeting of this section held on April 13th,
the chair was taken by Dr. T. A. Ross, the president,
and Dr. C. P. SYMONDS read a paper on
Mental Disorder following Head Injury
He confined himself to cases of closed injury—i.e.,
those without compound fracture—and omitted
all focal lesions and traumatic epilepsy. The out-
standing feature, he said, was loss of consciousness
in some degree; if a man subsequently forgot what
' he had done he could be assumed to have been
unconscious during the period of traumatic amnesia.
The picture in concussion was dominated by the
physical state of collapse; the mental state was one
of profound stupor, from which the patient recovered
THE LANCET]
[APRIL 17, 1937 929
ROYAL SOCIETY OF MEDICINE: SECTION OF PSYCHIATRY ’
in a period of varying length. He might remain for
some time in a state of automatism; or this state
might come on after an intermediate period of
consciousness. Or recovery might take days, weeks,
or months, constituting a state which resembled
Korsakow’s psychosis. It was these cases which
afforded opportunity for detailed analysis of the
acute traumatic psychosis. The prognosis was always
good. A regular sequence of symptoms could be
observed. They had been described as: first, the
stupor, then deep clouding of consciousness with
resistances ; clouding of consciousness with bewilder-
ment; and finally Korsakow’s condition. All were
included in the amnesia and it was better to treat
the state as a whole, noting successive stages in
which predominated stupor, confusion, and defective
memory for recent events with tendency to con-
fabulation. The stupor was accompanied by restless
bodily movements and absence of response to
stimuli except the deepest alimentary and protective
functions. This state rarely lasted more than a few
days. The patient then became excited and resistive ;
he was wet and dirty and had to be fed, and was
sometimes delirious. This lasted for days, weeks,
even months, with occasional relapse into stupor.
When he began to be accessible he showed profound
disorientation in space and time, defect of perception,
memory, and judgment, perseveration, disturbance
of speech function, tendency to interpret events in the
light of long past experiences, and very far-reaching
retrograde amnesia. There was a tendency to con-
fabulate. The difficulties in perception played a
large part in causing confusion, as did also persevera-
tion and the difficulty of distinguishing the figure
from the background in the thought process. There
was raised threshold and over-reaction as in lesions
of the sensory pathway at any level. Performance
was unduly influenced by external events. Persevera-
tion in thought, word, and deed was a striking
feature. Speech disturbance might be so prominent
as to suggest a focal lesion, but was only part of the
general mental disorder. After the first return of
automatic speech there was often a rush of jargon-
talk ; then the talk began to have direction, though
meaningless. At this stage the attention could be
gained for a minute or two, but responses were so
little related to the requests as to appear to be at
random,
An interesting illustration was afforded by the
response of a patient to the written command ‘“‘ Undo
the second button of your jacket and do it up again.”
He had seized the correct button and fiddled with it,
but got no further, and then asked ‘‘ I rather wondered
if you meant your second jacket or my second jacket ?
Was it your bottom you meant or my bottom ?”
This threw some light on the basic confusion of
thought which characterised the state. A month
later he had appeared perfectly normal, and he had
since returned to work. Response to written com-
mands returned more slowly than to spoken commands
because it was mare difficult to grasp the written
sentence as a whole.
The transition to the Korsakow state was gradual.
A tendency to confabulation continued when confusion
had gone. It might lead to false accusations in relation
to the accident. Gross defect of recent memory
might remain the outstanding symptom for a long
time. The mood affected the symptoms; elated
easy-going people confabulated readily. Sometimes
the mood was indifferent; sometimes there was
petulant childish depression ; but elation was more
usual, The end of the Korsakow stage was not clear
cut. The patient of ten showed no insight; its
return was an important landmark. The longest
record was that of a man of 67 who showed confusion
and defective memory fourteen months after the
accident, but was well a month later. Age was not a
bar to good prognosis. The pathological changes
must be reversible to the extent of allowing restoration
of function. The amnesia remained absolute for the
stupor and confusion and patchy for the Korsakow
stage.
POST-TRAUMATIC DEMENTIA
In minor injuries the whole sequence was run
through in a few minutes, and in minimal injuries
some stages were omitted. Some patients showed
residual injuries which might be in some degree
permanent.. There was no relation between the dura-
tion of the traumatic amnesia and the severity of this
post-traumatic dementia. Possibly it was due to
coarse lesions, slow to resolve and to some extent
irreparable, while the underlying condition in the
traumatic psychosis was a molecular change, easily
reversed. The chief symptoms were alterations in
mood, judgment, and memory, and scattered amnesia.
The mood changes were often exaggerations of pre-
existent traits. These symptoms varied with the
age and constitution of the patient and with environ-
mental stresses. This was in contrast with the acute
condition, which was rather an impersonal affair.
Children showed behaviour disorders
following encephalitis lethargica. Intellectual impair-
ment was commoner in patients over 45. Patients
of manic-depressive stock were especially liable to an
attack of this disorder after an injury. Under any
stress these patients tended to become sleepless,
anxious, and irritable. All tended towards recovery,
and residual disability was very rare apart from
coarse lesions. Dr. Symonds had notes, he said,
of only two cases with permanent disability, and
both had had a previous head injury, with apparent
recovery, before the causative accident. A persistent
long retrograde amnesia indicated serious damage.
Injury might’ precipitate paranoia, schizophrenia,
or manic-depressive insanity by exaggerating
previous traits and by creating a state of invalidism
to which the patient reacted according to his style.
There seemed to be a special liability of this kind in
manic depressives. Symptoms might appear, during
the confusion, of the traumatic psychosis.
Traumatic neurasthenia, as loosely used, covered
three groups of patients: those who suffered from
psychogenic hysterical or anxiety states; those
really suffering from post-traumatic dementia; and
those whose constitution was of the depressive or
anxious type and in whom the injury released a
condition which ran its course, usually towards
recovery.
Attempts had been made to explain the pathology
in terms of increased intracranial pressure or sub-
arachnoid hemorrhage, but lumbar puncture often
revealed a perfectly normal cerebro-spinal fluid.
The only conception of pathology left was the old
one of direct molecular damage. The late effects
could only be properly understood in the light of
a full psychiatric study of the patient. It was not
only the kind of injury that mattered but also the kind
of head.
| DISCUSSION
The PRESIDENT described his own experience of
slight concussion due to a riding accident. He
remembered his arm round the horse’s neck, then a
dream state of which he had many memories, and
finally, he came to in a farmhouse. He remembered
a cold, familiar but unplaceable landscape and a
like those —
930 THE LANCET]
babble of voices over his head; then he was on
and off a horse; then he saw a haystack- of which he
hated the colour; then he walked and talked most
politely with a young man. -Actually his niece, who
was with him, reported that he had sat on the ground
saying repeatedly that it was bloody cold. She
and a young man had tried to replace him on the
_ horse and to get him sheltered behind a haystack.
The selective memory was interesting. He wondered
if the patients really had amnesia, or if rather they
had dream-memories, consecutive but inconsequential.
Dr. T. TENNENT reported on 44 patients admitted
to the Maudsley Hospital between 1923 and 1936
who had stayed in from two months to two years.
Eighteen of them had been admitted between 1933
and 1936. Four had proved to be general paralytics.
The remainder had shown the symptoms described
in' the paper. In some, hallucinatory experiences
and bizarre ideas became prominent as the confusion
disappeared and none of these had recovered. Two
had developed a manic reaction and five a depressive
one. Children had shown moral change and intel-
lectual deterioration. In 25 cases the form seemed
attributable solely to the accident ; all had marked
memory impairment, six being of the Korsakow
type. Some ex-Service patients maintained the war
was still on. All this group had recovered enough
to be discharged and 22 had been followed up. Ten
had remained well; nine were improved but had
residual symptoms ; two were in mental hospitals ;
and one was dead.
Prof. E. MAPOTHER thought that amnesia could not
be identified with unconsciousness. He himself had
had a concussion while playing football; a little
after half-time he had suddenly found himself playing
in the opposite direction to the one he last remembered.
He had assumed he had had a kick in the first half
and played automatically but was now not sure
whether the kick had not occurred immediately before
“waking up” and he had suffered from retrograde
amnesia for 10 or 15 minutes. The gradual emergence
from coma was a most important study. He had seen
the sequence, described by Dr. Symonds, passed
through in about an hour by a pedestrian knocked
down by a car. There seemed a strong tendency to
an orderly sequence.
Mr. Hueu Carrn$ remarked on the extraordinary
persistence of this reversal process, with ultimate
recovery. He had seen symptoms start five days
after an injury, coinciding with the onset of sepsis
and cellulitis, and disappear as they cleared up.
Symptoms might also coincide with the exhibition of
barbiturate drugs. There must be a great deal of
compensation going op, so that the patient could
cerebrate until some extra factor, like sepsis or
drugs, complicated his state. He had known a
patient write out his delirium afterwards; it had
tallied with the ramblings noted at the time.
Dr. W. F. MENZIES protested against the misuse of
the term Korsakow’s psychosis in the absence of
peripheral neuritis, on which Korsakow had insisted.
He recalled three pre-war cases. One patient had
been able to repeat fifty lines of the Odyssey at a time
after being hit by a boom; he had never looked at
Greek since leaving school twenty years before. A
second patient, a dement, had fallen twenty feet on
to asphalt and had suffered a fractured skull with
permanent second and third cranial nerve paralysis,
but had otherwise recovered rapidly and been no
more demented after than before, but became very
bad tempered. This indicated molecular change.
Compound fractures turned epileptic or very bad
tempered because there had been fibrotic changes
ROYAL SOCIETY OF MEDIOINE : SECTION OF PSYCHIATRY |
[APRIL 17, 1937
and new blood-vessel formation. The third had
developed cerebral abscess three weeks after colliding
with a lamp-post; the surgeon had seen traces of
meningeal disturbance when operating and had
described the case in THE LANCET as “ general
paralysis without symptoms”! The patient had
completely recovered, but had a persistent difficulty
in recalling proper names.
Dr. E. GutTtmMann described work on twilight.
states in boxers. The transient disturbance of
consciousness through knock-out was functional ;
post-concussional delirium suggested organic lesion.
Some boxers felt the knock-out; some had seen it
coming; others forgot the whole round.
Dr. A. W. PETRIE referred to analogous alcoholic
states, and asked whether all speakers meant the
same thing by post-traumatic dementia. Possibly
the term might be confined to those who passed into
permanent true dementia after injuries, and not
applied to post-traumatic instability.
Dr. CLIFFORD ALLEN mentioned Janet’s views on
the structure of consciousness and said that patients
had repetitive dreams with terror that something
dreadful was about to happen. Accidents might be
unconscious attempted suicide in manic-depressive
personalities.
Dr. PURDON MARTIN said he grouped symptoms
into amnesias ; neuroses; negative symptoms, such
as disorientation and confusion; positive release
symptoms, such as restlessness, talkativeness, and
noisiness—many of these patients had hemorrhage
in the cerebro-spinal fluid and all showed increase of
protein—and late dementias.
into dementia after apparent recovery, and the good
prognosis must be qualified by this fact. Observers
had recently been finding excessive gliosis, especially
in the frontal lobes. Elation was often present; it
was to be regarded as a focal symptom, for it was
often seen in frontal lobe lesions. It was associated
with the symptom of, jocularity and nearly always
persisted throughout the illness. It might prevent
realisation of headache and other symptoms.
Dr. HENRY Witson spoke of the relationship
between the psychosis and the duration of confusional
symptoms. The confusion might be enough to send
a schizoid personality into schizophrenia. Great
unhappiness and anxiety might be caused by it.
Dr. SYMONDS, in reply, agreed that the patchy
amnesia left a dream-like memory; the termination
of traumatic amnesia was not abrupt. The high
proportion of residual disability in Dr. Tennent’s
series might be related to the greater environmental
stress in the hospital class and the different standard
of employability. Retrograde amnesia was very
brief—not usually more than half an hour. One
patient had suffered a return of confusion on an attack
of cystitis ; the influence of sepsis wasimportant. The
post-traumatic dementia was not a mere instability but
included a real failure to retain. Elation might
accompany organic lesions in various parts of the brain.
NATIONAL BIRTH CONTROL ASSOCIATION, — A
medical conference of this association will be held at
7, Drumsheugh-gardens, Edinburgh, on Friday, April 30th.
At 3 p.m. Mrs. Helena Wright, M.B., will open a discussion
on the technique of contraception, and at 8 p.m. Mr. J. R.
Baker, D.Phil., lecturer in cytology in the University of
Oxford, will speak on recent advances in the scientific
study of chemical contraception. Further information
may be had from the headquarter’s organiser of the
association, 26, Eccleston-street, London, S.W.1.
Some patients went .
THE LANCET]
[APRIL 17, 1937 931
REVIEWS AND NOTICES OF BOOKS
Textbook of Medicine
By CHARLES PHILLIPS Emerson, M.D., Research
Professor of Medicine, Indiana University ; Assis-
tant Professor of Medicine, Cornell University
(Ithaca). London: J. B. Lippincott Company.
1936. Pp. 1296. 36s.
THe issue of a large new text-book of medicine
prompts the question, “Is there something here
that is not to be found in the standard books ? ”
One answer here is that Prof. Emerson has tried to
set the clinical behaviour of disease in the forefront
of his presentation. The incidence, and the symptoms
and signs of a disease come early in its description,
being the basic facts of medicine; morbid anatomy,
bacteriological and biochemical findings follow on,
so that it may be seen just how far they elucidate
disease—and how far they fail to do so. This is no
fundamental departure from the common sequence,
but rather a shifting of emphasis, setting less store
by the contributions of laboratory science, and
showing how medicine is still in great part a lore of
disease and an art founded on generations of experi-
ence. Another answer is that this book is a bigger
one than most of its fellows. The clinical descriptions
are comprehensive, and little historical sketches,
and even biographical notes on great men, are included.
Modern scientific work relevant to each subject is not
ignored but is cited, often in smaller type or as a
footnote, and reference is made to important original
publications.
The author’s style has character to it; he is
always clear and succinct, but is fond of tricks of
inversion and apposition whose slightly stilted effect
is often rather telling. Choice of type and general
arrangement are good, but misprints, usually mis-
takes in spelling, are numerous enough to be irritating.
There are no illustrations. An immense labour must
have gone to the writing of a book so fully docu-
mented, and much of that labour has, in the nature
of things, been spent on books rather than on patients.
This leads inevitably to some distortions, of which
the statement that in the diagnosis of pulmonary
tuberculosis, ‘“ when the clinical findings are incon-
clusive the X-ray pictures are likely to be even more
so,” is a surprising example. But it is clearly impos-
sible in these days for a text-book of medicine to be
informed throughout by detailed first-hand experi- |
ence. Few could have performed so well as he has
the task which Prof. Emerson set himself, and many
students, qualified and otherwise, should find his
work of great value.
L’infection bacillaire et la tuberculose
Fourth edition. By A. CALMETTE. Revised by
A. BOQUET and L. NÈGRE, Chefs de Service à
VInstitut Pasteur de Paris. Paris: Masson et
Cie. 1936. Pp. 1025. Fr.175.
Calmette made many contributions to the study
of tuberculosis in the course of a busy life, but prob-
ably none was more brilliant than the text-book
which has now reached its fourth edition. Its well-
balanced exposition of the subject, its breadth of
outlook, and its lucidity of expression have all con-
tributed to make this work classic. Dr. A. Boquet
and Dr, L. Négre in their revision have been mindful
of the tenets of their late colleague, and have
brought the work up to date without deviating from
the original point of view or changing the personal
note. As far as possible footnotes indicate which
of the two editors is responsible for the new
material,
More. than one hundred pages have been added,
and the book is now bound in a serviceable black
cloth board cover which is a great improvement on
the old paper one. The new sections include fresh
descriptions of recent improvements in the clinical
pathology of tuberculosis, such as the technique of
gastric lavage and various new culture media.
Chapters have been inserted on the differentiation
of human and bovine strains, and on avian strains,
by Dr. Boquet, as well as a section dealing with
the dissociation of colonies which is demanding
much attention at the present time. Dr. Négre has
enlarged the chapter on the ultra-virus of tuber-
- culosis, whilst maintaining the general thesis con-
cerning its existence. The sections dealing with
BCG vaccine, which was Calmette’s last great con-
tribution to the study of tuberculosis, have been
expanded to include new work. It must have been
difficult, especially here, to know what to leave out
and what to insert, but it seems a pity that old
statistics on the fate of children born in tuberculous
households should have been used where modern
figures are available—notably the figures quoted
for London on p. 953 and for England on p. 949,
These are but small blemishes in a book which has
earned and will continue to earn the gratitude and
respect of all students of tuberculosis. It is note-
worthy that the only English version of this work
is that which W. B. Soper and G. H. Smith trans-
lated from the second French edition and published
in America in 1923. This new edition merits trans-
lation.
Towards Peace of Mind
By Kart M. Bowman, M.D., Chief Medical Officer,
Boston Psychopathic Hospital. London: George
Allen and Unwin Ltd. 1936. Pp. 278. 6s.
THis volume stands midway between a popular
exposition and a text-book suitable for students.
Its outstanding virtue is to combine a sound appre-
ciation of heredity and neurology with an accurate
and dispassionate exposition’ of Freudian psycho-
pathology. While numerous references are made to
recent advances in the study of the nervous system
and of the mind, the aim of the book is never lost
sight of and the pursuit of mental health is illustrated
by theory, clinical examples, and therapeutic advice.
The book can be strongly recommended to all prac-
titioners who want a scientific and human exposition
of modern psychological medical aims.
Operative Surgery
Second edition. By ALEXANDER MILEs, M.D.,
F.R.C.S. Edin., Consulting Surgeon, Royal
Infirmary, Edinburgh; and D. P. D. WILKIE,
M.D., F.R.C.S. Edin. and Eng., Professor of
Surgery, University of Edinburgh. London :
Humphrey Milford, Oxford University Press.
1936. Pp. 631. 21s.
IN this edition the text has been completely
revised, and the revision has been done well. In
all the main things the teaching appears to be sound,
but a few procedures might have been eliminated,
and naturally some advice is given with which all
932 THE LANCET]
will not agree. It does not seem necessary, for
instance, to mention the use of bone chips or wax
or sponge for filling a septic bone cavity. Again,
for stopping a cavity in the head of the tibia the use
of the gastrocnemius is more crippling than that
of the sartorius. We are told (p. 121) that the
shaft of the humerus can be exposed by an incision
“made through the appropriate muscular inter-
space,” without specifying what this space is. The
omissions include that of the occipital approach to
the fifth nerve. But the extraordinary amount
of information given is nearly always good and is
invariably sponsored by some eminent authority.
No student up for a higher surgical examination
will go wrong if he hands out the teaching of this
book to his examiners.
Clinical Handbook for Residents, Nurses,
and Students
Second edition. By Members of the Staff of
St. Vincent’s Hospital, Sydney. Edited by V. M.
CoPPLESON, M.B., Ch.M., F.R.C.S., and DOUGLAS
MILLER, F.R.C.S., F.R.A.C.S. London and Sydney :
Angus and Robertson. 1936. Pp. 205. 6s.
Tms is a book of instructions for the medical
student or the resident touching the hundred and one
things that he must learn to do with his hands, such
as sterilisation, use of needles, collection of specimens
for pathological examination, giving anesthetics,
examination ' of urine, and so forth. It includes
sections on the nursing and managementof ophthalmic,
ear, nose, and throat and gynscological cases; the
treatment of common skin conditions and of poison-
ing; preparations for X ray examination; the use
of plaster, and various other topics. Only the
routine practice at St. Vincent’s Hospital is described,
and the descriptions are simple, clear, sound, and
practical; blood transfusion, for instance, is given
with citrated blood, a funnel, and a tube, and no other
_method is mentioned. Not every hospital takes the
trouble to see that its students are well trained in
these routine matters of technique, and St. Vincent’s
Hospital is to be congratulated on providing its
residents, present and future, with such a compre-
hensive and workmanlike manual.
Fundamentals of Bacteriology
By MARTIN FROBISHER, Jr., B.S., D.Sc., F.A.A.A.S.,
Associate in Bacteriology, Johns Hopkins University
London: W. B. Saunders Co. 1937. Pp. 474. 14s.
Even the bacteriological enthusiast, proud of his
subject and convinced of its educational value might
be staggered by the opening words of the preface
of this little book: ‘‘ With bacteriology in its present
state of development, no one can be said to have
acquired a complete cultural education who remains
uninformed concerning the unicellular fungi of
the class Schizomycetes.” This certainly argues a
very broad or a very narrow conception of the
“ complete cultural education,” it is hard to decide
which. But the author’s later modification of the
statement, that a knowledge of bacteria “ not only
increases one’s general usefulness, but greatly
broadens his view of life and sharpens his appreciation
of the subtlety of nature” is one that (barring its
verbal construction) will be endorsed by everyone
familiar with the subject. It is to introduce bacterio-
NEW INVENTIONS.
[APRIL 17, 1937
logy to the general but cultured reader that Dr.
Frobisher has written his inttresting and accurate
little book. The subject is well set out in historical
perspective and the many activities of bacteria
in nature beyond their pathogenic rôle are attractively
described.
Within its scope it is one of the best introductions
to general bacteriology we have seen and it is just
the kind of book which a student of medicine who has
become interested in bacteriology for its own sake
might profitably read.
CoRRIGENDUM.—“ What is Osteopathy?’ The
authors of this book, which received appreciative
notice in our columns last week, are Dr. Charles Hill,
deputy medical secretary, British Medical Association,
and Dr. H. A. Clegg, deputy editor, British Medical
Journal. Mr. H. G. Wells contributes a preface.
NEW INVENTIONS
A NEW DOUCHING ATTACHMENT
THE douching attachment here illustrated has been
designed with two objects in view. First, it provides
a lotion carrier for use with a cystoscope, and so
eliminates separ-
ate stands for
holding such a
reservoir; and
secondly, the
whole attachment
can be sterilised,
It is made to clip
on to a lithotomy
crutch, and its
height can be ad-
justed. The funnel
carrier is loose on
the upright, and
fitted with
“ dogs ” to’ enable
it to be main-
tained in any
desired position.
It is also a useful
accessory in
gynæcological
work.
The apparatus
has the advantage
>
News
ples
LES eller Lele.
SR A BOSSES
of being portable, and can be used on any table
that has a suitable lithotomy crutch pole. It has
been made for me by Messrs. Allen and Hanburys,
London, W.1, to fit the St. Bartholomew’s operating
table.
CHARLES E. KINDERSLEY, F.R.C.S.,
Surgeon to the Royal United and Royal
Mineral Water Hospitals, Bath.
THE LANCET] |
THE LANCET
* LONDON: SATURDAY, APRIL 17, 1937
THE FUTURE OF OUR POPULATION
THE observant man can hardly be blamed if
he has a feeling of bewilderment, tempered perhaps
by scepticism, when he considers ‘the figures relating
to population. For years economists and other
experts have made the spectre of over-population
dance before his eyes. He has been told that
poverty and misery must be reduced by volitional
control of the size of the family—that the
“ planned ” family is the ideal at which we must
aim. There seems, moreover, ample justification
for the argument. - He knows that the population
-of our country has shown a phenomenal increase,
that it has multiplied nearly fivefold in rather
more than a century, and that it now depends
largely upon distant sources for its food-supplies.
Looking, even casually, around him he seems to
see additional evidence on every side; there is a
continual encroachment of the town upon the
country, building activity in every direction, town-
planning schemes in operation or visualised, traffic
congestion on road and rail affecting his everyday
life, depressing figures of unemployment, unsatis-
factory diets amongst the larger families in the
poorer strata of society, and an annual excess of
births over deaths so that the numbers in the
country continue to increase.
And yet the expert now tells him that we are
seriously threatened with depopulation. In the
daily press, and in books and pamphlets, he is
warned gravely that our population must shortly
follow a downward path, that unless people soon
begin to have more children we shall be threatened
with extinction, that a Royal Commission ought
at once to be appointed to “discover the facts
and to formulate a population policy.”* What
is he to believe? What is the explanation
of the seeming paradox? An excellent attempt
to answer these questions in simple terms has
now been made by the Population Investigation
Committee. This body, formed last autumn
under the chairmanship of Prof. A. M. CARR-
SAUNDERS, includes representatives of the British
College of Obstetricians and Gynecologists, the
Medical Research Council, the Royal Economic
Society, the Society of Medical Officers of Health,
the British Population Society, the Eugenics
Society, and a number of. medical and economic
authorities. It was formed to examine the factors
influencing contemporary trends of population in
-England and Wales with special reference to the
fall of the birth-rate. Its first task has been to
consider the recent history of our population, to
determine how its prodigious growth has taken
place, what effect. the declining fertility-rate is
1 Times, April 5th, 1937.
THE FUTURE OF OUR POPULATION
[APRIL 17, 1937 933
likely to have upon its future size and constitution,
and what have been the basic causes of that fall
in fertility. The results of these inquiries are set
out in a pamphlet prepared for the committee
by Dr. C. P. BLACKER and Mr. D. V. Grass.?
When the population began to increase towards
the end of the eighteenth century it is possible
that there was some rise in fertility, but the
evidence is scanty. Throughout the nineteenth
century the rise was certainly not due to an
increasing birth-rate but to a falling death-rate.
Between 1838 and 1913 the births annually
exceeded the deaths by about 300,000; in the
decade 1914—23 the excess was only 220,000 a
year; in 1934 it had fallen to 121,000.. Though
there is likely to be an excess in 1937 it will be
still smaller, and in another five years, or less,
that excess will have vanished. One result of
this falling birth-rate is the raising of the average
age of the population. In time this must lead to
an iticrease in the crude death-rate—although
with further advances in medical science and public
health the death-rates at ages may continue to
decline. A population that contains a large
proportion of old people must have a relatively
high death-rate and it is on this rate, in con-
junction with the fertility-rate, that the growth of
the population must depend. With an ageing
population we clearly cannot depend upon favour-
able changes in the death-rate to maintain our
numbers. To take a simple example, Dr. G. F.
McCLEary has shown ° that the effect on popula-
tion growth of an entire elimination of infant
mortality would be completely neutralised by a
reduction in the birth-rate of less than 1 per 1000.
It is mainly on fertility that the future population
must depend, and although at present the birth-
rate remains higher than the temporarily lowered
crude death-rate, it is now well below the replace-
ment-rate. It is, in fact, to this rate that we
must look, and the figures of the 1931 census of
England and Wales show that persons aged 20-35
were more numerous than the young persons in
the age-groups 0-15: in other words, there were
in 1931 not enough young people to replace the
men and women twenty years older than them-
selves. With the aid of a relatively new statistical
technique the level of this replacement-rate can be
measured—by an index known as the net reproduc-
tion-rate. Briefly this.expresses the number of
women who in the next generation will replace the
women of reproductive age in this generation. In
the words of BLACKER and GLass :
‘“ if the women of reproductive age in this generation,
who are mothers of children are having sufficient girl
children to replace themselves as well as those women
of their age who are childless, the net reproduction-rate
is 1 or unity and the population is maintaining itself.
If, allowing for deaths, they are not having enough
girl children to do this, the net reproduction-rate falls
below unity and the population is not replacing itself ;
if they are having more girl babies than is necessary
2 The Future of Our Population. By C. P. Blacker and D. V.
Glass. Issued by the Population Investigation Committee,
69, Eccleston-square, S.W.1. Pp. 31. 6d.
3 The .Menace of British Depopulation. By G. F. McCleary,
MD London ; . George Allen and Unwin. 1937. Pp. 144.
s
934 THE LANCET]
for this purpose, the net reproduction-rate is above
unity and the population will increase.”
Dr. ENID CHarues* has calculated that in 1933
the figure for England and Wales was only 0°734,
or according to the fertility- and mortality-rates
of that year 1000 women of reproductive age
were producing only 734 girl children who would
grow up to replace them in the next generation.
The figure is below unity in most of the countries
of western Europe and, as MoCLEARY emphasises,
amongst the British-born in the Dominions. It
is easy, though laborious, to calculate the down-
ward path along which this present position must
lead us, and an example of the calculation, by
Mr. C. A. GOULD, is given on p. 944. Naturally
the further ahead we endeavour to prophesy the
more we may deviate from the truth. But even
if fertility ceases to decline below its present level
we are faced with a declining population in the
near future, and with a population that some
believe will deteriorate in quality as well as
quantity, through the effects of differential fertility.
As BLACKER and Grass admit, many good
arguments can be urged for preferring a stationary
or a slowly growing population to a rapidly
expanding one; but a declining population is
quite another matter. Only an increased fertility
can avert it. Is that a likely event? Are there
any means of encouraging it? Unless we know
the reasons for the falling birth-rate we clearly
can take no steps to arrest its decline. In the
second section of their pamphlet BLACKER and GLASS
devote themselves to this subject. Sterility they
think is not increasing and they lay more stress
on social and economic reasons—the difficulty of.
parents supporting more than a small number of
children, of finding them suitable employment as
they reach maturity, of giving them and them-
selves the social advantages, comforts, and
standards of life that they desire. Under psycho-
logical reasons they refer to the parental instinct
that is satisfied by one or two children—“ when
parenthood is being increasingly planned, the
strength of the desire for children as measured
by the number of children by which it can be
adequately satisfied, comes into an entirely new
prominence as a biological factor to which is
attached the clearest survival value.” The uncer-
tain political and social condition of the world
must also play its part. Fertility cannot be
raised, they conclude, unless there is a change of
attitude of the kind they call “ psychological ”
about the family, unless people can somehow be
inspired to want children. McCreary is much of
the same mind. Though he is satisfied that
economic factors are at work, he thinks that the
really important causes of depopulation lie deeper
in the conditions of modern life. ‘If babies are
not to be had for love they are not likely to be
had for money.” Certainly the efforts by the
latter means taken in Germany and Italy have
been attended by no striking success,® though the
economic incentives offered may well have been
‘The Twilight of Parenthood. London. 193
4.
5 The Struggle for Population. By D. V. Glass. Oxford.
1936. See Lancet, 1936, 2, 441. i
NEW METHODS OF IMMUNISATION AGAINST DIPHTHERIA
e
[APRIL 17, 1937
too small. But if effective action is to be taken
we must know more of the possible factors that
are thought to influence people in restricting their
families. This problem the Population Investiga-
tion Committee hopes to investigate, and an
appeal is made for funds to enable it to do so.
There are two lines it wishes to follow—namely,
statistical analysis and direct inquiry. Under the
first, calculation may be made of the extent to
which people living in different regions, urban
and rural, and working in different industries and
occupations, are replacing themselves.` Under
the latter, by questionnaire, further light may be
thrown on differential fertility, on medical causes
of infertility, on the degree of success attending
contraception, on the effects of uncertainty of
employment, on the “psychological” factors
involved. Perhaps, as some have argued, there is a
law of population growth or there are, as BROWNLEE
believed, changes in germinal vitality that we
cannot influence. Perhaps, as others believe,
‘the innumerable distractions of modern life are .
far more tempting to the average man and woman
than is the bringing up of children,” the only remedy
for whichisthe ‘‘ reawakening of the race as a whole
to its responsibilities as a civilising factor.” ® The
problem is exceedingly complex, but of vital
national importance if “western civilisation is
not to go the way of Greece and Rome to decay
and death.’ That fear some may think unduly
alarmist, but the pamphlet under review shows
clearly the experts’ reasons for disquiet. It gives
no one an excuse for remaining ignorant of the
situation. 7
NEW METHODS OF IMMUNISATION
AGAINST DIPHTHERIA
To protect a particular child against diphtheria
is comparatively easy: there is a wide choice of
immunising agents and methods which are all
reasonably satisfactory for the purpose. To
protect a community is far less simple, since the
method adopted must be uniform, must give as
complete and lasting protection as possible,
must not produce serious reactions, and must be
cheap and manageable. The dilemma is well
known and no way of circumventing it has been
found. The difficulty is that, on the one hand,
a single injection either fails to give immunity
in a satisfactory proportion of cases or causes too
severe reactions, while on the other hand, mothers
do not like to bring their children for a series of
injections, particularly if these have to be repeated
at intervals in order to keep the antitoxin at a
suitable level.
A possible way out was demonstrated by Prof.
CLAUS JENSEN, director of the department of
biological standards at the State Serum Institute
of Copenhagen, in a paper given to the epidemio-
logical section of the Royal Society of Medicine
on April 9th. The method he adopts, which is
supported by many years’ work and much experi-
ment, is a single subcutaneousinjection of Sehmidt’s
® Daily Telegraph, April 6th, 1937.
THE LANCET]
purified aluminium-hydroxide toxoid followed by
intranasal instillations of purified toxoid dilution.
His conclusions are based entirely on quantitative
estimations of antitoxin, which clearly afford
more accurate information than, for example,
skin reactions. Various series of rabbits, children,
and adults first had their natural antitoxin
quantitatively determined and then were divided .-
into four groups according to the amount of
circulating antitoxin—i.e., less than 0:0005, less
than 0°01, less than 0°10, and more than 0°10
antitoxin unit perc.cm. Four weeks after the single
injection of purified Al(OH),-toxoid the groups
were redetermined, and this was done again after
6 or 3 nasal instillations at stated intervals. The
results were ingeniously shown by what Dr. JENSEN
calls “antitoxin spectra ’’—i.e., coloured histo-
. grams resembling the appearances seen in spectro-
scopy. In all three groups (rabbits, children, and
adults) the results appeared to be excellent, the
effect of the intranasal instillations being greatest
in those who gave a poor response to the sub-
cutaneous injection. There were no reactions to
the nasal instillations in children but in adults
(probationer nurses) transitory headache, nausea,
or fatigue were occasionally experienced. Of the
children 100 per cent. developed more than
0°01 unit of antitoxin six weeks later and 96 to
100 per cent. developed 0°10 unit or more. Nine
months afterwards the immunity appeared to
have fallen off considerably, but the response
to nasal reimmunisation only after twelve months
was even better than to the original combined
treatment. In the group of 319 probationer
nurses, 94 per cent. developed more than 0°01
unit and 85 per cent. more than 0°10 unit, while
1 per cent. were refractory. Dr. JENSEN is
sufficiently convinced of the value of his method
to recommend its adoption for all children without
preliminary or control Schick-testing. Mass
immunisation of the child population against
diphtheria has not been attempted in Denmark
hitherto, the experiments recorded being confined
to schools and institutions. This is partly owing
to the rarity of epidemics of diphtheria in Denmark
and. partly to deliberate abstention until the most
efficient and practical method had been determined.
But diphtheria is prevalent in many of the surround-
ing countries and the proportion of natural
immunes in the child population is low—far lower
than in England for example—and the danger is
therefore considerable. Dr. JENSEN hopes that
the Department of Health will now start a drive
for immunisation and thinks that by efficient
propaganda nearly the whole of the children of
Denmark—some 700,000—might be immunised
by his method within about a year and the immunity
kept up by repeated annual intranasal instillations.
In sum, several definite advantages may be
claimed for JENSEN’s method, and, since present
methods are not entirely satisfactory, bacterio-
logists and public health authorities should examine
his claims with care. Whether in England it
would be thought advisable to entrust the intra-
nasal instillation to the mothers is doubtful ;
perhaps the health visitor would be a more suitable
THE MEDIOINE DUTIES AND THE CHEMIST
\
O [APRIL 17, 1987 935
agent. But anything which smooths the path
between academic and practical immunology is
welcome and the careful work done in Denmark,
as well as its attractive presentation, demands
serious attention.
THE MEDICINE DUTIES AND THE CHEMIST
THE Select Committee on the Medicine Stamp
Duties was somewhat ruthless in its recom-
mendations. It was natural that its report should
display impatience at the continued retention on
the statute book of legislation like the Medicines
Stamp Act of 1812 with its list which begins with
Adam’s Solvent, Addison’s Re-animating European
Balm, and Aethereal Anodyne Spirit, and ends
with York Medicinal Preventive Lotion and
Zimmerman’s Stimulating Fluid. The committee,
of course, was concerned with the revenue aspect
not with pharmacology ; and it is reasonable to
suppose that the CHANCELLOR OF THE EXCHEQUER
will take no step in his forthcoming Budget without
careful consultation with the interests specially
affected. Strong protests are meanwhile being
made against the proposals in the committee’s
report. The recommendation that, with a few
exceptions, all drugs and medicaments, herbs,
disinfectants, and soaps should be made liable to
a duty based on the retail selling price is a proposal
for a novel and irritating form of sales tax. It is
urged that the State should not single out for
taxation those medicinal substances which are
used by persons in ill health. The weapon of
taxation, it is said, will be employed to discourage
a proper statement upon labels and accompanying
literature of the conditions in which a medicine
is to be taken. Manufacturers will cease to have
any inducement to disclose in their labels the
composition of their medicaments, with the result
that we shall return to the abuses of “secret ”
remedies. Prescribing over the counter would
be embarrassed ; the “last surviving privilege
of the pharmaceutical profession,” the chemist’s
right to prescribe and sell his own medicine to his
customers without having to stamp it, would dis-
appear. The consultative value of his training
would be belittled. If the customers ask for an
ounce of castor oil, they will get it at the normal
price of so much oleum ricini. But if they ask him
to suggest an aperient, or if they mention castor oil
and ask his advice about the dose, he will have to
affix a stamp and pay the duty.
The general position of the registered pharmacist —
seems to be threatened by the committee’s report.
It observes that the Act of 1783 was intended to
tax the quack and to exempt those “ bred to the
profession of physician or apothecary.” But,
observes the committee, qualified chemists have
in effect obtained the privilege of selling the bulk
of their ready-made preparations duty-free, while
precisely the same preparations, if sold by a grocer,
must pay duty. The committee seems to doubt
the benefit of specialised pharmaceutical training.
Is there no safeguard to the public in the presence
of a registered pharmacist on premises where
medicines are sold? The committee apparently
936 THE LANCET]
thinks this protection is illusory—at any rate
on premises where there are large sales of ready-
packed medicines. It may be doubted if Parlia-
ment or the public would share this very
depreciatory opinion.
IMPROVEMENT OF POSTURE
Mr. Pane Wues has chosen a good moment
for presenting his views on postural deformities
—the subject of his Hunterian lecture published
in our present issue. At a time when much is being
said about the need for improved physique and
the Government is prepared to spend money to
this end, the nation, like other sick persons, may
suffer from contradictory advice. It is therefore
important, wherever possible, to collect informa-
tion that will fill the gaps in our knowledge, so
that there may be no doubt as to what are the
fundamentals of physical efficiency and the methods
by which they may be attained. When “ physical
training ” is going to be made available for every
child and adult in the country, it is necessary
for example that zealous organisers should not
remain ignorant of the dangers of haphazard
application of gymnastic exercises to anyone and
everyone. Physical exercises, as LEDENT? puts it,
should be regarded as a drug; and no drug has
equally beneficial effects on all patients at all
times and in the same dose.
In his lecture Mr. Wmes brings together facts
gathered during many years by many workers,
both here and abroad. To these he adds observa-
tions he has made with an ingenious gauge for
measuring the pelvic tilt. These observations,
though few in relation to such surveys as that
made by the Board of Education in 1935, will be
found very interesting. He rightly points out
that as the pelvis is the base of the spine, its axis
has a fundamental effect on the attitude of the
parts above. The question is whether he does not
pass rather too lightly over the influence of the
parts below—the knees and feet for example,
which form the actual pedestal for the human
machine. Although he accepts as correct GOLD-
THWAIT’S straight axis for the human body, passing
through mastoid, shoulder, hip, front of knee, and
ankle, his photographs of “ normal” persons
would not coincide with GoLDTHWAIT’s satis-
factory posture. In regard to posture, more
perhaps than anywhere else in medicine, it is
difficult to get any two practitioners to agree to
the same definition of “ normal ”’ and “ efficient.”
Our ideal for the human race is by no means
synonymous with survival-value in evolution. The
biologist points out that the amceba has survived
from primeval times and is biologically as efficient
as the most brilliant scientist. Physical strength
does not necessarily imply strength against disease ;
and on the other hand the weedy slum-dweller,
with his comparative efficiency in the war against
bacteria, might easily be bowled over by an
overdose of “physical training.” Though Mr.
1 Ledent, R., Les erreurs gymnastiques, Scalpel, April 3rd,
1937, p. 430.
IMPROVEMENT OF POSTURE
[APRIL 17, 1937
WILEs refers to it, he does not perhaps put quite
enough emphasis on the necessity of balancing
the prescription of exercise with a correspondingly
weighty dose of rest. This is implied however
in his insistence that posture is a function of the
central nervous system as a whole, and that its
improvement depends on the patient’s codperation
and on the restoration of a series of reflexes whose
pattern has been disturbed by such disorders as
rapid growth, toxemia, or anxiety. The emotional
factors influencing posture can scarcely be exag-
gerated ; but if we were to argue too closely from
the physical to the mental, the sight of any gather-
ing of ordinary people—even a medical audience—
would bring despair for the intellectual prospects
of Britain !
Not all will agree with Mr. WmeEs in making
light of the influence on growing tissues of such
external factors as violins and _ school-desks ;
HUNTER demonstrated the plasticity of adult
bones in response to the strains of various trades.
He is on firmer ground in condemning attempts to
“ stretch ’’ muscles and ligaments by force, since
it is now recognised that muscles can only be
lengthened satisfactorily by encouraging their
reflex relaxation, as their antagonists contract ;
while ligaments yield best to persistent traction in
their long axis. It should not be forgotten that
lying on the ground provides just that resistance
to the flexors, and support for the extensors,
which Mr. WILES recommends as the basis of
exercises for correction of posture.
BRUCELLA MELITENSIS IN THE UNITED
STATES
EXCEPT in the hog-raising district of the middle
west, where infections with Brucella suts are common,
undulant fever in the United States is nearly always
due to Br, abortus, which comes directly or indirectly
from the cow. Br. melitensis infections have so far
been restricted to the south-western States where
some goat’s milk is drunk. From a survey by Miss
Alice C. Evans,! of the National Institute of Health,
it seems possible that infections with the melitensis
type may be rather commoner than has been apparent,
and that infection may sometimes be distributed
by cow’s milk. Using the quantitative absorption
technique she examined sera from 27 patients having
a titre of 1/160 or over. The results suggested that
14 were infected with the abortus and 13 with the
melitensis type. Of the patients in the latter group
5 lived in North Carolina and 6 in Texas—both
States in which goats are few. It is doubtful however
whether this justifies the conclusion that these patients
must have been infected from cattle. That cattle
may be infected with Br. melitensis, and that human
beings may contract undulant fever from cow’s milk
containing this organism, has been amply demon-
strated by Taylor and his colleagues at Montpellier.
But the evidence contained in Miss Evans’s present
paper is only circumstantial. Cows have never been
found to be infected with the melitensis type except
when running with goats, and the risk of their being
infected in areas free from goats seems slight. In this
country indigenous melttensis infection has never been
satisfactorily demonstrated.
aS
1 Evans, A. C. (1937) Publ. Hlth Rep., Wash, 52, 295.
THE LANCET]
[APRIL 17, 1937 937
ANNOTATIONS
AN INTERNATIONAL ASSOCIATION OF THE
MEDICAL PRESS
A MOVEMENT was projected from Milan last summer
for the organisation of an International Association
of the Medical Press and the preliminary statement
was to the effect that the first president would be
Dr. Hans Spatz, the editor of the Münchener Medi-
zimische Wochenschrift; the first treasurer Dr.
Benno Schwabe; and the secretary-general Signor
Santo Vanasia, giving his address as Casella
postale 3395, Milan. Among the council the names
were printed, without any previous sanction, of the
editor of The Lancet and the editor of the Journal
of the American Medical Assoctation, together with
the editors of a dozen or fifteen other medical journals,
who may or may not have given permission. The
editor of The Lancet, not being satisfied that anything
practical at the present stage of European politics
could develop from the movement, asked that his
name and that of The Lancet, placed on the circular
without approval having been asked, should be
removed. Dr. Fishbein, editor of the Journal of the
American Medical Assoctation, being communicated
with, said that his name and that of his journal
also appeared on the circulars without any authority,
and he enclosed to us a copy of a letter in which he
had protested against the treatment he had received.
Dr. Fishbein was more fortunate than the editor of
The Lancet, for he obtained a courteous statement
from Signor Santo Vanasia, the source of all the
communications, in the following words: “I was
merely showing the basis for my future work in case
of acceptance. According to your wishes I cancel
my previous indications although I have confidence
that your ideals agree with mine.” The editor of
The Lancet not only received no assurance that the
references to the paper and to himself would be
cancelled, but finds that his name and that of
The Lancet still remain on the circulars. In the last
circular received, the name of Dr. Hans Spatz is
still given as president of the projected Association
and that of Dr. Benno Schwabe as treasurer. We
have now received a communication from Dr. Hans
Spatz that his name has been used without his
authority and that, in spite of repeated protests, it
has until now not been expunged from the lists.
He adds also that false announcements of his appoint-
ment as president have been made in the German
daily press. Further, Dr. Spatz has been informed
by Dr. Benno Schwabe that the printed statements
of his position as treasurer to the movement have been
made without his consent. Dr. Hans Spatz has
published in the German press the withdrawal of his
name from the Association, with a criticism of the
extraordinary procedures of the secretary-general.
In publishing this repudiation by The Lancet of any
connexion with the movement, we are asked by
Dr. Spatz to associate his name with our protest.
DEFICIENCIES IN ULCERATIVE COLITIS
ONE of the most interesting aspects of biological
processes is the way in which a specific effect, however
brought about, always tends to set up the same train
of events. If a number of causes bring about the
specific effect, the resulting train of events may be
common to a number of conditions, although modified
and supplemented in each of them by the particular
exciting cause. The appreciation of these ‘‘syn-
dromes,’’ which are common to a number of diseases
is of enormous importance in theoretical medicine ;
although practical medicine—the slave of diagnosis—
depends more upon the recognition of the particular
response. The rise of body temperature (and its
inevitable sequels) which accompanies many toxic
processes is a good example of a general response
that may be produced by many different stimuli.
Another example is salt deficiency which is common
to Addison’s disease, pyloric stenosis, excessive
sweating, diarrhea and vomiting, and (according to
Welch, Adams, and Wakefield 1 of the Mayo Clinic)
ulcerative colitis. A third example, less often recog-
nised, is the response of the body to a forced and
continuous loss of protein material. Such losses are
met with in, for example, pregnancy, lactation,
chronic parenchymatous nephritis, and (as is also
demonstrated by Welch and his colleagues) ulcerative
colitis, In all of these conditions the blood-urea
tends to be low, indicating a small katabolism of
amino-acids and suggesting that all the available
ones are being used for the synthesis of the protein
which is being *“‘ lost” ; the urea nitrogen in conse-
quence forms very much less than the normal 70-80
per cent. of the total nitrogen leaving the body.
Where this happens it is clear that the treatment
should include high protein feeding; and while
the success of a generous protein intake in chronic
parenchymatous nephritis is well known and the
value of protein in pregnancy and lactation is also
accepted, the Mayo Clinic workers do well to point
out the necessity for a liberal protein diet in ulcerative
colitis.
FLUORINE POISONING
Many of our readers will recall the ‘“‘ fog disaster ”
which occurred ? in the valley of the Meuse above
Liége early in December, 1930. Within a few days
several thousands persons suffered from’ an acute
pulmonary affection, and 60 lost their lives. A
commission of inquiry was set up which came to the
conclusion that the disaster was due to the accumula-
tion of waste factory products, in the air of the narrow
steep river valley ; a blanket of cold fog during wind-
less weather acting like a closed roof to the valley.
The commission suggested that sulphur dioxide
(or its derivatives) was the chemical substance
responsible. Those who were familiar with the
physiological effects of SO., and especially those who
have experienced considerable or prolonged exposure
to this gas, were not impressed by the findings of the
commission on this head. Dr. Kaj Roholm of
Copenhagen now surveys the whole problem in
the light of more recent knowledge about the toxicity
of fluorine and its compounds, and makes out a strong
case for the belief that fluorine and not sulphur was
the peccant agent. Here was a narrow deep valley,
a dense pall of almost stationary fog, and in two places
in the valley (at Engis and in the Sclessin-Seraign
area) a number of factories (15 in all) throwing
considerable quantities of fluorine into the air. It
may be unlikely that such a combination of circum-
stances will arise in this country, but the possibility
that chronic fluorine poisoning may be occurring
cannot be so easily dismissed.
Fluorine poisoning may be produced as a result of
industrial processes, from the ingestion of fluorine-
1 Welch, C. S., Adams, M., and Wakefield, E. C., J. clin. `
Invest., January, 1937, Dp. 161.
2 Se e Lancel, 1930, 2, 1305.
3 A paper read before the Danish Society for Internal
Medicine, J. industr. Hyg. March, 1937, p. 126.
938 THE LANCET]
contaminated soil or water, or occasionally (as in
Iceland) it may arise from the dust of volcanic
eruptions after it has settled on the soil. A number
of industrial processes make use of raw materials
containing fluorides: (1) Blast-furnaces, steel and
metal works; Dr. Roholm estimates the world’s
yearly output of calcium fluoride (fluorspar CaF)
at 200,000-300,000 tons of which 80 per cent. is
used in blast furnaces. During the smelting of
iron and steel, silicon tetrafluoride escapes into the
air. (2) Glass and ceramic manufacture. (3) Zine
smelting: zinc oré usually contains fluorspar. (4)
Superphosphate manufacture: phosphatite contains
fluoride. (5) Chemical works. In the neighbourhood
of some of the factories in the Meuse valley, it was
observed that glass rapidly lost some of its trans-
parency. Plant life was damaged around some of the
factories. Animals fed upon contaminated herbage
suffered from dental and bone diseases or died with
emaciation and cachexia.
In acute fluorine poisoning resulting from breathing
contaminated air, the symptoms and signs are those of
an acute pulmonary cedema, similar to that seen
after exposure to certain ‘‘ poison gases.” In chronic
poisoning (whether the “fluorine” is air- or water-
borne), the characteristic symptoms are mottling of
the enamel of the teeth; bony changes, (a) either a
diffuse osteo-sclerosis with deposits in the ligamentous
insertions of the muscles, or (b) bony degeneration
and softening (when the poisoning is more severe) ;
general wasting; anemia and cachexia. Now that
attention has been drawn to this matter, no
doubt a careful study of’ the possible risk in our
industrial areas will be made. Dr. Roholm insists
that factories giving off fluorine compounds should
be required to take measures for effective removal
of the flusrine compounds from chimney smoke.
CAROTID SINUS FAINTING ATTACKS
Ir medical problems often stimulate physiological
research, physiological discoveries often point the
way to advances in medicine. The latter sequence
is exemplified by the story of the carotid sinus. In —
the last ten years the physiologists, led by Hering and
Heymans, have elucidated the function of this curious
bulbous dilatation at the origin of the internal carotid
artery, the walls of which, as well as the substance
of the adjacent highly vascular carotid body, are
furnished with numerous afferent nerve-endings.
These endings are stimulated by the mechanical
stretching of the sinus walls due to the pressure of
its contained blood, and also (probably those in the
carotid body) by certain chemical changes in the
blood, such as carbon dioxide excess, oxygen deficit,
and the presence of sodium cyanide in minute amounts.
Nerve impulses from the stimulated endings ascend
in the vagus and glossopharyngeal nerves to the
medulla and give rise to certain well-defined reflex
effects, notably slowing of the heart, splanchnic
vasodilatation with fall in blood pressure, and
increased breathing. In respect of blood pressure,
the carotid sinus mechanism clearly supplements
the earlier known depressor reflex from the aortic
wall in counteracting excessive rise in aortic pressure
and thereby regulating the general blood pressure
and the blood-supply to the brain. As to respiration,
some of the effects formerly attributed to the action
on the respiratory centre of changes in the amount
or composition of its blood-supply are now seen to
be brought about by the carotid sinus mechanism.
Soma Weiss and his colleagues have lately looked
to the carotid sinus as an explanation of some varieties
A SOUTH AFRICAN PROPRIETARY MEDICINES BILL
[APRIL 17, 1937
of fainting attack in man, and they summarise their
observations of the last few years in a recent paper.!
If the patient’s fainting attack can be reproduced at
will by digital pressure over his carotid sinus in the
neck, they argue that a hypersensitiveness of the
reflex is the mechanism of the attack; the conclusion
is supported by other evidence as well. They have
investigated 57 patients showing this phenomenon,
and they remark incidentally that many of them
showed local anatomical lesions, such as tuberculous
adenitis of glands near the carotid bifurcation, or
athero-sclerotic lesions in the vessel itself. The
induced fainting attacks fell into three groups. In
the first a vagal effect predominated, with slowing
or transient stoppage of the heart, which could be
prevented by atropine. In the second, splanchnic
dilatation and fall of blood pressure occurred, indi-
cating a release of sympathetic vasoconstrictor tone
as the chief reflex effect; adrenaline counteracted
this, while small doses of nitrites accentuated it.
In the third group carotid sinus stimulation appa-
rently produced curious faints, with features suggest-
ing amnesia, sleep, or cataplexy, which are more
dificult to explain physiologically, since blood
pressure and heart-rate were unaltered. The authors
note that the patients subject to carotid sinus attacks
often show evidence of what they call vegetative
neuroses—‘‘ functional ” symptoms such as constant
fatigue, mental depression, palpitation, emotional
instability. They could offer little evidence, however,
that the carotid sinus was responsible for any symp-
toms other than the fainting attacks and phenomena
directly associated with them. In 8 of 10 cases in
which the carotid sinuses were surgically denervated,
the syncopal attacks ceased but the other features
remained unaltered. The authors conclude there-
fore that they have displayed a reflex physiological
mechanism for a symptom hitherto classed as ‘‘ func-
tional ” and often ‘‘ neurotic,” and they wonder how
many more disorders of the same class, in the behaviour
of the autonomic nervous system, may be amenable
to similar explanation.
A SOUTH AFRICAN PROPRIETARY MEDICINES
BILL
A Proprietary Medicines and Appliances Bill has:
been introduced into the South African Parliament
which may have far-reaching results. It would
make it an offence to print, publish, or distribute any
advertisement of a proprietary article which is.
indecent or improper, or fails to state the manu-
facturer’s name and address, or refers to a testi-
monial, or offers free treatment, or states that the
article is a cure for any disease. The Bill goes further,
indeed, than similar proposed legislation elsewhere,
for it would penalise the use in advertisements of the
words ‘‘professor,” ‘doctor,’ “physician,” or
“ surgeon.” It forbids too any such advertisement
which is “likely to conjure up in the mind of a
reasonable man the fear of serious consequences from
some trivial complaint.” Finally, the advertiser
must not by name or implication refer to certain.
diseases scheduled as incurable or requiring special
treatment. There is an exception for appliances
for deafness or rupture, but the list in the schedule-
includes alcoholism, appendicitis, blindness, cancer,
deafness, diabetes, high blood pressure, infantile
paralysis, malaria, pneumonia, sexual impotence,
tuberculosis, and venereal diseases. If the Bill were-
1 Ferris, E. B., Jr. Canpi BR. B., and Weiss, S., Arch. Neur.
Psych. February, 1937, p. 365
THE LANCET]
SPEECH THERAPY
[arr 17, 1937 939
to be passed into law, it would of course affect British
newspapers introduced into South Africa which
contain forbidden advertisements of this kind.
Even if it does not become law in its proposed form,
the Bill will have offered opportunity for useful
discussion and will give newspaper proprietors `
material for considering the imposition of voluntary
standards.
ERADICATION OF TSETSE FROM RIVER AREAS
Tue Colonial Development Fund has lately financed
an interesting experiment in Kenya. By the expendi-
ture of some £2400 an area of 4000 acres of highly
fertile land, which had been derelict for thirty years
owing to sleeping-sickness, has been rendered safe
for habitation. An account of the measures adopted
has been written by Mr. C. B. Symes, medical
entomologist, and Mr. R. T. Vane, tsetse field
assistant,
The great epidemic of sleeping-sickness which
decimated Uganda between 1901 and 1906 spread
to the eastern shores of the Victoria Nyanza, and the
disease is still endemic on the coast and particularly
in the Kuja river basin. Kaniadoto, a district in
this area, was chosen for the experiment because
surveys had shown a high incidence of trypanoso-
miasis, The dense bush along the river and its
tributaries is infested with Glossina palpalis, and the
population has been driven to the higher ground
which is largely waterless and destitute of trees.
These conditions have compelled the people to go
down to the streams for water and wood and to water
their herds, and in doing so they could not avoid
contact with the heavily infested bush, which varies
from 100 yards to a mile in width. The essential
feature of the experiment was a piecemeal attack
on the bush; the trees are chiefly acacia and thorn,
but there is a mass of undergrowth and creepers.
Five clearings were made, varying in width from 500
to 1050 yards, at the sites of the most used watering-
places and fords. When the heavier vegetation had
been burned out, the undergrowth and creepers
were hacked down by gangs of natives. As soon
as the five clearings had been made the attack was
directed to the blocks of bush which had been left.
These were systematically cleared of fly by the use
of Swynnerton’s screen-traps which were most
efficient when the fiy-density was high. In the
later stages great and rapid progress was made by
hand-catching with nets. The efficiency of these
measures may be judged by the fact that in one
block nearly 40,000 tsetse were captured. The
glossina is big enough to be marked and at different
times some thousands of specimens, rendered
‘identifiable by spots of oil-colour, were set free.
Their recapture determined how far the clearings
were effective, and it was noted that few flies managed
to cross a cleared area 1000 yards wide. Other
interesting details of the habits of the tsetse were
also obtained ; for example, it was found to be more
active and more prolific during wet seasons. Among
the labour force, which comprised an average of
90 natives, 5 cases of trypanosomiasis were recognised,
but the men were immediately removed and treated
and are now well.
The net result of the experiment is that eleven
miles of river have been cleared of bush, and six
square miles of highly fertile land have been rendered
available for occupation. In June, 1935, 400 men,
1 The Eradication of G. palpalis from River Areas by the
“Block” Method. By C. B. Symes and R. T. Vane. Nairobi
Government Press. 1937.
women, and children (93 families) were settled on the
area, most of which is now under cultivation. Another
three square miles have been cleared, but will not be
safe until an extension has been made. Provided
that cultivation is maintained the cost of keeping
the cleared area “clean” will not exceed £75 per
annum. A complete scheme for this district would
probably require another six to eight years’ work.
Unfortunately the “‘ block ” method is not applicable
to the coastal districts, and until some measure be
‘devised for dealing with them we cannot expect a
return of the prosperous conditions which obtained
in this part of the Nyanza province before it was
attacked by the trypanosome.
SPEECH THERAPY
FORTUNATELY most of us learn to speak without
effort, or at least the effort is not remembered. The
vocal apparatus and its use are so complicated, how-
ever, that imperfect speech once acquired is difficult to
correct, especially as the patients are most commonly
either very young children, or over-anxious adults.
The mental energy required to study the physiology
of speech is greater than most medical students
have to spare, and as far as doctors are concerned
the subject has largely remained a mystery enshrined
in very specialised clinics. Two monographs recently
issued throw light on different aspects of the work of
speech therapy. Miss Parsons writes charmingly.)
The illustrated story of Mr. Tongue’s walks to the
houses of Mr. Soft Palate and Mr. Teeth, and his
meetings with the Diphthong boys provides one
example, among many, of how speech exercises for
the young child may be made entertaining. The
scientific part of the book is intentionally slight.
The book is obviously written by a born teacher, and
can be recommended not only to doctors who want
to know the sort of thing speech therapists do (or could
do), but to parents of phildren with speech defects.
Miss McAllister’s book ? is a more weighty contribution
to speech therapy, and. will arouse more controversy.
The two divisions of the book deal with stammering
and with stuttering, the terms being used in very
wide senses. For example all defects of articulation
are classified under the heading stammering, even
if these arise only on account of defective hearing.
The descriptions of such cases suggest some confusion
in the author’s mind between the intensity and the
pitch of sounds, and in respect of other physical
factors in the problem. Experienced teachers of
the deaf would certainly and rightly object to
children with grossly defective hearing being left in
a speech therapy clinic instead of being sent to a
school for the deaf. Miss McAllister quotes statistics
showing that 5-6 per cent. of 21,452 children in
Dunbartonshire suffer from some kind of speech
disability, and suggests that the incidence is similar
elsewhere. On this account she pleads for a trained
speech therapist on the staff of every school with over
400 children, believing that occasional attendance
at a clinic is unsatisfactory. Another written contri-
bution * to the popularisation of speech therapy has
recently come from Mr. H. St. John Rumsey, who
has corrected himself of stammering, and has had 15
years of experience in treating other people. He
1 The Gateway of Speech. By Freda Parsons. London:
Ginn and Co. 1937. p. 224. Ts. 6d.
2 Clinical Studies in Speech Therapy. By Anne H. McAllister,
.A., Ed.B., Lecturer in Speech Training, Jordanhill Training
College, Glasgow. London: University of London Press.
1937. Pp. 376. 15s.
3 Your Stammer and How to Cure It. By H. St. John Rumsey,
M.A., Speech Therapist and Lecturer in Speech Therapy at
Quy Hospital. London : Frederick Muller Ltd. 1937. Pp.88.
s. 6d.
940 THE LANCET]
discusses the subject clearly and concisely, and
his little book is particularly suitable for intelligent
adult patients.
ENCEPHALITIS IN JAPAN
THERE was an epidemic of encephalitis in Japan
in 1873 and another in 1911. The latter was looked
on as a cerebro-spinal meningitis, and it was not
until the epidemic of 1924, in which over 6000 cases
were reported, that the true nature of the 1911
outbreak was realised. In 1929 there was a smaller
outbreak, with nearly 2000 cases, and the disease
was prevalent again in 1935 (5000 cases). Apparently
it is more or less endemic in Japan, at any rate in
the summer months, especially in certain seaside
places. In 1933 a committee was appointed to
investigate it, and as head of this committee Inada
is now reviewing its work in a French journal.:
Real progress as regards the etiology of the disease
dates, he says, only from 1933, when Hayashi
succeeded in transmitting it to Java monkeys.
In the same year besides transmitting encephalitis
to monkeys Webster and Fite in the United States
succeeded in infecting mice. This opened up wide
possibilities, which the committee fully used in the
1935 epidemic. They find that up to the seventh
day of disease inoculations of brain matter will
usually infect mice. It has also been possible to
infect them with blood, either directly inoculated
or transmitted through mosquitoes. Cerebro-spinal
fluid was most infective for mice during the second
to fifth days of disease. It was noted that virulence
sometimes increased after the third or fourth passage
through the mouse. Monkeys, it now appears, are
less susceptible than mice, and their susceptibility
varies with species and age. The incubation period
when human material is directly inoculated into the
monkey appears to be about 5-8 days. As regards
mode of infection, Inada considers two hypotheses—
infection through the nasal mucosa and infection
by the bite of an infected mosquito. In weighing
these it must not be forgotten that the Japanese
epidemic and the St. Louis epidemic—with both
of which these observations deal—differed in several
ways from the great European epidemics of 1917-26.
In particular, the difference in the season at which
they occurred has a bearing on the mode of spread.
The outbreaks in the European (lethargic) epidemics
were almost limited to the colder months; their
recurrent peaks were in the second half of the winter ;
the Japanese and St. Louis outbreaks, on the other
hand, were in the summer. The idea that the disease
is transmitted through the nose is based on the fact
that typical changes have been found in the brain
after direct nasal infection of animals, and the finding
of the virus in nasal washings; the difficulty of
accepting it is the rarity of multiple cases of infection
in one household. All the Japanese workers agree
that in animals infection by the nose is more often
successful than subcutaneous or intraperitoneal
injection, and indeed is only second to direct cerebral
inoculation. Twenty-four hours after nasal injection
into the mouse the virus can be obtained from the
olfactory lobe and transmitted with it to another
animal. Infection by mosquito bites have been
unsuccessfully attempted in the United States, but
has been achieved in Japan with difficulty and after
repeated passages. It seems evident that certain
forms of mosquito can harbour the virus, but further |
observations are necessary before one can decide
how far this fact affects mankind.
1 Inada, R. (1937) Pr. méd. 45, 99 and 386.
ENCEPHALITIS IN JAPAN
[APRIL 17, 1937
CHOLINE DERIVATIVES
Nor long ago 1 we referred to the modern tendency
to search among substances chemically related
- to powerful drugs and hormones in the hope of
discovering compounds in which a single activity
of the parent substance is prominently exhibited,
and by way of example we cited the action of carb-
aminoylcholine on the bladder in certain cases of
retention of urine. A valuable account of the effect of
this drug on 26 normal persons has since been given
by Prof. Starr? of Philadelphia, and includes a
record of his own experience after taking a large dose.
A similar investigation by Myerson, Loman, and
Dameshek ? of Boston has been made for acetyl-beta-
methylcholine (Mecholyl), and a comparison of the
effects of the two substances is interesting. They
are both parasympathomimetic, acting on the
circulatory system, the alimentary tract, bladder,
and skin. The effect of mecholyl is prompt, marked,
and transient, and includes flushing of the face
and chest, perspiration, salivation, rhinorrhea,
lacrymation, fall of blood pressure, and an increased
pulse-rate which the authors are at a loss to explain.
Carbaminoylcholine (Doryl) is slower but more
prolonged in its action which is otherwise similar
in many respects to that of mecholyl. Prominent
among the symptoms to which it gives rise are,
however, increased peristalsis and colic, and although
flushing and sweating are conspicuous, the effects on
pulse and blood pressure are slight. With both drugs
atropine annuls unpleasant effects, though animal
experiments show that carbaminoylcholine has a
stronger “nicotine action”? than mecholyl and the
consequent stimulation of autonomic ganglia must
persist even after atropine. The action of mecholyl
on the alimentary tract is slight, but more work is
necessary before it can be assumed with confidence
that this is the drug of choice for circulatory effects
and carbaminoylcholine for visceral activity. The
length of time for which the substances act intro-
duces a complicating factor. Thus Kramer‘ of
Philadelphia reports good results in peripheral
vascular diseases using mecholyl, but finds difficulty
with thrombo-angiitis obliterans. Starr, on the other
hand, records two cases of thrombo-angiitis obliterans
which benefited greatly from carbaminoylcholine,
the reason being, apparently, the more prolonged
action of this drug.
seem primarily interested in the relief of peripheral
vascular lesions, and their results are on the whole
encouraging. They point out the danger of treating
patients with a tendency to asthma with choline
derivatives, and although atropine is effective in
preventing disastrous effects, such patients are not
likely to benefit from the more desirable peripheral
actions of the drugs.
Summer Time will commence in Great Britain,
Ireland, the Channel Islands, and the Isle of Man
on Sunday morning next, April 18th, at 2 A.M., when
the hands of timepieces should be advanced one hour.
It will end on Sunday, Oct. 3rd. Summer time
began in France on Saturday, April 3rd,.at 11 P.M.,
and will end there at midnight on Saturday,
Oct. 2nd.
1 Lancet, Jan. 30th, 1937, p. 276.
2 Starr, I., Amer. J. med. Sci. March, 1937, p. 393.
r” 3 Myerson, A., Loman, J., and Dameshek, W., Ibid,
February, 1937, p. 198.
4 Kramer, D. W., Ibid, March, 1937, p. 405.
The American investigators -
THE LANCET]
- [APRIL 17, 1987 941
PRINCIPLES OF MEDICAL STATISTICS
XVI—CALCULATION OF THE STANDARD
DEVIATION *
In Table III, which appeared in the article on the
variability of observations and is here reprinted,
there are given twenty observations of systolic
blood pressure of which the mean value was found
to be 128. The variability of these observations
was measured by means of the standard deviation.
Taste III
(Reprinted from THE LANCET, Jan. 23rd, 1937, p. 219)
Twenty observa- Deviation of each Square of each
tions of systolic observation from the deviation from
blood pressure. mean (mean = 128). the mean.
(1) (2) (3)
98 — 30 Š 900
160 +32 1024
136 | + 8 64
128 0 0
130 + 2 4
114 —14 196
123 — 5 25
134 i + 6 36
128 0 0
107 —21 441
123 | — 5 25
125 | — 3 9
129 + 1 1
132 | + 4 16
154 | +26 676
115 —13 169
126 — 2 4
132 + 4 16
136 | + 8 64
130 | + 2 4
Sum 2560 | 0 3674
This value was calculated by (1) finding by how
much each observation differed from the mean,
(2) squaring each of those differences, (3) adding up
these squares, and finding their mean by dividing
by the number of observations, (4) taking the square
root of this number. Putting this in symbols, if the
number of observations is n, each observation is
designated by x, and the mean of them by x, then
the standard deviation equals
[Sum of values of (x — x)?
This method of calculation would have been much
more laborious if the mean blood pressure had not
been a whole number—e.g., if it had been 128-4—
and if each of the original observations had been
taken to one decimal place—e.g., the first had been
98-7. The differences between the observations and
their mean, and the squares of these values, would
then have been less simple to calculate. But in such
cases the necessary arithmetic can still be kept
simple by a slight change of method.
The Ungrouped Series
Instead of measuring the differences between the
observations and their mean we can first take those
differences from some other point, any point which
makes the calculation simpler, and make a correction
at the end for having done so. For instance, taking
the figures of Table III, instead of calculating the
differences between the observations and their mean
*In accordance with many requests, I am adding to this
series, of which the main argument was concluded in THE
LANCET of last week, two additional articles on the calculation
of (1) the standard deviation,and (2) the correlation coetticient.
The latter will appear next week.
value, 128, let us measure the differences between
the observations and 100. These differences are
given in column (2) of Table JII a and their squares
in column (3). The sum of the squared deviations
from 100 is 19,354 and the mean squared difference
is, therefore, 19,354 ~ 20 = 967-7. To this value
we must now make a correction for having measured
the deviations from 100 instead of from the mean
of 128. The correction is to subtract from this
mean square value of 967-7, the square of the distance
between the value from which we chose to measure
the deviations (100 in this case) and the value
from which we ought to have measured them (128).
Thus we have 967-7 minus (128—100)2, or (28)?,=
967-7 minus 784, which gives 183-7. The standard
deviation is, then, 183-7 = 13-55, the value we
reached before by taking the deviations from the
mean itself.
TABLE IIIA
Calculation of Standard Deviation : Ungrouped Series
acu Oe Deviation of (Deviation.)* Square of
ons of systolic | each observa- eviation. i
blood pressure. | tion from 100. observation.
(1) (2) (3) (4)
98 — 2 9,604
160 +60 3,600 5,600
136 + 36 1,296 18,496
128 +28 784 16,384
130 + 30 900 16,900
114 +14 196 12,996
123 +23 529 15,129
134 +34 1,156 17,956
128 +28 784 16,384
107 + 7 49 11,449
123 +23 529 15,129
125 +25 625 15,625
129 +29 841 16,641
132 + 32 1,024 17,424
154 + 54 2,916 23,716
115 +15 225 13,225
126 ' +26 676 15,876
132 + 32 1,024 17,424
136 + 36 1,296 18,496
130 + 30 900 16,900
331,354
Sum 2560 = 19,354
If the observations all lie near one hundred this is
a convenient method of working, for the deviations
are thus reduced to a size which it is easy to handle
and the squares can often be done in one’s head.
On the other hand one has to make subtractions from
100 to obtain the deviations. Even this step can
be eliminated by measuring the deviations of the
observations from zero—i.e., by squaring the observa-
tions themselves, as is done in column (4). The
squares can be taken from a book of tables (e.g.,
Barlow’s Tables of Squares, Cubes, Square Roots, &c.
London: E. and F. Spon. 1930. 7s. 6d.)
This obviates finding any deviations at all.
The sum of these squares is 331,354, and the mean
Square is 331,354 ~— 20 = 16,567-7. In using the
squares of the observations themselves we have
measured their deviations from 0 instead of from the
mean value of 128. Therefore the distance between
the value from which we chose to measure the devia-
tions and the value from which we ought to have
measured them is 128; as correction we must, then,
subtract (128)2 from our mean square value. This
gives 16,567-7 minus 16,384 = 183-7, and the standard
deviation is V 183-7 = 13-55 as before. To calculate
the standard deviation in a short ungrouped series of
figures the procedure is, then, as follows: (1) find
the mean of the observations; (2) square each
l
942 THE LANCET]
observation ; (3) sum these squares and find their
mean ; (4) from this mean square subtract the square
of the mean; (5) the square root of this last value
is the standard deviation.
The standard deviation therefore equals :—
minus (mean of
{= of squares of observations
observations)?
number of observations
or in symbols is JEEE ay, |
(The proof of the correction is quite simple but the
worker who wishes to apply the method has no need
to worry about it.)
The Grouped Series
With a large number of observations this method of
Squaring each observation would be very laborious.
A shorter method which will give very nearly the
same result can be adopted. The observations must
first be grouped in a frequency distribution. As an
example we may take the distribution given in
Table II (see Lancet, Jan. 28rd, p. 219) of
the ages at death from diseases of the Fallopian
tube. This distribution is given again in column (2)
of Table III B.
| TABLE IJI B
Calculation of Standard Deviation: Growped Series
Number of Age in f
Ageia | deaths in each | worki (2) x (3). | (3) x (4).
age-group. units.
(1) (2) (3) (4) (5)
0- —6 — 6 6
5- — —5 — —
10- 1 —4 — 4 16
15- 7 —3 —21 63
20— 12 —2 —24 48
25- 35 —1 —35 35
30- 42 0 —
35- 33 +1 +33 33
40- 24 +2 +48 96
45- 27 +3 +81 243
50- 10 +4 +40 160
55- +5 +30 150
-60— 5 +6 +30 180
65- 1 +7 + 7 49
70-75 2 +8 +16 128
Total 206 —
To reach the mean age at death we could add up the
206 individually recorded ages and divide by 206.
But at the risk of making only an immaterial error
we can shorten this process by presuming that the
individuals belonging to each 5-yearly age-group
died at the centre age of that group—e.g., that the
42 women dying at ages between 30 and 35 all died
at age 32-5. Some will have died between 30 and
32-5, some, perhaps, at exactly 32-5, some between
32-5 and 35.‘ If the distribution is fairly symmetrical,
then the positive and negative errors we make by
this assumption will nearly balance out. The sum
of the 206 ages at death will then be (2:5 x 1)
+ (125 x 1) + (17-5.X 7) + (225 x 12) +
-+ (62-5 x 5) + (67:5 Xx 1) + (72-5 x 2) = 7670-0 and
the mean age at death is 7670-0 + 206 = 37-2 years.
Having found the mean in this way the standard
deviation could be found by calculating how much
the observations in each group deviate from it and
taking the square of this value. For instance the
12 individuals in the age-group 20-25 died on our
assumption at age 22:5. They differ from the mean,
therefore, by 14:7 (37-2 minus 22-5), the square of
which is 216-09, and this value we must take 12 times
as there are 12 individuals with that deviation.
PRINCIPLES OF MEDICAL STATISTICS
[APRIL 17, 1937
Following this procedure we should reach for the squares
of the deviations of the individuals from their mean the
following values :—
(—34:7)2 x 1 + (—24:7)2 x 1 + (—197)2 x 7+
(—14:7)2 x 12 + (— 9-7)2 x 35 + (— 47)2 x 42 +
(0-3)2 x 33 + (53)2 x 24 + (10°3)2 x 27 +
(15°3)2 x 10 + (20-3)2 x 6 + (25:3)2 x 54+
(30-3)2 x 1 + (35:3)2 x 2 = 26,310-54.
The standard deviation is, therefore,
4/26,310-54/206 = V 127-72 = 11-30.
SHORT METHOD, WITH GROUPED SERIES
This is a possible method of working but, it will
be observed, a somewhat laborious way. In practice
a much shorter method is adopted. The principle
of this method is that instead of working in the real,
and cumbersome, units of measurement we translate
them arbitrarily into smaller and more convenient
units, work the sums in those smaller units, and
translate the results back again into the real units
at the end. l
Let us, for instance, replace 32:5 by 0, 27-5 by —l1,
22:5 by —2, and so on, 37-5 by +1, 42:5 by +2, and so
on. (The original groups must be of equal size ; they were
all 5-yearly in our example.) Now instead of having to
multiply 27-5 by 35, for example, we have the simpler
task of multiplying —1 by 35. These multiplications are
made in column (4) of Table III B. Their sum, taki
the sign into account (as must be done), is +195. The
mean in these units is, therefore,
+195/206 = +0-947.
The standard deviation can be found in these same small
units, measuring the deviations of the observations from
the 0 value instead of from the mean for simplicity.
The squares of the deviations in these units are merely
1, 4, 9, 16, &c., and these have to be multiplied by the
number of individuals with the particular deviation—
e.g., 7 X 9 for the —3 group, 24 x 4 for the +2 group,
and so forth. A simpler process still of reaching the same
- result is to multiply column (4) by column (3), (instead
of multiplying 7 by 9 we multiply (7 x —3) by —83).
This gives the figures of column (5). The sum of these
squared deviations is, then, 1237 and their mean is
1237/206 = 6-0049.
' These deviations in working units have been
measured round the 0 value, whereas they ought to
have been measured round the mean (in working
units) of + 0-947. The correction, as stated before,
is to subtract the square of the distance between the
value round which the deviations ought to have been
measured and the value round which they were
in fact measured; in this case the distance is
0 — 0:947 = —0-947. The standard deviation in
working units is therefore V/6-0049—(—0-947)2 =2-26.
We have now to translate the mean, -+-0-947,
and the standard deviation, 2-26, back into the real
units. This is simply done. The mean in working
units is +0:947—i.e., 0:947 working units above
our 0. Tn real units our 0 is equivalent to 32-5,
for that is the substitution we made (note, the
centre of the group against which we placed the 0,
not its beginning, a mistake which is somewhat easy
to make). The real mean must therefore be
32-5 + 5 (0-947) = 37-2—which is the same as the
value we found by the long method using real units
throughout. |
The multiplier 5 is arrived at thus: the mean is found
to be 0:947 above the 0 value when the groups differ
in their distances from one another’s centres by unity—
e.g., from —1l to —2; but in the real distribution their
distance from one another’s centres is 5—e.g., from 27:5
to 22-5; therefore the mean in real units must be 5 times
0:947 above 32-5 (if the mean in working units had been
THE LANCET |
+1 clearly the real mean would be 37-5, for the latter is
the value for which -+1 was the _ substitute—i.e.,
32:5 + 5 (1)).
The rule then is this. Having found the mean in work-
ing units, multiply its value by the original unit of group-
ing (4, 5, 10, or whatever it may be) and add the
resulting figure (or subtract it according to its sign) to
the value of the centre of the group against which the
0 was originally placed. That gives the real mean
value. To reach the real standard deviation all that
has to be done is to multiply the standard deviation
as found in working units by the original units of
grouping—in this case by 5. For if this measure
of the scatter of the observations is 2-26 when the
range is only 14 units (from —6 to +8) it must be
5 times as much when the range is really 70 units
(from 2-5 to 72-5). The real standard deviation is
therefore 5 x 2-26 = 11-30.
CHECKING THE ARITHMETIC
As regards the final result it is immaterial where
the 0 is placed ; the same answers in real units must
be reached. From the point of view of the arithmetic
it is best to place it centrally so that the multipliers
may be kept small. For the sake of demonstration
the calculations for Table IIIB are repeated in
Table IIIc taking another position for 0. This,
in practice, is a good method of checking the
arithmetic.
TABLE IIIc
Calculation of Standard Deviation: Grouped Series
{
Apai ! Number of Age in
ge © | deaths in each | working | (2)x (3). | (4) x (3).
years. | age-group. units.
(1) | (2) (3) (4) (5)
- 1 -8 — 8 64
10- 1 —6 — 6 36
15- | 7 -5 — 35 175
20- | 12 —4 — 48 192
25— 35 —3 ~105 315
30- 42 -2 — 84 168
4- o a o ee ee
45—- | 27 +1 + 27 27
50- | 10 +2 + 20 40
55- | 6 +3 + 18 54
60- | 5 +4 + 20 80
65- 1 +5 + 5 25
70-75 | 2 +6 + 12 72
Total | 206 —217 1281
From the calculations in Table III c we have:
Mean in working units = — 217/206 = —1-053
.°. mean in real units = 42:5 —5 (1-053) = 37-2
(42-5 is the centre of the group against which the 0
was placed ; note that the correction has now to be
subtracted for the sign of the mean in working units
is negative).
Mean squared deviation in working
= 1281/206 = 6-2184
>, standard deviation in working units is
v 6:2184 — (1-053)? = 2-26
(1-053 is the distance between the value of 0 from
which we measured the deviations and the value
from which we ought to have medsured them ; note
that the correction is subtracted whatever the sign
of the mean in working units).
. ° . the real standard deviation is 2:26 x 5 = 11-30.
These values agree with those previously found.
units round
The Standard Deviation in Small Samples
Finally it may be noted that the standard deviation
found for a set of observations is an estimate of the
variability of the observations in the population,
THE FIGHT AGAINST LEPROSY
[APRIL 17, 1937 943
or universe, that has been sampled. A slightly
better estimate is reached by dividing the sum of the
Squared deviations from the mean by n—1 instead
of by n (where n is the number of observations).
If the number of observations is large, the difference
is immaterial; if it is small some difference results.
A simple method of making this change is to calculate
the standard deviation in the way just described
and multiply the result by 4
dard deviation of the 20 observations of blood pressure
in Table III would be 13-55 x o = 13-90. This
correction should be applied if the number of observa-
tions is less than about 30, especially if tests of
“ significance ” are to be applied. A. B. E.
e.g., the stan-
THE FIGHT AGAINST LEPROSY
THE fourfold objective of the British Empire
Leprosy Relief Association was outlined by Dr. Ernest
Muir, its medical secretary, at the annual meeting
held at the India Office on April 15th. The Associa-
tion is concerned with the study of leprosy and of
the conditions under which it exists and spreads.
It endeavours also to help the leper, by care, treat-
ment, and training; to combating leprosy with a
view to its final control; and to interest, rouse, and
educate the British public in the problem of leprosy.
Dr. Muir said that since the inception of the Association
13 years ago a much more accurate idea had been
obtained of the widespread distribution of leprosy
and of the various factors which govern its incidence.
Study of the disease itself had shown that while
most lepers are not infectious, a few highly infectious
cases can spread the disease to many others, and thus
one generation infects the next. Those infected in
childhood furnish most of the serious infectious cases.
As to treatment, it was now recognised that
though medicines are of value, the main remedy lies
in healthy occupation and sound nutrition. Com-
pulsory segregation and treatment were generally
worse than useless. The leper must be led, not driven ;
without his coöperation neither effective treatment
nor limitation of the infection could be secured.
Segregation by itself would never do more than
touch the fringe of leprosy control—at least in
poor and densely populated countries; but well-
equipped and staffed settlements could be used
as centres for an educative campaign, and
indeed their chief function should be to act as a
centre of training and enlightenment in the district.
The annual report of the Association emphasises
the fact that leprosy is a problem of colonial develop-
ment. At present two types of leper institution
are to be found; one is a refuge where patients
crippled and deformed and often non-infective
are concentrated, while infectious cases, not recognised
as such, mix freely with the community. The other
progressive type is that to which cheerful and
energetic lepers are attracted mainly by the hope
of recovery. It is to the organisation and multiplica-
tion of this latter type of settlement that the Associa-
tion is devoting its energies and as well as to the
education of all people in the nature of leprosy
and the means of its prevention. Sir William Peel
has succeeded Sir Edward Gait as chairman of the
executive committee of the Association. He made
an urgent plea for more support from the British
public for the maintenance and extension of its
activities.
944 THE LANCET]
[APRIL 17, 1937
SPECIAL ARTICLES
TREND OF THE POPULATION OF
ENGLAND AND WALES
DURING THE NEXT HUNDRED YEARS
By C. A. Gouxp, M.C., B.Sc.
ASSISTANT IN THE STATISTICAL SECTION OF THE PUBLIC HEALTH
DEPARTMENT, LONDON COUNTY COUNCIL *
For some time before the late war—in fact after
the year 1870—and to a greater extent since, there
has been in this country a steady drop in the fertility-
rate coupled with a gradual: lowering of the death-
rate. As a result of these two movements the popula-
tion of England and Wales is rapidly ageing. To
ascertain the effect of this tendency on the future
age-distribution of the population I have assumed in
these notes that for the next hundred years the
fertility-rate remains at the 1933 level, and that the
mortality-rates are as obtaining in 1931. The 1931
census population being taken as basis, successive
male and female populations at the various ages were
estimated for each future census by means of the
1931 life table, assuming the 1933 fertility-rates by
age-groups of all women (15-45) to persist and the
ratio of male to female births to be 1-050.
The results are set out below. Table I gives the
estimated population by age and sex at each future
census up to and including the year 2031, expressed
as a percentage of the corresponding population at
the 1931 census ; while Table II shows the percentage
age-distribution ‘of the male and female populations
at each future census for the next hundred years.
The various changes in age-distribution of the total
population and in the magnitude of each age-group
can be conveniently analysed for each sex in the fol-
lowing categories: infants (0-5), children of school
ages (5-15), young adult and early middle-age workers
(15-45), middle-age workers (45-65), and pensioners
(65+). |
TABLE I
Estimated population by age-groups at each census date
during the next hundred years expressed as a percentage
of the corresponding age-group population in 1931
MALES
Age 1931/1941 |1951 |19611971 198111991. 2001 20112021 2031
RLE EEN E ED TE ESEE E E E E Ae
0-5 !100] 90 |85 | 75) 68) 62j 56! 50 I 42| 38
5-15 |100 85 | 79 | 74| 65! 59 54 | 48| 44! 40| 36
15-45 e 105 |100+, 91| 82| 75 i 62 56 | 51| 46
45-65 100/105 (115 |128|129!115;103! 96| 86; 77| 71
65+ | 100 127 |145 | 151/170] 186 | 184 | 162 147 |136 | 122
ee oO Oe eee | een
Allages! 100 102- 102—| 99| 94| 871 80i 72| 65! 59|. 54
FEMALES .
0— 5 1100] 90 | 84 751 67) 61) 55] 50: 47) 41) 37
5-15 1100, 85 | 79 | 73) 65| 58| 54] 48) 43! 40] 36
15-45 |100 |100-| 92 | 82| 74| 68] 61| 55| 50: 45] 41
100 111 120 |126|121|105| 94| 67
65+ |100: 126 |152 |168|182/190/180 |158 l142 |130 |117
ge ee | ee E | | SS | ee
(1) Infants (0-5).—This group comprised 8 per cent.
of the whole population as regards males and 7 per cent.
* The opinions and conclusions expressed herein are my own
ene the London County Council accepts no responsibility for
em.
as regards females in 1931. In the year 2031 these per-
centages will each have dropped to 5. Also by this time
the number of males of this group will have steadily fallen
to 38 per cent. of their number in 1931 while the females
will be reduced to 37 per cent.
(2) School-children (5-15).—In 2031 the males of this
group will comprise 12 per cent. of the total male popula-
tion and the females 11 per cent. of the female population
as compared with 17 per cent. and 16 per cent. respectively
in 1931. Again the males and females of this group will,
as in the group above, steadily decrease in numbers during
the period ; in the year 2031 each will be only 36 per cent.
of the 1931 population of this group. |
(3) Young adults and early middle-aged (15-45).—In
1931 this group formed 47 per cent. of the total popula-
tion for each sex; in the year 2031, however, the males
will be reduced to 40 per cent. and the females to 38 per
cent. Moreover, the males will by then have fallen to
46 per cent. and the females to 41 per cent. of their
numbers respectively in 1931.
(4) The middle-aged (45-65).—The percentage of total
population formed by this group will increase during the
next hundred years from 21 to 28 for males and from
22 to 28 for females. In the year 2031, however, the males
will be reduced to 71 per cent. and the females to 64 per
cent. of their numbers respectively in 1931, the census
maximum of 129 per cent.for males being reached about
1971 and that of 126 per cent. for females in 1961, some
ten years earlier.
TABLE II
Percentage age-distribution of male and female populations
at each census during the next hundred years
Census Age .. 0-5 | 5-15 | 15-45 45-65 | 65+ —
1931 M , 8 17 47 21 7 100
F | 7 16 47 22 8 : 100
1941 M 7 14 | 49 | 22 8 100
F 6 13 47 24 10 100
1951 M 7 13 46 24 10 100
F 6 12 44 26 12 100
1961 M 6 13 43 28 10 | 100
F 5 12 40 29 14 100
1971 M 6 12 41 29 12 100
F 5 11 39 29 16 100
1981 M 6 12 40 28 14 | 100
F 5 11 38 28 18 | 100
1991 M 6 12 | 40 | 27 | 15 | 100
F 5 11 38 27 19 | 100
2001 M 5 12 40 28 15 | 100
F 5 12 40 23 20) 100
2011 M 5 12 | 40 | 28 | 15 | 100
F 5 11 38 28 18 100
2021 M 5 12 40 28 15 | 100
F 5 11 38 27 19 | 100
2031 M 5 12 | 40 | 28 | 15 : 100
F 5
11 38 28 18 , 100
(5) Pensioners (65+).—Male pensioners will increase
from 7 per cent. to 15 per cent. of the total male popula-
tion during the next hundred years, while the females
will increase from 8 per cent. to 18 per cent. The numbers
of both sexes will also rise rapidly until the year 1981,
when the males will be 186 per cent. and the females
190 per cent. of their respective numbers in 1931. By
the year 2031, however, these percentages will have
dropped to 122 and 117 respectively.
The maximum total population, 19,600,000 males
and 21,200,000 females, will be attained about the
year 1944, and at the end of a hundred years the
total population will be only about half of that in
1931—namely, 10,280,000 males and _ 10,680,000
females approximately.
`
`
POPULATION OF ENGLAND AND WALES DURING THE NEXT 100 YEARS [APRIL 17, 1937 945
TAGE 0-5 | 5-5 | 5-45 | 45-65 =| 65+
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Diagram showing the population of England and Wales at twenty-year intervals during the next century. The calculations are
based on the assumption that the fertility-rate is the same as in 1933 and the mortality-rate the same as in 1931.
Each homuncule represents one million persons.
The effect of these changes in the number and age-
distribution of the population will be far-reaching.
The reduction in the number of females of the child-
bearing ages (15-45) will mean fewer babies and
eventually fewer school-children ; this in turn may
lead to fewer schools and teachers in the years to
come, Moreover, any further lowering of the fertility-
rate, coupled with a drop in the number of potential
mothers and fathers, would cause a still further
reduction in the number of births.
As the older generations die off the fall in the
number of young adults of both sexes will cause a
dearth of employees and potential purchasers of
food and. commodities. Trade will consequently
suffer; on the other hand wages will tend to increase.
Another serious aspect is the financial effect of an
increasing pensioner group (age 65+) coupled with
a decreasing contributor group (aged 15-65) on
annuity and pension funds. ‘One thing is certain—
namely, that, in future, the annual pension will be
much greater; for example, at the end of the
period it will be more than twice the cost in
1931.
The flow of population to the large towns has
gradually drained the countryside of its workers,
and the steady decrease in population in the future
will accentuate this depopulation of the rural districts
more than ever. Unless a determined move is soon
made to repopulate country districts, our supply of
home-grown food, already inadequate to feed the
nation, will tend to disappear. It may also be asked
how we are going to maintain our fighting forces with
a regular supply of recruits and man our merchant
service with seamen in the future, in view of the
certainty of a steady fall in the number of young
male adults. These problems will force themselves
on the attention of our politicians before many years
are past; one of them—that of defence—is already
causing anxiety.
In this investigation the possible effects of migra-
tion have been ignored, since it is obviously impos-
sible to attempt to forecast the extent of emigration
that may take place from this country in the coming
years. There will doubtless be determined efforts
in the near future to increase the outward flow of
population to various parts of the Empire, especially
of young adults and children; this, of course, will
add to the increasing high proportion of persons over
45. It is unlikely that fertility-rates will fall much
lower—there are already signs of a slight upward
tendency—and it is doubtful whether there will be
a much further reduction in the general death-rate
in view of the steady increase in the percentage of
total population in the older age-groups amongst
which the majority of deaths occur. Should, how-
ever, an improvement in fertility take place in the
future, this will be largely counteracted for some years
to come by the increase in the death-rate. We can
therefore assume that apart from the effects of future
migration the above estimates give a reasonably
accurate forecast of the trend of the population of
England and Wales during the next century, unless
significant changes in fertility- and mortality-rates
occur during the period.
CHELMSFORD NEW HEALTH CENTRE.—The mayor
of Chelmsford has opened a new public health depart-
ment where clinics will be held and the statf of
the borough medical officer housed. There is a health
visitors’ room, a treatment department in which minor
ailments are dealt with, a dark-room, a consulting-room,
a dental department, and a recovery room. The cost has
been £8000.
946 THE LANCET]
MANCHESTER MEDICAL LIBRARY
THE question of increased accommodation, for the
storage of books and of improved facilities for their
easy use is a problem almost as pressing to medical
schools as is that of more laboratory and lecture
room accommodation. Manchester University is
recognising this in its present appeal for money and
in its plans for the future. Its medical library to
which, in addition to its own staff and students, the
members of the Manchester Medical Society have
access, and which is to a considerable degree supported
by the latter, is housed in the university medical
school. But the present accommodation is by no
means all that could be desired; Harvey Cushing,
himself an eminent authority on medical books, has
described the library as one of the best he had seen
but as one of the worst housed. The acids of the
Manchester atmosphere, some of them perhaps from
the university’s own chemical laboratories, assisted by
the fumes of the gas with which the rooms were for
many years lighted, have played havoc with the
bindings. Space too is deficient, both for qualified
readers and for the students who are using the library
in increasing numbers and who would use it still
more if elbow-room and comfort were improved.
The fact that the students’ reading room acts as
a passage for access to the general room and com-
mittee room tells its own tale. A lecture theatre
is also urgently required,
The library, which claims to be the largest medical
library in England outside London, contains some
75,000 bound volumes as well as many thousands
of pamphlets which are only now in process of being
sorted and catalogued. One of the avowed objects
of the Manchester Medical Society when it was founded
in 1834 was “‘ to establish a medical library and read-
ing room.” For many years its progress, at first in
a private house in Faulkner-street, then in the Royal
Institution (which is now the City Art Gallery)
was slow. In 1875 an arrangement was arrived
at by which Owens College housed the books in its
newly built medical school at the back of the Oxford-
road buildings, and provided the medical society
with headquarters. The college gave a grant to
help in maintenance and as this grant was augmented
it obtained increasing rights for its staff and students.
As the library grew the society found it more and
more difficult to maintain its standard of efficiency,
until in 1930 it was handed over to the university,
the members of the society retaining their right
to the use of the books and accommodation. As
the gift implied that the society could not now
break away taking the books with it, it became worth
while for the university to develop the library and
to spend money in housing it properly. The
university has allotted a site for it conveniently close
to the medical school.
The library, as it stands, is largely the result of the
work of Dr. Thomas Windsor (1831—1910), a bibliophile -
of bibliophiles. Valuable collections have been given,
one by Dr. Samuel Crompton, another by Dr.' Charles
Clay of ovariotomy fame, others by the Royal
Infirmary and the Manchester St. Mary’s Hospitals.
Many rare books are to be found on the shelves.
Among the incunabula are an Italian copy of ‘‘ Guy de
Chauliac ” (1480). Other early books are a ‘“‘ Herbal or
Boke of the Properties of Herbes ” (1548), of which no
other example is known, and a copy of Wolveridge’s
‘‘ Speculum Matricis or The Expert Midwives Hand-
maid ” (1671) which is very rare. The library possesses
MANCHESTER MEDICAL LIBRARY
. [APRIL 17, 1937
also a presentation copy of Beaumont’s work on
Alexis St. Martin, and two copies of Parkinson’s
“ Shaking Palsy,’ both rare works. Apart from
books there is John Hunter’s grandfather clock, his
dinner bell, and the seal of his diploma as Fellow
of the Royal College of Surgeons in Ireland, all of
which were acquired from the family of Sir Richard
Owen, to whom they came through his marriage
with the daughter of William Cliff who assisted
Hunter.
In part.owing to want of space in the main library
rooms, and in part for convenience, a system of
departmental libraries—physiology, anatomy, pharma-
cology, gynecology, cancer, public health, and
dentistry—has been inaugurated ; these hold all the
books on their own subjects and facilitate study
though they create difficulties of control. Another
special section is given up to local medical history—
of Manchester in particular, but also of Lancashire
and Cheshire in general—which contains some 1100
volumes and 230 boxes of unbound material.
PARIS
(FROM OUR OWN CORRESPONDENT)
THE HAWKING OF DRUGS
LAST year a new law regulating the sale of drugs
came into force in France. This law was the inevit-
able reaction to the self-prescribed pharmacological
orgies in which the country has indulged with ever-
growing zest. The law strikes at the sale of drugs
outside the chemist’s shop which, if the chemist
himself is on duty, is supposed to serve, if not as
an absolutely fool-proof safety valve, at least as a
check on the public’s ardently misguided search for
health in a bottle. The new law also attempts to
put a spoke into the wheel of the circularising
‘*‘herborist ’? who, through the post and persuasive
touts, offers Nature’s cures without discrimination.
A recent number of the Siècle Médical reports an
important judgment of the tribunal correctionnel
of Nancy. In this town a certain doctor of pharmacy
was prosecuted for the sale of drugs under conditions
infringing the law of Sept. 4th, 1936. On the first
occasion he was acquitted by the tribunal which
found that he had acted in good faith. Regarding this
judgment as an incentive he employed nine motor
lorries on regular circuits of neighbouring villages,
collecting orders and distributing goods already
ordered. These lorries were in effect chemists’
shops on wheels without a duly qualified chemist to
put on the brake. The leniency shown by the
tribunal on the first occasion was not repeated,
and the chemist was fined 300 francs and ordered
to pay 10,000 francs damages to the Syndicat des
pharmaciens de Lorraine, The judgment in this
test case should prove an obstacle to the sale and
delivery of pharmacological preparations at the
customer’s door as though they were the daily
necessities of life.
THE FUTURE OF NURSING IN THE AIR
Dr. P. Béhague, who is “ vice-président délégué ”
‘of the Comité Central d’Aviation Sanitaire, and who
has done much to organise a network of first-aid
posts on the French main roads, is not a little con-
cerned about the future of nursing in the air. During
the past two years more than 200 French nurses have
passed all the tests required of them for air ambulance
service, and now they find there is little scope for
their activities in this sphere. From a national
THE LANCET]
point of view, their sacrifices in time and money and
energy have certainly not been wasted, for these
enterprising young women have set an excellent
example to their brothers and other members of the
‘ sexe faible.” The authorities are not to be blamed
unreservedly for having encouraged young nurses to
qualify for duties of a hypothetical character, and
it was made plain enough from the outset that the
emergencies in which air nurses might be called to
serve might never materialise. But the fact remains
. that these nurses have found no immediate return
for a relatively costly investment. Dr. Béhague is
inclined to think that there has been a certain
fundamental misconception about first aid in the
air. As he points out, both peace-time and war-time
emergencies may make calls on air ambulance space
so great that it will often be given to two patients
rather than to one patient plus a nurse. If nursing
is required in a particularly important case, this
can be given by a doctor. His advice to would-be
first-aid workers in the air is, in effect, that they
first learn to fly, and that they then master whatever
may be required of them as first-aid attendants.
Merely to qualify as an air nurse and not as a pilot is to
risk being left behind on the ground in an emergency.
Experience with first aid on the highways has con-
vinced Dr. Béhague that the most satisfactory arrange-
ment is to teach the men in charge of first-aid posts
on the roads the elements of first-aid. which can thus
be given far more promptly than were the injured
to be cared for by skilled first-aid workers rushed
up from some distant centre. And in this connexion
he compares the man on a highway present at the
time of an accident with the pilot who has learnt
not only to fly but also to nurse.
It is probable that the majority of Dr. Béhague’s
200 nurses have followed a course of a few hours
in first aid, or at most have completed a nursing
course of only a few months; and the guess may be
ventured that few possess the official nursing diploma.
It is not surprising, therefore, that these 200 have
been unable to find employment in a country where
the State regulates the training of nurses and has
created a State diploma.
COMPULSORY ANTI-TYPHOID AND ANTI-DIPHTHERIA
VACCINATION FOR MEDICAL STUDENTS
It will be remembered that last summer the
attention of the French Academy of Medicine was
drawn to the high diphtheria-rate among medical
students and the need for protecting them against
it by artificial immunisation. Dr. Clément’s advocacy
of this measure was supported by no less an authority
than Dr. Rouvillois, who went one better by advocat-
ing triple associated vaccination of medical students
against typhoid, diphtheria, and tetanus. The
commission created by the Academy was remarkably
strong and representative, and its rapporteur was
Prof. Tanon. When it met in February of this year
it decided that compulsory vaccination against
tetanus might be dispensed with considering how rare
this disease is in medical students. On the other
hand, it was agreed that associated vaccination
against typhoid and diphtheria should be recom-
mended as a compulsory measure early in the medical
curriculum and without recourse to the Schick test.
The Academy of Medicine has now adopted the
findings of its commission, and the next step will
presumably be their presentation to the Ministers
of Public Health and National Education.
NOTIFICATIONS OF THE CAUSES OF DEATH
The inability or unwillingness of many doctors
to state in writing why some of their patients died
PARIS.—IRELAND
1935, and the latter from 13-15 to 13-98.
[APRIL 17, 1937 947
has for many years been a thorn in the flesh of the
public health authorities. In 1927 there were as
many as 70,000 deaths whose cause was not accurately
specified in the death certificates. In 1933 this
figure rose to 113,000, or 17 per cent. of all the deaths
recorded in this year. Since Jan. Ist, 1929, a more
or less concerted effort has been made by five depart-
ments or counties to reform matters in this respect,
and the departmental inspectors of hygiene have
coéperated with medical practitioners so effectively
that the proportion of deaths from unknown causes
has been reduced to less than 5 per cent. The
principles on which this reform has been based are
now to be introduced in all the other departments
in France as from July lst, 1937. In the past,
vagueness in the wording of death certificates has
often reflected a doctor’s sense of obligation to
professional secrecy ; and it is to ease his conscience
in this respect that in the future death certificates `
will be so drafted that the part showing the cause of
death will be detached from the part on which the
name of the dead person is inscribed. There will
also be such a speeding up of the passage of the death
certificate to its final destination that if it is faultily
worded it can promptly be referred back to its author.
IRELAND
(FROM OUR OWN CORRESPONDENT)
A REVIEW OF THE YEAR
Tue introduction of the estimate for the Depart-
ment of Local Government and Public Health by
the Minister gave an opportunity in the Dáil last
week for a general discussion of questions of public
health. The total grant asked for was £1,259,068,
which included a sum of £769,432 for housing and
£327,005 for social services. The Minister stated
that the administration of public health was now
supervised in every county by a county medical
officer of health. Throughout the country the
organisation of public health measures was being
gradually perfected, and further improvements in the
public health might be hoped. for. The vital statistics
for 1935—the latest available—showed a slight rise
in both birth-rate and death-rate. The former had
increased from 19-49 per 1000 in 1934 to 19-61 in
The
increase in the death-rate was largelv due to a high
incidence of the principal infectious diseases, which were
more numerous than in 1934, being 1865 as compared
with 1359. Three cases of typhus fever were recorded,
the lowest number in the history of the country.
The incidence of diphtheria had diminished, the
decrease being greatest in those areas where the most
intensive immunising campaigns had been carried out.
There had been heavy mortality from measles during
the year, the number of deaths being 316, whereas
they were 50 in the previous year. Infant mortality
shared. in the general increase of the death-rate,
being 68 per 1000 births as compared with 63 in the
previous year. The greater mortality among infants
was chiefly due to congenital defects and to outbreaks
of diarrhea and enteritis, The Minister hoped that
the carrying into effect of the regulations made in
pursuance of the Milk and Dairies Act, 1935, would
go a long way to reduce the incidence of those
diseases. The infant mortality was highest in the
urban areas ; in Waterford it was 126 per 1000 births,
in Kilkenny 110, in Limerick 106, and in Wexford 103.
The rate in Dublin had risen from 80 in 1934 to 94
in 1935. Valuable work for the safeguarding of
948 THE LANCET]
infant life was being carried out under approved
maternity and child welfare schemes in many of the
urban areas and in a few counties. Approved schemes
for the supply of free milk to poor children had been
in operation in all areas except two urban districts
in which the local authorities declined to avail them-
selves of the amounts of money allocated. School
medical inspection was now carried out in every
county, and was associated with medical and surgical
treatment for certain defects. School meals were
now supplied by 51 local authorities, the number of
meals supplied in 1936 being approximately 4,231,872.
There was an increase in the number of deaths from
tuberculosis from 3520 to 3770, the death-rate being
much higher in the urban than in the rural areas.
There had been a grant from the Hospitals Sweep-
stakes Fund of £10,000 toward medical research,
and a council to administer the Fund had been
appointed. A sum of £10,000 had also been allocated
for the establishment of a hospital library service.
The Minister dealt at length with what had been
done in regard to housing. The total number of
houses built since 1932 would appear to be 14,895
in urban areas and 8662 in rural areas.
SITUATION OF THE HOSPITALS
In the subsequent discussion the Minister was
questioned as to his intentions in regard to the
development of the hospital system of the country,
and specially with reference to the Dublin hospitals.
Dr. Rowlette (Dublin University) drew attention to
the report of the Hospitals Commission which had
been in the Minister’s hands for some 18 months.
The report had recommended a certain line of
development of the Dublin voluntary hospitals but
the Minister’s decision had not yet been given. The
hospitals concerned were at a standstill through not
knowing what their future was to be. At the same time
the pressure on their bed-accommodation was steadily
increasing. Not only was the population of Dublin
growing rapidly but the desire and need for hospital
treatment in preference to home treatment were also
growing, and would continue to grow. He empha-
sised that the Sweepstakes were organised by those
interested in the voluntary hospitals for the aid of
the voluntary hospitals, and the voluntary hospitals
had a primary claim on the Sweepstakes Funds.
This contention was admitted in his reply by the
Minister. He agreed that the voluntary hospitals
“had, ethically and in all justice, a right to primary
consideration when distributing the Hospitals Sweep-
stakes Funds.” He declared also that it was not his
intention to spend on the hospitals of local authorities
more than one-third of the net amount received out
of the Hospitals Sweepstakes Funds for hospitals.
THE SERVICES
ROYAL NAVAL MEDICAL SERVICE
Surg. Lt.-Comdr. D. R. F. Bertram to St. Angelo for
R.N. Hospital, Malta.
Surg. Lts. C. J. Robarts to Halcyon and F. Bush to
Pembroke for R.N.B.
Surg. Lt. (D) D. D. Craig to Wildfire.
ROYAL NAVAL VOLUNTEER RESERVE
Surg. Capt. L. S. Ashcroft to President.
Surg. Lt.-Comdrs. E. F. St. J. Lyburn to Resolution;
S. B. Borthwick, F. E. Stabler, T. ,C. Larkworthy to
President; and C. Seeley to Royal Sovereign.
Surg. Lts. G. L. Foss to President and D. R. Maitland
(proby.) to Victory, for R.N. Hospital, Haslar.
ARMY MEDICAL SERVICES
The War Office announces that Brevet-Col. R. C.
Priest, Hon. Physician to the King, has been selected
THE SERVICES
[APRIL 17, 1937
for appointment as Professor of Tropical Medicine, Royal
Army Medical College, and Consulting Physician to the
Army, with effect from June 6th, 1937, in succession to
Col. J. Heatly-Spencer, Hon. Physician to the King, who
is retiring.
. ARMY DENTAL CORPS
Lt. T. A. Smitham to be Capt.
ROYAL ARMY MEDICAL CORPS
TERRITORIAL ARMY
Col. A. P. Watson, O.B.E., T.D., having attained the
age limit, retires and retains his rank, with permission to
wear the prescribed uniform.
Lt. T. W. Preston to be Capt.
J. L. Murray (late Offr. Cadet, Durham Univ. Contgt.
(Med. Unit), Sen. Div., O.T.C.) to be Lt.
A. D. Kelly (late Cadet C.S.M., Durham Sch. Contgt.,
Jun. Div., O.T.C.) to be Lt.
TERRITORIAL ARMY RESERVE OF OFFIOERS
Capt. H. W. A. Post from Active List to be Capt.
ROYAL AIR FORCE
Wing Comdr. H. S. C. Starkey, O.B.E., to No. 3 Flying
Training School, Grantham, for duty as Medical Officer.
Squadron Leader P. D. Barling to R.A.F. Station,
Feltwell, for duty as Medical Officer.
Flight Lt. G. H. J. Williams to Home Aircraft Depdt,
Henlow. i
Flying Offrs. N. P. R. Clyde to R.A.F. Station,
Waddington, and D. F. Shaw to R.A.F. Station, Harwell.
Dental Branch.—Flight Lt. W. D. Guyler to R.A.F.
Station, Seletar, Straits Settlements.
INDIAN MEDICAL SERVICE
Maj.-Gen. Sir C. A. Sprawson, Kt., C.I.E., K.H.P., retires.
Brevet-Col. A. A. C. McNeill has been appointed as
Deputy-Director of Medical Services at Army H.Q.,
New Delhi, in place of Maj.-General F. D. G. Howel,
D.S.O., M.C., K.H.S., transferred to Aldershot as D.D.M.S.
in March last. ;
Majs. to be Lt.-Cols.: S. L. Patney, D. N. Bhaduri,
B. Basu, O.B.E., M. A. Jafarey, G. Verghese, and A. D.
Loganadan.
Col. W. H. Hamilton, C.I.E., C.B.E., D.S.O., K.H.P.,
to be Maj.-Gen.
Lt.-Col. A. F. Babonau, C.I.E., O.B.E., to be Col.
Lt.-Col. T. L. Bomford retires.
Capt. K. Cunningham resigns his commn.
Indian Medical Department.—Asst. Surgns. (lst Cl.) to
be Lts. (Sen. Asst. Surgns.): W. G. Sherard and S. G.
Jackson. Lt. (Sen. Asst. Surg.) A. E. Gomez, M.B.E.,
retires.
COLONIAL MEDICAL SERVICE
Dr. B. S. Jones and Dr. G. E. McVitie have been appointed
Medical Officers, West Africa, and Miss M. J. Lyon, M.B.,
B.S., Medical Officer, Malaya. Sir Robert G. Archibald,
C.M.G., D.S.O., M.D., has been appointed Medical
Superintendent, Chacachacare Leper Settlement, Trinidad.
Dr. G. E. Craig becomes Deputy-Director of Medical
Service, Gold Coast, Mr. R. M. Dannatt, Resident Surgeon,
Colonial Hospital, Grenada, and Dr. L. G. W. Urich
(Medical Superintendent, Chacachacare Leper Settlement)
Medical Officer of Health, Trinidad.
DEATHS IN THE SERVICES
The death occurred at Southsea on April llth of
Surgeon Captain Huen Pripreavux TURNBULL. Born at
Plymouth in June, 1873, he was son of the late
Alexander Turnbull, M.D., of the Naval Medical Service.
He was educated at St. Paul’s School (1884-90) and
St. George’s Hospital, London, qualifying M.R.C.S. Eng.
in 1897. He at once entered the Navy, was appointed
surgeon of the sloop Torch (101 men), and landed in
Samoa in 1899 for service with the Naval Brigade, and
was mentioned in dispatches. He became surgeon
commander in May, 1913. He served in the European
war on H.M.S. Roxburgh (1914-16), and then was put in
charge of the Royal Naval Hospital, Bermuda (1916-19).
In 1922 he was squadron medical officer in the battleship
Barham, and he subsequently held the post of professor
at H.M. Navigation School, Portsmouth. `’
THE LANCET]
[APRIL 17, 1937 949
PUBLIC HEALTH
MILK EXAMINATION
A COMPARISON OF THE PLATE COUNT AND
REDUCTASE TEST
By J. STEVEN Favurps, M.D.
PATHOLOGIST TO THE CUMBERLAND INFIRMARY, CARLISLE
Dvurine the past year several papers have been
published comparing the methylene-blue reductase
test with plate count and B. coli estimation. Opinions
differ about their merit, but it is agreed that the
results of the plate count are not consistent. The
most obvious reasons for the inconsistency are the
difficulty of obtaining an accurate representative
sample of a fluid difficult to shake efficiently, the
difference of temperatures, and the agitation of
samples during transit, which quickly changes their
bacterial content.
To ascertain how far the results of the methylene-
blue reductase test and the plate count are in agree-
ment I have examined 1500 samples by both of them
(end of March to end of November, 1936). For the
_ reductase test the technique described by Prof. G. S.
Wilson (1935) was observed, particularly regarding
methylene-blue (Dr. Orla Jensen, Stockholm), water-
bath temperature and half-hourly inspection. The
plate count was carried out according to the Ministry
of Health Memorandum (1923), the media being
simple Lab. Lemco and not a milk-enriched variety.
Plates were made from dilutions 1/10 and 1/100
in 15 cm. plates and 1/1000 and 1/10,000 in 11 cm.
plates and a count made of each plate unless the total
number of colonies made the counting an impossibility.
If any plate showed a substantial discrepancy it was
discarded ;
from an average of the most countable plates.
B. colt was estimated by taking 1 ml. of 1/10, 1/100,
and 1/1000 dilution in standard McConkey fluid
medium. Two technicians did all the plating-out
and periodically the accuracy was checked by duplicat-
ing a sample of milk, when the figures obtained were
always approximately the same.
In comparing results of the reductase test with the
count and colt, I found that there were 22-3 per cent.
of samples which passed one test but not the other.
The inconsistency was greatest in June and July
when we had warmer weather, and it evidently
depended upon the temperature of the milk on arrival.
A total of 5-3 per cent. passed the reductase test but
failed by the count and coli estimation (accepting the
“ tuberculin-tested ” standard, 1936, of 200,000
per ml. and colt-negative in 1/100 ml.) and of these
79 milks, 80 per cent. failed owing to there being
colt present in 1/100 ml. The remaining 17 per cent.
passed the count and colt standard and yet failed by
the methylene-blue reductase test. The reductase
test, was, therefore, not stringent enough in 5 per
cent. of milks and too severe in 17 per cent. I then
tabulated all those samples which failed by the
reductase test and which had not more than 100,000
organisms per ml. and were colt-negative in 1/100 ml.
according to the time at which the colour was
discharged. There was no apparent correlation.
Evidently the time of reduction by the reductase
test did not always depend on the total number of
organisms. When, however, all the milk specimens
were grouped according to the temperature on arrival
and a graph drawn of the discrepancies at each
otherwise the total count was struck -
temperature, a curve was produced which, while
irregular, showed that there was a higher percentage
of discrepancies at higher temperatures (see Figure).
When the discrepancies were subdivided into those
that passed the count and colt standard and failed
30
25
N
©
Per Cent.
12 l4 6 18 20
Degrees F
Graph showing the percentage of discrepancies at various tem-
peratures. Continuous line = total discrepancies. Inter-
rupted line = count and colt pass, reductase test fail.
by the methylene-blue reductase test a similar curve
was obtained. At a temperature around 13°-15° C.
there was only 15 per cent. of difference between
the two results. When the temperature of the milk
on arrival was 20°C. there was a total difference of
27 per cent. )
DISCUSSION
The cause of the reduction of the methylene-blue
is obscure, but with aerobic cultures and correctly
performed the test is alleged to be an index of
bacterial metabolism. Different organisms have
different reducing powers and it has been found that
Streptococcus lactis reduces even more rapidly than
B. colt, given an equal amount of equivalent suspen-
sions, and that strains of haemolytic streptococci
vary considerably in their reducing-time. Some are
as active as coli while others do not reduce within the
six hours. On the whole, however, we can accept
the fact that a milk incubated aerobically that
reduces methylene-blue does so because of bacterial
growth, though the converse does not hold as Malcolm
and Leitch (1936) have proved.
When it comes to comparing the plate counts with
the reductase test difficulties arise, especially when the
results of different laboratories are compared. Wilson
(1935) states that the experimental error in plate
counts is high and that any given count may be either
half or double that shown. I tried to check this
observation, but never managed to obtain a difference
of anything like this figure. The error arises more in
the dilutions than in the readings of the plates and this
observation supports the work of Mattick and others
(1935) who found that two observers using exactly
the same technique and examining the same milk
at the same time got results as close as did one
observer plating a milk out in duplicate. On the
other hand, the results obtained by different workers
using the same technique on identical samples of milk
950 THE LANCET]
in different laboratories were by no means the same,
because of the different conditions the milk was
subjected to before being tested. Though Wilson
does not regard the tests as strictly comparable, it is
reasonable to expect that different laboratories
submitting samples of milk to both tests will obtain
similar results; but even this does not happen.
The accompanying Table compares the results of
four independent analyses. Malcolm and Leitch
(1936) found 45 per cent. of discrepancies, Tudor and
Thomas (1936) 22 per cent., and I have found 22 per
Table showing results of comparisons between reductase and
plate-count tests
Pelee ne Per cent.
Number | reductase Canea D Toral
gg o and passed) “coli and | crepancies
samples. by plate p
count and passed by | per cent.
coli reductase :
Malcolm and
Leitch 7248 11 34 45
Thomas and
Tudor 400 9 13 - 22
Nichols and
Edwards 1000 24° 22% 10
Faulds .. .. 1500 17. 5 22
* No coli estimation.
cent.; Nichols and Edwards (1936) found that of
milks with counts between 30,000 and 200,000,
24 per cent. reduced methylene-blue while of milks
with a count of over 200,000 22 per cent. failed to do
so, but when these were classified into readings above
and below 200,000 the error was reduced to 10 per
cent. These observers did not include the presence
of B. colt in 1/100 ml. nor did they adhere to the
standard time the milks were to be kept, according
to the memorandum, differentiating morning from
evening samples. The time the methylene-blue was
read was 5 and 6 hours, not 44 and 5} as stipulated.
The figures of Malcolm and Leitch show much higher
plate counts than I obtained, but-that could be
accounted for by the enriched medium used.
The plea that the reductase test is better than the
older method must be based on its being either simpler
to perform or more accurate. The accuracy I doubt,
for to quote Breed (1936), New York State agri-
cultural bacteriologist, ‘‘ the mere fact that duplicate
results of the reductase test are generally uniform
does not, of course, prove anything regarding the
accuracy of the results.” The advantage must be in
simplicity. The reductase test is much easier to
perform and saves time and material; it can be
carried out by semi-skilled labour unless we include
the coliform test. By including this, which I feel
is necessary for accuracy, the dilutions entail time,
material, and skill; and the end-result is a test
requiring the same skill, time, and material as the
old plate count and coliform test.
The argument of economy is doubtful. The average
charge for the plate count and coliform test was
3s. 6d. and the suggested charge for the reductase
test alone ls., or, when the coliform test is added,
ls. 6d. The cost of the material is less than ld.,
but the overhead charges and arrangements for
collecting samples and supplying outfits justifies
this charge. The laboratory charges however are
only a fraction of the cost of sampling. In some
areas the council employs a whole-time sampling
officer who has to take morning and evening samples
of milk. In other areas, as in Cumberland where the
PUBLIO HEALTH
i
[APRIL 17, 1937
area of milk production is large, the sampling is
done by the local councils through their sanitary
inspectors and a grant is made by the county council
to the inspectors for every sample taken. In the
case of rural samples this grant is 5s., but in urban
samples it is 1s. In Westmorland, the sum is a flat
rate of 2s, 6d. per sample. Now a reduction of
3s. 6d. to ls. will be no economy if the Ministry’s
recommendation of sampling each milk twelve times
a year be carried out, for the cost will rise in proportion.
CONCLUSIONS
The methylene-blue reductase test is much simpler
to apply than the plate count and it yields 75 per
cent. of comparable results. On the whole it is
a more stringent test in warm weather and less
stringent in cold weather—the opposite of what is
needed. The arguments in favour of its adoption
as an economy are weak if the cost of the collection
is taken into account. If the coliform test has to be
performed in addition, the advantage of the reductase
test over the plate count and coliform test is not so
great as would appear.
= I wish to acknowledge with thanks the help and
stimulus I have received from Mr. R. Simpson, F.R.C.V.S.,
county veterinary officer for Cumberland,
REFERENCES
Breed, R. S. (1936) Personal communication to Dr. J. F.
Malcolm quoted by Malcolm and Leitch.
sere J.F., and Leitch, R. H. (1936) Scot. J. Agric. October»
Mattick, A. T. R. (1935) J. Dairy Res. 6, 130.
Ministry of Health (1923) Memo. No. 139.
Nichols, A. A., and Edwards, S. J. (1936) J. Dairy Res. 7,258.
Thomas, S. B., and Tudor, J. A. (3936) Unpublished figures.
Wilson, G. S. (1935) Bacteriological Sring of Milk, Spec. Rep.
Ser. med. Res. Coun., Cone Se
INFECTIOUS DISEASE
IN ENGLAND AND WALES DURING THE WEEK ENDED
APRIL 3RD, 1937
Notifications.—The following cases of infectious
disease were notified during the week: Small-pox, 0 ;
scarlet fever, 1661 ; diphtheria, 926 ; enteric fever, 16 ;
pneumonia (primary or influenzal), 1337; puerperal
fever, 27; puerperal pyrexia, 110; cerebro-spinal
fever, 24; acute poliomyelitis, 4; acute polio-
encephalitis, 1 ; encephalitis lethargica, 3; dysentery,
9; ophthalmia neonatorum, 108. 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 April 9th was 3314 which included: Scarlet
fever, 856; diphtheria, 961; measles, 45; whooping-cough,
530 ; puerperal fever, 16 mothers (plus 11 babies) ; encephalitis
lethargica, 283; poliomyelitis, 1. At St. Margaret’s Hospital
there were 18 babies (plus 8 mothers) with ophthalmia
neonatorum.
Deaths.—In 123 great towns,* including London,
there was no death from small-pox, 2 (0) from enteric
fever, 23 (0) from measles, 5 (1) from scarlet fever,
31 (8) from whooping-cough, 26 (4) from diphtheria,
47 (14) from diarrhoea and enteritis under two years,
and 101 (17) from influenza. The figures in parentheses
are those for London itself.
Barking and Cardiff each had 1 death from enteric fever.
Six deaths from measles were reported from Birmingham,
3 from Walsall. Fatal cases of whooping-cough were scattered
over 21 great towns: Brighton reported 3. Fatal diphtheria
was reported from 20 great towns: Liverpool had 3 deaths.
The number of stillbirths notified during the week
was 274 (corresponding to a rate of 43 per 1000
total births), including 38 in London.
* Twickenham with a population of 86,600 became a great
town on April lst as the result ofa change of boundary.
THE LANCET]
[APRIL 17, 1937 951
PANEL AND CONTRACT PRACTICE
Panel Practitioner Fined for Non-attendance
A DOCTOR has been fined £5 by the Middlesex
insurance committee for breach of the medical
service regulations. There was evidence that she
.. was called at 6.40 p.m. on Dec. 19th to visit a young
woman who was a panel patient. She did not come
and was sent for again at 10 P.M. Again she did not
come but left a prescription on the window-sill and
gave the parents a bottle of medicine and some oil
to rub on the patient’s chest. She excused herself
on the plea that she was tired after a very busy day.
The father tried to obtain another doctor’s services
in vain. Next morning the doctor called at 10.30,
diagnosed bronchitis, asked for the prescription
= which had been. left on the window-sill, altered it,
and said she would send a nurse. At 12.30 P.M.
she came again, in answer to a fresh summons, sent
for an ambulance and had the patient removed to
hospital. At the hospital the parents were told that
it was too late to do anything more; the patient .
died at midnight of the same day from pneumonia.
The amount of the fine may perhaps be deemed to
indicate that the most serious view was not taken
of the practitioner’s default. While the insurance
committee evidently could not overlook what had
occurred, those who know the strain under which
practitioners work at times when ill health is specially
prevalent may be ready to appreciate that moments
may come when the doctor is genuinely “‘ too tired
to attend.”
Dispensing ‘in Scotland
Some statistics relating to the Scottish drug bill
were recently analysed by the superintendent of the
Central Checking Bureau in Scotland. It appears
that during 1936 some four and a quarter million
prescription forms were received from many sources :
(1) 54 insurance committees in Scotland; (2) the
government of Northern Ireland; (3) various local
authorities ; (4) the Ministry of Pensions; (5) public
medical services. Only the first two categories
include National Health Insurance prescriptions. The
receipts of Scottish panel chemists have risen by 79 per
cent. in the 20 years from 1915 to 1935 and by another
9 per cent. in 1936. The average price per form had
increased from 9-74d. in 1915 to 13-32d. in 1935
and 13-60d. in 1936. These figures did not include
the cost for insulin. In 1935 the cost per person in
Scotland for drugs and prescribed appliances ranged
from 17-17d, to 52:76d., with an average of 23:17d.
In England the cost ranged from 23-ld. to 52-8d.,
with an average of 36d. Frequency in Scotland
ranged from 1:10 to 2-93, with an average of 1:73
as compared with 2-69 to 6-76 and 4-60 in England.
The average price per prescription form ranged from
11-21d. to 17-99d., with a general average of 13-32d.
The comparable English figures were 7:ld., 10-1d.,
and 7-38d.
Some insured persons were the recipients of
expensive prescriptions, for example: six prescrip-
tions for amino-acetic acid, cost in all £20 10s. 6d. ;
one insured person still under treatment received
during eleven years 1083 1b. of an ointment, which
cost £138; one insured person in a period of three
years received insulin, liver extract, and mixtures
at a total cost of £235.
Prescribing in Lancashire
` The Lancashire panel committee has been examin-
ing the report issued by the insurance committee
in April, 1936, on the cost of drugs and medicines
prescribed for insured persons in the county. The
cost of supplying drugs to the insured population has
increased steadily during the last twelve years not
only in Lancashire but in all parts of the Kingdom ;
the committee are anxious to help to prevent further
increases and indeed to bring about a reduction
in cost if this can be done without reducing thera-
peutic efficiency. In Lancashire frequency has
increased from 3-87 in 1923 to 5-05 in 1935, but the
committee point out that this latter figure is only
0-2 higher than in London and is 1-40 lower than in
Manchester. The increase corresponds to that for
visits or consultations all over the country. The
Insurance Acts Committee showed that in 1923 each
insured person was seen, on an average, 3-75 times
and in 1935 the figure had risen to 5-11. The increase
in frequency is attributed entirely to the altered habit
of the insured population and to the increased amount
of work done by the doctors; recent health propa-
ganda has caused the insured person to become
“health conscious’? and even ‘“ disease’ conscious.”
He takes more notice of slight ailments and consults
his doctor earlier and more frequently. Gradually
the insured population is becoming composed of
persons who never at any time have paid private fees
for medical attendance, whereas the original insured
population had already acquired an economic habit
in this respect. It is likely, therefore, that the
frequency factor has not yet reached the peak and
will not do so until the entire insured population
consists of persons who have never received medical
attendance in any other way. The panel committee
express the opinion that the frequency factor is
almost entirely outside the control of the doctors.
With regard to the total cost per prescription, the
dispensing fee is a fixed cost, practically constant,
and is also entirely outside the control of the doctor.
The ingredient cost however was 3-79d. in 1935.
A number of prescriptions are for specially expensive
products—e.g., about 100 autogenous vaccines (two
guineas each) are prescribed every year and about
150 stock vaccines at half a guinea. A few months
ago the attention of the Lancashire panel com-
mittee was called, though not by way of complaint,
to a prescription for Felton’s serum, costing over
£7. One doctor ordered in seven days for one patient
oxygen costing £75. Many prescriptions are for
expensive products for intramuscular or intravenous
injection, and other special prescriptions cost four
to five shillings. Ifthe cost of expensive but perfectly
justifiable prescriptions were separated before the
average for the ordinary prescription was taken,
the ingredient cost of a 10 oz. bottle of medicine
would probably be somewhere about 2:5d. The use
of proprietary products does not seem to have been
an important factor in the increased cost of prescrib-
ing, but the committee believe that some slight
economy might be effected by the avoidance, when
possible, of the use of such remedies. In their
opinion the occasions on which the ordering of pro-
prietary products can be justified are comparatively
few.
The committee observe that in May last the
Minister of Health stated in reply to a question in the
House of Commons that he had received a report
from the Lancashire insurance committees to the
effect that there was unnecessary prescribing by
doctors in Lancashire. So far as the panel com-
mittee were aware, the insurance committee had
expressed no such opinion.
952 THE LANCET]
[APRIL 17, 1937
GRAINS AND SCRUPLES
Under this heading appear week by week the unfettered thoughts of doctors in
various occupations. Each contributor is responsible for the section for a month ;
his name can be seen later in the half-yearly indez.
FROM A TADDYGADDY
III
“The wisdom of a learned man cometh by opportunity of
leisure; and he that hath little business shall become wise
Tuar, oddly enough, was written also by Ben-Sira,
and in the very same chapter as that into which we
have dipped already. It seems untrue at first; but
when we go on reading we find out what he really
was getting at. He was thinking of leisure from
bodily toil. He had few illusions concerning that.
“Send him: to labour that he be not idle; for
idleness teacheth much mischief,’ he wrote of the
slave. Apparently there were people in his neigh-
bourhood, men in advance of their time, who were
trying to set up some sort of Labour Party. Ben-Sira
did not at all approve. ‘‘ How,” he asks, “can he
get wisdom that holdeth the plough, and that glorieth
in the goad, that driveth oxen, and is occupied in
their labours, and whose talk is of bullocks? So
every carpenter and workmaster that laboureth night
and day. ... They shall not sit in the judges’ seat,
nor understand the sentence of judgment: they
cannot declare justice and judgment; and they shall
not be found where parables are spoken.”
* * *
That is not quite in accord with modern ideas» —
though there are plenty only too ready to agree-
How does the suggestion affect us? Few of us in
active practice have much leisure, yet some of us
do become wise in spite of our considerable business.
Indeed it is due largely to our press of work that
we acquire wisdom, or at any rate a useful store of
common sense, That, I have felt for many years,
is not used as freely as it should be. There is so
much more we doctors might do, so much we have to
offer, in the public service. Some of us serve on town
councils, some as magistrates; but relatively few of
us do that. The plea put forward for not doing it
is that we have no time to spare. Is that wholly
true? My experience is that there is always time
for what one really wants to do. I say that advisedly.
I have been a town councillor, I am a magistrate,
and I have never in my life been leisured. The years
during which I was a town councillor were extremely
busy ones, but there was always time for a meeting.
Only very seldom were the meetings barren of
interest. I found my brethren, especially the more
aged of the aldermen, fascinating to study, and I
made a collection of mayoral impressions that is
quite beyond all price. That a doctor should be
interested in the doings of a health committee is
obvious. What is not so obvious is the undoubted
fact that as a member of a health committee he has
opportunities for studying the underlying causes of
all manner of public activities, and—even more
illuminating—inactivities. If he has cultivated a
sense of humour—and he will not be a real doctor
if he has not done that—he will find in his work on
a town council infinite reason for laughter; and if
he can succeed in making the lay brethren laugh with
him he will have done more than justify his retention
of his seat.
* * *
On the bench his opportunities are even greater.
Knowledge of men and women, understanding of
the infinite twists and turns of human behaviour,
are needed in the courts more, perhaps, than any- `
where else. Why, the man on the bench must be
asking all the time, did that fellow in the dock
behave as apparently he did? Why? That must
be the keynote all through. And—I say this advisedly,
and with a due sense of responsibility—that keynote
seems very often to be muffled. The fact of some act
contrary to public order is established: the reason
for that act is not. That is where we come in, or
should come in. Our training and our experience
have caused us to look, almost instinctively, for -_
causes. We know that without some understanding
of the cause no problem of our professional life can
be fully solved: that treatment under such a condi-
tion can be no more than empirical. So is it with
the problems of the courts. And that is of the very
first importance when we are dealing with the prob-
lems of the juvenile courts. Children do the oddest
things which get them into trouble with the police.
Why? It should be our job to find out if we can.
It is not easy. Often it is extremely difficult. How-
ever, if our good fortune gives us a seat in a juvenile
court we shall have plenty of opportunities for
trying. Those courts, as established now, provide
facilities, freed from all red tape fetters, for making
any investigation that may seem advisable.
x * K
Our training and experience should render us
peculiarly fitted for work in the courts. We know
the people of our district better, perhaps, than any-
body else. We are familiar with the language called
by the police “ obscene.” It is really no more than
ugly and lacking originality : the coarse back chat
of a rough fellow stirred by (not infrequently alcoholic)
emotion. It is not easy to persuade our lay brethren
of the bench to appreciate that. We know how
easily back-street tempers get stirred by the basic
fact that back-street people see too much of one
another, living as they do almost in one another's
pockets. We understand the bitterness lying dor-
mant, and often not so very dormant, in a yard
common to three or four little houses. We know
something of the back-street pride that is so very
easily wounded. All these are features that bring
people to the defendant’s pen in what is called, quite
improperly, the police-court. If we will, and if our
luck has given us a seat on the bench, we may do
much in the way of interpreting behaviour that
seems, at the first glance, very odd. ,
* xæ xk
“ They shall not understand the sentence of judgment. . .”
Ben-Sira wrote that a very long time ago, and he
did not mean by it quite what it may seem to mean
to-day. But it is as true to-day as when he wrote it.
“ They ” very often do not understand. How should
they? The sentence so often is quite incompre-
hensible to the sentenced. A fine of a couple of
pounds, to be levied from a man whose income
already is inadequate, means that he and his family
will have to go short of vital necessaries. A sentence
of fourteen days’ imprisonment, with the consequent
“ sack,” means—what does it mean? We, whose
working life has taken us in and out of little houses,
visualise at once the problems raised by action in
the courts. If we have the will we become vocal
>
THE LANCET]
about them. That does not make us popular in our
immediate circle, but .
sort of popularity ? : 7
In practice, a pie who takes part in public
life is likely to find it all rather difficult. He knows
too much. That is a very decided handicap—in the
eyes of other people. On the health committee
he will be in immediate conflict with those who own,
or are friends of those who own, insanitary property.
On the bench he will be in conflict with those who
have an itch for punishing, and no desire whatsoever
for understanding. He is not unlikely to find his
path very thorny indeed, But if he be dogged—and
what real Taddygaddy is not dogged ?—he will win.
For there are those who will heed if only he express
himself with sufficient force.
ANZEMIA AND THE PITUITARY
. Should we play for that:
[APRIL 17, 1937 953
Why is it that so few of us, relatively, take part in
public life? I think it is because we are, like miners,
content to be a class apart. Miners shelter in ugly
dwellings remote from other people. We shelter
behind brass plates and surgery lamps. While
actually as sociable as any other men, in our working
time we assume a sort of esoteric aloofness and, most
unfortunately, many of us carry our working habits
into our play time. I suppose we are, in a way, shy.
Also there is this undoubted fact to be faced—a
doctor must not take sides on any subject too fer-
vently if he is to make good at his main job. His
day-to-day work brings him into contact with all
sorts, and he does not wish to offend any. That is
reasonable ; but it does in practice mean that a great
deal of potentially valuable public activity is allowed
to run to waste.
CORRESPONDENCE
ANEMIA AND THE PITUITARY
To the Editor of THE LANCET
Smr,—We have read the annotation on p. 877
of your last issue with considerable interest, but we
should like to point out that it does not give a very
clear view of the position. This is, we suggest,
as follows :—
(1) We published in 193412°*a series of papers
describing the appearance of a gastric lesion in the
rabbit and other animals following the injection of
posterior-lobe extracts. This has been. confirmed
by a large number of workers.3-8
(2) We have also shown that small doses of
pituitary extract will inhibit gastric secretion.’
(3) We showed that the injection of posterior-
lobe extract into the rabbit will cause in about
20 per cent. of the animals a very severe macrocytic
anæmia, and since this was associated with reticulo-
cytosis and with excessive production of bile, we were
led to make the following comment: ‘“ The interpreta-
tion of these results is at present obscure. The
possibility arises that the control of blood destruction
by the reticulo-endothelial system may be vested
outside the system itself and may reside in the
posterior lobe of the pituitary gland.’’®
(4) Gilman and Goodman, in a series of papers, ®*!4
have repeated these observations and have fully
confirmed the fact that the injection of posterior-
lobe extract into rabbits will produce an anæmia
of exactly the same type as that described by us.
They, however, advance a different explanation from
` the very tentative suggestion put forward by ourselves.
We shall in the near future produce further evidence
on this point.
(5) The paper referred to by your annotator,
by McFarlane and McPhail,!? again confirms our
findings, using guinea-pigs. These workers demon-
strate the development of anæmia in guinea-pigs
foflowing the injection of posterior-lobe extracts.
They killed their animals at a date so long after the
injection that the stomach lesion that would have
been present would undoubtedly have been healed.
It is interesting to note also that these workers found
that the ansmia did not come on in the guinea-pig
until so late a date after the injection as to render the
explanation advanced by Gilman and Goodman
extremely unlikely.
Our object in writing this letter is to point out
that in all these papers there is no question of the
validity of the fundamental observation that a severe
anæmia may be produced by the injection of pituitary
extracts.
We are, Sir, yours faithfully,
E. C. Dopps,
R. L. NOBLE.
Courtauld Institute of Biochemistry, The Middlesex
Hospital, London, W.1, April 13th.
REFERENCES
Dodds, 3, 818.” , Noble, R. L., and Smith, E. R. (1934) Lancet,
34) J. Soc. chem. Ind., Lond. es 1026.
Bergami, G 11985) Boll. Soc. ital. Biol. sper. 16, 90.
Lucchesti, G., and Zilioli, E E. (1935) shai Glin, med. 16, 649.
teh e, R. and Collip, J . (1936) Canad.
Selye, H.,
med.
"A , 33
Nedzel, A. J. 1936) Proc. Soc. exp. Biol., N.Y. 34, 150.
Dodds, E. C ills, G. M., Noble, R. L., and Williams, P. C.
(1935) J ) tancete 1, 1099.
ORIN oble, R. L. (1935) Nature, 135, 788.
Gilman, A., and Goodman, ait 282) Proc. Soc. exp. Biol.,
N.Y. 33, 238.
OR et te eee a
10. — — 1936) J. Pharmacol. 57, No. Zii
11. 1937) Amer. J. Physiol. 118,
12. McFarlane, D 388 and McPhail, M. K. oT "Amer. J. med.
THE TAVISTOCK CLINIC
To the Editor of ‘THE LANCET
Sir,—The council of the Institute of Medical
Psychology have decided, after much deliberation,
to change its title and revert to the original name of
“The Tavistock Clinic.” I should like through
your columns to notify the profession of this fact
so that no confusion may arise in their minds.
The Tavistock Clinic was the original name adopted
when in 1920 the work of providmg psychological
treatment was ‘begun in a house in Tavistock-square.
As the clinic grew, its name became well known
amongst the profession at home and also on the
Continent and in the United States. A good many
people seem hardly to have realised that it was
changed some four or five years ago, and to them
there will seem nothing unusual in our new title.
The change has seemed advisable largely because
of the constant confusion which arose as a result of
the non-medical institutes of psychology and psycho-
therapy which have arisen during the past few years.
Some of these have gone so far as to copy our
literature and our stationery, evidently feeling that
this was likely to be of value to them. Any hospital
is reluctant to change its name because there is
inevitably some loss of goodwill, particularly amongst
those who support or might support the work. I
am confident, however, that we can rely upon our
many friends in the profession to see that such loss
does not occur, and that whatever good reputation
the Institute of Medical Psychology had shall be
954 THE LANCET]
carried over to the Tavistock Clinic which certainly
needs all the help that they can give it.
I am, Sir, yours faithfully,
HENRY B. BRACKENBURY,
. Chairman of the Council.
- The Tavistock Clinic, Malet-place, London, W.C.1, April 12th.
MEDICAL EDUCATION OF WOMEN
To the Editor of THE LANCET
S1r,—Medical women will have welcomed the sympa-
thetic letter from the regius professor of physic at
Cambridge in the Datly Telegraph of March 25th, in
which he supports a plea made by a group of Cam-
bridge women students for more educational facilities
in London. I doubt, however, whether his suggestion
that the big London schools should admit women,
and thereby win the applause of the multitude by a
“ generous gesture,” will tempt them to act against
their feelings and possibly their judgment. Medical
education is a practical issue, and its development
depends on expediency as well as lawfulness. I
remember that four London schools admitted women
during the war when fees were scanty, and excluded
them again when male students became more
numerous.
I do not think it is necessary, or desirable, to
hammer at unwilling London hospitals, and the
Cambridge students little know what they are in for
if they should obtain concessions by that means.
Women are probably better off even in a second-rate
school without prejudice, than in a first-rate school
where they are unwelcome.
The opposition of the London hospitals is not
altogether without reason. It is said, for instance,
that the success of the medical schools depends to
some extent upon athletic prestige, and we are assured
that athletes hate to be educated with women. It is
hardly to be expected that the authorities should
forego a clientele they want, for a clientele they
don’t want. There is another objection, one which
may have a wider appeal. In the choice of students
-a medical school is guided by the return it is likely to
get from them—either intellectual or commercial.
Compared with men, there is said to be a greater
risk of a woman failing to finish the course and still
more risk of her failing to practise her profession.
The survey of the fate of women medical students
educated at St. Mary’s between 1916 and 1924
(Lancet, 1936, 2, 1370) is of interest in this connexion.
Popular medical schools may consider it wasteful to
take this chance when they can avoid it. The com-
mercial return from women is also likely to be less
valuable because their practices are not usually so
lucrative either to themselves or to the consultants.
All this need not unduly depress us. The time will
surely come when St. Bartholomew’s, St. Thomas’s,
and Guy’s (I quote the hospitals mentioned by
Prof. Ryle) will realise that a superior woman may be
worth more to them than an inferior man, and in
this connexion, also, the report mentioned above is
ilummating. Meanwhile the larger non-teaching
hospitals, such as the West London and the Royal
Northern, might find it a positive advantage to take
women as students. Neither is London the only
centre of learning; there must be nearly a dozen
other universities which provide good medical educa-
tion. Oxford and Cambridge strike one as being
obviously suited to provide the clinical work for
Oxford and Cambridge women; they have large
modern hospitals, fully staffed and equipped, and
numerous professors and research departments.
It should be understood that no plan for extending
medical education is going to be the slightest use to
MEDICAL EDUCATION OF WOMEN
[APRIL 17, 1937
women unless it includes giving them resident hospital
appointments. Openings in hospitals are a far more
pressing need than openings in medical schools,
and it is misleading, to say the least of it, if a
medical school offers equality of education when the
hospital connected with it excludes women from
competing for the resident posts after graduation.
I am, Sir, yours faithfully,
NoraH H. SCHUSTER.
Upper Harley-street, N.W., April 7th.
ERGOTAMINE TARTRATE IN MIGRAINE
To the Editor of THE LANCET
Sir,—I can confirm the experience of your corre-
spondents on the value of ergotamine tartrate in
the treatment of migraine. I have been subject
to attacks of migraine for 63 years. During the
last 40 years I have tried every diet and tested
every drug that anyone could suggest. I have
seen every consultant in London of whom I heard
as having a special knowledge of migraine and
have had various injections but all without avail.
Twelve months ago I began using ergotamine tartrate
in the form of Femergin tablets and it is the first
remedy with any prophylactic effect which I have
taken. In my case it has been more the severity
than the frequency of the attacks which it has
influenced. I have been taking two tablets every
night now for over a year without any ill effect
except that for a couple of weeks at first there was
a daily attack of slight intestinal colic for about
two hours. When I began the treatment I was
spending a day in bed every ten days but the interval
at once lengthened to three months. The intervals
of freedom from headache lengthened to about
fifteen days. The fasting during the continuance
of the pain must of course continue. No doubt
with injections the relief would have been still more
marked. I am, Sir, yours faithfully,
Jersey, C.I., April 9th. J. H. CROWLEY.
PRECIPITATE LABOUR
To the Editor of THE LANCET
S1r,—Some of your readers may be interested in
the following case :—
A European primipara aged 28, healthy except for a
mild degree of glycosuria controlled without insulin by ten
lines of R. D. Lawrence’s diet, went into labour at full
term on the night of July 29th, 1936, at 11.10 p.m. The
. pains were slight and only amounted to abdominal dis-
comfort but, merely as a precaution, she called the nurse
at 11.30 P.M., At 11.40 she had the first real pain and this
was followed by another which ruptured the membranes
and produced the infant at 11.45 P.M., much to the dismay
of the nurse who had naturally not anticipated such
rapid developments and had made no attempt to control
the passage of the head over the perineum. The placenta
followed the infant within three minutes and examination
of the patient on my arrival at midnight revealed a com-
plete tear of the perineum and from 1} to 2 in. of the
rectum. The infant weighed 64 lb. and the whole duration
of labour from the first premonitory signs until the delivery
of the placenta was less than 40 minutes.
Immediate suture of the torn perineum’ and rectum
resulted in an uneventful convalescence.
The two questions suggested by this case are, first,
whether the glycosuria had any connexion with the
precipitate labour and, secondly, why nature in such
a case did not provide for the preservation of at least
the rectal sphincters.
I am, Sir, yours faithfully,
Digboi, Assam, March 18th. W. B. CRAWFORD.
THE LANCET]
COLLECTIVE AUSCULTATION AND THE
REGISTRATION OF HEART SOUNDS
To the Edttor of THe LANCET
Sir,—Dr. Vaughan Henriques’s interesting paper
in your issue of March 20th leads me to give you an
account of my own researches. With the help of
my assistant, Mr. G. Minot, engineer E.P.C.I., an
apparatus has been invented which makes it possible
(1) to reproduce by loud-speaker the murmurs and
sounds of the heart, and (2) to register on films and
records the sound vibrations heard in the loud-
speaker. Our instrument, which was standardised
by the firm Petit (Ezanville, Seine-et-Oise, France),
has been in use for two years in my service at the
Tenon Hospital in Paris. It was shown at the
International Cours Tomarkin in Spa (Belgium)
in September, 1935, to the Société des Médecins
des Hôpitaux de Paris on May 15th, 1936, and to the
Société de Biologie on May 16th, 1936. It is made
in three parts: the telestethophone, for collective
auscultation ; the phonostethograph, for registering
the sounds on films; and the medical pick-up, for
registration of sounds on records and their sub-
sequent reproduction. It has been made especially
for the heart, but we have made use of it also for the
arteries, lungs, and abdomen.
The telestethophone includes a microphone, an
amplifier, and a loud-speaker. The microphone
is intended to catch and transform into electric
waves the audible vibrations of the chest-wall.
Its special structure renders it insensitive to the infra-
auditory vibrations of this coat and also the vibrations
of the air. For this last reason, the sounds diffused
by the loud-speaker have no influence on the micro-
phone; it is therefore quite possible to speak near
the patient without interfering with the clearness of
the auscultation and to place him near the loud-
speaker without any screen in between. The
amplifier is regulated so as to amplify the electric
oscillations, the frequencies of which are included in
the audible scale of the auscultation phenomena
(20 to 800 periods a second). It is placed in a metal
portable box 20 in. long by 10 in. wide by 12 in. high.
The telestethophone has neither dry battery nor
OBITUARY
[APRIL 17, 1937 955
accumulator and is connected to the main. To make
it work, one needs only to press two knobs, one of
which regulates the intensity, the other the tone.
The phonostethograph is included in the box of the
telestethophone, It consists of a special oscillograph
joined to the loud-speaker and permitting the registra-
tion of the vibrations on a film as they are heard.
This apparatus has also been made without a loud- |
speaker but with one or two head-phones for hearing.
The sensitiveness of the normal ear varies greatly
according to the frequency of vibrations, and the
oscillograph has been regulated so that its sensitive-
ness resembles that of the ear for vibrations of 20 to
800 periods a second. The reproduction of heart
sounds (phonocardiogram) is thus rendered as exact
as possible and its interpretation is made easier by
the simultaneous registration, for example, of the
electrocardiogram on the same film. A tracing
“ with notches ”? (en dents de scie) can also be made.
The medical pick-up allows us to engrave on a
record the cardiac sounds and murmurs heard in the
loud-speaker or ear-phones of the telestethophone.
A special little apparatus allows us also, to engrave
on the record oral explanations of the sounds heard.
The medical pick-up, when used alone, gives faithful
reproduction, by loud-speaker, of the sounds
registered. A special process of registration and of
reproduction enables us to eliminate the noise of the
friction of needles. Records of the auscultation of
the heart (stéthodiscs) are being prepared for issue.
This instrument is useful for teaching because it
enables a whole class of students to hear a patient’s
heart or the records made from auscultation. It
is also of value at medical meetings for the presenta-
tion of interesting cases. From a practical point
of view, it enables us to follow the sounds and. murmurs
of the heart at various periods of an illness, and leaves
us ‘‘ documentary ” evidence of previous conditions.
Thus in Paris it has been adopted by the Ministry
of Pensions. Lastly, from a scientific point of view,
the study of films is rich in new ideas.
I am, Sir, yours faithfully,
C. LIAN,
Professeur Agrégé in the Medical Faculty of Paris
and Physician to the Paris Tenon Hospital.
Paris, April 4th.
OBITUARY
FREDERICK STAPLETON DICKEY HOGG,
M.R.C.S. Eng., L.R.C.P. Lond.
WE regret to learn of the death of Dr. Frederick
Hogg, for 35 years medical superintendent of the
Dalrymple Home for Inebriates, Rickmansworth, which
occurred at a nursing-home at Brighton on April 5th.
The elder son of the late Sir Frederick Hogg,
Director-General of the Post Office of India, he was
educated at Repton and Jesus College, Cambridge,
and went for his medical training to St. George’s
Hospital. His career at the hospital was broken
by an interval of some three or four years, during
which he was engaged in sheep farming in Australia,
but on his return to the hospital he took the English
double qualifications in 1888. He held appoint-
ments at the West London Hospital and the Ear,
Nose, and Throat Hospital, after which he went to
India in the service of the Bengal-Nagpur Railway.
At the expiration of his appointment as chief medical
officer to the railway, he returned to England and
entered for a short time into a partnership in
north London. His wife’s health led him to leave
London and take a practice in Southminster, and
while there he was elected medical superintendent
to the Dalrymple Home for Inebriates, Rickmans-
worth. This position he occupied for 35 years until
the institution was wound up under the conditions
of its foundation. At the Dalrymple Home he made
a name for himself in the treatment of inebriety.
His management of the patients was sympathetic
and remarkably successful, while his notes on drug
habits -were the result of careful and ingenious
attention, many of his experiments on the effects
of the remedies employed, and their dosage and
periods of administration being attended with success
often of a permanent nature. He took his patients
into his confidence and made them the intelligent
assistants of their own treatment, inviting them also
to keep in regular touch with him, especially
through their own doctors. He was asked on many
occasions to record his experiences, but always
seemed unwilling to do so, the one exception
being the article on drug habits in “ Quain’s
Dictionary of Medicine.” But the practical nature
of his insight into inebriety was known to many
colleagues who consulted him, and was often of
valuable assistance to THE LANCET.
956 THE LANCET]
Dr. Hogg had lived in retirement at Brighton for the
last three years, a cardiac condition entailing upon him
a very quiet life. His devotion to the interests of his
patients in a residential institution which he never
seemed free to leave led to the making of few personal
friends, but to those who knew him his simple and
generous nature as well as his all-round knowledge
of his work made a strong appeal. He had been a
widower for some years and leaves one son.
FRANCIS GARLAND COLLINS, M.R.C:S. Eng.
D.P.H.
Dr. Francis Collins, medical officer of health for
West Ham, who died on March 30th, was a distin-
guished public servant. He received his medical
education at University College, London, and the
London Hospital and took the English double
qualification in 1907. After serving as house physician
to the London Hospital he was appointed assistant
medical officer to the Whipps Cross Infirmary and
from that time his whole professional life was spent
in municipal medical work. He was appointed
assistant medical officer, becoming later senior
resident medical officer at the Plaistow Fever
Hospital and was tuberculosis officer at West Ham
when he took a commission in the R.A.M.C. He
saw service throughout the war, first at home and
then in Servia and with the army at Salonika. He
returned to his duties as tuberculosis medical officer,
and in 1924 was appointed medical officer of health
for West Ham, a position which he held at the time
of his death. He earned golden opinions by his
work, paying special regard to maternity and child
welfare, while the reduction in the maternal mortality-
rate in the district under his supervision was remark-
able enough to obtain special comment in the House
of Commons from the Minister of Health.
Dr. Collins made communications to THE LANCET
of a valuable character. In 1920 he related the after-
history of 570 tuberculosis dispensary cases, being
at that time medical adviser to the West Ham
insurance committee. He gave facts and tabular
statements in support of the views that it is seldom
that any but early cases derive permanent benefit
from sanatorium treatment, and that much more
strenuous preventive measures should be adopted,
such as the foundation of additional suitable open-
air schools and institutions for very advanced cases.
He collaborated with Dr. Helen Campbell, then
assistant medical officer for maternity and child
welfare at West Ham, in reporting a series of
cases of pemphigus neonatorum in which the practical
conclusions were arrived at that any midwife or
doctor who had been in contact with a case should
not attend another confinement until after thorough
disinfection of both person and belongings, adding
that the disease should be made notifiable.
Dr. Collins had been in bad health for a long period,
the result of dysentery incurred during his war
services, and for the last five months of his life he
was confined to bed. He was only 55 years of age
at the time of his death.
CÉCILE BOOYSEN, M.R.C.S. Eng.
THERE are very many who have learned with
regret of the death on April 7th of Dr. Cécile Booysen.
This occurred after an illness of five weeks’ duration
at the age of 42. Her career was that of a woman of
outstanding vigour and strong personality. She was
the daughter of a South African farmer who, having
determined to become a doctor, borrowed the money
OBITUARY
[APRIL 17, 1937
necessary for her medical education. After attending
classes at King’s College, she went for clinical training
to Charing Cross Hospital and in 1926 obtained the
English double qualification. She served as house
surgeon at Charing Cross Hospital and acted also
as clinical assistant at the Paddington Green Hospital
for Children. She then went into practice in north
London and in 1935 founded a voluntary birth
control clinic, the Goswell Women’s Welfare Centre,
in a very poor and overcrowded district. Her environ-
ment as well as her natural impulses led to a deep
interest in politics, which manifested itself in her sup-
port of the labour policy. The horrors of war made a
strong impression upon her, and after attending the
Brussels Peace Conference in 1936 she started and
worked actively for the Medical Peace Campaign
where she acted as honorary secretary.
Prof.*J. A. Ryle writes: “ The news of Dr. Cécile
Booysen’s death will have brought grief and distress
to all who knew her. Among the many able women
doctors in London, she belonged to a group and
a generation which stands particularly high in
my estimation, and established unobtrusively a
position which will cause her to be long remembered
and revered. It was a privilege to meet her in con-
sultation and to observe the care and thought and
consideration which she devoted to her patients
and which in turn earned their evident devotion
to her. She was the organising secretary and inspira-
tion of the Medical Peace Campaign in this country,
and in her conduct of its affairs she must have
expended a great deal of the energies of her later
months. Whatever success attends this movement
in the years to come—and it must be recognised
as one of the first serious attempts to investigate the
psychological causes and consequences of war, and
to study and anticipate the medical problems asso-
ciated with war—a very great measure of that success
must be attributed to her self-imposed task. That
task had for its goal the better and safer world
for which we all hope but few so assiduously strive.”
RICHARD WHITTINGTON, M.D. Oxon.
Dr. Richard Whittington, whose death occurred
at Hove on March 30th, was educated at King’s
College, London, and Merton College, Oxford, proceed-
ing for his medical training to St. Thomas’s Hospital.
He took honours in the natural science tripos at
Oxford and graduated as M.B., B.Ch. in 1898,
proceeding to the M.D. degree at a short interval.
At his hospital he held for a time an appointment
in the skin department and was later resident medical
officer at the Royal Free Hospital, and house physician
and pathologist at the Sussex County Hospital,
Brighton. He acted for a time as surgeon to the
Second African Field Force and recorded his
experiences in a paper in Treatment entitled ‘‘ Prophy-
lactic Measures against Enteric Fever in Armies.”
He settled in practice in Brighton over thirty years
ago and became prominent alike as practitioner and
public worker. He was an active member of the
British Medical Association, holding the post of
chairman of the Brighton division, and being a
representative at the recent annual meeting at
Oxford. During the war he served on the staff
of the 2nd Eastern General Hospital which was
officered by the R.A.M.C.
Dr. Whittington will be long remembered in the
borough for his public work. He was a member
of the old Brighton board of guardians and served
on the education committee of which he was chair-
THE LANCET]
man. He was for twelve years a member of the
Hove town council, and served continuously on the
East Sussex council of which body he was at the time
of his death an alderman. He was on the directing
bodies of the Brighton, Hove, and Sussex Grammar
School, the Brighton Technical College and School
of Art, and the Hove County School for Girls. The
conscientiousness with which he performed all his
public duties was illustrated by the record of his
attendances, for during the year 1935-36 out of 152
summonses to meetings by the Hove town council
and the Hove education committee, he attended
138 times. During the last year of his life he suffered
from cardiac symptoms which made of this energy
a remarkable record of devotion to duty.
Dr. Whittington married a daughter of the late
Mr. E. L. J. Ridsale of Rottingdean, a sister of Mrs.
Stanley Baldwin. She predeceased him, leaving one
daughter who was a frequent companion of her father
at social functions where official positions made his
presence necessary.
THE LATE PROF. C. C. CHOYCE
Dr. Arthur Davies writes: “So deeply do we
revere the memory of Charles Coley Choyce at the
Seamen’s Hospital that it would be a dereliction of
duty not to support the appreciations of his worth
that have been so well expressed by his friends at
University College Hospital. Coming to us as
house surgeon to Mr. William Turner in 1902, he
returned in 1905 as medical superintendent, succeed-
ing Mr. Johnson Smith who had held that post with
great distinction for over 40-years. His appoint-
ment coincided with a change of policy as regards the
staffing of the hospital, and this was effected with
characteristic courtesy by Choyce, who always
referred to his predecessor as ‘that great gentleman
J. S? In 1907 he was appointed assistant surgeon,
and became teacher in operative surgery, worthily
upholding the high traditions that had been established
at the Seamen’s Hospital. In the same year he was
PARLIAMENTARY INTELLIGENCE
[APRIL 17, 1937 957
selected to shoulder another heavy responsibility,
being appointed Dean of the London School of
Clinical Medicine, an adventurous essay into post-
graduate teaching undertaken by the staff of the
Seamen’s Hospital, and by extramural lecturers
of eminence. The daily task of coérdinating the
activities of such an unparalleled combination of
teachers was successfully carried out by Choyce,
notwithstanding the constant difficulties of finding
adequate material suitable for clinical demonstrations.
The fierce protests made by the teaching staff,
rightly importunate for such material, were met with
equanimity and serenity, and peace was marvellously
conserved as none misdoubted his motives, none his
absolute integrity. It was at this period that Sir
Malcolm Morris, one of the post-graduate teachers,
selected Choyce as editor of the now famous ‘ System
of Surgery,’ and again a difficult task was carried
through with conspicuous success. ` At that time
Choyce was a young and relatively junior
surgeon, and it was not easy for him to codrdinate
the strong individualistic opinions of his distinguished
contributors ; nevertheless his editorial blue pencil
prevailed. During this period began his friendship
with Mr. Gwynne Williams and their daily discussions
on current surgical practice were a happy blend of
pungency and good humour. Little did either think
that this friendship was to be consummated at a
later date in common service to University College
Hospital. In 1912 Choyce became senior surgeon and
in 1919 consulting surgeon to the Seamen’s Hospital.
Associating ourselves with all that has been so well
written of him, we would recall how often it fell
to Choyce to undertake tasks that were arduous
and extremely difficult,, and how consistently he
succeeded. At all times and in all places he was
unchangeably himself, ‘in loco parentis’ to all and
sundry, serene, ‘valiant, and wise. Our thoughts
go out to his father in New Zealand and to his wife
to whom we owe our especial gratitude for his
comradeship vouchsafed to us and which is now our
precious heritage.”
PARLIAMENTARY INTELLIGENCE
PHYSICAL TRAINING AND RECREATION BILL
IN the House of Commons on April 7th Mr. OLIVER
STANLEY, President of the Board of Education,
moved the second reading of the Physical Training
and Recreation Bill. He said that Clause 1 of the
Measure gave statutory authority to the National
Advisory Council which had been at work since
March Ist. Clause 2 provided for a scheme of local
committees whose membership would be like that
of the National Council—invited to serve as individuals
rather than nominated as representatives of different
bodies. Those committees would be charged with
propaganda and with seeing that the scheme and its
possibilities were brought home to the locality,
and would examine applications from voluntary
bodies for assistance from the Government. All
‘such applications would be submitted by them to the
Grants Committee which was dealt with in Clause 3.
Sir Henry Pelham would be chairman of the com-
mittee. Clause 4 was a machinery clause which
dealt with the powers of local authorities. The
most important new power was that given to a local
authority to provide throughout the area that sort
of community centre which at the present moment
a housing authority could provide on its own housing
estate, but which the local authority was not able
to provide anywhere else.
the compulsory purchase of land and Clause 6
remedied the difficulty under the Education Act
which enacted that if the local education authority
Clause 5 dealt with .
provided certain facilities for social recreation and
physical training they had unlimited powers for
children under 18, but powers in regard to those
above that age only if they attended educational
institutions. The same powers would now exist
in regard to those above 18 as in the case of the
younger children. Clause 7 dealt with the setting
up of the national college. The whole scheme was
now ready for submission to the National Advisory
Council. He still heard criticisms that this scheme
was militaristic, but the leaders in the physical
health movement on the Continent had not been
in the past, and were not now, Germany and Italy,
but Sweden, Czechoslovakia, the democratic popular
States, and he thought that we could draw valuable
lessons from the systems adopted in those countries.
Those systems had no element of compulsion and
were not applicable as a whole, for it was not wanted
to substitute physical training for games, but to
supplement games by physical training. The ‘‘ keep
fit ’’ slogan was one of the best ever invented. What
was not so widely known was the remedial effect
that physical training could have, and that wise
training given under proper instruction, and with a
scientific basis, could do much to remedy some of
those minor, and indeed some of the major, ills to
which a highly civilised and industrialised society
was liable.
Attempts had been made to found arguments
against this scheme upon a nutritional basis, but
this was an entire mistake. The machinery necessary
958 THE LANCET]
to ensure that the school child should come to physical
training with a well-nourished body was in existence,
and if it was properly used there should be no mal-
nutrition in our schools. He was determined that
that machinery should be used, and he appealed to
all hon. Members to help him in impressing the
importance of this machinery on local education
authorities in their areas, and in inducing them to
put it into the fullest possible operation. He would
remind the House that the recent block grant made
available largely increased sums to the local authorities
on which services of this kind might well have the
first call. Anyone who read the First Report of the
Advisory Committee on Nutrition would gather from
its whole tenor that the picture of a nation in general
suffering from malnutrition was a false one. The
committee laid stress on the possibility of extending
the consumption of milk both in the schools and
afterwards. That report would, of course, receive
careful consideration from the Government. It
was a difficult and not wholly an economic problem ;
it was not just a question of the price of the product
and the pocket of the purchaser, but a question of
taste, of belief in it, and although a child could lead a
man to a milk bar a whole Cabinet could not make
him drink. ©
This was a scheme not only for physical training,
but also for recreation. It was part of a problem
just as important, namely, the use of leisure. Leisure
was to be different not only in content, but in quality
from anything that the general masses of the people
had experienced up to now. It was going to be
regular and not spasmodic. What use were we
going to make of such leisure ? He was quite certain
that regular leisure of the kind he mentioned would
demand some more active occupation than just
sitting about and resting. The real use of leisure
would call for the development of interest, taste and
knowledge. Physical recreation, vigorous games,
physical training, and hiking would form an important
part of any right use of leisure, but it could not be all,
He did not believe that physical activity alone
was ever going to be wholly satisfactory, but the
facilities provided for in this Bill might well lead
to the development of other and wider interests.
Mr. Less-SmitrH thought there was a great deal of
exaggeration in the belief that strenuous physical
exercises up to about 25 years of age would guarantee
health for the rest of a long life. Lord Dawson,
in a letter to the Times a few days ago, had pointed
out that he had seen a group of territorials marching
—here they had very selected men—and he carefully
noted them and came to the conclusion that 50 per
cent. of them were suffering from physical defects
which mere exercises would not remedy, and which
would take a heavy toll in later life. Lord Dawson,
was one of the two medical members of the committee
controlling the scheme, and he wished there had been
more. The scheme needed not only the development
of remedial exercises, but the development of open-
air recreation, differing in type from violent physical
exercises,
A matter which was quite definitely at issue between
the two sides of the House was the connexion between
this scheme and the problem of nutrition. He knew
that the Board of Education had issued figures
showing that the number of children in which nutrition
was apparently bad, and who would come under the
scheme, was 0°7 per cent. He did not think that the
record of the Board of Education on this question
of the proportion of children suffering from mal-
nutrition was a very reliable one. The figures
were based upon the impression made on medical
officers of health by looking at children. It was
clear that the standard taken by a medical officer
of health in looking at children was that to which
he was accustomed in the neighbourhood in: which
the school was situated. According to that standard—
if they took it as a standard—they got the figure
of 0°7 per cent. with bad nutrition, and 74 per cent.
who were normal. The whole basis of attempting to
judge this problem by the method of looking at the
PARLIAMENTARY INTELLIGENCE
[APRIL 17, 1937
children in front of them, and asking whether they
were up to the average of the neighbourhood, was
entirely unscientific and was now being condemned.
Mr. STANLEY: When the right hon. gentleman
says that the method is now being condemned, may
I point out to him that the Nutrition Advisory
Committee say that the method of the Board of
Education is the most promising ?
Mr. LEEs-SMITH said that the committee added
that the trial had not been sufficiently prolonged to
establish its reliability and the method was not
reliable. There was another method which scientists
said gave results—viz., the calculation of the number
of proteins, calories, and vitamins required for
physical efficiency at different ages. Then one
calculated what it cost, taking the average over a
group of people, to buy sufficient food to provide
the minimum essentials of those elements. Then
one calculated what proportion of the people of this
country were buying that food and could afford to
buy it. .Those were the methods which were being
followed up by the Committee on Nutrition, which
had not yet reached a final conclusion as to what
percentage of the population, judged by this method,
would be found to be suffering from malnutrition,
but individual members had reached their own
conclusion. They could take either of the two limits,
the report of the British Medical Association, which
stated that 30 per cent. of the school population were
suffering from malnutrition, as against the 0°7 per
cent. of this report, or the report of Sir John Orr,
who was a member of the committee, and who had
come to the conclusion that the optimum diet was
absent from 50 per cent. of the school-children.
The most valuable part of the Government scheme
would undoubtedly be that it would force open the
whole issue of the standard of living of the people
of this country. i
Sir FRANCIS ACLAND said he welcomed the Bill.
Undoubtedly it was a move in the right direction,
and would do great good. But he was sure that the
campaigi which it would be necessary to have behind
this Bill to ensure better physical training and recrea-
tion would have gone better in that House ifit were
being more visibly connected with, and accompanied
by, a preliminary campaign for better nutrition.
Viscountess ASTOR said she begged the Govern-
ment when considering the question of payna
fitness to bear in mind that there was no other way
that they could get the children properly trained,
fed and matured except by beginning before they
got into school. No child under 18 ought to
work more than 40 hours per week. If they attended
to that they might in time get a really A 1 nation.
Mr. EDE said that the nursery school had its place,
but they must be very careful to see that it was not
made an excuse for bad social conditions.
After further debate, -
Mr. SHAKESPEARE, Parliamentary Secretary to the
Board of Education, said that his right hon. friend
had every reason to be gratified at the reception
given to the Bill by members of all parties. The
Government had appointed a body of experts on
nutrition who he hoped would educate the layman
in the course of time.
It was moonshine to conceive that the people
who might come under this Bill—that was to say,
some 14,000,000 persons between the ages of 14 and
35—were so enfeebled by lack of nourishment that
they could not stand up, let alone take any recreation.
Mr. Lees-Smith, he thought, had rather confused
two things—the assessment of the nutritional state
and the means to be taken to overcome any deficiencies
in the nutritional state. Although the present system
of assessing nutrition was not foolproof, it was
the best yet devised, and indeed the experts said
that it was the best at present known. He assured
the right hon. gentleman that if research would find
a better one—and he believed that the League of
Nations was trying to find a better one—the Govern-
ment would consider it with a view to adopting it.
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The Bill was read a second time and the financial
resolution in connexion with it was agreed to in
Committee.
EXTENSION OF CONTRIBUTORY PENSIONS
SCHEME
In the House of Commons on April 8th Sir KINGSLEY
WoOoD, Minister of Health, moved the second reading
of the Widows’, Orphans’, and Old Age Contributory
Pensions (Voluntary Contributors) Bill. He said
that the measure would concern at least 2,000,000
persons, enabling them to participate in the benefits
of the Widows’, Orphans’,and Old Age Contributory
Pensions Act on a voluntary basis.
received these benefits were, broadly speaking, those
who were already compulsorily insured under the
National Health Insurance Act, or who having
once been insurably employed, had elected to become
voluntary contributors.: There had been one consider-
able gap in the provisions of the principal Act.
There had been persistent requests from a section
of the community, many of whom paid to pro-
vide for others this protection which they needed
just as much themselves. Our scheme of social
insurance, considerable and extensive as it was, could
not be regarded as complete so long as persons with
small means, but not themselves insurably employed,
were unable to share in its benefits. This Bill had
been popularly called ‘‘ The Black-coated Workers’
Bill.” That did not by any means adequately
describe its scope. It would be almost impossible,
even if it were desirable, to make a scheme of this
kind compulsory, because experience had shown that
compulsory contributions could be successfully
collected only when linked with the payment of
wages. It was essential, that if the scheme was not
to be unfair between applicants, and not indefensibly
expensive to the taxpayer, they must lay down two
broad principles. In the first place contributions
in a scheme of this kind should increase with the age
of entrants, and as there was to be no medical
examination whatever, there must be a substantial
waiting period before benefits were payable. They
had been able to make provision for continuance
in insurance even when full contributions had not
been paid, and for maintaining the insurance of a
contributor who was unable to pay contributions
owing to protracted illness which prevented him
from earning a living. The Bill permitted of entrance
within a year of the inception of the scheme at a
favourable flat rate subject to a maximum age limit
of 55. The great majority of the men who entered
would be married and many of them would be getting
on in years. The scheme would naturally be most
attractive to them, but the insurances provided
for in the scheme were mainly for the benefit of
women. Its chief attraction for men would be that
it enabled them to make provision for widows and
children in the event of premature death, and
he would point out that of the ls. 3d. asked for
under the scheme nearly a shilling was apportioned
for making provision for the wife, widow, or children.
The Government Actuary put the number of
unmarried women of middle age at 500,000 who
would satisfy the conditions of eligibility in the
first year of the scheme. The difference between the
£400 a year income limit for men and the £250 a
year income limit for women was not one of sex
differentiation at all. It had relation to the responsi-
bilities of the burdens that had to be carried. The
greater part of the man’s risk was the security of his
wife in her old age, or his widow and children in the
event of his premature death, and there was no such
cover available for him in any insurance institution
on any terms that he could afford. Under this scheme
the Government gave adequate benefit and security
according to needs, circumstances, burdens, and
responsibilities in a fair and proper way. As far
as the State contribution and help was concerned,
if anything, it erred in favour of women rather than
men.
- PARLIAMENTARY INTELLIGENCE
Persons who bad-
He could promise the House that he would |
[APRIL 17, 1937 959
examine the precise terms of the measure when it
reached the Committee stage, but he commended it
to the House as one more measure of British social
security and justice, and one which he suggested would
take a considerable place among social services
which were unequalled in the world.
_ After further debate, the Bill was read a second
time and the financial resolution in connexion with
it was agreed to in Co ttee.
The financial resolution in connexion with the
Physical Training and Recreation Bill was agreed to
on report.
THE FACTORIES BILL IN COMMITTEE
The Factories Bill was further considered by a
Standing Committee of the House of Commons on
April 8th. Major LLOYD GEORGE was in the chair,
Examination was begun of Part IV of the measure,
which deals with special provisions and regulations
in relation to health, safety, and welfare.
Clause 46 (which prescribes that where a process
in a factory causes dust or fumes likely to be injurious
or offensive, measures shall be taken to protect the
workers and to prevent the accumulation of dust
or fumes in a workroom), |
Mr. Ruys DAVIES moved an amendment to insert
the words ‘“‘ or other impurity.” He said that there
were other impurities which were altogether outside
the description given in the clause.
Mr. G. LLOYD, Under-Secretary, Home Office, said
that on further inquiry the Home Office found that
there were impurities which would not strictly be
covered by the words in the clause. They were
therefore ready to accept the amendment with other
necessary consequential alterations.
The amendment was agreed to.
On Clause 47 (which deals with washing facilities
and meals in relation to certain dangerous trades),
Sir E. GRAHAM-LITTLE moved an amendment to
leave out the word ‘‘ washing ” and insert “ cleansing.”
He said he was the only medical man on the Com-
mittee and he had received suggestions from expert
associations outside Parliament as to what they
would desire to put into this Bil. A number of
amendments had been put forward by two expert
bodies—the Royal Sanitary Institute and the Society
of Medical Officers of Health. It had been a common
experience with him for patients to show signs of
injuries to the skin caused not by the substances
with which they had been working, but by materials
used for washing their hands. Washing was invariably
understood as washing with soap and water, and the
purpose of the amendment was to give a wider
choice. | |
Sir J. Suwon, Home Secretary, did not deny that
the point had force, but he opposed the insertion
of the word “cleansing.” The expression ‘‘ washing
facilities ” was well-known in the industrial code,
and it was most undesirable to introduce at one
point a phrase like ‘‘ washing and cleansing ” and to
leave the more familiar expression ‘‘ washing facilities ”’
in other places. No doubt there were certain soaps
containing a chemical ingredient which if brought
into contact with the skin of persons suffering from
a certain ailment might do more harm than good,
but that was an argument against washing, and they
must take a rather broader view. He doubted
whether the legal construction which might be put
on these additional words would add to the clearness
of the law.
Sir E. GRAHAM-LITILE said that he had voiced the
opinion of the experts, but in view of what the
Home Secretary had said he asked leave to withdraw
the amendment.
The amendment was withdrawn.
Mr. SHORT moved an amendment giving the
Secretary of State power to prescribe by regulations
what in practice was a room in which there was
sufficient siliceous dust to be dangerous.
The amendment was agreed to.
960 THE LANCET]
PARLIAMENTARY INTELLIGENCE
[Arem 17, 1937
Mr. RHys DAVIES moved an amendment which
he said was designed to make sure that persons
employed in dangerous and injurious processes should
not take food or drink in the room where the
processes were carried on.
Mr. LLOYD said that if the Committee inserted the
amendment in the form in which it was moved they
would really be making not a reasonable prohibition
but an unnecessary restriction. It was essential in
regard to the dust which it was poisonous even to
swallow, to provide that workers should not stay
in the workroom during their rest or meal periods,
and also that they should not swallow the smallest
particle of food outside their rest or meal periods.
With regard to asbestos or silica dust, it was
sufficient to provide, however, that they should
not remain there during their meal times or rest
periods and thus be inhaling the dust.
The amendment was withdrawn, and Clause 47
as amended was ordered to stand part of the Bill.
On Clause 48 (which provides that the Home
Secretary may make such special regulations as
appeared to him practicable for extending the
provision and use in factories in which the weaving
of cotton or other cloth is carried on, of shuttles
which are not capable of being threaded or readily
threaded by suction of the mouth, and any such
regulations may impose duties on workers as well as
occupiers).
Mr. Rays DAVIES moved an amendment to delete
the word ‘ special” in relation to the regulations.
He said that the habit of what was called ‘ shuttle
kissing ” had grown up but now both employers and
workers would like to do away with it. The Home
Secretary should be able to make regulations to deal
with the matter without having to go through all the
machinery of inquiry that would be necessary if the
regulations were special regulations.
Mr. J. HEPWORTH said that most employers pro-
vided apparatus for threading a shuttle, but the
difficulty was to get the workers to use it.
Sir J. Summon said it did not appear to have been
absolutely proved that ‘‘ shuttle kissing” caused
injurious consequences. It would be very rash if he
made regulations on such a matter without making
full inquiry. That was the reason why they put in
the words “‘ special regulations.” They all wanted to
stop the habit of ‘‘ shuttle kissing ” if they could and
he would undertake to take the matter up!as soon
as the Bill became law for the purpose of making
proper inquiries. He promised to look further into
the matter.
The amendment was withdrawn, and Clause 48
was ordered to stand part of the Bill.
Clause 49 (which provides that no person shall use
white phosphorus in the manufacture of matches)
and Clause 50 (which deals with humid factories)
were both ordered to stand part of the Bill with
minor amendments.
On Clause 51 (which provides that no work shall be
carried on in any underground room, which is certified
by the inspector as unsuitable as regards construction,
light, or ventilation, or on any hygienic ground, or
where adequate means of escape in case of fire are
not provided),
Mr. SHORT moved an amendment to make the
clause provide that no underground room should be
used for work unless it was certified by the inspector
to be suitable.
Mr. BANFIELD, supporting the amendment, said
that an underground room was not a suitable place
for processes to be carried on at all. There were
hundreds of underground workrooms that ought to
be closed, many were absolute rat-holes.
Mr. LLOYD said Mr. Banfield had referred to
underground workrooms which were in the nature of
objectionable cellars, but an underground room in
the clause meant any room half of which was
below the level of the ground. In a number of the
luxury flats in the West End of London there were
rooms of that kind. The information in the Home
Office did not indicate that conditions in regard to
lighting and ventilation were generally bad. On the
contrary, a comprehensive inquiry had shown that
conditions were much better than might be antici-
pated and that an improvement had taken place.
If the amendment was carried a large number of
Inspectors would be wanted and there would be a
considerable delay in dealing with bad cases.
After further debate, Sir J. Smmon said that his
advisers took the view, and he did not differ from it,
that the clavse was in proper form. But he would
consider the whole matter again.
The amendment was withdrawn.
On Clause 52 (which provides that a basement
bakehouse shall not be used as a bakehouse unless it
‘was lawfully so used at the date of the passing of
the Bill into law, and any basement bakehouse whicb,
for a period exceeding 12 months, is not used as a
bakehouse shall not be so used again),
Mr. BANFIELD moved an amendment to provide
that all existing basement bakehouses should not be
used after the expiration of five years after the
passing of the Bill into law.
After further debate, Sir J. SmMon said that the
proposal in the amendment had only just come
before him. It had never been put forward previously
in any of the representations made to the Home
Office when the Bill was being drafted. It was their
policy te discourage the use of underground bake-
houses and he was disposed to share the strong feeling
shown about the matter. He could not, however,
accept the amendment without having an oppor-
tunity of consultation.
Mr. BANFIELD agreed to withdraw the amendment,
but Mr. G. BUCHANAN objected, and it was negatived.
The clause was ordered to stand part of the Bill.
Clause 53 relating to the temperature of ironing
rooms in laundries and fumes in laundries was also
ordered to stand part of the Bill.
The Committee adjourned.
The Factories Bill was further considered by a
Standing Committee of the House of Commons on
April 13th. Major LLOYD GEORGE was in the chair.
On Clause 54, which provides that a young person
shall not be employed to lift, carry, or move any load
so heavy as to be likely to cause injury,
Mr. Ruys DAVIES moved an amendment to delete
the word ‘‘ young.”
Mr. LLOYD, Under-Secretary, Home Office, said
that regard should be had to a proviso in the clause
empowering the Home Secretary to make special
regulations prescribing the maximum weights which
might be lifted, carried, or moved by persons employed
in factories." That power to make regulations, he
said, was regarded as an important way of dealing
with special cases and they intended to use that
power.
After further debate,
Sir Joun Smoon, Home Secretary, said that the
clause was a new one in the Factory Code and was an
improvement. There were already regulations to
prevent young persons lifting heavy weights, but they
could not put into an Act of Parliament some prohibi-
tion which was so vague in its terms that it could not
be effectively and fairly applied.
The amendment was withdrawn and the clause was
ordered to stand part of the Bill.
On Clause 55, which prohibits the employment of
female young persons in any part of a factory where
the following processes are carried on: melting
or blowing glass, other than lamp blown glass;
annealing glass, other than plate or sheet glass;
CVA POTAE of brine in open pans or the stoving
of salt.
Mr. W. BROMFIELD moved an amendment to
include in the prohibition the making or finishing
of bricks or tiles not being ornamental tiles. ;
Sir J. Simon said there was a new sub-clause which
gave the Home Secretary power to extend the clause
by regulation to any process in which it appeared
undesirable that female young persops should be
employed, and if he was satisfied that the prohibition
THE LANCET]
referred to ought not to apply to any of the processes
specified, or ought to be relaxed, he might make
regulations accordingly.
The amendment was negatived and the clause was
ordered to stand part of the Bill. |
On Clause 56, which prohibits the employment of
women and young persons in certain processes
connected with lead manufacture,
Sir E. GRAHAM- moved an amendment
to exclude women from the prohibition. He said
there was no evidence that women were more subject
to lead poisoning than men. A discrimination of the
kind proposed in the clause would operate against
the employment of women.
Viscountess ASTOR supported the amendment.
Anything that would shut out women from any
employment would be resented by them.
The amendment was negatived and the clause was
ordered to stand part of the Bill.
Clause 57, which includes provisions in regard to the
employment of women and young persons in processes
involving the use of lead compounds, was ordered to.
stand part of the Bill.
Clause 58 (which gives the Home Secretary power to
make special regulations for safety and health),
Clause 59 (prohibition of importation and sale of
articles made with prohibited materials), Clause 60
(power to take samples), Clause 61 (certificates required
before approval of building plans relating to cotton
cloth factories), Clause 62 (notification of accidents
in factories), and Clause 63 (power to extend dangerous
occurrences provisions as to notice of accidents)
were all ordered to stand part of the Bill.
On Clause 65, which requires notification of certain
industrial diseases,
Mr. ELLIS SMITH moved an amendment to delete
the list of diseases specified in the clause (lead,
phosphorus, arsenical or mercurial poisoning, or
anthrax) and substitute the definition ‘‘ any industrial
disease to which the provisions of Section 43 of the
Workmen’s Compensation Act, 1925, apply or
silicosis.”
Sir E. GRAHAM-LITTLE supported the amendment.
Sir J. SIMON opposed it and the amendment was
withdrawn.
The Committee adjourned.
NOTES ON CURRENT TOPICS
Voluntary Sterilisation
In the House of Commons on April 13th on the
motion that the Speaker do leave the chair on the
House going into Committee of Supply on the Civil
Estimates,
Wing-Commander JAMES called attention to the
need to implement the report of the Committee
on Voluntary Sterilisation, and moved “ that, in the
opinion of this House, the Government should give
further consideration to the potentialities of voluntary
sterilisation for hereditary defectives in accordance
with the unanimous recommendations of the Depart-
mental Committee that reported to the Minister of
Health on Jan. 8th, 1934.”
Sir KinGstEY Woop, Minister of Health, replying
to the debate which followed, said there wasno question
that opinion in this country was growing in favour
of sterilisation, but they could not disguise from them-
selves the fact that opposition remained and that there
was still much conflict of opinion, particularly on
religious grounds. The medical profession were by
no means unanimous on the matter. It was desirable
that ample time should be given for full consideration
of the whole problem and for public opinion to develop,
as he thought it was developing.
Wing-Commander JAMES said that in view of
what the Minister had said he would withdraw his
motion.
Mr. Rowson called attention to the question of
nutrition.
Sir Kinestey Woop said that the Ministry of
Health Advisory Committee on Nutrition in their
most valuable first report said that a good deal of
PARLIAMENTARY INTELLIGENCE
[APRIL 17, 1937 961
further information on the facts must be obtained
before it was possible to reach a final policy on
nutrition. He had asked the authorities to review
the scale of income observed in connexion with the
requirement for repayment for milk or for food
supplies. He had also asked the authorities to
consider afresh the question of a properly organised
system of meals, and he had reason to believe that
the authorities would be able to continue and extend
the work they were now doing. The Department
would undertake certain dietary surveys which the
Advisory Committee recommended. This would
take time, but would not stop the work now going on.
The motion that the Speaker do leave the chair
was carried by 161 votes to 120.
QUESTION TIME
WEDNESDAY, APRIL 7TH
Underground Protection against Air Attack
Major Stourton asked the Home Secretary to what
extent underground protection would be made available
to the civilian population of London in the event of an
air attack.—Mr. GEOFFREY LLoyp, Under-Secretary,
Home Office, replied : Where accommodation exists below
ground level which can be suitably protected against
splinters, falling debris, and poison gas, the occupiers of
premises will be advised to make use of it. As, however,
underground accommodation is rarely proof against a
direct hit by a high explosive bomb, the overriding con-
sideration in the choice of air-raid refuges must be to keep
the population well dispersed in splinter-proof and gas-
proof accommodation, whether it is below or above
ground level.
Medical Jurisprudence
Captain ELLIston asked the Home Secretary whether,
in accordance with the recommendations of the advisory
committee on the scientific investigation of crime, it was
proposed to establish a medico-legal institute for patho-
logical research and as a training centre for experts in
medical jurisprudence.—Sir JoHN Simon replied: The
Committee’s report is primarily concerned with measures
for improving medical education in certain directions ;
while I am in sympathy with their recommendations they
fall also within the province of the Minister of Health,
with whom I am in consultation on the matter. My hon.
friend will, of course, appreciate that the Committee’s
proposals would involve a substantial charge upon the
Exchequer.
Medical Research Council and Silicosis
Mr. JAMES GRIFFITHS asked the Lord President of the
Council what progress had been made by the Medical
Research Council in their investigations into the problem
of silicosis, and other lung diseases, among coal-miners ;
and whether he could give any indication as to when the
committee’s investigation would be completed.—Mr.
Ramsay MacDonatp replied: The standing committee
appointed by the Medical Research Council to direct
research into disease of the lungs among industrial workers
has already promoted several investigations into silicosis
and other conditions; the results have been published in
a series of official reports and scientific papers. These
researches were in most cases not specially directed to the
particular problem of lung disease among coal-miners, but
during recent months attention has been concentrated on
this, and a scheme of intensive investigation in South
Wales has been initiated. The work already done shows
the problem to be one of great difficulty and complexity,
and the investigation is not likely to be completed in less
than two years.
Mr. J. Grirritas said that in view of the unsatisfactory
nature of the reply and the position of the men who
were affected he would raise the matter at the earliest
opportunity.
Hospital Treatment in Staffordshire
Mr. MANDER asked the Minister of Health if he was
aware of the great dissatisfaction caused in Wednesfield
and Willenhall as a result of the coming into force on
962 THE LANCET]
PARLIAMENTARY INTELLIGENCE
2
[apr 17, 1987
April lst of the new arrangements for the treatment of
invalids, both public assistance applicants and hospital
contributors, under the new Staffordshire County Council
scheme; if he realised that it was now necessary for
patients to be taken a distance of from 8 to 10 miles to:
Wordsley Institution instead of receiving treatment in
the immediate vicinity at the New Cross Hospital of the
Wolverhampton Borough Council; and what resident
medical officers were available at Wordsley for the treat-
ment of these patients.—Sir KinestEy Woop replied :
The plans of the Staffordshire County Council for the
reorganisation of hospital and other institutional accom-
modation in the county include the reconstruction of the
present institution at Wordsley as a general hospital to
serve the sick in the southern part of the county, and
I have given my consent to this proposal. The hon.
Member will appreciate that the improvement of insti-
tutional services and the better classification of patients,
which were one of the objects of the Local Government
Act of 1929, must sometimes involve the removal of certain
patients to a greater distance from their homes, but if the
hon. Member has any particular cases of hardship in mind
I will make inquiries. With regard to the last part of the
question, I understand that the medical officer of the
Wordsley Institution lives near at hand and is always
available, and that the council propose to appoint a
resident medical officer or officers as soon as the recon-
struction permits. |
Overcrowding in Croydon District
Dr. SALTER asked the Minister of Health whether he
was aware that, despite the serious shortage of accom-
modation available at rents within the means of the
lower-paid wage-earners in the Croydon district and the
grave overcrowding prevalent in the area, the Corporation
of Croydon had made regulations under which an applicant
for a municipal house must have resided in the borough
for a period of at least 10 years to render such applicant
eligible for a dwelling let at a rent of less than £1 per
week; and whether such a policy had his approval.—
Sir Kwasy Woop replied: I understand that the
regulations made by the town council include a condition
to the effect mentioned, but that this condition is relaxed
in the case of overcrowded families, persons displaced by
slum clearance and the abatement of overcrowding, and
other cases where special circumstances exist. My
approval is not required to the regulations made by local
authorities for the management of the houses provided
by them.
Cost of Living Inquiry into Family Budgets
Mr. Sanpys asked the Minister of Health whether it
was the intention of the Government to institute the
inquiries into income distribution, family budgets, and
diet recommended by the Advisory Committee on
Nutrition in their recent report, in so far as these were
not already covered by existing investigations.—Sir
Krnastey Woop replied: Yes, Sir. The dietary surveys
have already commenced. As regards family budgets, it
is hoped to obtain information as to food consumption in
the course of the inquiry which is being undertaken by
my right hon. friend, the Minister of Labour, for the
purpose of the revision of the cost of living index number.
The method of carrying out the remaining proposal is
receiving immediate consideration.
MONDAY, APRIL 12TH
National Health Insurance Referees
Mr. GranamM WHITE asked the Minister of Health how
many referees had been appointed under Section 90 of the
National Health Insurance Act, 1924, and the rates of
their remuneration.—Mr. Hupson, Parliamentary Secre-
tary, Ministry of Health, replied : The number of referees
in England and Wales is eight, and their remuneration is &
fee not exceeding 10 guineas a day, or 12 guineas where &
hearing extends beyond seven hours.
Supervision of Nursing Homes
Miss RATHBONE asked the Minister of Health (1) whether
he would institute an inquiry into nursing-homes all over
the country, in view of the many complaints as to the
inadequate and insufficiently qualified nursing stafis and
the insufficient precaution taken in regard to the prevention
of infection; and (2) whether he had reason to believe
that nursing-homes were adequately inspected from the
point of view of the sufficiency and qualifications of the
nursing staff, and also that adequate care was given to
the prevention of infection, particularly when maternity
patients were taken in addition to general medical and
surgical cases.—Mr. Hupson replied: The attention of
local authorities has recently been called to the importance
of the adequate supervision of nursing-homes in a circular
letter of Sept. 30th last. As at present advised my right
hon. friend sees no necessity for a special inquiry, but he
will look into any case which the hon. Member may have
in mind if she will communicate the particulars to him.
Nursery Schools
Mr. Lyons asked the President of the Board of Education
the latest progress in the development of nursery schools ;
and what proposals were in immediate contemplation.—
Mr. GEOFFREY SHAKESPEARE replied: The present
position is that 86 nursery schools are recognised by the
Board of Education, of which 83 are recognised for pur-
poses of grant, and three as efficient but not in receipt of
grant. In addition, 34 proposals for new nursery schools
have been approved in principle and in a number of
these cases final plans have been approved by the Board,
and seven proposals are at present under consideration.
TUESDAY, APRIL 13TH
National Health Insurance Drug Fund
Colonel RopnEr asked the Minister of Health whether,
in view of the incidence of sickness during the early
months of the present year, he proposed to make special
provision to ensure that the Drug Fund should be able,
at the end of the year, to meet in full its liabilities to
chemists and bodies corporate dispensing under the
National Health Insurance Acts.—Mr. Hupson replied :
As the Drug Fund relates to the calendar year it would be
premature at this stage to estimate the extent, if any, to
which payment of the chemists’ accounts will be affected
by the sickness experience early in the year. My right
hon. friend undertook at the time the present agreement
with the chemists was made to consider representations
regarding any abnormal deficit in the Fund.
Overcrowding in Scotland
Mr. Maxton asked the Secretary of State for Scotland
what progress had been made since the passing of the
Housing Act, 1935, in combating the problem of over-
crowding in Scotland; and in how many places had the
appointed day been fixed.—Mr. ELLIOTT replied: Since
the passing of the Housing (Scotland) Act, 1935, tenders
have been approved for 36,012 houses and 24,377 houses
have been completed. These houses are not specifically
approved for subsidy purposes under either the Act of
1930 or the Act of 1935, but, under arrangements designed
to secure that the most economical use is made of the
new accommodation they are used for slum clearance or
overcrowding purposes as local circumstances or needs
may dictate. There is no record of the number of families
actually removed from overcrowded houses prior to
April Ist, 1936, but from that date to Feb. 28th, 1937,
6444 families living in overcrowded conditions were
rehoused. The appointed day under the Housing (Scot-
land) Act, 1935, has so far been fixed for only one area—
namely, the Dysart Ward of the Burgh of Kirkcaldy.
The date fixed in this instance is May 15th, 1937.
INTERNATIONAL CONGRESS OF OPHTHALMOLOGY.—
This congress will be held at Cairo from Dec. 8th
to 15th. Several tours, leaving Marseilles on Dec. 3rd,
have been arranged in connexion with it under the
auspices of the International Council of Ophthalmology.
Visits will be paid to Upper Egypt, Palestine, and Syria.
Dr. E. Marx of Rotterdam is acting as secretary-general
of the congress, and further details about the tours may
be had from the Bureau des Croisiéres et Voyages
Médicaux, 29, Boulevard Adolphe Max, Brussels.
THE LANCET]
[APRIL 17, 1937 963
MEDICAL NEWS
University of London
At a recent examination the following candidates were
successful :—
D.P.H.
Part I..—Beatrix H. Bakewell, J. S. B. Bray, Enid S. Davies,
Sylvia C. Ben? Ee D Harte, M. U. Hayat, S. M. H. Naqvi,
A. W. Rasiah, Pag rea Margaret B. Steel, M. N. de S.
Suriyawansa, aa V. M. Vatv
Sir Ernest Graham-Little has been appointed repre-
sentative of the University at the celebrations to be held
on the occasion of the 400th anniversary of the foundation
of the University of Lausanne from June 3rd to 5th.
Three lectures on the meninges and the cerebro-spinal
fluid will be given on May 24th, 26th, and 28th, at
University College at 5.30 P.M., by Dr. Lewis H. Weed,
director of the school of medicine and professor of
anatomy in the Johns Hopkins University, Baltimore.
Dr. J. Henderson Smith, head of the department of plant
pathology at Rothamsted experimental station, will
speak on virus diseases of plants at 5.30 P.M. at the
Imperial College of Science and Technology on May 13th,
20th, and 27th. Prof. I. M. Heilbron, F.R.S., Sir Samuel
Hall professor of chemistry and director of the chemical
laboratories of the University of Manchester, will also
lecture there at 5.30 P.m. on May 24th, 25th, and 26th.
He will speak on the chemistry of the carotenoids and
vitamin A. Prof. H. Rein, director of the physiological
institute of the University of Géttingen, will lecture at
University College on May 3rd, 4th, and 6th at 5 P.M.
His subject will be some economising mechanisms as a
condition of the body’s adaptation to increased activity.
It has also been arranged for Prof. H. Fredericq, professor
of physiology in the University of Liége, to give a lecture
at King’s College on interpretation of the normal electro-
cardiogram. The lecture will take place during June
and the date will be announced later. The lectures are
open without fee to all who are interested.
The following examiners for the diploma in theory and
practice of physical education have been appointed :—
Anatomy.—Dr. Doris Baker and Dr. Lilian Dickson.
Hygiene.—Dr. Ruth Proctor and Dr. James Kerr.
Theory of Gymnastics.—Dr. Anna Broman and Surgeon
Commander G. Murray Levick.
University of Birmingham
On May 18th and 20th, at 4 p.m., Prof. Arvid Wallgren,
physician-in-chief to the Children’s Hospital at Gothen.
burg, will deliver the Ingleby lectures. The first will be
on erythema nodosum and the second on childhood
infection and adult type of pulmonary tuberculosis.
From May 24th to June 4th a post-graduate course will
be held on the care of the injured workman, and from
June 14th to 25th there will be an intensive course in
industrial hygiene and industrial medicine. Further
information may be had from Dr. Howard Collier at the
department of industrial hygiene and medicine at the
University.
Provisional arrangements are being made for a post-
graduate course in neurology to be given from May to
July in hospitals associated with the University. Further
_ information may be obtained on application -to the dean
of the faculty of medicine of the University, Edmund-
street, Birmingham, 3.
Pathological Research in Relation to Medicine
Our advertisement columns contain particulars of a:
course of lectures on this subject to be given in the
institute of pathology and research at St. Mary’s Hospital
at 6 P.M. on Tuesdays from April 27th to June 22nd.
The first is by Sir Almroth Wright, F.R.S., principal of
the institute, and the other speakers will be Dr. F. M. R.
Walshe, Mr. W. T. Thompson, F.R.S., Prof. E. C. Dodds,
Mr. F. T. Ridley, Dr. Wilson Smith, Prof. J. A. Gunn,
and Dr. W. E. Gye. An abstract of each lecture will be
found in our advertisement columns the week before its
delivery. The lectures are open to all members of the
medical profession.
Royal College of Surgeons of England
A meeting of the council was held on April 8th with
Sir Cuthbert Wallace, the president, in the chair. The
Jacksonian price for 1936 was awarded to Mr. W. E.
Underwood, F.R.C.S. (St. Bartholomew’s Hospital).
The subject for the Jacksonian prize for 1938 will be
surgery of the heart. The John Hunter medal and triennial
prize was awarded to Mr. L. F. O’Shaughnessy, F.R.C.S.,
for his research work on the surgery of the thorax.
Mr. Ernest Eric Young and Mr. Arthur George Wells
were elected fellows of the college under the charter
which permits the council to elect annually to the
fellowship, without examination, two members of the
college of twenty years’ standing.
It was decided that the post of fourth house surgeon at
the Royal Surrey County Hospital, Guildford, should
also be recognised for the six months’ surgical practice
required of candidates for the final examination for the
fellowship.
Diplomas of membership were granted to A. E. H.
Eades (Univ. of Edin.), to K. C. Royes (Univ. of Oxford
and St. Thomas’s Hosp.), and to Eric Vernon (Univ. of
Manch.). Diplomas in child health were granted jointly
with the Royal College of Physicians to the following
candidates :—
Margaret D. Baber, H. a Basu, M. L. Biswas, V. S. H.
Davies, J. G. H. w, J. Green, Joyce B. Jewson, Bernard
Kenton, A. H. M. Koraha, S. K. Lee, G. K. rme Louise A
Teom Dorothy Miller, A. L. Smallwood, S. E. Stoning,
Elisabeth J. McQ. Thomas, Enid L. Weatherhead, H. Ž “Williams,
Margaret Š: Winter, and Shuan S. Yang.
St. Bartholomew’s Hospital Medical College
A post-graduate course open to all will be held at this
hospital on June 17th, 18th, and 19th. Further infor-
mation may be had from the dean of the medical college.
Royal London Ophthalmic Hospital
The Gifford Edmonds prize at Moorfields has been
awarded to Mr. J. Bruce Hamilton of Hobart, Tasmania,
for an essay on the significance of heredity in ophthal.
mology. The prize is awarded ' biennially.
Central Midwives Board
This board has unanimously re-elected Sir Comyns
Berkeley as its chairman. Mr. John Bright Banister
and Mr. Eardley Holland have been appointed to fill
vacancies in the membership of the board.
Toronto Anatomical Session
The fifty-third annual session of the American Asso-
ciation of Anatomists was held on March 25th to 27th
at the University of Toronto. Prof. Frederic T. Lewis
(Harvard), the president, delivered an address at the
dinner on the fundamentals of cell shape. There were
151 papers and thus many of them had to be presented
simultaneously. Six round-table conferences were held,
covering subjects like sperm production, capillaries,
modern conceptions of the neuron, gross anatomical
research, heart, and teeth. Anatomy now claims as its
own all changes in cells having to do with function, and
there were papers dealing with subjects such as the hypo-
physis, the adrenal and other ductless glands, the adrenal-
pituitary relationship in lactation, changes in the adrenals,
livers, and thyroids of guinea-pigs as affected by environ-
mental temperatures and thyroxine, and the effect of
cortical adrenal extract on sympathetic ganglia of
adrenalectomised cats. There was much emphasis on the
influence of heredity on form. Some of the papers
bordered on the pathological field, such as that on
abnormal blood production in hydrops feetalis. One of
many communications on the blood held that lympho-
cytes could develop in tissue cultures into myelocytes.
Other papers were of the older anatomical type, including
a notable one on the arrangement of the cranial venous
sinuses in the occipital region in man. Various aspects
of the nervous system were also discussed. Seven motion
pictures were shown, illustrating such phenomena as
foetal behaviour, leg transplantation, and foetal respiration.
An afternoon was set aside for the presentation of sixty
demonstrations,
964 THE LANCET]
APPOINTMENTS.—VACANCIES
[APRIL 17, 1937
Dr, Charles David Green, who died in St. Thomas’s
Hospital on Monday, April 12th, aged 75, had retired
from practice. Formerly M.O.H. for Edmonton, he
practised with success in the City of London.
exceptionally highly qualified and made useful contri-
butions to our columns and to the Transactions of the
Pathological Society.
New Maternity Home for Beckenham
At a meeting of the Beckenham borough council recently
it was decided to build a new maternity home containing
38 beds at a cost of £49,640. | \
Falkirk Royal Infirmary
A new nurses’ home is needed here and an appeal for
£40,000 is to be made. For the first time in the hospital’s
history an adverse balance is reported ; the deficiency on
Dec. 31st was £757.
Journées Médicales de Bruxelles
This congress will be held in Brussels under the presi-
dency of Prof. Albert Dustin from June 19th to 23rd.
The speakers will include Sir Joseph Barcroft, F.R.S.,
Prof. D. Danielopolu (Bucharest), and Prof. F. Rathery
(Paris). Dr. R. Beckers, the secretary-general, may be
addressed at 141, rue Belliard, Brussels.
Greater London Provident Scheme for District
Nursing
An inaugural meeting to explain the purpose of this-
scheme will be held on Monday, April 19th, at 4 P.M., at
the Grocers’ Hall, Prince’s-street, E.C. The scheme seeks
to provide an organisation self-sufficient and auxiliary to
the existing district nursing services in the metropolitan
area. Lord Horder and Miss Mercy Wilmshurst, general
superintendent of the Queen’s Institute of District Nursing,
will be among the speakers. The executive committee
may be addressed at 1, Sloane-street, S.W.1.
British Empire Cancer Campaign
In the absence of Viscount Hailsham, Sir Cuthbert
Wallace, president of the Royal College of Surgeons,
presided at the quarterly meeting of the grand council
of the British Empire Cancer Campaign held on April 12th.
The council was informed that the campaign would move
into its new offices at 11, Grosvenor-crescent, next door
to the present offices, on May Ist. The following grants,
totalling £2900, were made, in addition to the bulk grants
of last November and January: £1000 to be placed at
the disposal of Mr. F. Dickens, D.Sc., director of research
of the North of England branch of the campaign, at
Newcastle, for the continuation of the special ‘short ”
wave investigations being carried out under his direction
on behalf of the scientific advisory committee at head-
quarters ; £1200 for the purchase of a plaque of radium
in use by Dr. F. G. Spear at the Strangeways Research
Laboratory, Cambridge; an additional grant of £300
for 1937 to the Westminster Hospital; an additional sum
of £300 to Mr. F. C. Pybus for the salaries of his assistants
and expenses during the second half of 1937; and a grant
of £100 to Mr. L. H. Gray, D.Sc., at Mount Vernon Hos-
pital, in connexion with the neutron investigations.
Sir James Walton was unanimously elected a member
of the Council.
Appointments
BARLOW, DONALD, M.S. Lond., F.R.C.S. Eng., Hon. Assistant
Surgeon to St. John’s Hospital, Lewishai.
BINNING, PES B.A. Camb., M.R. C.S. Eng., Anæsthetist to the
ei hey Alexandra Hospital for Sick ‘Children, Brighton,
to the Brighton and Hove Dental Hospital.
Duncan, A. S., M.B. Edin., House Surgeon, Hospital for Sick
Children, Great Ormond -street.
FRASER, ROBERT, M.B.Aberd., D.P.H., Resident Medical
Assistant at the City Hospital for "Infectious Diseases,
Newcastle-upon-Tyne.
LUMSDEN, A. G., M.B. Aberd., Hon. Assistant Ophthalmic
Surgeon to St. John’s Hospital, Lewisham.
MACLEOD, HENRIETTA M., M.B. Lond., Assistant Medical
Otlicer for Maternity and Child Welfare Work for N otting-
ham
MoNEILL, JANE L., M.D. Belf., L.M., Medical Officer in the
Maternity and Child Welfare Department for Birmingham.
Rowse, A. J., L.R.C.P. Lond., House Surgeon to the Evelina
Hospital for Sick Children, London.
He was
WALKER, J. V., M.B. Birm., M.R.C.P. Lond., D.P.H., Assistant
Medical Officer ‘of Health and Assistant .School Medical
Officer for Bootle.
WISON, REGINALD, M.D. McGill, D.C.H., House Physician,
Hospital for Sick Children, Great Ormond-street.
London Hospital.—The following appointments are announced :
GowaR, F. J. SAMBROOK, M.B. Lond., F.R.C.S. Eng., First
Assistant to the Department of Thoracic Surgery ;
GAVEY, C. J., M.D., M.R.C.P. Lond., Paterson Research
ele al and Chief’ Assistant to the Cardiac Department ;
an
LISTER, ARTHUR, M.B., B.Chir. Camb., F.R.C.S. Eng.,
First Assistant to the Ophthalmic Department.
ie 2 Surgeons under the Factory and Workshop Acts:
G. A. BECKETT (Ely District, Cambs); Dr. J. ©, S.
and Dr. C. R. FIELDING (Tarvin District, Cheshire).
Tr (St. Mary’s, Isles of Scilly, District, Cornwall);
Vacancies
For further information refer to the advertisement columns
Alderley Edge, Ancoats Hosp. Convalescent Home, Great
Warford.—Hon. Visiting M.O.,
Baghdad, Royal College of M ehane ‘—Prof. of Pathology
and Prof. of Bacteriology, each £150 a month.
Barking Borough.—Asst. M.O., £500.
Barnsley, Beckett Hosp.— Res. Surg. O., £300.
Bath, Royal United Hosp.—H.S. to ‘Rar, Nose, and Throat
Dept., at rate of 8150.
Beckenham, Bethlem Royal Hosp., Monks Orchard.—Cons. Surg.
Also Radiologist, 150 guineas
Blackburn, Calderstones Certified Institution for Mental Defectives,
Whalley. —Deputy Med. Supt., £750.
Blackburn Royal Infirmary.—Res. H. 4° £175.
Bradford, Royal Eye and Ear Hospital. — H. S., £180.
Bristol Mental H osp.—Fourth Asst. M.O., £500
British Postgraduate Medical School, Dies road, W.—Three
Part-time Demonstrators in Clinical Medicine, ‘each £100.
Canterbury, Kent and Canterbury Hosp.—Hon. Anesthetist to
Ear, Nose, and Throat Dept.
Cheltenham General and five Hosps.—H.S. to Eye, Ear, Nose,
and Throat Dept., £150.
Chester Royal I nfirmary. ae S., £150.
Chesterfield and North Derbyshire Royal Hosp.—H.S. to Ophth.
and Ear, Nose, and Throat Depts., at rate of £150.
Connaught Hosp., Walthamstow, E.—Cas. O., at gene of £100.
Coventry and W arwickshire Hosp.—Res. Cas. O.,
Croydon, Mayday Hosp.—Asst. Pathologist eth Becteriologist,
£350. Also two Jun. poe Asst. M.O.’s, each £300.
Doncaster Royal Infirmary, and Dispensary.—Cas. H.S., £175.
Eastbourne, Princess Alice Hospital.—Res. H.S., £15
Edgware, Redhill County Hosp.—Asst. Pathologist, £650.
Edinburgh Royal College of Physicians.—Kirk Duncannon Fellow-
ship for Medical Research, £300.
Edmonton, North Middlesex County Hosp. —Jun. Res. Asst.
M.O., at rate of £250.
Elizabeth Garrett Anderson Hosp., Euston-road, N.W.—Hon.
Asst. Surgeon to Throat, Nose, and Ear’ Dept. Hon.
Physician to Children’s Dept. Radiologist, £200. Also
Pathologist for Dept. of Morbid Anatomy, &e., £350.
Exeter City and County.—Temp. Asst. School M. Ò. and Asst.
M.O.H., at rate of £600.
Exeter, Royal Devon and Exeter Hosp.—H.P. and H.S. to
Ear, Nose, and Throat Dept., each at rate of £150.
T County Hosp., Enniskillen. —Surgeon Superintendent,
Grimsby and District Hosp.—Jun. H.S., £150.
Halifax General Hosp.—Jun. Res. M. O., £250.
Hastings, Royal East Sussex Hosp — Sen. H. S., at rate of £200.
Hertford County Hospital—Sen. H.S., at rate of £200.
Hosp. for Sick Children, Great Ormond- street, W.C.—Out-patient
Med. Reg., £175.
Hove General ‘Hosp. —Jun. Res. M.O., £120.
Huddersfield Royal Infirmary.—Two H. S.’s. each at rate of £150.
Hull Royal Infirmary.—H.P. to Sutton Branch, and Second
H.P., at rate of £160 and £150 respectively.
Ilford, King George Hosp.—H.S., at rate of £100.
Kettering and District General Hosp. —Res, M.O. and Second
Res. M.O., at rate of £175 and £125 TE DeivS y
King’s College Hosp., S.E., Squint Clinic.—M.0O.,
L.C. Li M.O.’s, "Grade I, £350. Also Asst. M. yy A ‘Grade II,
£25
Lincoln County Hosp.—Jun. H.S., at rate of £150.
Liverpooland District Hosp. for Diseases of the Heart.—H.P., £100.
London Child Guidance Clinic, 1, Canonbury-place, N. —Three
Fellowships in Psychiatry, each £300.
“4 aes ge .—First Asst. to Gynecological and Obstet.
ep
London Pesh Hosp., Stepney Green, E.—Hon. Clin. Asst,
London Lock Hosp., 283, Harrow-road, W.—Res. M.O. to Male
Depts., at rate of £175.
Macclesfield General Infirmary, &:c.—Sen. H.S., at rate of £180.
M e Š R Hall Hosp. for Children. —Deputy Med.
u
Manchester City.—M.O. for Maternity and Child Welfare, £600.
Manchester, Royal Children’s Hosp., Pendlebury.—Res. Surg. O.,
at rate of £150.
Manchester Royal I nfirmary. —Jun, Asst. M.O., £350.
Middlesbrough, North Riding Infirmary.—Cas. O., £150.
Dimi or oe Whitehall, S.W.—Temp. ” Serologist, at
rate o :
Nelson Hosp., Merton, S.W.—Res. H.S., at rate of £100.
Newark General Hosp.— Res. H.S., £175.
THE LANCET]
Newcastle- ee hae Wooley Sanatorium, near Hexham.—dAsst.
+
Norwich Norfolk and Norwich Hosp.—H.S. to Spec. Depts.,
Nottingham boa Dispensary, Hyson Green Branch.—Res.
Surgeon
Nottingham ‘General Hosp.—Res. Cas. O. and H.S., each at
rate of £150.
inert ouduny Park Municipal Hosp.—Res. A.M.O., at rate
of £200
ene. WV ingfield-Morris Orthopedic Hosp., Headington.—Res.
$ £100.
Binna Prince of Wales’s Hosp., Devonport. —Jun. H. S., at
rate of £120.
Prince of Wales’s General Hosp., N.—Hon. Clin. Asst.
Princess Louise Kensington Hosp. for Children, St. Quintin-
avenue, W.—Hon. Radiologist.
ohana Hospital for Children, Hackney-road, H.—H.S., at rate
Ratiu Ir nstitute, Riding House-street, W.—Res. M.O., at rate
O 50.
Royal Chest Hosp., eee een E.C.—Res. M.O., at rate of £150.
Also H.P., at rate of £100.
Royal Free Hosp., Gray's Inn-road, W.C.—Asst. Physician to
Dept. of Physic al Medicine. Also First Asst. in Children’s
Dept., at rate of £100.
Royal London Ophthalinic Hosp., City-road, £H.C.—Out-patient
Officer, £100.
Royal Naval Medical Service —M.O.’s
St. Alban’s and Mid-Herts Hosp — Res. H.S., N
St. Helen’s County Borough.—Asst. M.O.H., £500.
St. Thomas’s Hosp., S.E.—-Asst. Pathologist, SSB.
Salisbury General Infirmary —H. P., at rate of £125.
Seamen’s Christian Friend Society "Hospital Trust. —Asst. Med.
Su upt. for Hosp. in Mediterranean.
Sheffield Children’s Hospital.—H.S., at rate of £100.
Sheffield Royal Hosp.—H.S. to Ear, Nose, and Throat Dept.,
at rate of £80.
Shrewsbury, Royal Salop Infirmary.—Res. H.P., at rate of £160.
Stoke-on-Trent, North Staffordshire Royal I nfirmary.—Hon.
Aneesthetist.
aaa Esc ar Wordstey Public Assistance Institution.—Res. Asst.
Sunderland Royal Infirmary.—Two H.S.’s, each £120.
Swansea, Adelina Patti Hosp.—H.P., at rate of £150.
Swansea County Borough Mental Hosp. —Asst. M.O., £350.
Swansea General and Eye Hosp.—Cas. O., at T of £150-£175.
Taunton and Somerset Hosp.—H.S., at rate of £100.
Tunbridge Wells, Kent and Sussex ’ Hosp.— H.S. to Ear, Nose,
and Throat and Ophth. Depts., £150.
View Hosp. for Children, Tite-street, S.W.—Cas. O., at rate
200.
Walsall General Hosp.—H.P. and Res. Asst. Pathologist, at
rate of £150.
West End Hosp. for Nervous Diseases, 73, Welbeck-street, W.—
ayers Psychotherapist. Also Hon. Clin. Asst. for Out-patient
D
Westminster Hosp., Broad Sanctuary, S.W —Asst. M.O. in
X Ray and Electrical Dept.
Whitechapel Clinic, Turner-street, E.—Asst. Farhologist, £500.
Wolverhampton, New Cross Hosp. Res. Asst. M. 0O., £20
Woolwich and War Memorial Hosp., Shooter’ 8 Tilt, S.E.—
H.P. and H.S., each at rate of £100.
Worcester Royal Infirmary. —H.S. to Gynecological Dept., £140.
Also Locum Jun. H.S., £5 5s. weekly.
Y u d Hosp.—H.S. to Eye, Ear, Nose, and Throat Dept.,
York Dispensary.—Res. M.O., £175.
The Chief Inspector of Factories announces vacancies for
Certifying Factory Surgeons at Youlgreave (Derbyshire)
and Fauldhouse (West Lothian).
Ei Medical Diary
Information to be included in this column should reach us
én 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, April 20th.
General Meeting of Fellows. 5.30 P.M.
to the Fellowship.
THURSDAY.
Neurology. 8.30 P.M. Pathological Meeting.
Urology. 10 A.M. Annual General Meeting. Mr. Clifford
Morson : The Harris Operation and its Modifications.
11.30 a.m. Mr. Kenneth Walker: ‘Trans-urethral
Operations on the Prostate Gland. 2.30 P.M. Demon-
stration of museum specimens and report of experi-
aoe urinary work at the Royal College of Surgeons.
Urology. 10.15 A.M. Sir John Thomson-Walker: The
Bladder in Spinal Injuries in War. Prof. G. Grey
Turner: ‘The Place of Surgery in the Undescended
Testicle. 2.30 P.M. Operations and demonstrations at
l Saints’ Hospital, St. Paul’s Hospital, St. Peter’s
Hospital, Middlesex Hospital, and King’s College
Hospital.
Disease in Children. 5 P.M. (Cases at 4.30 P.M.) Cases
which have previously appeared before. the section
will be shown.
Ballot for election
VACANCIES.—MEDIOCAL DIARY
[APR 17, 1937 965
MEDICO-LEGAL SOCIETY.
THURSDAY, April 22nd.—8.30 P.M. (26, Portland-place, W.),
Dr. G. Roche Lynch, Dr. D. Harley, and Mr. D.
Harcourt Kitchin: The Medico- -legal Importance of
the Blood Groups with Special Reference to Non-
paternity.
CHELSEA CLINICAL SOCIETY.
TUESDAY, April 20th.—8.30 p.m. (Hotel Rembrandt,
Thurloe-place, S.W.), Mr. E. Rock Carling: The
Doctor and His Dependants. :
LECTURES, ADDRESSES, DEMONSTRATIONS, &c.
UNIVERSITY OF BIRMINGHAM.
THURSDAT, April 22nd.—4 P.M., Prof. W. N. Haworth,
» F.R.S.: The Chemistry of the Carbohydrates :
Ascortle Acid and other Water-soluble Vitamins.
(William Withering lecture.)
Baa POSTGRADUATE MEDICAL SCHOOL, Ducane-
roa
MONDAY, April 19th.—2.30 P.M., Dr. C. W. Buckley :
Arthritis.
WEDNESDAY, —2.30 P.M., Dr. J. Vaughan : Sedimentation-
rate. 3 P.M., clinical and pathological conference
(surgical). 4 P.M., Mr. J. E. H. Roberts: Surgery
of the Chest. 4.30 P.M., Dr. W. E. Gye: Experimental
Cancer Research.
THURSDAY.—Noon, clinical and pathological conference
(obstetrical and gynæcological). 2.30 P.M., Dr. Duncan
hite: Radiological Demonstration. 3. "30 P.M., Mr.
A. K. Henry: Demonstrations of the Cadaver of
Surgical Exposures. 3.30 P.M., Mr. Malcolm Donaldson :
Radiation Therapy in Gynæcology.
FRIDAY.—2 P.M., operative obstetrics. 3 P.M., clinical and
pathological conference (medical).
aily, 10 A.M. to 4 P.M., medical clinics, surgical ies
and operations, obstetrical and gynæcological clinics
and operations.
WEST LONDON HOSPITAL POST-GRADUATE COLLEGE,
Hammersmith,
MONDAY, April 19th.—10 A. M., Dr. Post: X Ray Film
Demonstration, skin clinic. 11 A. M., surgical wards.
2 P.M., operations, surgical and gynecological wards,
medical, surgical, and gyneecological clinics. 4.15 P.M.,
Mr. Green-Armytage : Endometrioma,
TUESDAY.—10 A.M., medical wards. 11 A.M., Surgical wards.
2 P.M. , operations, medical, surgical, and throat clinics.
4.15 P. -M., Mr. Woodd Walker: ‘Adhesions around
oints
WEDNESDAY.—10 A.M., children’s ward and clinic. 11 A.M.,
medical wards. 2 P.M., gyneecological operations,
medical, surgical, and eye clinics. 4.15 P.M., Mr.
Hasler: Pre-anesthetic Medication.
THURSDAY.—10 A.M. .» neurological and gyneecological
clinics. Noon, fracture clinic. 2 P.M., operations,
medical, surgical, and genito-urinary and eye clinics.
FRIDAY.—10 A. M., medical wards, skin clinic. Noon, lecture’
on treatment. 2 P. M., operations, medical, surgical,
and throat clinics.
SATURDAY.—10 A.M., children’s and surgical clinic. 11 A.M.,
medical wards.
The lectures at 4.15 P.M. are open to all medical practitioners
without fee.
FELLOWSHIP OF NNS AND POST-GRADUATE
MEDICAL ASSOCIATION, Wimpole-street, W.
MONDAY, April 19th, to ONDAY April 25th.—WEST
END HOSPITAL FOR NERVOUS DISEASES, Welbeck-
street, W. All-day course in neurology.—INFANTS
HOSPITAL, Vincent-square, S.W. Sat. and Sun.,
course in infants’ diseases.—RoyaL CANCER HOSPITAL,
Fulhbam-road, S.W. Sat. and Sun., course in cancer.—
Courses are open only to members of the Fellowship.
TAVISTOCK CLINIC, Malet-place, W.C.
TUESDAY, April 20th.—8.30 P.M., Prof. E. Kretschmer :
Heredity and-Constitution in the Ætiology of Psychic
Disorders.
WEDNESDAY,—$8.30 P.M., Prof. Kretschmer : The Structure
of the Personality in relation to Psychotherap py.
THURSDAY.—8.30 P.M., Prof. Kretschmer: Instinct and
Hysteria.
NATIONAL HOSPITAL FOR DISEASES OF THE HEART,
Westmoreland-street,
TUESDAY, April 20th. —5.30 P. M., Dr. B. T. Parsons-Smith :
Right Heart Failure.
Py Ge FOR SICK CHILDREN, Great Ormond-street,
THURSDAY, April 22nd.—2 P.M., Sir Lancelot Barrington-
Ward: Developmental Abnormalities of the Mesentery
and Gut. 3 P.M., Dr. Bertram Seas Skiagraphic.
Ap pentontes in Rickets, Scurvy, &
Out-patient Clinics daily at 10 a.m. and Ward Visits at 2 P.M.
ST. JOHN CLINIC AND INSTITUTE OF PHYSICAL
MEDICINE, 42, Ranelagh-road, S.W.
FRIDAY, April 23rd.—4.30 P.M. (St. Stephen’s Hospital),
pe mountre on of various methods of physical treat-
ment.
MANCHESTER ROYAL INFIRMARY.
TUESDAY, April 20th.—4.15 P.M., DT, Geoffrey Jefferson :
Surgery of Intracranial Aneurysms.
FRIDAY.—4.15 P.M., Dr. Crighton Branwell? Demonstration
of Medical Cases.
GLASGOW POST-GRADUATE MEDICAL ASSOCIATION.
WEDNESDAY, April 21st.—4.15 P.M. (Western Infirmary),
Dr. J. G. Macgregor-Robertson : Venereal Disease in
Men.
$
966 THE LANCET]
BLOOD PRESSURE AMONGST ABORIGINAL
ETHNIC GROUPS OF SZECHWAN
PROVINCE, WEST CHINA
By W. R' Morse, M.D. McGill, LL.D., F.A.C.S.
DIRECTOR OF THE COLLEGE OF MEDICINE AND DENTISTRY AND
HEAD OF THE DEPARTMENT OF ANATOMY, UNION
UNIVERSITY, CHENGTU, WEST OHINA; AND
Y. T. Ben, M.D.
INSTRUCTOR IN ANATOMY AT THE UNIVERSITY
THE blood pressure plays an important part in
anthropology in relation to heredity, environment,
social life, diet, attitude, stress and strain of ethnic
groups. Publications dealing with the blood pressure
of little known and isolated ethnic groups are probably
. not very extensive. Here is a report on three such
_groups,- the Chwan Miao, the Ta Hwa Miao, and
Noso (Lolo).
-~ Ten expeditions * have been made by the senior
author amongst the aboriginal ethnic groups of the
borderlands of the above province to secure anthropo-
. logical data. The blood pressure of the Chwan
Miao was taken by Y. T. Beh and that of the Ta Hwa
Miao and the Noso by Dr. L. G. Kilborn, professor of
TABLE I
Blood Pressure of the Chwan Miao
Systolic
pressure.
Diastolic
pressure.
Pulse
pressure.
NOTES, COMMENTS, AND ABSTRACTS
16—20 3 |103:5| 110 | 94/697 | 81 32°3 | 36 | 29
21-25 | 35 |111:9| 130 | 90|71°4] 81 41°9 | 61 | 22
26-30 | 34 |108°1) 130 | 90/69°7 | 91 39°2 | 65 | 20
31-35 | 13 |106'2| 120 | 90/:71°9 | 90 37°5 | 55 | 20
36-40 | 21 |107:3| 128 | 86|)71°1 | 85 37:0 | 59 | 20
41-45 | 15 |1079; 120 | 92)72°1 | 85 40°6 | 62 | 25
46-50 | 10 |107°1| 130 | 86|74°7 | 81 37°2 | 61 | 18
51-55 4 |1195) 120 |118/77°5 | 90 42°0 | 50 | 28
56-60 4 |113°0} 140 | 100/|73°8 | 92 39°8 | 48 | 35
61-65 2 |106°5| 108 | 105 |700 és 36'°5 | 38 | 35
66-70 2 |1116°0; 130 |102/72°0 | 78 44°00 | 52 | 36
Total 143 | .. = ae
Aver. .. |109°7 ‘ 72°1 38°9
Systolic Diastolic Pulse
pressure. pressure. pressure.
Number 140 Number 140 Number 140
Range .. 85-140 Range .. 40-93 Range .. 18-65
_ Age -- 21-70 Age . 21-70 Age ~- 21-70
M= 107°37 + 0°59 M= 70°56 + 0°45 M= 37°84+ 0°58
= 10°37+ 0°43 e = 789+ 0°32 o = 10°15+ 0°41
V= 967+ 0°39 V = 11°18 + 0°45 V = 26°82 + 1°08
physiology. Physical anthropological measurements
and observations were made on the above groups.
Photographs were taken, but in only one group
(the Chwan Miao) do the photographs indicate the
individuals on whom the blood pressure and the
other anthropological measurements and observations
were taken.
All of these aboriginal groups are relegated by the
pressure of the Chinese to the fastnesses of the
mountains of the provinces. The Chwan Miao
are found in Szechwan and Kweicheo; the Ta Hwa
* These ten expeditions embraced the following groups—
viz., Tibetan, Chiang, Gia Rong, Noso (Lolo) Black and White
Bones, Hsi Fan, Bo Lo Tsi, Ta Hwa Miao, Chwan Miao, and
Chung Chia. Of these groups some 1306 individuals, have been
measured and observed, but the statistical results have not
been fully worked out.
[APRIL 17, 1937
Miao chiefly in Yunnan and Kweicheo; the Noso
in Szechwan, Yunnan, and Kweicheo.
Method.—A Nicholson’s mercury, or a Tycos sphygmo-
manometer was used. The subjects were seated facing
the experimeter, and a 12 cm. cuff was applied'to the right
arm of the subjec+. The pressure in the cuff was raised
until all sounds had disappeared, and then as the pressure
in the system was lowered the first point at which sounds
reappeared was recorded as the systolic blood pressure.
As the pressure was stili further lowered the point at
which the clear sounds suddenly changed to dull and
muffled ones (so-called fourth point) was recorded as the
diastolic pressure. Readings were made at various times
of the day as they had to be taken whenever the subjects
were available.
The recording of the blood pressure was but one
item in a series of complete anthropological measure-
ments carried out by members of our expedition
into the Miao country.
The results on the Chwan Miao are set out in
Table I.
Table II shows the results on the Ta Hwa Miao .
and the results on the Noso (Lolo) are given in
Table III. .
TABLE II
` Blood Pressure of the Ta Hwa Miao
Systolic
pressure.
Diastolic
pressure.
8
dR
ka (]
Number
examined
ee or gD | es aaa | rc | eons | SEND Gee | ce ree RTD |
16-20 17 | 108 | 124 | 78 70 90 40 38
21-25 | 26 | 106 | 122 | 92 68 87 54 37
26—30 22 | 109 | 134 | 82 76 88 64 35
31-35 | 21 | 106 | 123 | 92 70 90 60 36
36-40 22 | 103 | 122 | 85 72 82 58 32
41-45 2 | 100 | 114 | 86 71 83 58 29
46—50 16 99 | 118 | 78 | 68 90 55 30
51-70 14 | 100 | 108 | 78 73 75 52 32
Total |150 | pen
Aver. e. ` 104 70 34
TABLE III
Blood Pressure of the Noso
16-20 6 98'6) 106 | 90 | 66°1 78 45 |32°1 51 22
21-25 33 | 1047| 128 | 90 |732 95 58 | 31°4 57 20
26-30 26 |107°7| 124 | 86 | 73°3 90 58 | 34°4 46 26
31-35 102°7| 130 | 86 | 73°4 88 56 |29°3 42 22
36—40 14 |101°8} 118 | 90 |71°6 90 55 | 31°4 42 20
41-45 106°3| 123 | 97 | 77°3 90 66 |307 45 17
46-50 4 | 1062| 127 | 90 | 73°2 90 63 | 33°0 37 27
51-60 6 99°6} 122 | 78 | 73°8 90 53 | 25°8 42 15
6 1 |118°0 ; 72°0 .. | 46°0 Si
Total |105 s ra a ini
Aver .. |104°5 72°8 31°7 sna
The blood pressure of these three groups is uniformly
low, the Chwan Miao being somewhat the highest.
There is no tendency towards an increase in the blood
pressure with age.
All these people live in the mountains above sea
level, the Chwan Miao at or about 3000 ft., the
Ta Hwa Miao at 7-9000 ft., and the Noso at 5—10,000 ft.
They all live in a fairly rigorous climatic environment
not subject to extremes of temperature. The location
of these groups is approximately Lat. 28°-31° N.
and Long. 100°-104°, this section being in parts of.
Szechwan, Yunnan, and Kweichow provinces. None
of these groups live in villages or cities but they
are scattered about the countryside. They are
agricultural and pastoral people; some are hunters.
In all cases the chief diet of these mountaineers is
corn and not too abundant in amount; the Chwan
THE LANCET]
Miao eat some rice. Meat is not used as a general
diet, being almost entirely limited to weddings,
funerals, and celebrations. Milk, butter, and cheese
are not used in either group. Vegetables are sparsely
eaten. They live on a restricted low diet. The
sexual life of the Miao groups is rather free amongst
themselves, except the Christians. The Noso are
not sexually free.
These groups are relatively isolated from the
Chinese, especially the Independent Noso of Szechwan.
The Miao groups are not so isolated. They are living
where might is right. All have been and the Noso
now are very antagonistic with the Chinese. The
Miao, formerly very warlike, are now subdued. The
Ta Hwa Miao are practically serfs of the Noso.
SUMMARY
This paper reports the blood pressure of three
ethnic groups as follows :—
TABLE IV
‘
Systolic | Diastolic| Pulse
Group Number: Age pressure.| pressure.| pressure.
Mean Mean. Mean. .
Chwan Miao 143 16-70 109°7 72°1 38°9
Ta Hwa Miao. 150 16-70 104°0 70°0 34°0
Noso (Lolo) .. 105 16-64 104°5 72°8 31°7
The blood pressure of the Noso and Ta Hwa Miao
does not increase with age and the Chwan Miao
only slightly so. `
REFERENCES
Kilborn, L. G. 31999) Blood Pressure of a Primitive Race,
Chin. med. J. Suppl. March, pp. 29-34.
— (1936) A Note on the Blood Pressure of a Primitive Race,
Pa spectat reference to the Miao of Kweichow, Chin. J.
ysiol.
AIR-RAID PRECAUTIONS AT PUBLIC
SCHOOLS
MEMBERS of the Medical Officers of Schools Associa-
tion met together on April 9th, under the presidency
of Dr. J. LAMBERT, to hear an address from Dr.
STUART BLACKMORE, of the air-raid precautions
department of the Home Office. Dr. Blackmore
put before them the problem set by air attack and
asked for suggestions as to how it should be solved
by those in charge of schools. Of the three kinds of
missile to be expected the first, the high-explosive
bomb, was so powerful that the effects of a direct
hit might be left out of account in devising preventive
measures. The damage done by splintering and by
the pulse-wave following the explosion could, however,
be minimised. The gravest danger was from the
incendiary bomb, which produced a temperature
of 2000° C., and was inextinguishable. From the fire-
fighting point of view, it would be useless to direct
energy to using water or chemicals on the point of
contact or the bomb, and they must be employed
on the surroundings to limit the extent of the fire.
Dr. Blackmore placed the gas bomb last because
it was the least dangerous of the three forms of air
attack, if only the mass of the people could be given
the necessary minimum of instruction and training.
Gas, if used against an unprotected and ignorant
populace, was absolutely devastating, both in pro-
ducing casualties and in ruining morale ; but against
an instructed mass of people its effects were less
to be feared than those of the high explosive and the
incendiary bomb.
It was agreed that each public school should make
suggestions suitable to its own circumstances and
situation.
NOTES, COMMENTS, AND ABSTRACTS
[APRI 17, 1937 967
PROTECTION OF MOTHERS AND CHILDREN
IN RUSSIA
BEFORE the war infant mortality in Russia was about
270 per 1000 live births, and in 1914 a third of all
deaths in Moscow were estimated to be among children
under five. Immediately after the Revolution a
department for the protection of motherhood and
infancy was set up, and the comprehensive service
it has instituted is described and illustrated in a
book entitled ‘‘ Nursery School and Parent Education
in Soviet Russia.”! According to the authors, the
State takes entire responsibility for protecting
its women and children and, though at present the
standard varies greatly between towns and country
districts, the ultimate aim is to provide adequate
intelligent care in nursery institutions for every young
child in the Union. A woman engaged in physical
work is now entitled to eight weeks’ leave before
and eight weeks after confinement, with full wages,
and the nursing mother may take half an hour after
every three and a half hours of work to feed and
attend to her baby. Consultation centres cater
both for mothers and children, and the doctor in
charge of a centre is held responsible for certain
streets, where he must visit any infants who are
seriously ill, besides those suffering from infectious
illness. Creches are of different types according
to the mother’s occupation. A factory worker takes
her baby to the creche attached to her place of work,
to remain there as long as she is on duty. Many
women are employed on collective farms, and summer
travelling creches follow them round from place
to place, the babies being kept for as many as eighteen
hours a day when necessary. Travelling in Russia
is notoriously slow, but it is enlivened for mothers
and infants by the establishment of special rooms with
nursery equipment at the larger railway stations.
A mother with a child is expected and encouraged
to break into the queue when waiting to take tickets,
and on some trains special coaches for mothers and
children are provided.
Nursery schools only cater for children up to the
age of four, but they have a strong political bias.
An account of one school shows babies of fourteen
months playing in a room with a portrait of Lenin
for their inspiration; from infancy ‘the air of
education is collectivism,’’ teachers being instructed
to think out every part of the apparatus and play-
material “in the light of the educational goals of the
State.” Furniture and equipment are carefully
designed, and the toys are exceptionally good, many
being made by peasants from the simplest materials.
Probably at times both teachers and children forget
that their institution is ‘‘a principal weapon in the
struggle for socialism in the nursery field,” and play,
like anybody else, just for the fun of the thing.
Education of parents is carried on by parent-
teacher meetings, by exhibitions, temporary and
permanent, by literature and posters. Research
departments are working in Moscow and Leningrad,
studying both normal and abnormal children under
three years of age, and special attention is devoted
to the training of deaf and dumb children.
E. MERCK’S JUBILEE REPORT
IT was in January, 1887, that the chemical works
of E. Merck in Darmstadt began to issue a summary
of ‘‘short and useful informations” about new
pharmaceutical preparations for the use of doctors
and pharmacists. It was not the firm’s first venture
of the kind because Heinrich Emanuel Merck (1794-
1855), whose portrait is attached to the jubilee
issue now before us, had already embarked on a
serial entitled ‘‘ A Cabinet of Novelties’’ and had
collaborated with Liebig, Trommsdorf, and Mohr
1 By Vera Fediaevsky, formerly Senior Scientific Worker
of the Central Institute for the Protection of Motherhood and
Infancy, in collaboration with Patty Smith Hill, Professor
Emeritus of Education, Columbia University, New York.
London: Kegan Paul, Trench, Trubner and Co., Ltd. 1936.
Pp. 265. 10s. 6d.
968 THE LANCET]
in the Annals of Pharmacy. For half a century
the Jahresbericht has appeared, giving what its
editor regards as the ‘really important” in the
pharmaceutical year. The report has contained
original articles from the firm’s own laboratories
and often contributions from outside authors, of
which one of the earliest was J. v. Mering’s ‘‘ Physio-
logical and Therapeutic Investigations on the Action
of some Morphine Derivatives.” The present volume
is prefaced by congratulatory notes from directors
of pharmacological institutes all over the world
including Heubner (Berlin), Tschirch (Bern), Krehl
(Heidelberg), Hansen (Oslo), Aschoff (Freiburg),
Marinesco (Bucharest), Eppinger (Vienna), Barger
(Edinburgh), Cesa-Bianchi (Milan), Tsi-Lung
(Shanghai), Crocco (Buenos Aires), Lebeau and
Tiffeneau (Paris). The next 170 pages contain original
contributions dealing for the most part with hormones,
vitamins, and the newer alkaloids, leaving 120 pages
for brief summaries of some 600 preparations and
drugs, with precise references to the literature.
Merck has not been unmindful of foreign readers,
for French, Russian, Spanish, and English editions
of their annual report have appeared for many years.
A general index of all 50 numbers is promised in the
near future.
PALLIATIVE TREATMENT OF CANCER
A PLEA for a different mental attitude towards
methods of treating cancer is made by Dr. B. R.
Shore.! His thesis is that to prolong life with the
greatest possible measure of physical and mental
comfort is the goal in treating all chronic non-infectious
diseases, including cancer. Shore holds that the
modern practice of classifying treated cases of
malignant disease as three-, five-, or ten-year ‘‘ cures ”’
is unfair to existing therapeutic methods which should
also be credited with the vast measure of physical and
mental relief afforded to patients who do not survive
long enough to fall within any category of “‘ cure.”
The biology of any given cancer and of the patient
suffering from it are two unknown quantities; no
patient is too ill for therapy in some form and the
prognosis is often quite uncertain. To illustrate his
point the author quotes six cases of apparently
inoperable carcinoma of breast on whom palliative
mastectomy followed by radiation was done. Three
of the six are still alive without recurrence 8 years
later; one died of recurrence after 7 years and
another after 6 years, and one died of heart disease
7 years after operation. The importance of histo-
logical diagnosis in cases of cancer is emphasised.
It is a counsel of perfection that biopsy specimens
should be of adequate size and taken from repre-
sentative portions of the growth by gentle surgical
means. Gynecologists might ask whether curettings
from a case of suspected carcinoma of the body
of the uterus may be regarded as adequate biological
material ; it would be difficult to obtain larger portions
of material in such cases without resorting to laparo-
tomy. A disturbing fact disclosed by an investiga-
tion. of 744 consecutive cancer cases admitted to
St. Luke’s Hospital, New York, to which Dr. Shore
is attached was that only 24°4 per cent. were radically
operable. In a group of 255 private patients, 53 per
cent. were radically operable, a proportion consider-
ably higher though still falling far short of perfection.
Making due allowance for other factors, the conclusion
is reached that cancer is detected earlier among the
better-to-do patients. This is what one would expect.
Prof. A. E. NaisH writes: ‘‘ My attention has
been called to recent articles in the provincial lay
press in which it is stated that a research group
is working at Sheffield University under my direction
investigating the treatment of hemophilia. I wish
to state most emphatically that these articles have
been published without my knowledge, and that,
although I have been associated with the work,
it is not being done under my direction.”’
1 Ann. Surg. March, 1937, p. 442.
BIRTHS, MARRIAGES, AND DEATHS
[APRIL 17, 1937
Births, Marriages, and Deaths
BIRTHS
BEVAN.—On April 9th, at Devonshire-place, W., the wife of
Dr. Charles E. Bevan, Colonial Medical Service, Cyprus, of
n.
GRANT NIcoL.—On April 8th, at Wimbledon, the wife of Dr.
C. Grant Nicol, of a daughter. |
eure March 31st, the wife of Dr. H. M. List, of Rochdale,
son. l
McKIsBIN.—On April 9th, at Blackheath, the wife of Major
F. McKibbin, R.A.M.C., of a son.
NEWTON PRICE.—On April 11th, at Hove, the wife of Dr. E.
Newton Price, of a son. :
O’ConnoR.—On April 8th, the wife of Dr. W. J. O'Connor,
High Wycombe, of a daughter. ;
PATERSON.—On April 4th, at Portsmouth, the wife of Dr.
Gerald Paterson, of a daughter.
PORTER.—On April 7th, at Faversham, the wife of Dr. T. W.
Herdman Porter, of a son.
THURSTON.—On April 8th, the wife of Dr. Gavin Thurston, of
Clapham Common, of a son.
WATERS.—On April 6th, the wife of Captain H.. S. Waters,
I.M.S., Presidency Surgeon, Bombay, of a daughter.
WHITE.—On April 13th, at Belsize Park-gardens, N.W., to
Sylvia, wife of Norman White, F.R.C.S.—a son.
WRIGLEY.—On April 8th, at Hamilton-terrace, N.W., the
wife of Arthur Joseph Wrigley, M.D. Lond., F.R.C.S. Eng.,
of a son.
MARRIAGES
GREGERSON—CAMPBELL.—On April 10th, at Christ Church,
Westminster, Dr. Gerald J. Gregerson, of Adelaide,
S. Australia, to Sheila, elder daughter of Mr. and Mrs.
W. R. Campbell, of Sydney, N.S.W.
WHITFIELD—DENCE.—On April 3rd, at St. Mark’s Church,
Torquay, George J. Newbold Whitfield, of Sunderland,
to Audrey Priscilla Dence, M.B. Lond., daughter of the
late Rev. A. T. Dence, formerly of Abbotskerswell, and
Mrs. Dencc, Torquay.
DEATHS
BURTON.—On April 6th, at Clifton-court, N.W., Alfred Henry
Burton, M.D., of Laxfield House, Suffolk, aged 84.
GUTHRIE.—On April 13th, at Wimbledon, Robert Lyall Guthrie,
O.B.E., M.D., C.M. Edin., Lt.-Col., R.A.M.C. (T.), Barrister-
l at-Law, Coroner, Eastern District, County of London.
JACKSON.—On April 5th, John Luke Jackson, M.B., B.Ch. Belf.,
son of the late Rev. John Jackson, D.D., Ballycastle.
LEAK.—On April 10th, at Winsford, Cheshire, Hector Leak,
M.R.C.S. Eng., in his 81st yeaf.
MurpPHY.—On April 6th, at Liphook, Hants, William Murpby,
M.B. Edin., in his 83rd year.
Prok.—On April 5th, at Bridgnorth, Salop, Awdry Peck,
M.A. Oxon., M.R.C.S. Eng., aged 89.
SMART.—On April 7th, at Liverpool, David Smart, M.B. Edin.,
V.D., Colonel, A.M.S.T., for 35 years Medical Officer in
charge Smithdown-road Hospital, Liverpool.
TIGHE.—On April 4th, at Castlerea, Co. Roscommon, Ireland,
J. . Tighe, R.C.P.I.& L.M., Surgeon-Commander,
Royal Navy (retd.), only son of Dr. J. M. Tighe, and the
late Mrs. Tighe, of Melbourne.
TURNBULL.—On April 11th, at Southsea, following an opera on,
Surgeon Captabi Hugh Prideaux Turnbull, R.N. (retd.),
of Emsworth.
N.B.—A fce of Ts. 6d. is charged for the insertion of Notices of
Births, Marriages, and Deaths.
A CONFERENCE ON PROSTITUTION.—The French
Government has introduced a Bill to abolish maisons
tolérées and to organise the fight against venereal
diseases. The International Abolitionist Federation is
taking the opportunity to organise an international
congress in Paris from May 20th to 22nd. The problems
of prostitution and venereal disease will be studied during
this congress from three points of view—legal, medical,
and moral. Dr. Veldhuyzen, director of the Wilhelmine
Hospital at Amsterdam, who will open the discussion on
the medical aspect, will describe the progress in treating
venereal diseases and explain why voluntary methods of
treatment have proved more successful than compulsory
methods. Miss Alison Neilans, general secretary of the
Association for Moral and Social Hygiene, will deal with
the effect of regulation on morality, youth, and the women
concerned. Information about the congress may be had
from the Secretariat of the Federation, 8 rue de l’Hôtel-
de-Ville, Geneva.
THE LANCET] |
[APRIL 24, 1937
ADDRESSES AND ORIGINAL ARTICLES
THE PREVENTION OF
PULMONARY TUBERCULOSIS AMONG
ADULTS IN ENGLAND
IN THE PAST AND IN THE FUTURE *
By P. M. D’Arcy Harr, M.D. Camb., F.R.C.P. Lond.
ASSISTANT PHYSICIAN TO ITY COLLEGE
HOSPITAL, LONDON
IN 1879 Dr. Milroy, the founder of this lectureship,
wrote as follows of a group of diseases that included
tuberculosis: ‘‘No question of public hygiene is
perhaps of more importance in respect alike of
individual suffering and of the welfare of communities
than the Atiology of the chronic Cachexiz.”
In spite of the discovery of the tubercle bacillus
by Koch three years later, it is clear that pulmonary
tuberculosis is still one of the major problems of
medicine. Thus at the present time it is responsible
for the deaths of about 25,000 persons annually in
England and Wales alone, a figure that amounts to
about 5 per cent. of deaths from all causes. Among
young men and women of 15-24 it causes more deaths
than any other single disease ; indeed, its death-rate
at that age is about two-thirds of that of all other
diseases taken together. It is also costly in money,
for in 1933-34 the local authorities of England and
Wales spent on their tuberculosis services nearly
£4,000,000, or 7 per cent. of their total expenditure
under the heading of public health (Ministry of
Health 1935-36). This sum represents about 2s.
per head of the population of the country. |
Tuberculosis, therefore, still presents a health
problem of great medical and economic importance.
I shall try to show that in the future, as in the past,
success in its solution is most likely to be attained by
measures of prevention. The term “preventive ”’
will be used here in a broad sense to comprise all
remedial measures other than the actual technique
of treatment. Thus it will cover the prevention of
progressive lesions after infection has taken place,
the prevention of further advance in such lesions after
their presence has been recognised, and the prevention
of their breakdown after the stage of regression is
attained.
The age of 15 will be taken as the dividing line
between the child and the adult, because it is at this
age that in England most members of the working-
class enter the labour market, suffering a radical
change in their mode of living.
Two types of pulmonary tuberculosis will be
recognised as occurring in the adult, though a hard
and fast separation between the two may in time
prove to be unjustified.
1. The first and less common type may accompany
first-infection—with its change from negative to positive
tuberculin reactivity—-when this process takes place
in adult life instead of, as is more common in urbanised
communities, in childhood. The lesions take the form of
pulmonary infiltrations around the primary focus (which
may occur in any part of the lung), enlarged tracheo-
bronchial glands, pleurisy, erythema nodosum, &c.
Because these lesions are of the kind sometimes associated
with first-infection received in childhood, the term child-
oe of tuberculosis is often applied to them also in
the $
The Milroy lectures for 1937 delivered before the Royal
college of Physicians of London on Feb. 18th and 23rd.
2. The second type is much the more common in this
country, and is: usually known as the adult type. Its
progressive lesions are due, it is usually held, to the
extension of a reinfection process that occurs peculiarly
in the apical or subapical region of the lungs of persons
already first-infected.
Many aspects of these two types of pulmonary
lesions remain obscure (for different views of patho-
genesis see Opie 1935, Blacklock 1936, Pagel 1936).
Nevertheless additions to knowledge during the past
two decades permit us to indicate fresh lines of
activity in the field of prevention of pulmonary
tuberculosis among adults.
Social Preventive Measures Applicable to the
Community
FACTORS RESPONSIBLE FOR THE TREND OF PULMONARY
TUBERCULOSIS IN ENGLAND
Mortality figures, which provide the most complete
available estimate of the past trend of pulmonary
tuberculosis, showed a satisfactory decline in all
age-groups in England from the middle of the last
century until the beginning of the present one.
Latterly, however, although the figures for most age-
groups have continued their downward course, except
during the late war, the mortality in young adults
(aged 15-24), more especially in young women, has
shown a less rapid decline. Thus for young women
the mortality in 1930-32 was only 4 per cent. lower
than in 1911, as against a reduction of 36 per cent.
for women aged 25-44. There is reason to think
that the situation is now again improving, but this
is still uncertain.
A decline in mortality from any disease may
result either, from a decrease in its morbidity or
from a fall in its case-fatality. Comparison of
mortality and morbidity figures for pulmonary
tuberculosis since 1923 shows an approximate
parallelism between the two (see Ministry of Health
1935a). If this can be assumed to be true also of
earlier periods, we arrive at the important conclusion
that the decline in mortality is probably due to the
decrease in incidence of new cases rather than to a
reduction in the case-fatality.
It is now widely accepted that the general decline
in pulmonary tuberculosis has been mainly the result
of improvement in the general social and economic
conditions of the mass of the people. Although
specific antituberculosis measures might be expected
to have played an important part in the reduction,
it is hard to determine the extent of their contribution,
at least in the case of adults. For the general decline
in mortality from pulmonary tuberculosis began
in this country before any specific measures were
taken against the disease, and has been accompanied
by a substantial decline in mortality from all other
diseases taken together. On the other hand, the
recent check in the reduction of pulmonary tuber-
culosis mortality among young adults—a check that
was not shared by the mortality from other diseases—
has occurred during a period when interest in matters
of public health in general has been greater than ever.
This serious check in the decline of tuberculosis
mortality among one of the economically most
important groups of the population has naturally
attracted much attention, and it seems of great
consequence to establish the factors responsible.
The following is a résumé of certain parts of work
in preparation by Payling Wright and myself.
R
970 THE LANCET] |
Stocks (1936) rightly points out that one must consider
not only the retarded decline in the country as a whole,
but also the differences in decline experienced from one
locality to another. He attributes the general retardation
in the age-group 15-24 to the after-effects of war-time
privations. But though such privations readily account
for the temporary rise in tuberculosis mortality both among
child and adult civilians while the war was in progress,
they cannot be accepted as a complete explanation,
since in young females, at any rate, the check in decline
in mortality began some years before 1914. To explain
the local differences in mortality decline, internal migration
of young adults in search of better economic conditions
has been advanced as an important factor by Bradford
Hill (1936); these migrants being, he believes, less likely
than non-migrants to develop pulmonary tuberculosis.
This belief in the superior health of migrants in recent
years may be disputed; and even if correct, migration
will only partly account for the local differential fall in
mortality, as indeed Bradford Hill himself is ready to
admit
It seems possible, in our view, to ascribe both the
decline in the country as a whole and the local differences
to the reaction upon health of associated social conditions,
to which, it is suggested, young adults are especially
sensitive. i
IMPORTANCE OF VARIOUS SOCIAL FACTORS IN
PULMONARY TUBERCULOSIS
(1) Nutrition and housing.—If it is true that the
trend of pulmonary tuberculosis has hitherto been
mainly the result of social measures not especially
directed to this disease, which social factors are of
major importance? According to current belief
these are housing, nutrition, and fatigue; and
clothing, heating, and hygiene.
Housing conditions affect the frequency and
intimacy of personal contact, and consequently the
spacing and dosage of droplet infection. They may
also perhaps influence individual resistance. It is
doubtful if either nutrition or fatigue has any influence
upon the actual occurrence of tuberculous infection,
which is predominantly the result of contact. On
the other hand, they probably affect the course of
the tuberculous process once infection has taken
place.
It is difficult to separate the importance of these
various individual social factors because, being to a
large extent determined by income, they are usually
correlated with one another. On Tyneside Bradbury
(1933) found a relationship between tuberculosis and
both overcrowding and undernourishment (as
judged by deficient dietary) and concluded that
both these social factors are important as causes
in tuberculosis. This agrees with the high degree
of correlation found between overcrowding and adult
pulmonary tuberculosis mortality in different localities
—#¢.g., by Hart and Wright for English county boroughs.
The separate importance of undernutrition agrees with
the clinical observation that adequate diet is important
in treatment of the disease, and also with the striking
evidence of the effects of food shortage on tuberculosis
mortality that was provided by the late war.
The rise in tuberculosis mortality then seen involved
not only belligerent countries but also some neutral
states affected by food shortage. In England and Wales
the total civilian deaths from tuberculosis during the years
1914-18 were 18,000 more than would have occurred
had the death-rate continued at the same figure as in
1914. But the worst effects were seen in Germany and
Austria, where the qualitative and quantitative reductions
in food allowance were the most extreme. It has been
estimated that Germany lost an extra 280,000 civilian
lives from tuberculosis as a result of the war and sub-
sequent economic depression (1914-27); this works out
as one person for every ten fatal military casualties.
DR. D’ARCY HART : PULMONARY TUBEROULOSIS IN ADULTS
[APRIL 24, 1937
While the main cause of the war rise is generally believed
to have been the shortage of food, the employment of
large numbers of persons in injurious trades, and over-
crowding due to shortage of fuel, may also have played
a oe part (see Beveridge 1928, Memorandum
6).
If, as seems probable, deficiencies in housing and
in nutrition predispose to pulmonary tuberculosis, it
is desirable to consider the present position of the
country with regard to each of them.
(2) Deficiencies in nutrition and possible remedies.—
It is still unknown whether shortage of any particular
food factor encourages. tuberculosis. Out of the
polemics that have surrounded the subject of nutrition,
however, is emerging a rather new conception which
may be of great importance in our future attitude
towards the prevention of tuberculosis. According
to this conception, a diet sufficient for optimal health
should be aimed at in order to maintain physique
and prevent disease (see Orr 1936, p. 12). While
the composition of such an optimal diet cannot
yet be stated with complete certainty, enough is
known of the particular functions of individual food-
stuffs apart from their energy value to be sure that
it exceeds, both in quantity and in quality, the diet
previously regarded as adequate for minimal health—
i.e., to prevent actual starvation or malnutrition in
the older sense.
The main direct evidence for the existence of suboptimal
nutrition has been provided by dietary or feeding experi-
ments in school-children and adolescents (e.g., Corry
Mann 1926, Orr 1928, Orr and Clark 1930, Leighton and
McKinlay 1930, Friend 1935). These investigations are
supported by the beneficial results of administering a
liberal diet to substandard army recruits for short periods
(see Duff Cooper 1937). These latter results are of
particular interest since the subjects are drawn from the
age-group whose tuberculosis incidence has been giving
rise to especial anxiety in recent years.
Inquiries into working-class dietaries in selected
population groups provide information from another
angle on the prevalence of suboptimal nutrition. In
some instances individual dietaries have been assessed
(Cathcart and Murray 1936, Newcastle-on-Tyne 1937),
while in others group-averages of dietaries in relation to
income have been used—a procedure that involves certain
assumptions (e.g., Orr 1936). Most of the investigators
have found their groups under examination to contain
many persons who are consuming diets which cannot
be fairly accepted as up to any reasonable optimum,
The desirability of raising the level of nutrition
in the nation is now recognised, The chief measures
put forward for securing such improvement are an
increase in food-purchasing power, education in the
apportionment of available means, and, where
necessary, direct supply of suitable nutrients as
a part of the social services. The relative emphasis
to be laid upon the first and the second of these
measures has been disputed, but a recent statement
of opinion may be quoted in this connexion :—
. “ Tt is undoubtedly true that, even if there were abundant
money for food expenditure in every household, ignorance
and stupidity would often prevent the maximum nutritional
benefits from being obtained, as they certainly do in many
of the houses of the well-to-do at present. At the same
time, it is equally certain that the limiting factor in a
large section of the community is food-purchasing power.
In any steps taken to improve the physical fitness of the
community, both aspects of this problem, the educational
and the economic, must therefore be dealt with ” (Medical
Research Council 1936).
It is clear that no amount of education will over-
come the restricted food-purchasing power of a-
substantial section of the people; for the latter an
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DR. D’ARCY HART: PULMONARY TUBERCULOSIS IN ADULTS
[APRIL 24, 1937 971
increase in real earnings or in the direct supply of
suitable nutrients is therefore an essential.
Another fundamental condition of improvement is
the availability of suitable, foodstuffs for distribution and
purchase. This is largely bound up with agriculture and
international trade, and is being studied by the League of
Nations Committee on the Problem of Nutrition, which
has (1936) issued an interim report. It is to be hoped
that the recommendations of this committee will lead to
better planning of the supply of suitable nutrients at
prices within working-class means, and will obviate in
some measure the unfortunate restriction in supplies that
have resulted from recent schemes for raising the price
levels of important internally produced foodstuffs in the
interests of a limited section of the community.
(3) Housing and ts improvement.—Though we
have no certain knowledge of what constitutes an
entirely satisfactory standard of housing in relation
to the prevention of tuberculosis, we may be sure
that for accommodation to be suitable it should
comply at least with a standard of overcrowding
such as that of the Housing Act, 1935, the survey for
which showed a substantial proportion of the popula-
tion to be living under sub-standard conditions.
This Act marks an advance in thatit encourages the
eventual reduction, by local authorities, of overcrowding
in all areas to the same standard, whatever be the amount
shown to be present by the recent survey. So far as the
prevention of tuberculosis is concerned, probably the best
indications of progress in a local ‘authority’s area after
each year’s working would be: (a) the number of persons
formerly living under overcrowded conditions who have
been rehoused during the year, expressed as a percentage
of the total number reported as overcrowded at the
time of the recent survey; and (b) the percentage of the
population still living in overcrowded conditions at the
end of the year, Such figures might give more valuable
information from the health standpoint than would the
mere number of persons rehoused, which measures the
absolute rate of improvement. It is of course essential
that rehousing should not force the tenant to reduce
expenditure on food, clothing, and other necessities beyond
the margin of safety, because of increase in rental and
fares; otherwise more harm than good may result
(McGonigle 1933, McGonigle and Kirby 1936).
FUTURE IMPROVEMENT IN STANDARD OF LIVING
We have implied that raising of the level of nutrition
and housing would help to prevent pulmonary
tuberculosis. Now housing, nutrition, and various
other factors, when integrated, determine the general
level of social conditions, or standard of living.
We could, therefore, have taken the standard of
living as a whole and discussed the indications for
its improvement. And from the influential part
_played in the past by a rising standard of living
in reducing tuberculosis in this country (see above),
together with the evidence that the mortality still differs
considerably at different social -and economic levels
(Registrar-General 1921, Greenwood 1935), we might
justifiably have concluded that the average standard
of living of the working-class is still inadequate to
provide full health, and that a continued rise would
be a preventive measure of the first importance.
And if this be true of a rise in the average level it
applies even more where living conditions are below
the average.
“The facts that in this country at least the standard
of living has improved, except where unemployment is
prolonged and acute, that knowledge of the nature of
food has increased, and that it has been possible to mitigate
hardships by regulated insurance and assistance, do not
afford reasons for relaxing efforts, but are an encourage-
ment to persevere. The problems of want are now of
manageable dimensions ” (Bowley 1936).
. result of their residential treatment.
Social Preventive Measures Applicable to
Tuberculous Families
We must now consider certain social measures,
embodied in the national tuberculosis scheme, that
are specifically directed to tuberculous persons and
their families. These operate from the time of
notification, and are concerned with the family
of the patient during his absence for residential treat-
ment, and later with himself in addition after his
return home. Their chief objects are to maintain
the standard of living of the family, to prevent
spread of the disease among its members, and to
prevent relapse. They probably confer most benefit
on persons whose condition is diagnosed before it
reaches the advanced stage, and whose lesions cease
to progress unfavourably, or begin to regress, as a
Unless bed-
rest for sufficient time to attain clinical ‘‘ cure”
comes to be found practicable as a rule for such
patients, the subsequent few years will remain a
critical period for many of them, and after-care will
continue to play perhaps as important a part as the
original form 6f treatment in determining the ultimate
prognosis. The care and after-care of these patients
and their families, rather than of advanced cases with
little hope of recovery, will be discussed here.
INFLUENCE OF ECONOMIC STATUS UPON PROGNOSIS,
AND OF PROLONGED ILLNESS UPON ECONOMIC STATUS
For a proper understanding of the functions of
social care and after-care, the influence of economic
status of the patient upon the ultimate results of
treatment must be recognised. This influence,
as judged by case-fatality, has been pointed out by
many authorities (see MacNalty 1932a, Burnet 1932),
and is supported by Bentley’s (1936a) report on the
recent experience of the London County Council
with pneumothorax treatment. There are grounds
for the view that the major function of the care and
after-care organisations is to provide for the poor
some of the more essential health facilities which the
rich are able to buy; for the effects of the presence
of a tuberculous member in wealthy families and in
the families of many sections of the working class are
often very different,
The patient of ample means, returning home from
sanatorium, can often afford to absent himself from his
duties until advised by his doctor that it is quite safe to
resume them. When he does so he is often able to arrange
that at first they shall be less arduous, or that he can
have intervals for rest and recuperation. At home he
can make special hygienic provisions and can arrange
suitable sleeping accommodation, while the standard of
living of his wife and family will not become seriously
affected by his disability provided this be not unreasonably
prolonged.
The working-class patient, after the benefit of a not
dissimilar treatment in sanatorium (which, in the case of
the London County Council area, has been free during the
past three years), returns to a home environment where
the provision of suitable hygienic arrangements may be
difficult, and of separate sleeping accommodation (see
Bentley 1936a) impossible, even under conditions that
would not constitute actual overcrowding under the 1935
Housing Act. Unless: he is fortunate enough to have
substantial savings or private sickness insurance, the
standard of living of his family will usually have become
lower than it was before his illness, and its resources will
now be further strained by the return of a non-contribu-
tory member. Unless some portion of the patient’s
wage continues, his income will eventually consist of sickness
insurance benefits, originally designed to tide over short
periods of illness, and—in the case of National Health
Insurance—these will be ae after six months,
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972 THE LANCET]
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t
[APRIL 24, 1937
This income will be unable to meet the week’s expenses
for a man, wife, and several children of school age unless
sufficient contributions are available from any additional
earners in the family, and it may therefore have to be
supplemented by private charity or by public assistance.
The dietary of the family, even if supplemented by grants
of extra milk to the children, and of extra nourishment
to their father, will usually be restricted compared with
what they were when the father was at work; and while
it may seldom become less than that regarded as adequate
to prevent gross malnutrition, it must often fall below
any reasonable standard for optimal health. Diversion of
food to the patient on sentimental grounds intensifies
risk to the remainder of the family. Under such circum-
stances the wage-earner, anxious to restore his family’s
standard of life to its former level, fearing or knowing that
his job will not continue to be kept open, or—should
he already have lost it—unwilling to risk refusing the
offer of another one, not infrequently returns to work too
soon. This is especially harmful because he has small
chance of obtaining light work, or of transferring from an
unsuitable occupation.
This gloomy picture shows how pulmonary tuber-
culosis in the primary wage-earner of a working-
class family accentuates just those social differences
between himself and the head of a wealthy household
that probably made him more liable to develop the
disease in the first instance. As Sir Arthur MacNalty
(1932d) puts it :—
** Tuberculosis ,.. occurs most frequently in persons who
are badly housed, who live under conditions of over-
crowding and whose egrnings are frequently inadequate
to secure more than the bare necessaries of life. The
occurrence of tuberculosis in its turn increases the poverty
of the family still more and the unfavourable conditions
become intensified, thus reducing the chances of recovery
for the patient and increasing the probability of the
spread of infection to other members of the household.”
It is therefore not surprising that the similar
sanatorium treatment obtained by poor and rich,
with’ its equally satisfactory immediate results, is
followed by a divergence in the subsequent course
of the disease as it affects the patient and his family..
To find the best means of mitigating these inequalities
is thus an after-care problem of the first importance.
MEASURES OF SOOIAL AFTER-CARE
Possible guiding princitples—The following points
of principle might reasonably serve as the objective.
(1) That the dietary of the patient, and also of each
member of his family in contact with him, should be
substantially higher than the minimum standard at
present regarded as sufficient to prevent clinical mal-
nutrition in the older sense, and should correspond rather
to standards for optimal health ; and that separate sleep-
ing accommodation (as defined by Bentley 1936a) and not
merely ‘‘ non-overcrowded ”’ premises should be available
for the patient.
(2) That the family income should to some extent be
related to its level before the illness of, the patient, if
he was in employment, so that he be not tempted to return
to full or unsuitable work before fit to do so.
(3) That, on the view that the prospects of cure in
slight or otherwise favourable cases of pulmonary tuber-
culosis are prejudiced by the social deterioration apt to
follow prolonged absence from remunerative work, social
expenditure on care and after-care in such cases should be
treated, for a limited period after diagnosis, as on an equal
basis with the medical expenditure on their residential
treatment.
How far are these principles being translated
into practice ? |
Basic measures.—Within the limits of the powers
assigned to them, medical officers, health visitors,
nurses, social workers, and others in the care and
after-care organisations make every effort to supply
the . basic needs of tuberculous families. Among
their contributions are preferential treatment in
rehousing, home supervision and nursing, extra
nourishment to the patient, and public assistance.
Yet only too often the good work of residential treat-
ment is speedily undone. The question therefore
arises whether wider powers should be sought.
If policy were to be developed according to the
principles just outlined, an increase in national
expenditure would probably be required. It could,
however, be argued that this would be justified
financially by a decrease in the number of failures
following residential treatment that had already
cost the community a considerable sum.
In order to provide for such increased expenditure,
it might be necessary to create a special insurance
fund for tuberculosis (and perhaps for certain other
prolonged but hopeful illnesses) administered under
National Health Insurance, or to permit local
authorities to raise their scales of assistance or to
make larger grants in kind for all members of affected
families. Some progress in this direction has already
been made: for example in Sheffield the rent due
from a tuberculous family may be paid by the local
authority after adequate rehousing has taken place.
Rehabilitation and re-employment.—Rehabilitation
and the provision of lighter or more suitable work for
tuberculous patients also form an essential though
difficult part of after-care activities. Two of the
present experimental schemes must be mentioned.
The first is the village settlement, complete with industries.
The best-known example is Papworth, so ably conducted
under Sir Pendrill Varrier-Jones. Here, and at Preston
Hall, a somewhat similar institution, patients—usually
those with intermediate or somewhat advanced disease—
settle with their families semi-permanently (Papworth
1935, London County Council 1935a). It has been
suggested (Marx 1936) that at most 10 per cent. of
ex-sanatorium patients are suitable for this type of life.
The second consists of workshops and cottages at sanatoria,
e.g. in Wales and at Birmingham—which allow patients
to remain beyond the usual course of treatment. Not
only temporary work, but also instruction in the hygiene
that should be aimed at on return home is thus available
(Powell 1926, Ministry of Health 1935c).
The wider development of settlement, workshops,
and cottages at or in connexion with the various
municipal sanatoria seems to offer a definite advance
in after-care. But even with such provisions on a
large scale, there would remain a great mass of
patients with slight or intermediate disease, and with
good or fair ultimate prospects of health, who require
rehabilitation in the city environment where their
homes are situated. Many of these patients, after
return home from sanatorium, are—for some time
at least—unfit to resume full-time work at their ,
former occupations, but would be capable of safely
undertaking short-time work or of transferring to-
fresh occupations involving less arduous duties.
It is hard to see any satisfactory solution of this.
part of the problem without the active coöperation
of industry. In the Soviet Union attempts are being
made to solve it as follows :—
In some types of case ordinary factory work is carried
out, but the hours are, say, only half-time, the balance of
pay being made up from social insurance funds. Alterna-
tively, a room may be provided with a conveyor belt
that moves at reduced speed—a scheme that seems less.
practicable. For other types of case special workshops
are provided from social funds. Stress is laid, upon the
desirability of maintaining the skilled man in skilled work,
even though his occupation within his original industrial
grade may be changed.
The medical authorities of the factories are responsible
for making these arrangements for their substandard
tuberculous workers, and for regulating their hygienic
THE LANCET]
DR. STEPHEN TAYLOR: SCURVY AND CARDITIS
[APRIL 24, 1937 973
conditions both in the factory and at home. For those
whose home conditions are unsatisfactory night sanatoria
are available in their own districts; the latter provide
meals and sleeping accommodation under better conditions
of hygiene, and with a smaller risk of conveying serious
infection to contacts (see Webb and Webb 1936,
Lancet 1936, Dobbs and Russell 1937).
In this country an arrangement whereby doctors
could secure light work in industry for their tuber-
culous patients with greater regularity than at present
would be of value, though the existence of able-
bodied unemployment would make its function
difficult; while the provision of night sanatoria
in cities for the use of workers whose home conditions
are unsatisfactory would also be useful.
Conclusions on Social Measures of Prevention
Social measures are important throughout the
course of pulmonary tuberculosis, for not only do they
influence the liability to develop progressive lesions
but they also affect the ultimate results of treatment.
Improvement in the standard of living of the mass
of the people, and extension and intensification of
the activities of the care and after-care organisations
would be valuable measures of prevention.
(To be continued)
SCURVY AND CARDITIS
By STEPHEN TAYLOR, B.Sc., M.B. Lond.
GROCERS’ COMPANY RESEARCH SCHOLAR ATTACHED TO
THE MEDICAL UNIT, ST. THOMAS’S HOSPITAL
THAT scurvy may be associated with cardiac
lesions was shown by Erdheim (1918). He dissected
many children who had died of scurvy in Vienna
in the post-war period. Two-thirds of the hearts
showed hypertrophy of the right ventricle. In the
other one-third the scurvy was only incipient or mild.
In the more severe cases both ventricles were hyper-
trophied. The older the children, the more constant
was the enlargement. Sometimes cardiac failure led
to hepatic stasis, but this was also seen in the absence
of heart changes. Findlay (1923) produced chronic
scurvy in guinea-pigs (hereinafter called ‘‘ pigs ”’)
and infected them with pneumococci and staphylo-.
cocci; post mortem he found fatty degeneration of
the heart muscle. Höjer (1924) examined the cardiac
muscle of 19 scorbutic pigs. He found the same
changes as in the skeletal muscle (hyperemia and
atrophy). Occasionally there was necrosis going on
to calcification. Changes appeared during the latent
stages of scurvy. Meyer and McCormick (1928) and
Bessey, Menten, and King (1934) found fatty degenera-
tion and hemorrhage into the heart muscle in
uninfected scurvy. Rinehart and Mettier (1934),
while stuyding the response of scorbutic pigs to intra-
dermal infection with B-hæmolytic streptococci, found
degenerative and proliferative changes in the
heart valves and muscle,
In control pigs the valves were compact, with abundant
wavy fibres; the nuclei were arranged axially, with no
visible cytoplasm. The myocardium showed occasional
accumulations of lymphocytes, with or without mono-
nuclear cells and fibroblasts. In scorbutic pigs the valves
usually showed hyaline or mucoid degeneration of the
fibres, with fragmentation and lack of axial arrangement.
Occasionally there was slight proliferation of the endo-
thelial and subendothelial cells. In the scorbutic infected
pigs, the valves, especially the mitral valve, were greatly
swollen. They showed eosinophilic hyaline areas and
paler mucoid material. Two-thirds of the heart valves
showed as well a proliferative reaction of the stroma and
subendothelial cells, giving rise to many cells with large
hyperchromic or vesicular nuclei, and some multinucleate
cells. The myocardium showed a fibrinoid degeneration
with an endothelial infiltration. Only one heart was
stained for bacteria and none were found. In a later
paper, Rinehart (1935) states that in one instance a large
number of bacteria were seen associated with a lesion.
Joint changes were also described, being again most
marked in scorbutic infected pigs. These will not,
however, be considered in this paper.
The organisms used were hemolytic streptococci
obtained from spontaneous cervical adenitis of pigs.
An intradermal injection of 0-1 c.cm. of a 24-hour glucose
veal broth culture was given into the skin of the thigh,
t g X = J ie
FIG. 1.—The normal mitral valve of the guinea-pig. (x 50.)
and local suppurative lesions developed. To protect the
average pig from scurvy, 4 c.cm. of orange juice per day —
was needed. The biggest heart lesions were seen in
infected pigs with subacute scurvy, receiving 1-2 c.cm
orange juice on alternate days.
Rinehart and Mettier considered .that the lesions in
the scorbutic infected pigs were essentially similar to
those of human rheumatic fever.
Stimson, Hedley, and Rose (1934) confirmed these
results, using hemolytic streptococci from human
lymphadenitis, but many negative findings were
recorded. They also produced similar myocardial
but no valvular lesions by intracardiac injection of
scarlatinal streptococcal toxin in scorbutic pigs.
Schultz (1936a) has carefully repeated all Rine-
hart’s work, using the same organisms. He did not
stain his heart sections for organisms,
Of his. 24 control pigs, 4 died from acute spontaneous
hemolytic streptococcal infections, and 5 of the uninfected
ones showed pericarditis. Half the controls showed slight
cardiac lesions, the commonest being subendocardial foci
of mononuclear cells, especially in the left ventricular
papillary muscles.
His scorbutic pigs, which were never completely
deprived of orange juice, showed in about half no more
than the controls. The rest showed diffuse valvular
degeneration, with shght proliferation and occasional
intense localised proliferation. Once only were there
extensive changes including myo- and peri-carditis.
His scorbutic infected pigs, also never completely
deprived of orange juice, showed, in addition to very
severe local lesions at the site of injection, the following :
1. Fibrinoid degeneration of the valves, the pericardium,
and the perivascular areas, the connective tissue becoming
homogeneous, waxy, and deeply eosinophilic. 2. A pro-
liferative reaction of large mononuclear cells and lympho-
cytes around the degenerations. 3. No endocardial
thrombi in spite of the destruction of the endothelium.
4. Rarely, a myocarditis, with necrosis of the muscle-
fibres, an increase in connective tissue cells, and, still
more rarely, a diffuse infiltration with small mononuclear
cells, and localised perivascular nodules of mononuclears
and a few polymorphs. 5. A microscopic aortitis with
mononuclear cells and a few eosinophils between the media
and adventitia. Rarely, intimal degeneration was present.
Some of the pigs were spontaneously infected with
hemolytic streptococci, and these showed more marked
lesions than the pigs with induced infections.
Schultz considers that these lesions differ from those
of human rheumatic fever in that no verrucous
974 THE LANCET]
endocarditis is seen, that the myocardial lesions do
not closely resemble Aschoff nodules, and ‘that they
are few in number and are not distributed as are the
multiple granulomata of rheumatic fever.
Objects of the Experiments
‘The experiments to be described had five objects
in view. First, to confirm the occurrence of lesions
in infected scorbutic pigs; secondly, to attempt
NO? tes ATE
y :
z
= Cs
i DaS k p >i Lay
‘oo Ug es week am. SE eye
elas i POP EEL. abe
r “for fee. wee oe
= oe haass toa S>
Py ie ~s’
te
- *¥
— pee m =
OS TN et etre
fe A es ee
art a, “i wo 7 a
ES
$ S
i 7 X Z
FIG, 2.—Mitral valvulitis (scurvy + S. viridans). (x 50.)
to produce chronic lesions by the maintenance of
chronic scurvy for as long as possible; thirdly, to
see whether organisms were present in the heart
substance ; fourthly, to see whether the Streptococcus
viridans was as efficacious as the hemolytic strepto-
coccus in producing lesions; and lastly, to see
whether full doses of orange juice after infection
would prevent or cure the lesions.
Technique
Large pigs of over 300 g. were used, as small ones
perish very rapidly on a scorbutic diet. The basal
diet was that of Rinehart and Mettier (1934); it
contains adequate supplies of all vitamins except C,
also sodium chloride and ferrous lactate. The diet
and water were given ad lib. Measured rations of.
orange juice from fresh oranges were given with a
fountain-pen filler. The pigs were weighed weekly.
For the injections, 24-hour glucose beef broth
cultures of human organisms, obtained from acute
lesions, were used; and 0'2 c.cm. was injected intra-
dermally into the thigh. The hemolytic strepto-
cocci were obtained from an appendix abscess and
the green streptococci from an infected sinus. The
hearts were opened, fixed, and embedded so that,
as far as possible, all valves were cut. Approxi-
mately every thirtieth and thirty-first section was
taken and stained with hematoxylin and eosin, and
by the Gram-Weigert method for bacteria.
It was only in the later stages of the investigation
that the possible value of post-mortem heart cultures
was realised, and these were done in 13 pigs, but the
injected organisms were never recovered and the
inconstancy of the results demonstrated the well-
known difficulty of the technique.
Results
Weight changes.—On the basal diet without orange-
juice, or with only 1 c.cm. on alternate days, the pigs
rapidly lost weight and died of scurvy in from one
to three weeks. On 4 c.cm. orange juice per day they
gained weight steadily. On 2 c.cm. orange juice on
alternate days, scurvy was maintained in a chronic
state. |
- Olinical changes—The scorbutic pigs showed the
typical clinical signs—the head held on one side (the
DR. STEPHEN TAYLOR: SCURVY AND CARDITIS
[APRIL 24, 1937
scurvy face-ache position), paralysis of the hind
limbs, loss of hair, loss of appetite, and haemorrhagic
diarrhea. Post mortem they showed subperiosteal,
adrenal, and bowel hzmorrhages, and the charac-
teristic heart changes. Only one pig showed any
local reaction at the site of injection, an intradermal
hemorrhage, i
Cardiac changes.—The control pigs showed fre-
quent subendocardial infiltrations with lymphocytes
and endothelial cells, especially in the papilary
muscles, and one showed a spontaneous pericarditis,
a confirmation of the findings of Schultz (1936a).
In the acute and chronic scorbutic pigs, whether
infected or uninfected, the lesions were essentially
the same, except that in the most chronic cases the
hearts were considerably enlarged. Macroscopically,
the mitral valves were usually thickened and puckered
or actually nodular, sometimes with hemorrhages
into the nodules. The aortic valves were sometimes
thickened and very occasionally nodular. The
papillary muscles sometimes showed hzmorrhages.
Microscopically, lesions were found at five sites:
(1) the mitral valves; (2) more rarely, the aortic
valves ; (3) the auriculo-ventricular junction (herein-
after called the A.V.J.); (4) the myocardium,
between the. muscle-fibres, especially at the apex
and in the papillary muscles, in the perivascular
spaces, and in the auricle walls; and (5) the aorta.
The cells in the lesions were polymorphs, endothelial
cells, lymphocytes, and fibroblasts. In the acute
lesions, polymorphs predominated ; in the subacute
and chronic, endothelial cells, lymphocytes, and
fibroblasts. Giant cells were never seen. Most
lesions showed interfibrillary and intercellular exudate,
and a homogeneous appearance of the connective
tissue. Small areas of calcification, as described
TABLE I—Group 1
Myocardium. A.V.J. Mitral valve.
| im | intr. | & | mm | g| $ | Inm.| 2
ô ôl & 6
A — + = JE ai E: T E
B — ++ I++) ++ |-| + - |-
c — + I++) ++ |-]+++ - |-
D | ++ + |-|] + |-]| - | +] -
E -— ~ — + -| + | ++) -
F — — — + -| = |++4! -
G — -— - - -| ++] ++] -
H — — = - -| ++] + |-
I ++ + = ++ |-| + | +4] -
J ojttet] +++|-i++++ -| + | + 4 -
K | ++ + - + -| ++] + |+
L | +++ [Fett -+++ + lett] + H
M + + -| ++ | + [+4+4/+44) -
N | ++ | +++] - — -| ++) +|-
O ++ + + + [++] + + |-
P ++ | +++] + + -|+++ -— | +
Q | ++ | ++ |+] ++
Sa ea eee S
Note.—In all Tables: P.V. infn.= Perivascular infiltration ;
I.M. infn.= Intramuscular infiltration; Infn.= tration ;
and A.V.J.= Auriculo-ventricular junction. When a pig is
mentioned outside its own group, the group number is placed
before the pig’s letter, thus Pig O of Group 1 becomes Pig 1C.
THE LANCET]
DR. STEPHEN TAYLOR: SCURVY AND CARDITIS
[APR 24, 1937 975
by Höjer (1924), were occasionally seen in the
myocardium. —
Mild degrees of congestion of the lungs and liver
were seen in some of the acutely scorbutic pigs.
Advanced degrees were, however, consistently seen
in the chronic cases. This was not due to the method
of slaughter as the pigs died naturally.
Vascular lesions in scorbutic infected pigs have
been described by Menten and King (1935). They
state that scorbutic pigs injected with diphtheria
toxin, or green or hemolytic streptococci, show
diffuse hyperplasia of the media of the arteries of
the lungs, liver, spleen, and kidneys. This is hard
to estimate as, unless the vessels are injected, the
elastic tissue of the media contracts, producing an
apparent medial thickening. This was observed in
the lungs and livers of control, scorbutic, and scor-
butic infected pigs, but one could not be certain that
it was greater in the latter two groups. The coronary
arteries of the scorbutic and scorbutic infected pigs
frequently showed organised thrombi, but without
evidence of infarction. Inflammation extending into
the wall of the coronary artery was occasionally seen.
Once, complete hyaline degeneration of the media
of the coronary artery was seen (Group 4, Pig C).
The pigs were divided into six groups :—
GROUP 1l
SCURVY ALONE
The seventeen pigs in this group received the basal
diet, supplemented in eight cases by small doses of orange
juice—never more than 2 c.cm. on alternate days. Two
pigs (B and D), having received 4 c.cm. of orange juice
on the twenty-first day, and 1 c.cm. on alternate days
from then on, survived from 44 and 73 weeks respectively—
the latter being killed. (The survival times are in all
cases from the start of the experiment.) Four (A, C, L,
and P) died within 2 weeks of starting the diet, while the
remaining eleven died within 4 weeks.
The macroscopic changes found were the typical scor-
butic lesions, hemorrhages and congestion of the lungs
(E and I), slight congestion of the liver (F, K, M, N,
and QO), and more marked congestion (O), fatty changes
-
In some hearts there were intense polymorph reactions
around the organisms. In others, reactions and organisms
were dissociated. The severest lesions were often in hearts
entirely free from organisms (I, J, and N).
Lesions somewhat resembling Aschoff nodules were
present in the myocardium of L, P, and Q, and at the
A.V.J. in L and Q (Figs. 7, 9, and 10). These lesions
were usually perivascular, with intramuscular exudate,
endothelial cells, lymphocytes, fibroblasts, and a few
> a
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. "v * xe
- ae g
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HHA 7 >
“=~ A “te
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Er drat $
RIRA Y See
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a / ‘ GEN
7 7
MFU C a n
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V, r abies LY Mae 4
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we aby tO OSS awe
s F ie N
7 a ody ae gt ee
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"A ¥ e f ee a ee
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ae *
FIG. 4.—Mitral valvulitis (scurvy + S. hemolyticus). (x 160.)
polymorphs, but no giant cells. Other myocardial lesions
were two areas of necrosis 2 and 3 mm. across, with an
intense inflammatory reaction around, but no organisms
associated (J), perivascular polymorph infiltrations (J,
Fig. 8), massive active inflammatory infiltration in the
auricle (B, C, I, J, and Q), and large planes of endothelial
cells, lymphocytes, and some polymorphs distending
apparently the ventricular lymphatic vessels (L). Organised
thrombi in the coronary artery at the A.V.J. were present
in N, O, and P. ,
The mitral valves showed varying degrees of oedema
between the fibres, exudate, hemorrhage, and diffuse
and localised cellular infiltration. In the diffuse infil-
trations, the cells were endothelials, sometimes whorled
around a small blood-vessel, and lymphocytes. The
localised infiltrations (D, F, I, M, and Q) showed a necrotic
centre with a polymorph reaction around, with some
endothelials and lymphocytes as well. The valve endo-
thelium was never destroyed and platelet deposits were
absent. A mass of fibroblasts on the auricular surface of
the valve was present in M.
GROUP 2
SCURVY PLUS S. HZ MOLYTIOCUS
For the first 3 weeks the eight pigs in this group received
basal diet only and all developed well-marked clinical
scurvy. From then on they were given 0°5 to 2 c.cm. of
orange juice on alternate days, according to the severity
TABLE II—Group 2
FIG. 3.—Aortic valvulitis a scurvy + S. hemolyticus).
x 80.
in the liver (G, K, M, O, P, and Q), and diffuse miliary
pyzmic abscesses (J, L,
liver, spleen, kidneys, and heart (J).
enlarged in three (H, K, and L) and the mitral valve
thickened and nodular in all except six (A, B, C, D, N,
and O). The microscopic heart lesions are shown in
Table I.
Organisms were present (though none had been injected)
in 8 hearts; 4 of these (L, O, P, and Q) showed other
evidence of autogenous infection — miliary pyzmic
abscesses. In C they were large Gram-positive bacilli.
In the rest they were Gram-positive cocco-bacilli, usually
in pairs and sometimes showing polar staining (Fig. 6).
Myocardium. ANJ. Mitral valve.
PIE oy I.M. |O , Oren Orga
.V.| I.M. |Organ- gan- rgan.
‘infn.| infn. | isms. Infn. isms. (Edema; Infn. | isms.
A — cam =< En n =< — ==
B | -= |+++ +++ +++) - + ++ +
cl+| = | =- [+++ 44+] - + | ++
D |+ +++ ++ [t++4] +4] ++ [44+44]/4+4+4+
N, O, P, and Q) affecting the
The heart was ©] +] — E SAU ESE ERE E
F|+| + — + - | ++ | ++ -
of their condition. G and H survived for 11 weeks, A for 7,
B and D for 6, and the rest for 4-5 weeks. After 3} weeks,
0:2 c.cm. of a 24-hour culture of S. hæmolyticus was
injected intradermally ; no local lesions developed.
The macroscopic changes found were the typical scor-
butic lesions, acute mediastinitis (B and D), congestion
of the liver and cardiac enlargement (G and H, the two
976 THE LANCET]
pigs which survived for 11 weeks), puckered nodular
mitral valves with hemorrhages (D, E, F, G, and H), and
papillary hemorrhages (D and F). The microscopic heart
lesions are shown in Table II.
Organisms were present in four in considerably greater
numbers than in the hearts of Group 1. In three the
organisms were Gram-positive cocci in pairs or short
FIG. 5.— Gram-positive coe in tip of mitral valve (scurvy +
S. hemolyticus). ( x 250.) A dense mass of organisms is seen
on the extreme left.
chains, morphologically identical with the injected strep-
tococci. The remaining organisms were Gram-positive
cocco-bacilli in pairs showing polar staining, similar to
those found in Group 1. The mass of cocci in the valve
of D is shown in Fig. 5. In C, cocci were present both
in the folds of the valve surface and in the valve
substance.
Small polymorph masses were present in the ventricular
muscle of B, D, and F. B and D showed large acute
inflammatory infiltrations in the auricular muscle. The
mitral valves showed acute inflammatory nodules in
D, E (Fig. 4), and F, while B and C showed diffuse
infiltration only. |
GROUP 3
NORMAL DIET PLUS S. HEMOLYTICUS
The three pigs in this group received the basal diet
plus 4 c.cm. orange juice daily. In the 8 weeks of the
experiment their weights steadily increased from an
average of 270 g. to an average of 490 g. After
34 weeks, 0:2 c.cm. of a 24-hour culture of S. hemolyticus
was injected intradermally. No local lesions developed
and the pigs continued to gain weight. After slaughter,
one pig showed a chronic adhesive pericarditis, such
as is commonly seen in controls (Schultz 1936a), and
an organised thrombus in one coronary artery, but no
organisms. There was no myocarditis or valvulitis.
The other two pigs showed no abnormalities,
TABLE III—Group 4
Myocardium. | AVS ; Mitral valve.
a P.V. | IM. lina: Organ- | lorgan-
infn. | infn. | isms. | totes! isme. | Etema Anis semis.
A + — — + = ++ | ++ +
B] + - | - + - + - -
C i+++| ++ = | = = ++ I++ ++
D| +, |+++) — +++ - e +++) ++
GROUP 4
SUBACUTE SCURVY PLUS S. HEHMOLYTICUS
For the first 124 weeks the pigs received 1 to 2 e.cm.
orange juice on alternate days, hemolytic streptococci
being injected as before after 4 weeks. A died after
9 weeks, and B and D after 12 weeks. C was then given
4 c.cm. orange juice daily and it gained weight steadily
for the next 5 weeks. It was then killed.
DR. STEPHEN 'TAYLOR: SCURVY AND CARDITIS
‘endothelial cells, was present in C.
[APR 24, 1937
Post mortem A and B showed typical scorbutic lesions.
The liver of C was very fatty (cf. Group 5). Those of
A, B, and D had a typical nutmeg appearance, and
histologically they showed intense congestion with fatty
change. The lungs of B and D also showed marked
congestion on histological examination. In all, the heart
was greatly enlarged and the mitral valves thickened and
nodular. In D, the aortic valve was nodular. The micro-
scopic heart lesions are shown in Table III. The organisms
in A were Gram-positive diplococci and in C and D Gram-
positive cocco-bacilli in pairs with polar staining.
Lesions somewhat resembling Aschoff nodules were
present at the A.V.J. of D. Organised thrombi were
present in the coronary arteries of C and D. The valvu-
litis was localised in A, C, and D. The aortic valve of D
showed an inflammatory mass composed of polymorphs,
lymphocytes, and endothelial cells, the valve endothelium
being intact (Fig. 3). C showed an inflammatory reaction
in the intima and adventitia of the aorta.
TABLE [V—Group 5
Myocardium. A.V.J. Mitral valve.
rae P.V. | I.M. |Organ-| nfn. |Organ- Œd Organ-
infn. | infn. | isms. isms. ome aa isms.
A + + = + = ++ + =
B + ++ = + == ++ + =
C tI tt = ++ = ++ + =
D + + — I+++) ee ++ Oia a te ol -—
GROUP 5
SCURVY PLUS S. HEMOLYTICUS, FOLLOWED BY
NORMAL DIET
The four pigs in this group received the basal diet only
for 4 weeks. Organisms were then injected as in Groups 2,
3, and 4, and thenceforward the pigs received 4 c.cm.
orange juice per day. All recovered from their scurvy
and gained weight continuously for the remaining 15 weeks
of the experiment. They were then killed. None showed
signs of scurvy post mortem. The livers were very fatty,
the hearts were all slightly enlarged, and the mitral valves
were all nodular. The microscopic heart. lesions are
shown in Table IV. In C, the ventricular lymphatic
FIG. 6.—Gram-positive cocco-bacilli with polar staining in
mitral valve (scurvy). (x 800.)
vessels were filled with cells as in 1L. Massive in-
flammatory infiltration of the auricle, mainly with
The valvular
infiltration was diffuse in A, B, and C and localised in D.
The valvulitis was endothelial and in A, B, and D
many fibroblasts were present. The valve of C contained
an immense hemorrhage. Acute inflammatory masses in
the aorta were present in B (media) and C (adventitia).
GROUP 6
SCURVY PLUS S. VIRIDANS
The four pigs in this group received the basal diet for
34 weeks. They were then injected intradermally with
0:2 c.cm. of a 24-hour glucose beef broth culture of
THE LANCET]
Streptococcus viridans. B developed a hemorrhage at the
site of injection. The others showed no local lesions.
From then on the pigs received 2 c.cm. orange juice on
alternate days. B died after 4 weeks, D after 5, and
Afafter 6. C gained weight on this dose of orange juice,
so it was reduced first to 1 c.cm., then to 0:5 c.cm. on
alternate days. It died after 13 weeks.
(x 65.)
FIG. 7.— Aschoff-like area in myocardium (scurvy).
Post mortem A, B, and C showed typical scorbutic
changes. C showed dilated auricles, congested lungs, and
a nutmeg liver, the congestion and fatty change being
confirmed histologically. A showed slight congestion of
the liver on histological examination only. D showed
miliary abscesses of the liver and spleen. All hearts
showed puckered nodular mitral valves. The microscopic
heart lesions are shown in Table V. Gram-positive diplo-
TABLE V—Group 6
i Myocardium A.V.J. Mitral valve.
K-
| BI: | EM [Organ mt. Qrean- ordema) Into. |Qrean-
A} — | ++] - ae ee |
B| + + | ++] + = + + -
C| + |++]| - ~ — + |++++| +
Di+ ++ +++] -— |+++) — |+++| + -
cocci were present in the myocardium of B, associated
with a small polymorph abscess. The valve of C (Fig. 2)
contained two short chains of streptococci and a few Gram-
positive coccobacilli in pairs with polar staining. D showed
Aschoff-like areas at the A.V.J. The valvular infiltration
was localised in A and C, and in C—the most chronic
case—endothelial cells and fibroblasts predominated.
Discussion
The findings in the six experimental groups are
summarised below.
Scurvy alone——In the absence of extraneous
infection, scurvy leads to valvulitis and myocarditis
with acute and subacute inflammatory foci. Gram-
positive cocci or bacilli were present in half the
diseased hearts, but many of the severest lesions
showed no organisms.
Scurvy plus intradermal hemolytic streptococcal
infectton leads to heart lesions differing in no essential
way, either in incidence or histology, from those
‘geen in scorbutic pigs not so infected. Two-thirds
of the hearts showed organisms, and they were more
numerous than in the scorbutic hearts—but one
DR. STEPHEN TAYLOB: SCURVY AND CARDITIS
[APRIL 24, 1937 977
group of organisms was definitely not streptococcal.
The two pigs which lived in subacute scurvy for the
last 7 of their 11 weeks both showed enlarged hearts
and very congested livers.
Intradermal hemolytic streptococcal infection in non-
scorbuttc pigs does not result in the characteristic
heart lesions seen in scorbutic pigs.
Subacute scurvy plus intradermal hemolytic strepto-
coccal infection leads to heart lesions similar to those
seen in acutely scorbutic infected pigs, but the hearts
of these pigs were large, and the livers and lungs
showed much venous congestion. The livers also
showed fatty changes. A chronic congestive cardiac
failure appears to have been produced, The one pig
which spent.the last 5 weeks of its life on an adequate
diet showed no venous congestion, and although
there was no antemortem debility—it was killed in
apparent good health—its mitral valve contained
organisms.
A full antiscorbutic diet, started immediately after
intradermal hemolytic streptococcal infection, did not
cure the cardiac lesions, These showed evidence of
chronicity, in the absence of polymorphs and the
abundance of endothelial cells, lymphocytes, and
fibroblasts. The full diet appeared to free the valves
from organisms and prevent the development of
congestive failure:
Scurvy plus intradermal Streptococcus viridans
infectton results in cardiac lesions which do not
differ from those seen in scorbutic pigs with or with-
out extraneous hemolytic streptococcal infection.
Two hearts showed organisms morphologically iden-
tical with those injected, but the second also showed
diplo-cocco-bacilli with polar staining. Once again,
subacute scurvy was associated with passive venous
congestion.
iy"
`
FIG. 8.—Perivascular infiltration (scurvy). (x 160.)
CAUSE OF THE CARDITIS
The carditis may be due to scurvy alone, to scurvy
plus autogenous infection, or to scurvy plus extrane-
ous experimental ‘infection. Since the lesions were
as common in scorbutic pigs as in scorbutic experi-
mentally infected pigs, the first or second explanation
must be true, though this does not exclude the third
possibility.
The lesions occurred in 16 pigs in which no orga-
nisms were found. But, as only about 60 of the 500
sections from each heart were examined, it is quite
possible that organisms were missed. Organisms
were present in 8 out of 17 scorbutic pigs with lesions,
and in 9 out of 13 scorbutic experimentally infected
pigs with lesions. Further, organisms were present
978 THE LANCET]
in much greater numbers in the second group. Of
the scorbutic pigs, 1 showed Gram-positive bacilli,
while 7 showed Gram-positive cocco-bacilli with
polar staining. Of the scorbutic experimentally
infected pigs, 5 showed Gram-positive cocci in pairs
or chains, while 4 showed Gram-positive cocco-
bacilli with polar staining.
If the lesions represent thé response of the scorbutic
heart to infection, it appears that the infection is in
no way specific. Bacilli and cocco-bacilli are just as,
if not more, important than streptococci.
The frequent dissociation of lesions and organisms
suggests that they may be a non-causative secondary
infection. The occurrence of organisms in a recover-
ing pig (4C) is against their being a terminal infection.
= Oonclusions.—The one specific factor associated
with the cardiac lesions is scurvy. Extraneous
infection. increases neither the incidence nor the
severity of the lesions. The lesions sometimes con-
tain organisms, even in pigs not experimentally
infected. Organisms are more frequently seen after
extraneous experimental infection. The infection
does not appear to be a terminal one, but it may
well be a secondary phenomenon of no importance.
COURSE OF THE DISEASE
All the 6 pigs with subacute or chronic scurvy
showed considerable congestion of the lungs and | Au
- FIG. 10. D-—Aschoft-like area at suriculo-ventricular junction
liver, with fatty changes in the liver. Of the rest,
1 showed moderate hepatic congestion and 6 slight.
Apparently the scorbutic carditis, if allowed to
become chronic, results in congestive cardiac failure,
Clinical cure of scurvy in 5 pigs did not result in
the disappearance of the cardiac lesions. It seems
that once the heart is damaged, vitamin C will not
FIG. 9.—Enlarged view of Fig. 7.
( x 400.)
cure it, though it does prevent the development of
congestive failure.
RELATION OF LESIONS TO RHEUMATIC CARDITIS
Grant (1936) has pointed out that there is nothing
specific for rheumatic fever in the tissue reaction
seen in the heart. All the cells seen in the Aschoff’s
nodules are met with in infections from other causes ;
for example, the large mononuclear and multinuclear
cells are seen in the vegetations of subacute bacterial
endocarditis. But in no other disease do we find
these small foci distributed throughout the fibrous
DR. STEPHEN TAYLOR: SCURVY AND CARDITIS
_ nodules.
[APRIL 24, 1937
framework of the heart and its coverings, and other
parts of the body. Experimental rheumatic fever
should therefore show not only Aschoff’s nodules
but also these nodules characteristically distributed.
This scorbutic carditis cannot claim to do.
curvy). (x
Myocardial lesions.—The commonest sites of inflam-
mation in the scorbutic pigs were at the base of
the interventricular septum and the origins of the
papillary muscles, both common sites for Aschoff’s
But in rheumatic fever the nodules are also
distributed diffusely throughout the ventricular
1 © myocardium, and this was never seen in the pigs.
Lesions bearing some morphological resemblance
to Aschoff’s nodules were seen in 6 hearts (3 in the
myocardium and 4 at the A.V.J.). These lesions
were usually perivascular or near arterioles. ‘They
showed much intramuscular exudate, in the early
stages a polymorph reaction, and in the later stages
endothelial cells, lymphocytes, and fibroblasts. Giant
cells were never seen. But many of the myocardial
lesions bore no resemblance whatever to Aschoff’s
nodules, for example, the huge areas of necrosis in
lJ, the frequent small polymorph abscesses in the
ventricles, and the massive polymorph infiltrations
in the auricles. The infiltration of the lymphatic
vessels with cells (1L and 5C) is sometimes seen in
rheumatic carditis but is not specific (Grant 1936).
Bacteria in rheumatic carditis are, to say the least,
rare. Klinge and McEwen (1932) made complete
serial sections through rheumatic hearts. Bacteria
were occasionally seen, but their position and pleo-
morphism suggested that they were of no setiological
significance.
“Valve lesions. —The valves attacked in the scorbutic
pigs were the mitral and rarely the aortic. In
rheumatic fever the aortic valve is attacked in a
somewhat higher proportion of cases. The valvulitis
in the pigs was similar to the rheumatic valvulitis,
but polymorphs were perhaps more abundant. New
blood-vessels with whorling of the endothelial cells
around, such as are seen in rheumatic valvulitis
(Coombs 1924), were common. Vegetations were,
however, never seen. But, very rarely, rheumatic
valvulitis occurs without the formation of vegeta-
tions (Grant 1936). The valvulitis is the essential
feature and the vegetations are secondary. Organ-
isms are not seen in rheumatic valvulitis. In
THE LANCET]
scorbutic valvulitis they are frequently present,
sometimes in large numbers. Yet the valvulitis bore
no morphological resemblance to human bacterial
endocarditis. .
‘Aortic lestons.—The aorta in the scorbutic pigs
sometimes showed polymorph infiltrations. These
are sometimes seen in human rheumatic carditis
(Coombs 1924, Shaw 1929).
Conclusions.—The lesions in scorbutic carditis are
those of non-specific inflammation. In so far as
rheumatic carditis shows non-specific inflammation,
they can be said to be similar. But that is all. The
scorbutic lesions often bear no resemblance to rheu-
matic lesions, and bacteria are frequently present in
the scorbutic lesions. However, neither clinically
nor morphologically does scorbutic carditis resemble
human bacterial endocarditis.
RHEUMATIC CARDITIS AN D VITAMIN C
Rinehart (1935) has pointed out that scurvy and
rheumatic fever both show joint lesions, a degenera-
tion of the collagenous tissues, and hemorrhagic
manifestations. Geographical, social, environmental,
and seasonal incidences show no convincing correla-
tion. Warner, Winterton, and Clark (1935) found no
lack of fresh fruit and vegetables in rheumatic
children, but, at Christ’s Hospital, an increase in
ee was associated with a fall in rheumatic
ever :
Years 1918-22 1923-27 1928-32
Consumption of fresh
fruit and yeseunbles
per day ; 0'21 1b. 0°29 Ib. 0°41 Ib.
Cases of rheumatic
fever.. sė -. 19 (2°4%) .. 9(1'°1%) .. 6 (075%)
But in the first five-year group the children had no
fresh butter, less total protein and fat, and more
carbohydrate.
Perry (1935) examined the vitamin-C reserves in
5 active and 6 quiescent children, and concluded that
lack of vitamin C is not an important factor in the
cause of acute rheumatism, though mild degrees of this
deficiency are not uncommon in rheumatic children.
Sendroy and Schultz (1936) found an apparent
ascorbic-acid deficiency in 8 out of 13 rheumatic
children, but in only 2 of these could it be ascribed
to a poor diet. The others vomited the test doses
or failed to absorb them. They considered that
their results did not support the C-lack hypothesis.
Schultz (1936b) found that large doses of ascorbic
acid reduced the capillary fragility in 28 children
with old rheumatism but did not reduce the incidence
of recurrent rheumatic manifestations. This seems
to show that the rheumatic children were not
completely saturated with vitamin C.
Abbasy, Hill, and Harris (1936), using 107 active
rheumatics, 88 convalescent rheumatics, 64 controls,
42 cases of active and half-active surgical tuber-
culosis, and 46 quiescent cases, found a striking
decrease in vitamin-C excretion in the active and
convalescent rheumatics and in the cases of active
tuberculosis. The cases of quiescent tuberculosis
gave normal excretions. Further, it was extremely
difficult to saturate the rheumatic children with
vitamin C. They conclude that there is in rheumatic
fever a greatly increased metabolic use of and need
for vitamin C. They accordingly recommend large
amounts of vitamin C, both therapeutically and
prophylactically.
In the unlikely event of there being any direct
relation between human rheumatic fever and the
scorbutic carditis of pigs, the results described in
this paper would suggest that vitamin C is of the
greatest prophylactic value, but of less use thera-
DR. STEPHEN TAYLOR:
[APRIL 24, 1937 979
peutically. Once the scorbutic carditis has been
produced, cure of the scurvy has no effect on the
appearance of the heart lesions, though it does
prevent the. development of congestive failure.
Further, a mild degree of scurvy (plus infection) is
enough to produce the carditis, so that the absence
of frank scurvy in rheumatic children does not
exclude the possibility of a relationship.
SCURVY AND CARDITIS
Summary
1. Guinea-pigs suffering from scurvy show in
their hearts valvulitis, myocarditis, and occasionally
pericarditis, often associated with Gram-positive
organisms, even when none has been injected.
2. The lesions are commonest in the mitral valve,
the auriculo-ventricular junction, the perivascular
areas in the myocardium, and the papillary muscles.
3. In the acute lesions polymorphs predominate ;
in the chronic lesions, endothelial cells, lymphocytes,
and fibroblasts. Exudate is usually present. Giant
cells and vegetations are never seen.
4. The lesions resemble those seen in rheumatic
carditis only in that they are both a diffuse non-
purulent carditis, without gross valvular vegetations.
5. The intradermal injection of hemolytic or green
streptococci in scorbutic guinea-pigs does not increase
the incidence or severity of the lesions, but does
increase the incidence with which organisms are
found in the heart.
6. Organisms are found in the mitral valves, the
auricular and ventricular muscle, and the auriculo-
‘ ventricular junction. They are Gram-positive bacilli,
cocco-bacilli in pairs showing polar staining, and,
when these have been injected, streptococci. They
were not recovered by heart culture. They are
usually, but not always, associated with lesions, but
many of the largest lesions contain none. This
autogenous or extraneous infection of the heart is
probably not terminal, but may be secondary and
sara hear in causing the lesions.
Infected guinea-pigs with mild subacute scurvy
ior similar lesions.
8. Infected guinea-pigs kept in a state of subacute
scurvy for a ‘considerable time develop congestion _
of the lungs and liver, the latter having a nutmeg
appearance.
9. Once the heart lesions have developed, curing the
scurvy will not remove the lesions, though it “does
prevent the development of congestive failure.
I have to thank Prof. S. J. Cowell, Prof. O. L. V. de
Wesselow, and Dr. J. Bamforth for their criticism and
encouragement, and A. James and E. J. Lucas for their
help with the animals and the histological work. The
Marmite Food Extract Company kindly supplied dried
yeast for the animals’ diet free of charge.
REFERENCES
Abbasy, M, A., Hil, N. G., and Harris, L. J. (1936) Lancet,
Bessey, O. A., Menten, M. L., and King, C. G. (1934) Proc. Soc.
exp Biol., N.Y. 31, 455
Gömbe. C. (1 §24) Rheumatic Heart sere Bristol.
Erdheim, J. (1918) Wien. klin. Pr ecler 293.
Findlay, G. Pir (1923) J. Path. Bact. 2
Grant, is . (1936) Guy’s Hosp. Rep. k 20.
Höjer, J oe (1924) Acta TEAT Stockh. ' (Suppl .), 8
Klinge, F and McEwen, C (1932) Virchows Arch. 23, 425.
Menten, M. L. and King, C. G. (1935) J. Nutrit. 10, 141.
Meyer, A. W., "and McCormick, L. M. (1928) a aies on Scurvy,
stanford University Press.
Perry, C. B. (1935) Lancet, 2, 426.
Rinehart, J F. (1935) Ann. iniern. Med. 586.
and Mettier, S. R. (1934) pemer J. Pas 10, 61.
Schultz, Mi P. 36a) Arch. Tah a , 472.
— (19 36b) q ore rhe i
Sendroy, J and Schultz, M P "(1936 ne, 15, 369.
Shaw, A. F. B. (1929) Arch. Dis. Childh.
Stimson, A. M., Healey, O. F., and Rone, pA (1934) Publ. HUh
Rep ts Wash. 11.
Warner, Ë 4-38. Winterton, F. G., and Clark, M. L. (1935) Quart.
R3
—
TUBERCULOUS GLANDS OF THE NECK
IN CHILDREN
RESULTS OF SURGICAL TREATMENT
By SIR LANCELOT BARRINGTON-WARD, K.C.V.O.,
Ch.M., F.R.C.S. Edin., F.R.C.S. Eng.
SENIOR SURGEON, HOSPITAL FOR SICK CHILDREN, GREAT ORMOND
STREET; SENIOR SURGEON, ROYAL NORTHERN HOSPITAL
RECENT articles and correspondence in the medical
journals have painted a gloomy picture of the surgical
treatment of tuberculous glands of the neck.
Dr. Brian C. Thompson, district tuberculosis officer,
seems to have been peculiarly unfortunate in his
experience and has condemned the radical surgical
treatment wholeheartedly (Lancet, 1936, 1, 946;
Brit. med. J. 1936, 2, 584). After personal observa-
tion of 44 cases, representing 55 radical operations,
he found that there was a gross, palpable, local
recurrence in 50 cases. Of 36 patients, 18 had a
persistent discharging sinus. Of 43 cases, in 21
the scars were bad. Results such as these are
grievous indeed and would certainly condemn the
surgical treatment of tuberculous glands of the neck,
if this were. the general experience of surgeons
accustomed to deal with large numbers of these cases.
These findings were so completely at variance
with my own experience that I determined to check
my position and see exactly what my results had been
at the Hospital for Sick Children, Great Ormond-
street, over a period of years. In a children’s
hospital with an age limit of 12 a prolonged follow-up
is difficult, but with the aid of an efficient almoner’s
department I was able to trace 95 cases from a
consecutive list of 133 radical operations. Of the
95 cases traced, I have personally examined 89.
The patients were examined in my out-patient clinic
and the visiting post-graduate and undergraduate
students served as a jury in assessing the cosmetic
and general results of the operation.
In estimating the success of any method of treat-
ment, the essential points to be determined are: (1)
the mortality; (2) the cure of the disease; (3) any
deformity due to the operation, structural damage,
and scarring; (4) the time taken to effect a cure.
The results in this series were as follows :—
(1) Mortahty.—There was no operative mortality.
Ninety-four of the 95 patients traced were alive and well.
One patient had died three years after the gland opera-
tion from mastoiditis and streptococcal meningitis.
It has been suggested that generalised tuberculosis some-
times follows the excision of tuberculous glands of the
neck. I have never seen this, but I have notes of 2 cases
in which scraping of a tuberculous abscess was followed
by tuberculous meningitis.
(2) Cure of the disease——Onity 1 case required any
further treatment. Eleven patients had slightly enlarged
glands in a different part of the neck from the original
operation, but the patients were not aware of them.
They were all in perfect general health.
(3) D:formity—This may arise from nerve injury
or from scarring. In no case was there any injury to
any nerve. As to scarring as critical an ‘attitude as
possible was adopted in estimating the amount of deformity.
It was decided that good should mean a scar that was
invisible or could just be detected on close inspection.
Fair should denote a scar that could be seen but not be
considered a disfigurement. Such a scar would be in
the line of one of the neck creases, but a little broad or a
little thickened. Poor should include the others—
scars (puckered, irregular, or broad), not in one of the
natural creases, scars that made it at once apparent that
an operation had been performed on the neck.
the patients were photographed as a record and these
Many of
980 THE LANCET) SIR L. BARRINGTON-WARD : TUBERCULOUS GLANDS OF THE NECK IN CHILDREN [APRIL 24, 1937
photographs can be inspected by anyone interested in
examples of what was judged good, fair, and poor.
Good.—Of the 65 patients considered good, in 26 the
scar was practically invisible.
Fair.—20 patients.
Poor.—The 4 patients in this category had suffered
from severe skin infection and sinuses before coming to
operation.
(4) Time taken to effect a cure-——The average stay in
hospital was 22 days. Three had had a discharging wound
after operation.
DISCUSSION
In the consideration of these results, it must be
remembered that the majority of the glands were
caseous ; 30 of them were complicated by an abscess
and 10 by sinuses—the result of no treatment or
treatment elsewhere. Extensive involvement of the
skin makes a good cosmetic result difficult. They
were nearly all instances of primary pharyngeal
infection and therefore presumably bovine in origin.
The tonsillar gland was usually the first infected, and
removal of the tonsils formed part of the treatment.
All the patients were children. In these respects
this series may differ from patients of all ages in
tuberculosis dispensaries, where general infection
and infection by the human bacillus may be more
prevalent.
It is not my intention in this short paper to criticise
closely alternative methods of treatment. Syrup
ferri iod., various tuberculin, X rays and radium,
actinotherapy of different kinds have their convinced
supporters who will probably remain convinced of
. their efficacy. The variety alone of the therapeutic
measures indicates some weakness in position.
Moreover, there are certain obvious disadvantages.
Non-surgical treatment may have to be prolonged
for months or years. In this series treated by
dissection the average stay in hospital was 22 days,
and the patients could then be considered cured.
The presence of discharging sinuses in ambulatory
patients cannot be considered healthy for the com-
munity. It would not be tolerated in the circles
from which private patients are drawn. After
dissection only 3 of 89 patients had a discharge from
the wound after operation, which persisted a few
weeks in one case, 2 months in another, and 6 months
in the third.
SURGICAL MANAGEMENT
The surgical management of a tuberculous gland
in the neck should be, in brief, as follows :—
When the patient is first seen, a thorough search
is made for any focus of infection. From the
anatomical situation of the gland, it is usually possible
to deduce the portal of entry—tonsils, adenoids,
scalp, teeth, or ears—and the appropriate treat-
ment, if necessary, is instituted. Rest is enjoined,
in mild cases by splinting the neck, in severer cases
by recumbency. A convalescent home may be
desirable. Every measure is taken to improve the
general resistance of the patient. The glandular
enlargement is watched and many will recede and
disappear under this treatment. The simple gland,
due to a septic infection alone, will certainly subside.
If the gland persists after 3 months of general treat-
ment, or if at any time it shows signs of softening or
enlargement, it should be excised. The removal of
a tuberculous gland intact leaves an invisible scar
and terminates the illness. If the patient is seen
for the first time with the glands caseous, with deep
or superficial abscess formation, excision is still the
best treatment. Incision and aspiration lead to
infection of the skin and a sinus in most cases. A
superficial abscess, provided that the skin is not too
widely involved, is no contra-indication to operation.
THE LANCET]
Removal of all the underlying glands from which the
abscess has arisen leads to a speedier cure. All the
glands in the affected area can and should be dis-
sected out. If every visible gland is removed, there `
will be no local recurrence. It has been often remarked
that the operation is not one to be undertaken
lightly, and should not be relegated, as so often in the
past, to a new house surgeon for a minor surgical
exercise. It requires good anesthesia, good light,
and adequate assistance. Under these conditions
the surgical removal of tuberculous glands of the
neck by dissection is one of the most satisfactory
operations in surgery.
I am greatly indebted to Mr, John TEENA F.R.C.S.,
surgical registrar to the hospital, for the great trouble
-he has taken in collecting these cases and checking my
observations.
THOROTRAST AS A CONTRAST MEDIUM
A CASE REPORT
By CLAUDE ELMAN, M.D., M.R.C.P. Lond.
_ ASSISTANT PHYSICIAN TO QUEEN MARY’S HOSPITAL, STRATFORD ;
PHYSIOIAN TO THE MARGARET-STREET HOSPITAL FOR
DISEASES OF THE CHEST, LONDON ; AND
ELIZABETH Haworta, M.R.C.S. Eng., D.M.R.E.
RADIOLOGIOAL ASSISTANT AT THE LONDON HOSPITAL
WE have observed the use and effects of Thorotrast
-in a case in which a detailed post-mortem examination
was made, and we think it may be useful to place
our investigations on record.
Thorotrast is absorbed by the reticulo- endothelial
system and is radio-opaque, so that it makes the
liver and spleen visible on radiography. It is des-
cribed by the manufacturers as a highly dispersed
thorium dioxide sol, containing 25 per cent. of
thorium dioxide, and ‘‘ miscible under any conditions
with body fluids without flocculence.”’
CLINICAL RECORD
The patient was admitted to Queen Mary’s Hospital,
Stratford, on Oct. 5th, 1934. His age was 58 and he had
been quite well until June, 1934, when he had an attack
of ‘“ pleurisy ” for which he had a week in bed. Six
weeks later he thought he had a swelling in the right
upper abdomen. His appearance was fairly healthy,
but his speech and mental processes were slow. His
teeth were carious and there was a good deal of pyorrhea. -
The tonsillar glands were enlarged. The lungs, nervous
system, and heart showed no abnormal physical signs
apart from frequent extrasystoles. The liver, however,
was greatly enlarged, reaching to within one inch of
the umbilicus, and there were three elastic swellings
palpable near the lower margin. No free fluid was apparent
in the abdominal cavity. In the out-patient department
a tentative diagnosis of secondary malignant disease
of the liver had been made, but a barium-meal examination
performed on Sept. 20th did not indicate malignant
disease of the stomach.
Pathological investigations.—A blood count (Oct. 5th)
showed 13,200 white cells per c.mm., with polymorphs
64 per cent., lymphocytes 29 per cent., monocytes 5 per
cent., eosinophils 1 per cent., and basophils 1 per cent,
(count of 300 cells). There was moderate anisocytosis
(microcytosis without megalocytosis) and some pallor
of the red cells; also occasional poikilocytosis and poly-
chromasia. The blood Wassermann reaction was negative,
and the complement-fixation test against echinococcus
antigen was also negative. An examination of the urine
(Oct. 10th) showed albumin, +; sugar, 0; there were
a few white cells and epithelial cells, but no casts or
crystals. B. coli was grown in culture. A test for occult
blood in the faces was positive.
Course of illness.—On Oct. 13th the patient developed
some coryza with pyrexia. For the next fortnight his
condition remained about the same, with a slight rise in
DRS. ELMAN AND HAWORTH : THOROTRAST AS A CONTRAST MEDIUM [APRIL 24, 1937 981
the evening temperature. It was then decided to give
75 c.cm. of thorotrast in three doses of 25 c.cm. on
alternate days. No ill effects were noticed after the first
injection on Oct. 29th, but after the injection on Nov. 2nd
the patient complained of headache and the temperature
rose to 101° F. in the evening. Various X ray photo-
graphs were taken on Nov. Ist, 3rd, 5th, and 6th. On
Nov. 13th a barium-meal radiogram showed a large
growth of the stomach, extending into the liver near the
cardia. The patient’s condition on the 17th was now
changing for the worse, and on the 18th he had a hema-
temesis of four ounces. On Nov. 19th he had obvious
melena. From that time he became progressively weaker
and he died on Dec. 3rd. |
Summary of X ray reports.—As already stated, a barium-
meal examination on Sept. 20th produced no certain
evidence of carcinoma of the stomach. On Oct. 10th
the chest and large bowel were also examined without
positive result. In making the thorotrast investigations
the technique adopted was that described by Porritt
(1934). The full course of 75 c.cm. was given. Twenty-four
hours after 25 c.cm., the liver shadow appeared well
_defined and already showed large circular non-opaque
Bat i AA AAA L 4, dio }
AS @ AAN Y os, yi at ra py “ns i
A} Th ooh Ved Ş
gé . re Mak oun Wan S jo DN
ANTA vy yy Wawa P R WG r |
ire So? Aes í chic Ty
y 5
. F f SUIF aa 2
) N WI he Nice VM ANN iE, e|
' ER ARs | UO sana Mi ~~
* SRA h EANN ted PA AINS S RENS
j $e; ENG BULLS RARAS ES “29 nt wi; e
AA t ot A Ri i $ PEAN \ { UR e ick g 4
ee N We A Tes ` t Gr ait 4 ~ ANSA KA Ae? A
> +5 Uy ve ADE L oe by ie
YY BSR > TRY CRANKS “r
Ws non 4 shg A yey “prs
Pe. SORES OL < oe ture? TIa
i CAI DA TIU s > ô ce. Gs N yi AP & Ty, i
a SRE Os 7 ATAN Ge Rom ee ih; |
IA Ka ATRL Vier HI S à oi A EEC TRON
F . é E í A ; e 4 , + y
` : i hoy hoe Cf -) Lek ot DOW ee
x F AT avi PES { % ty | q 7] ry eo |
. Whe BEAR es oe Wad Rares see WR
nat A j tays k WS) l
THEN SE PASTS eet TON ox aa’
FIG. 1.—Section of liver with secondary growth. The right
part of the section shows the liver tissue and the distended
Kupffer cells packed with thorotrast. The tumour cells on
the left contain no thorotrast. (x 100.)
areas. Maximum definition of these areas was attained
on the films taken 72 hours after 75 c.cm, had been injected,
These appearances were taken to be conclusive of meta-
stases in the liver. On Nov. 13th the stomach was again
investigated and the film now gave convincing evidence
of a new growth of the cardiac end.
POST-MORTEM FINDINGS
Large ulcerated growth in the stomach, perforating
into the ‘‘lesser sac ”?” of the peritoneum, with. localised
peritonitis ; massive secondary growths in the liver and
gastrohepatic lymph glands; small secondary growths in
the kidneys.
On section the growth proved to be a spindle-celled
sarcoma of uniform structure throughout, both in the
primary and in metastases. Thorium was present in the
reticulo-endothelial cells of all tissues and was almost
confined to these cells, except for a little in some endo-
thelial cells and fibroblasts in inflamed tissue (lesser sac),
The Kupffer cells of the liver showed the largest amount
of thorium (Figs. 1 and 2), with the spleen, bone-marrow,
and lymph glands following in that order. There was
almost none in the liver cells, and none in the tumour
cells (Fig. 2). In the lungs thorium was present only
in one of the two phagocytes in the alveolar lumina.
There was much proliferation of the Kupffer cells
of the liver and of the reticulo-endothelial cells of the
spleen. A few of the thorium-containing cells in the
latter were apparently disintegrating.
DISCUSSION
The immediate after-effects of thorotrast in this
case are difficult to assess since the patient was
gravely ill before the injection; but at least no
important immediate harm was done. The. radio-
grams obtained with it made the diagnosis of secondary
malignant disease definite, although the diagnosis
- would have been established in any case by the
second barium meal; but where the clinical evidence
of secondary growth from say a primary stomach
982 THE LANCET]
or bowel neoplasm is non-existent, thorotrast would
be useful.
The pathological evidence in this case confirms
previous observations that the reticulo-endothelial -
system is the main site of storage of thorotrast.
Five weeks after injection the substance was present
in only trifling quantities in other tissues and at that
date the amount even in the liver parenchyma was
very small. The histological picture described suggests
some damage to cells of the system together with
some proliferation. The rate of elimination is obviously
extremely important in considering the possible
risks in the use of thorotrast. The present case
can do no more than indicate that apparently very
little elimination occurred in five weeks. Examination
of the various possible excretory tissues revealed
scarcely any thorium. The largest amount was
se = y np ' pra r ; vor
P" 4 a3 PF, K ag s 7 eo 4
9 ji ER c$ S i V i la
Os TRAR, o A a) OD
Fe Se & FRE 4 i ` J" r
FEO O. arn E 2 ee a vy
e Epa % SS AN
P OD v ca ee ~ eS : x pa
aa thy E ent y <
~>™~ . < g os Fa ; Nise 3 PA
; > Coe. ed 3 / Ç G? i E,
MEE fe Oe & % at Pi i
TEER A fe “> `
FIG. 2.—Section of liver showing Kupffer cells distended with
orraa: The actual liver cells contain no thorotrast.
x
found in the lungs, but even here the quantity was
very small. If this be the main or only route of
excretion it seems likely that complete elimination
would take a very long time.
CONCLUSIONS
(1) In the single case recorded thorotrast was useful
for the radiological demonstration of a gross hepatic
lesion. (2) It produced no serious immediate reaction.
(3) On the other hand the post-mortem findings
suggested damage to the reticulo-endothelial system
and very slow elimination. (4) We are not satisfied
therefore that the use of this substance is desirable.
We are indebted to Dr. John Gray (late director of
pathology and Lyle Research Scholar at Queen Mary’s
Hospital, Stratford) for the pathological examinations and
photomicrographs.
REFERENCE
Porritt, A. E. (1934) Proc. R. Soc. Med. 27, 1295.
ACUTE DACRYOADENITIS
By B. Roco, M.B. Dubl.
HOUSE SURGEON, PRINCESS LOUISE KENSINGTON HOSPITAL
FOR CHILDREN, LONDON
INFLAMMATION of the lacrymal gland, whether
acute or subacute, is so extremely rare that I am
recording the following case :—
A girl, aged 8, presented herself at the casualty depart-
ment of the Princess Louise Hospital on Jan. 25th, 1937,
with pain and swelling in the region of the left eye. Two
days previously the parents had noticed that the upper
lid of the left eye was slightly swollen, although the
child herself did not complain, This state continued until
the following night when the child did not sleep owing
to intense pain. In the morning as the swelling was
MR. B. ROGOL : ACUTE DACRYOADENITIS
s
[APRIL 24, 1937
considerable and the pain persisted, she was brought to
hospital. Both left eyelids were swollen and it was
almost impossible to open them because of tenderness
on pressure, especially over the outer half of the upper
lid. The palpebral conjunctiva was slightly injected
and there was some chemosis. The temperature was
normal. The parents refused to allow the child to be
admitted to hospital so she was treated in the out-patient
department by instillation of Argyrol 25 per cent; twice
daily and frequent hot fomentations. After two days
the swelling was reduced sufficiently to allow of more
thorough examination. By this time the swelling appeared
to be greatest in the outer half of the upper lid. There
was tenderness on pressure over this area and a nodular
mass could be felt projecting from beneath the outer angle
of the orbit. With the eye open the edge of this mass
could be seen. Chemosis was now conspicuous and
movements of the eye itself were limited in all directions.
There was no proptosis. A diagnosis was made of acute
dacryoadenitis..
The parents now allowed the child to be admitted to
hospital (Jan. 27th). A swab was taken and the Koch-
Weeks bacillus found. Argyrol was discontinued, hot
fomentations were applied every two hours, and the eye
washed regularly with weak saline. This was continued
for four days without much improvement. The treatment
was then changed to instillation of argyrol 25 per cent.
twice daily, hot fomentations, and washing with oxy-
cyanide of mercury 1 in 10,000 every four hours. After
several days on this routine there was definite improvement.
Pain and tenderness disappeared though the gland was
still palpable. The fomentations were then discontinued
and the eye only bathed with oxycyanide of mercury
three times daily till Feb. 7th when the patient was dis-
charged with no signs or symptoms. The temperature
had remained normal throughout. The condition thus
resolved within a fortnight of its onset without suppuration,
I am indebted to Mr. A. E. A. Loosely, ophthalmic
surgeon to the hospital, for permission to publish
this case.
ORAL ADMINISTRATION OF STOVARSOL
IN CASES OF NEUROSYPHILIS
CERTIFIED AS INSANE
By R. PAKENHAM-WALSH, B.M. Oxon., D.P.M.
ASSISTANT MEDICAL OFFICER; AND
A. T. RENNIE
LABORATORY TECHNICIAN, COUNTY MENTAL HOSPITAL,
LANCASTER f
VERY little has been written about the use of
Stovarsol by mouth in the initial treatment of general
paralysis of the insane; only 3 cases have been
recorded (Cady and Aitken 1933), and in these a
mercury preparation was also given. Promising
results in this disease, however, following injections
of the sodium salt, have been described by several
authors, notably Sézary and Barbé (1930, 1936).
Stovarsol, first discovered by Ehrlich, is a pentavalent
arsenical which can be given in tablets by mouth, or by
injection of the sodium salt. It is a preparation of
3-acetylamino-4-hydroxyphenylarsonic acid which is
made in this country by Messrs. May and Baker. Other
preparations of the same compound are sold in England
under the synonyms of Kharophen (Burroughs Wellcome),
Orarsan (Boots), and Spirocid (Bayer). It is also referred
to as acetarsol (British Pharmacopeia Addendum 1936),
Ehrlich 594, Fourneau 190, Acetarsone, Goyl, Acetphe-
narsine, Orsarsol, Osvarsan, Paroxyl, Stovarsolan,
Dynarsan, Arsaphen, and Ovalcid. We give it the name
stovarsol here because the May and Baker preparation
was used throughout, having been supplied gratis by the
makers for clinical trial.
In the title of this paper caution has been taken
in the definition of the disease concerned. A certified
THE LANCET] DR, PAKENHAM-WALSH AND MR. RENNIE: STOVARSOL IN NEUROSYPHILIS [APRIL 24,1937 983
M., 40
F., 43
M., 37
Dates of
hd, =»
. 14th, 1937
Ist, 5
. 27th, 1936
. 21st, 1937
. 13th, 1936
20th, ,,
1th 4
2nd, 5
16th, „
» 30th, ,
April l 4th, ,
May 13th, ,,
5th, ,
e 22nd, 5
July 6th, ,
8th, ,
17tb, ,,
31ist, »
l4th, „
8th, »
9th, »9
23rd, »
. 21st, ,„
. 19th, 1937
1s » ”
2nd, 1936
8th, ,,
4th, ,
5th, »
wth, »
21st, 1936
Jan. 19th, 1937
Feb. Ist, .,,
April 22nd, 1936
May 6th, ,»
” Ist, ”
June sth, ,,
» 22nd, ,,
July 6th, ,,
Aug. 6th, ,
» 20th, ,,
” lst, ”
Sept. 14th, ,
” 9th, ”
Mar. 12th, 1936
» 18th, ẹ
» dlst, ,
April 14th, _,,
” “2 th, ”
May llth, ,
” nd, ”
June 9th, ,„
» 23rd, »„
July "7th, ,,
” st, ”
April 27th, 1936
ay 13th, ,
” th, ”
June 8th, ,,
” ”
July 7th, ,
lumbar puncture.
25th, 1936
y 20t
”
. 17th, ,
. 4th, 1937
- 11th, 1936
22
No. of Pandy,
. W.R. | protein
4-grain $ Lange. Cells.
tablets. (C-S-F-) at
— +++ 0°06 5554310000 8
60 +++ 0:06 5555433200 5
28 +4 0°04 5544210000 4
28 +++ 0°04 5444210000 4
28 ++4 0:035 | 5543200000 3
28 +++ 0°03 4432100000 4
28 +++ 0°03 0001321000 4
84 ++ 0:035 | 2453210000 2
28 ++ 0:03 5554431100 4
28 ++ Blood | 5555432000 | Blood
28 + + 3 5555430000 bs
56 ++3 0°04 5555421000 4
28 ++ 0°03 4443210000 2
— +++ 0:03 5554321000 16
70 +++ 0°035 | 5555432100 8
35 +++ 0°04 5554321000 10
25 +++ 0°04 5544321000 9
35 +++ 0°04 5543220000 8
35 +++ 0:045 | 5555421000 6
63 +++ 0:035 | 5555543200 4
35 +++ 0:04 5555531000 5
56 +++ 0:035 | 5555531000 4
35 +++ 0°04 5555431000 3
— +++ 0°14 5555555443 80
32 +++ 0°14 5555554310 16
39 +++ 0:09 5555554200 15
40 +++ 0°08 5555431000 10
— +++ 0°10 5555554310 72
60 +++ 0:085 | 5555542100 6
— +++ + + 5555311000 42
33 +++ ++ 5555542000 36
35 Blood | 5554320000 | Blood
35 +++ + 5542110000 12
35 +++ ++ 5544210000 8
35 +++ ++ |'5443200000 6
23 +++ ++ 5442100000 6
35 ++ + 5542100000 5
35 +++ + 5543100000 3
35 ++} + 5544320000 5
35 + 4+3 + 5443210000 7
70 +++ + 4432110000 2
35 ++} + 5433210000 3
— ++4 + 5433200000 10
35 +++ + 5433210000 5
35 +++ + 5543100000 4
35 +++ + 0123100000 2
35 +++ + 0014320000 2
105 +++ + 5555442100 4
11 +++ + 5555421000 3
35 +++ + 5555541000 2
70 + +4 + 5554210000 2
35 +++ + 5555410000 3
— +++ 0°06 5555421000 30
8 +++ 0°045 | 0001321000 13
52 +++ 0°035 | 5544311000 4
8 +++ 0°04 5554431000 30
++4 0°05 5555431000 8
— +++ 0°11 5555554310 9
68 ++ + 0°08 5555432000 | . 6
28 +++ 0°055 | 5555420000 11
— +++ | +++ | 5555543100 40
51 +++ ++ 5555431000 28
47 +++ ++ 5544310000 8
28 +++ + 5443310000 12
28 +++ ++ 1123210000 15
28 ++4 + 0123110000 9
56 +++ + 5321000000 5
28 +— + 5432110000 7
28 ++4 + 1121100000 2
28 +++ + 0001100000 2
28 + +3 + 0000210000 3
«e — +++ ++ 5555421000 54
19 +++ ++ 5555420000 52
21 +++ ++ 5554420000 30
21 +++ | Blood | 5543200000 | Blood
21 +++ 0'1 0001320000 10
21 +++ 0°07 1123430000 4
5 +++ 0°06 0001210000 7
21 0°035 | 5544321000 9
21 +++ 0°04 1112431000 2
21 +++ 0°03 4443321000 3
21 0°03 5544431000 32
— +++ + 5554200000 20
33 +++ 0°04 0001310000 20
21 +++ 0°04 0001221000 18
21 +++ 0°05 0012200000 9
21 ++} 0°03 0001221000 8
21 ++ 4 0°03 0112110000 4
22 + + P.M. | 0001110000 | P.M.
TABLE SHOWING SEROLOGICAL AND CLINICAL RESULTS OF TREATMENT OF G.P.I. BY STOVARSOL
Clinical notes.
Duration ‘several weeks.” Chinese. Elated,
garrulous and restless on admission. Settled.
down and became a useful ward-worker.
History 2 months. Melancholic, suicidal, confused,
and exhibiting mannerisms on admission.
Recovered except for hypochondriacal symp-
toms. Became a very useful worker and was
piven Tonne parole. (Now on malarial treat-
ment.
History 5 months. Improvement in gait and
speech. Stopped being noisy at night, but
otherwise no mental change.
Slight mental and physical improvement.
History 3 months. Grandiose, acutely hallucinated,
and very restless on admission. Settled down
and became a useful worker, but is still hallu-
. cinated. He is a native of Africa, and malarial
inoculation on July 10th, 1936, failed to take
after 4 weeks, during which period no stovyarsol
was given.
History 2} months. Slight mental and physical
improvement during period of oral treatment.
Stovarsol eventually stopped owing to diarrhea,
but he subsequently tolerated injections of the
sodium salt and further improvement was
obtained. First two “‘ punctures ” were cisternal.
History 6 weeks. Improving.
4 months’ history characterised by seizures. Rest-
lessness and other acute symptoms rapidly
subsided, and his speech, gait, and writing
improved, but there was a residual dementia and
fits recurred. Subsequent malarial treatment
was followed by a cessation of the fits but he
remained partially demented. o
History of poor health for 4 years and mental
symptoms for 2 years. Advanced caso on admis-
sion, almost moribund. Oral stovarsol treatment
was followed by temporary revival, but he
eventually died after seizures had become
frequent.
History 1 month. Health poor. Melancholic type.
Mental symptoms improved but he died from
an intercurrent disease. Last ‘‘ puncture ’’
cisterna] after death.
984 THE LANCET] DR. PAKENHAM-WALSH AND MR. RENNIE: STOVARSOL IN NEUROSYPHILIS [APRIL 24, 1937
TABLE SHOWING SEROLOGICAL AND CLINICAL RESULTS OF TREATMENT OF G.P.I. BY STOVARSOL.—(continued)
Sex ; Da P No. of wa Pandy.
age on ates o Sane ; protein :
admis- | lumbar puncture. fot Loren (C.S.F.) per Lange. Cells. Clinical notes.
sion. 5 cent
M., 58 | Nov. 20th, 1935 — +++ + §555431100 95 History defective. Fairly advanced case. Restless
» 29th, , 30 +++ + 5554320000 32 and violent on admission. Acute symptoms
Dec. 12th, , 30 ++ 5554310000 21 rapidly subsided during oral treatment.
Malaria three rigors later. Died..
M., 40 | Mar. 19th, 1936 — + ++ 5554210000 35 Hin ory 6 months. Restless, confused, grandiose,
» 30th, » 28 ++ ++ 5554210000 28 and hallucinated on admission. Acute symptoms
April 14th, „ 28 ++ + 5555420000 10 modified. Improvement in gait and speech.
» noh 28 at 0°08 5554210000 10 “ Income ” diminished from millions to hundreds.
May 12th, , 28 + 0°04 5544310000 10 He subsequently had a fit during a malaria]
» 25th, » 28 ++ 0°04 5544321000 8 rigor and died.
June 8th, , 28 + 0°045 | 5544310000 8
{M.,51 | July 3rd, 1936 — ++ 0:085 | 5553200000 13 History 1 year. Fairly advanced case with upward
Aug. th, , 72 +$ 0°04 5543210000 8 plantar responses. Unfit for malaria. He became
„»„ l17tb, » 21 +4 Blood | 5433100000 | Blood rapidly worse and died on Oct. 10th, 1936.
Sept. Ist, , 21 ++4 0°035 | 4433100000 8
» 5th, » 21 ++ 0°025 | 0013210000 7 l
» 29th, » 21 +4 0°03 0001421000 10
M., 56 | Nov. 9th, 1936 — +++ 0°035 | 5555421000 3 History 5 years. Advanced case on admission with
» 25th, » 40 +++ 0°04 5554431000 2 overfiow incontinence. Later passed urine when
Dec. 7th, ,, , 28 +++ 0°02 5555421000 3 requested. Relatively free from bedsores. Last
» 22nd, , 13 +++ | 002 | 5555432000 3 “puncture” cisternal after death.
Jan. 4th, 1937 15 +++ P.M. 5555543200 | P.M. —
M., 46 | Nov. 27th, 1935 — +++ + + 5555421000 | 250 One week before admission he had two seizures.
Dec. 11th, , 30 +++ + + 5443210000 40 Restless and very weak on admission. Apparently
» Brd, 3 28 ++ 4443210000 15 recovered on oral treatment, but on Jan. 21st
Jan. 6th, 1936 28 +++ + 4433200000 11 fits recurred. Subsequent pyrifer and anti-
» 20th, , 28 +++ + 4432100000 10 syphilitic treatment failed to prevent further
seizures and he died on April 15th, 1936.
F., 47 Oct. 28th, 1935 — +++ + 5555421000 21 Improved appetite and physically. `
Nov. 27th, »„ 26 +++ ++ 5555410000 20
F., 18 Oct. 5th, 1935 — dkt p 5554221000 14 Improved appetite and physically. (Congenital
Dec. 13th, ,, 49 +++ ++ 5544210000 | Blood type.)
F., 38 May 25th, 1936 — +++ 0:065 | 5555432100 18 No improvement. Treatment stopped owing to
June 12th, _,, 21 + | 0075 | 5554421000 12 intolerance. .
M., 49 | June 25th, 1936 — +++ 0°15 5555433200 13 History 9 months. Less confused, tremor of lips
July 20th, ,, 75 +++ 0°10 5555543200 6 disappeared, gait and writing improved. Residual
Aug. 6th, , 35 +++ 0°09 5555432000 6 dementia persisted after subsequent malarial
» istb, ,, 35 + + + 0°09 5555432100 5 treatment.
M.,46 | Aug. 12th, 1936 — +++ 0°09 §555543100 25 History 4 months. Although off-hand and inter-
Sept. Ist, ,, 60 +++ 0°045 | 5544332000 13 fering on admission, he became more amenable
» 15th, , 35 +++ 0°07 5554310000 7 and started work. Further improvement after
» 29th, ,, 35 +++ 0°055 | 5555421000 9 malaria.
Nov. 2nd, , 35 + +4 0°05 56544210000 9
M.,44 | Jan. 6th, 1936 — +++ + + 5555432100 54 Improvement in gait and speech. No longer
D ae 28 +++ ++ 5554321000 30 antagonistic towards daughter.
Feb. 10th, ,, 28 +++ ++ 5554321000 10
M., 55 | April 20th, 1936 — Neg ++ 5555431000 20 He became less restless, steadier on his legs, and
» 27th, » 28 > + 5555431000 12 clearer in speech. C.-S.F. on May 11th, 1936, gave
May lith, , 28 ob 5554210000 7 + + + Meinicke (C.M.H. Hereford lab.).
mental patient admitted to a mental hospital exhibit-
ing the characteristic serology of general paralysis
may still be suffering from the meningovascular
condition. Biggart (1936) states that he has found
20 per cent. of cases diagnosed as paresis to be
examples of cerebro-spinal syphilis. This distinction
is of importance when estimating the value of a new
chemotherapeutic remedy in alleged cases of general
paralysis, since one must bear in mind the readiness
with which meningovascular cases respond both
clinically and serologically to ordinary antisyphilitic
treatment. In fact it has even been suggested that
a serological response to such treatment excludes a
diagnosis of general paralysis (Greenfield and
Carmichael 1925).
-In the present investigation all the patients had
been certified as insane, and the predominance of
mental symptoms indicated that the lesions were
parenchymatous rather than interstitial. The cerebro-
spinal fluid changes, moreover, provide striking
evidence of the antisyphilitic value of an oral remedy,
whatever the exact nature of the pathological lesions
may have been.
Owing to the small number of cases in this series
and the short periods of time over which the treat-
ments extended, this paper is presented mainly as a
laboratory report, the clinical results being only
briefly indicated in the Table.
COMMENT
Stovarsol given by mouth, if its action could be
proved, would be an ideal remedy in neurosyphilis
because it is so easy to administer, especially to
out-patients. On the other hand, several toxic
effects may be produced, requiring the use of calcium
thiosulphate (McLachlan 1933) as an antidote, and
this had to be given on a few occasions in the above
series. The symptoms produced, however, are
dramatic and unlikely to escape the notice of the
nursing-staff, whereas the insidious onset of blindness,
sometimes observed with Tryparsamide, is a rare
complication (Sézary and De FTont-Réaulx 1933,
Sézary and Barbé 1932). Strict attention to dosage
probably does much to prevent ill effects, and the
scheme adopted here was to give the drug only on
alternate weeks, the number of tablets given daily
being regulated approximately by the body-weight.
Thus patients weighing 11 st., 9 st., and 7 st. would
THE LANCET]
receive 5, 4, or 3 tablets (each of 4 grains) respectively.
Slight variations of this scheme became desirable
when there were complications, but in only two
cases did it become necessary to stop the treatment
altogether for this reason. As a rule, however, the
stovarsol was stopped on account of malarial inocula-
tion. In some cases it was used later to terminate
the induced fever, but its action was found to be less
prompt than that of quinine.
A comparison of the data set out in our Table
with those from a control series of untreated cases
is impracticable, but two papers (Barbé and Sézary
1924, Targowla 1924) on the spontaneous modifica-
tions of the cerebro-spinal fluid in general paralysis
make it evident that consistent changes towards the
normal must be attributed to the treatment. More-
over, the results compare very favourably with the
laboratory reports following treatment with malaria
(Grant and Silverston 1924) or tryparsamide (Lorenz
and others 1923, Bedford and Fleming 1928), both
of which methods appear to be standing the test of
time. The paretic curve, however, appears to have
been relatively stable when other specific drugs have
been given in the absence of induced pyrexia
(Fordyce 1926, Halloran 1924, Hearn 1922, Yorke
and Murgatroyd 1936, Stokes, Miller, and Beerman,
1931).
The Table illustrates to some extent the different
stages of the “ übergangsbefund ” referred to by
Dattner (1933, 1935)—namely, successive return
of first the cell count, then the protein, and finally
the colloidal reactions to normal as the result of treat-
ment. It will also be noted that slight reduction in
the strength of the Wassermann reaction has been
recorded in some cases.
ROYAL SOCIETY OF MEDICINE: RADIOLOGY
[APRIL 24, 1937 985
CONCLUSION
The serological results in 22 cases of general
paralysis treated with stovarsol by mouth warrant
further trial of this method. The clinical results,
although favourable in some cases, do not at present
justify any conclusions.
Our thanks are due to Dr. R. P. Sephton (medical
superintendent) and Dr. J. D. Silverston (deputy medical
superintendent) for their kind assistance and permission
to submit this work for publication; to Messrs. May and
Baker for providing the stovarsol; and to Mr. G. Hannah,
who carried out valuable work during the investigations.
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Barbé, A., and Sézary, A. (1924) Rev. neurol. 31
Bedford, P. W. and d Fleming, G G. W. T. H. (1988) Rep. Ba Contr.
Lunacy, Lo
15
Biggart X ; n. (1 936). ° Pathology of the Nervous System,
urgh.
Cady, L. D., and Aitken, L. F. (1933) Urol. cutan. Rev. 37,
Dattner, B. (1933) Moderne J herapis der Neurosyphilis, Vienna.
(1935) Klin. W schr. 161.
Fordyce, J. A. een The Himan ‘Cerebro- spinal Fluid, New
T ori; pr 507, 5 514.
Grant, A and Beeston. J. D. (1924) Lancet, 1, 540.
Greenfield Ry G., and Carmichael, E. (1925) The Cerebro-
spinal ue in Clinical Diagnosis, Tondon D 54.
HA oran R. D. (1924) Boston med. surg. J. 190, ba.
Hearn, R , (1922) Brit. med. J. 2, 37.
Lorenz, Loevenhart, - S., Bleckwenn, W. J., and
Hodges, F ¥. J. eae Amer. med. Aes. 80, 1497.
McLachlan, "A. E. W. (1933) Brit. med. J. 916.
Sézary, A., and Barbé, A. tios (930) Les aate modernes de
la 'paralysie générale
32) Bull. Soc. méd, Hôp. Paris, 48, 388.
1936) Int. Clin. 130.
nd De Font-Réaulx, B. (1933) Ann. Derm. Syph., Paris,
4, 289.
Stokes, J. H., Miller, T. H., and Beerman, H. (1931) Arch. Derm.
Syph., N.Y. 23, 624.
Targowla, M. R. (1824) Bull. sag méd. Hôp. Paris, ‘o, 1537.
Yorke, W , and Murgatroyd, F. (1936) Brit. med. J. 1, 1042.
MEDICAL SOCIETIES
ROYAL SOCIETY OF MEDICINE
SECTION OF RADIOLOGY
AT a meeting of this section held on April 16th,
the chair was taken by Dr. DouGLAS WEBSTER, the
president, and Dr. HARRISON ORTON read a paper
prepared by Dr. CoURTNEY GAGE on some of the less
common lesions and special methods of
Investigation of the Alimentary Tract
and the influence of adjacent organs. Dr. Gage had
first considered sarcoma of the stomach, which he
believed could be distinguished from carcinoma when
it was of the sessile type of myosarcoma growing into
the lumen; the prognosis of this type was excellent.
Myosarcomata might protrude into the lumen or
burrow into the wall and distort the organ like an
extrinsic growth. These growths, like sarcoma as a
whole, might appear at any age between 8 and 80,
being commonest about 40, though the peak for
lymphosarcoma came earlier. They most often
originated close to but not on the curvature, and did ©
not cause obstruction at either orifice. They were
liable to degeneration and might become nodular
from cyst formation. Pain might be prominent but
cachexia and anemia were less marked than in
carcinoma. Bleeding was rare except from the
myosarcoma projecting into the lumen; the radio-
logist was responsible for diagnosing these removable
growths. Malignancy was low. The shape was that
of a slightly squashed sphere or tangerine; the
tumour might be pedunculated or sessile. Rupture
through central necrosis produced a single deep
bleeding ulcer. Barium was trapped between the
tumour and the gastric wall, causing a characteristic
picture. Rugs were pushed away on either side
and smoothed out over the tumour, smooth and
regular if not ulcerated. Peristalsis would pass
over a pedunculated tumour and go right up to a
sessile one.
Retroperitoneal hernias, especially those into the
duodeno-jejunal fossa, were Dr. Gage’s next subject.
They were, he thought, more common than the
literature indicated, and were not always diagnosed as
the cause of duodenal ileus. Lord Moynihan had
described nine fossæ in this region, but they could
not be differentiated radiologically. Symptoms of
obstruction varied from occasional colic to an acute
emergency. Every case of duodenal ileus extending
to the left of the midline should be regarded as of
grave import and examined in detail. The intestine
might appear as if wholly enclosed within a bag.
Smaller ones might show only stasis in a knuckle of
gut near the junction. Differentiation from diver-
ticulum was easy; the barium shadow was not
uniform, and the gut line was continuous. Nor was
the site a common one for diverticulum. Unusual
causes of duodenal ileus included annular carcinoma
of the third part of the duodenum and carcinoma
just beyond the junction.
Crohn’s disease had been described under various
titles before its entity had been established by Crohn
and his colleagues. The common site was the
terminal ileum, but the condition might occur else-
where. Non-specific chronic inflammatory granu-
loma of the intestine was the best title. It was a
multiple lesion, usually found in young adults and in
986 THE LANCET]
ROYAL SOCIETY OF MEDICINE: RADIOLOGY
[APRIL 24, 1937
males but recorded in both sexes and many ages.
The part was increased in size, rather rigid and firm,
presenting a sausage-like tumour. Granulation tissue
was found in all layers of the wall. The mucosa
might ulcerate and perforate, or be so swollen as to
cause obstruction. The clinical picture varied with
the site and the presence of acute, subacute, or
chronic inflammation or obstruction. Acute cases
suggested appendicitis. The string sign might be
seen in radiological examinations of chronic cases.
Examination of the small intestine required a special
technique. Linear ulceration of the mucosa along the
mesenteric borger with tendency to perforate there
was the most characteristic sign if it could be shown
up radiologically as serrations. Adhesions were
uncommon, even with mesenteric abscess. The
thickened gut might be freely angulated on
the cecal wall or might even indent it, proving
the freedom of the cecum from involvement.
Ascaris lumbricoides could be demonstrated by
hourly radiograms, the opaque food filling the gut
of the worm.
Dr. S. COCHRANE SHANKS pointed out that unusual
methods were essentially experimental and difficult
to assess. The true lateral view, with air as the
medium and the patient blowing his nose, was a
valuable technique for the pharynx. Msophageal
mucosæ might be difficult to demonstrate, but for
varices a thick barium-water cream was best. For
the stomach a useful medium was a thick colloidal
barium-water cream, which mixed better with the
juice and gave a better coating than tragacanth mix-
tures. Air-inflation might give a good picture of
polyposis and fundal tumours, but was contra-
indicated in gastric ulcer from fear of perforation.
For fundal tumours the gas bulb was sufficient.
Spasm could be counteracted by benzamine sulphate.
The pancreas was difficult to examine and a number
of methods might be needed according to the lesion.
Barium enemata might give evidence of steatorrhea
in chronic pancreatitis. Twining used the barium
meal, taking lateral views of the supine patient to
show the posterior incisura—a triangular filling defect
—produced by the normal pancreas, and the influence
of tumours on it. Gastric inflation might be used in
pancreatic investigation to study the space between
stomach and spine, but Twining’s method was the
better. Cases of acute obstruction should be radio-
graphed lying supine in bed with the Schonander
grid, which showed fluid levels well.
The small intestine was generally well seen in the
prone view, but sometimes Gage’s technique was
needed: a small barium-water suspension meal was
given (4 0z.) and the patient kept prone throughout
the five or six hours of the examination. This kept
the distribution even. Radiograms were taken hourly
in full inspiration. Another of Gage’s methods was
to fill the colon per anum and inject lipiodol through
a urethral syringe to show up fistule. For gastro-
colic fistula the enema method was better than the
meal, as the flooding of the stomach with the enema
was conclusive. Stierlin’s sign was supposed to be
due to a spasm of the cecum but might be partly
due to organic narrowing; the meal should therefore
be followed by an enema, when the spasm might
relax. The triple contrast method for study of the
colonic mucosa must be preceded by complete
evacuation, for which the Sude chair was the best
irrigation method. A colloidal preparation was the
best. The thorium three-stage enema was a variant.
Thorium deposited better than barium in the colonic
mucosa. As little of the medium as possible should
be given, and that intermittently. There were many
failures. No deposition or irregular deposition
might result, or the bowel might fail to empty.
Pitressin helped to. produce emptying. The appear-
ances of the first stage were those of the ordinary
enema, except that the colon was less distended.
After the vacuation the colon was plicated, showing
haustration, and tranverse and longitudinal plication.
An irritable colon showed small plice; asterisk or
honeycomb pattern appeared in polyposis or diver-
ticulitis, and absence of plice in grave ulcerative
-colitis or neoplasm. After the air injection the
calibre, contour, and anterior and posterior walls
en face should be observed.
Dr. R. S. PATERSON said that anatomical variations
were most often due to failure to descend or to
rotate. Faulty fixation might produce hyper-
mobility. Intussusception was usually associated
with a polyp or small growth in adults and was
revealed by sudden arrest of the enema at the
tumour, tailing off of the shadow into a fork, and
sometimes a thin streak of barium through the
intussusception. The barium enema in some cases
cured the condition. Simple colitis in the acute
stage might make the bowel too irritable to retain
the enema; the lumen was much narrowed, and the
line of barium might be no thicker than a lead pencil.
Accurate pictures of the mucosa, if obtainable, gave
a characteristic tufted pattern. In more chronic
forms the spasticity and irritability became reduced
and the colon appeared as a parallel-walled tube
with no haustra. Often the enema flowed unusually
quickly. Notching had been described as repre-
senting ulcer craters, but was an unusual finding.
The diagnosis of colitis was really clinical. Polyps
might occur anywhere, and vary from a large single
one, causing filling defect, -to a condition of polyposis
which gave a characteristic marbled shadow effect
beautifully shown by the double contrast method.
Certain foods gave an identical appearance, and
retention of fæces also caused diagnostic errors ;
preparation for the enema should therefore be very
thorough. In conclusion, Dr. Paterson showed radio-
grams of a case where a barium enema very satis-
factorily converted a breech presentation into a
vertex.
Dr. G. B. BusH spoke of displacements due to
extrinsic causes below the diaphragm. Routine
investigation would sometimes reveal unsuspected
enlargements under the costal margin, in the pelvis,
or in obese patients. The examiner must appreciate
the wide normal variations and must know the
anatomy of the peritoneum and the abdominal
cavity and recesses. Enlargements of the spleen
might displace the stomach and cause an indentation
resembling new growth of the greater curvature ;
they also pushed the splenic flexure down. Renal
tumours had variable effects on the stomach ; a large
growth might push the stomach down and to the
left and indent the lesser curvature, and also displace
the descending colon forwards and inwards, without
affecting the flexure. Retroperitoneal neoplasms dis-
placed the stomach. Enlargements of the head of
the pancreas—cysts or growth—splayed out the curve
of the duodenum. Enlargements of the liver depressed
the duodenum: and were unmistakeable. The gall-
bladder was occasionally displaced by a liver cyst.
Many tumours affected the transverse colon and
flexures. Pelvic swellings gave interesting displace-
ments of the mobile sigmoid, but reduction in its
mobility must be demonstrated to verify true dis-
placement. Pregnancy had little effect on the
sigmoid because the uterus at first enlarged at right
angles to the plane on which the colon was visualised.
THE LANCET]
Ovarian cysts pushed the sigmoid up and uncurled
the S-bend. An enormous lipoma originating under
the diaphragm had displaced the stomach and colon
right over to the right side.
‘LIVERPOOL MEDICAL INSTITUTION
AT a meeting of this society on March 18th, with
Prof. R. E. KELLY, the president, in the chair, a
Paper on Lobectomy
was read by Mr. HucH Rew. He outlined the common
indications and complications of lobectomy, and
illustrated the technique by means of a colour film.
Only recently, he said, had the mortality of this
operation been so lowered as to bring it within the
region of practical surgery. Brunn had described
the one-stage operation in 1929, and although various
refinements had been added, his fundamental
principles had not been altered, and this was the
method adopted by Mr. Reid himself. He pointed
out, however, that the one-stage operation had not
been accepted by everyone for every case of lobec-
tomy. Alexander, for instance, had made out a very
good case for the two-stage method, particularly
as regards complications. The greatest field for
Brunn’s operation was in bronchiectasis and in
carcinoma of the lung. It had been shown that if the
whole lung was removed from one side, the empty
cavity filled up with a reticulated fibrin, while the
remaining lung increased in size by hyperplasia
and hypertrophy without emphysema, the medias-
tinum being pushed over, the ribs on the affected
side falling in, and the diaphragm rising in an attempt
to obliterate the cavity. If only one lobe was removed,
it was surprising to notice that after a few days the
remaining part of the’ lung had enlarged to obliterate
the cavity completely.
Dr. N. B. Capron spoke of the great benefit that
a patient of his had received from the operation
described, and referred to other cases in which still
more extensive lobectomy had been successfully
performed. The cases required careful diagnosis and
selection, with full investigation of the supposedly
unaffected lobes, in order to avoid disappointments.
A satisfactory course of medical treatment with
postural drainage should be given a thorough trial
before operation was undertaken. The ideal was, of
course, to prevent bronchiectasis whenever possible, and
more positive efforts should be made to attain this.
Dr. ROBERT CooPE agreed that to advise lobectomy
was a serious responsibility. The physician in charge
of a patient with bronchiectasis was in a difficulty.
On the one hand, the operation was a severe one, with
a high risk—though with the development of their
technique surgeons skilled in lung surgery were now
achieving far better results, especially in the young.
On the other hand, the natural history of the disease
made it certain that many a patient with bronchi-
ectasis, though reasonably well at the moment, would
in perhaps five or ten years time be a distress to
himself and to those about him. To wait until the
patient and his friends were desperate before advising
operation was fair to neither patient nor surgeon.
By that time an originally unilateral bronchiectasis
might have become bilateral, with widespread damage
to the lungs, and in any case the patient would be a
poor subject for surgery. If operation was to offer
any chance of cure, it was the duty of someone with
expert knowledge of the disease to advise it, after full,
careful, and unhurried consideration, at a time when the
LIVERPOOL MEDICAL INSTITUTION
[APRIL 24, 1937 987
patient was fit enough to have a good chance of
recovery from an extremely severe procedure, That
is the very time, however, when there was a temptation
to carry on with merely palliative treatment; for
while the doctor knew the course and future of the .
disease, the patient and his friends could hardly
grasp it. With the modern advance in lung surgery,
the physician could feel reasonably happy in passing
on young and otherwise healthy subjects to the
competent thoracic surgeon. With older patients
` there was still need for the utmost caution in weighing
up the pros and cons of surgical treatment, with a
bias at present against it. In spite of occasional
recorded cases of lobectomy or total pneumonectomy
for bronchial carcinoma, both physicians and surgeons
would agree from actual experience that the number
of cases suitable for this procedure must be very few
indeed.
Mr. H. V. FORSTER said that Frenckner of Stock-
holm had described a close-fitting bronchial catheter
and an ingenious instrument called the spiro-
pulsator, which could be used for positive pressure
narcosis to one lung alone. These instruments might be
useful in the operation of lobectomy or pneumonectomy.
The laryngologist had been a pioneer in the study
of lung disease by bronchoscopy, but now he saw
how these aids were being employed by the physician
or surgeon himself. Possibly the bronchoscopist
by helping to avoid pulmonary atelectasis in children
would be able to contribute to the prevention of
established bronchiectasis.
The Value of a Bronchoscopic Clinic
Mr. J. E. G. McGrpson and Dr. E. T. BAKER-
Bartes contributed a joint paper in which they
described the difficulties of accurate diagnosis in
certain cases of pulmonary disease, even after the
most careful clinical examination and investigation.
If bronchoscopy was properly carried out under
local anesthesia it was a safe and harmless pro-
cedure even in the presence of serious lung disease.
They then reviewed the work and methods of the
bronchoscopic clinic of the Royal Southern Hospital,
Liverpool. The number of foreign body cases was
small. Suspected bronchial neoplasm, pulmonary
suppuration such as bronchiectasis and lung abscess,
dyspnea due to tracheal and bronchial obstruction,
collapse of the lung, recurrent hemoptysis of obscure
origin, and certain doubtful cases of asthma, . all
called for bronchoscopic inspection and appropriate
treatment when possible, and formed the bulk of the
work of the clinic. Foreign bodies were classified
as radiologically opaque and radiologically non-
opaque, and with regard to their composition as
organic and inorganic. The organic foreign body
cases were dramatic and serious and called for imme-
diate removal. Several cases of non-opaque organic
foreign bodies were encountered which had previously
been thought to be lung abscess, unresolved pneu-
monia, and new growth. Bronchoscopy revealed an
unsuspected foreign body, removal of which brought
about resolution of the lung condition and cessation
of symptoms in the majority of cases. Careful
investigation whenever possible by direct radiography
and with lipiodol was essential in the cases, undue
haste in attempts at unskilled removal proved as great
a source of danger as the foreign body itself. Pul-
monary suppuration in the widest sense was next
discussed; it was necessary to bronchoscope all
cases of unresolved pneumonia, localised non-
tuberculous pulmonary fibrosis, lung abscess, and
bronchiectasis, in order to exclude suppuration and
pneumonitis distal to simple and malignant bronchial
988 THE LANCET]
neoplasms and foreign bodies. True unresolved
pneumonia and localised non-tuberculous pulmonary
fibrosis were rare in their experience and, in most
cases referred to the clinic with this diagnosis, a
cause such as foreign body or new growth had been
found. The diagnosis should only be accepted with
caution after a process of exclusion, especially in the
adult. The results of bronchoscopic aspiration
and lavage in chronic lung abscess and bronchiectasis
were in their experience disappointing and no better
than that obtained by postural drainage when
properly carried owt. Simple new growths were
rare; all cases discovered during life had been
revealed by bronchoscopy and what had been thought
to be an extremely rare condition might prove to be
much commoner when bronchoscopy is more generally
employed in obscure lung lesions. The majority of
these growths were curable by endoscopic methods—
simple removal, diathermy, and radiation—but if
left untreated they ultimately gave rise to serious
secondary effects. Angiomata and fibromata had
been seen and treated successfully at the clinic.
Malignant bronchial new growths were common;
by bronchoscopy their diagnosis could be made
beyond doubt. In cases with suppuration distal to a
bronchial occlusion by growth, the process of dilatation
with bougies of a carcinomatous stricture, removal of
exuberant portions of growth by biting forceps,
and the introduction of radon seeds or a radon
tube lead in certain cases to re-aeration of the collapsed
portion of lung and drainage of secretions. By such
means the complicating suppurative lesion was
usually relieved, the toxemia lessened, and the
sufferings of the patient were minimised. Cure,
of course, was impossible at this stage, and probably
would remain so in view of the situation of the growth
and its mode of spread into the lung parenchyma
and mediastinum. In early cases of bronchial carci-
noma the clinical and radiological findings were
negative, and the patients looked well; recurrent
hemoptysis was the only presenting symptom. If
any successful treatment were possible for this
terrible condition, its success would depend on early
‘diagnosis, and for this bronchoscopy was essential.
A case suitable for lobectomy had not yet been
seen. In some cases the diagnosis of malignant
disease had been disproved by bronchoscopy and
foreign bodies removed. Except in cases of emer-
gency, bronchoscopic examination should always be
preceded by complete clinical and radiological
examination including lipiodol bronchography. The
cases should be followed up, when the significance of
-unusual findings could be assessed, as it was not
always possible to remove suitable fragments for
pathological examination. Bronchoscopy would
always remain team-work, and it necessitated the
closest liaison between laryngologist, physician,
and radiologist in a well-equipped clinic to which cases
‘would be sent from a wide area.
Mr. FORSTER said he would like to understand
better the value of the diathermy cautery as used
in a bronchus when compared with the insertion
of radon seeds in cases where the obstructing growth
had not been proved to be malignant. Some cases
after operations on the upper abdomen by the general
surgeon used to develop ether pneumonia, at least
in his early student days. The inhibition of diaphrag-
matic respiration had something to do with this.
-The laryngologist rarely saw such complications
in spite of the greater danger in his operations of
inhalation of blood and secretions. He had not
met a case of lung abscess after these operations in
the practice of his teachers and so far had been
MANCHESTER MEDICAL SOCIETY
[APRIL 24, 1937
spared the complication in his own. Further, he had
found the asthmatic patient stood ether narcosis
wonderfully well though he had seen an asthmatic
paroxysm under nitrous oxide.
Mr. COURTENAY YORKE said that in his opinion
the principal use of the bronchoscope would always be
the removal of foreign bodies, of which very many
are not opaque to X rays and quite unsuspected.
He felt dubious as to the value of radon seeds in the
treatment of bronchial carcinoma. The inaccessi-
bility of the lower edge of the growth and the limita-
tions of radon seeds both in range and duration
of action made him feel that on the whole the possible
temporary relief would hardly outweigh the risk
and discomfort involved in their insertion. Malignant
disease in the larynx was a hundred times commoner
in men than in women, and he thought, on that
account, an inquiry into the relative sex incidence
in bronchial carcimona would be very interesting and
might raise important questions in regard to ztiology.
Dr. V. COTTON-CORNWALL said that in investigating
the cause of hemoptysis, bronchoscopy was some-
times the only means by which a correct diagnosis
could be made. He quoted a case at Fazakerley
Sanatorium where all investigations, including
bronchography, had been negative and bronchoscopy
had revealed a bronchial carcinoma.
MANCHESTER MEDICAL SOCIETY
AT a meeting of this society held on April 7th,
with Mr. GARNETT WRIGHT, the president, in the
chair, Dr. S. W. PATTERSON spoke on
-= Neoplasm of the Colon
In presenting the results of an investigation. of
82 cases of carcinoma of the colon and rectum he
said that Sir Edmund Spriggs had during the last
few years analysed the admissions to Ruthin Castle
of patients with diseases of the colon and had collated
and published papers on diverticulitis, ulcerative
colitis, and functional disorders of the colon. Amongst
the 82 cases of cancer of the colon and rectum in the
series 68 were in the various parts of the colon and 14
in the rectum. Two-thirds of the cases had occurred
in men. The average age was 62 years, 64 for men
and 57 for women. The age of most lay between
50 and 70; five were under 50 years old and eight
were over 70. The sigmoid and pelvic colon were the
parts of the colon most affected. The length of
history ranged from a week or two to three years, but
was usually a few months. The lesion was sometimes
well advanced before it caused any sign or symptom,
The symptoms at onset were divided into five
main forms: (1) increasing constipation ; (2) irregular
stools or looseness, colitic type; (3) pain, usually.
above or below the navel, but occasionally in the
back, thighs, or rectum; (4) upper abdominal dis-
comfort or nausea, sometimes related to food—
dyspeptic onset; (5) the early passage of blood
from the rectum. There might be an overlapping
of two types of onset in the same patient. In some
cases the onset was insidious and the bowel symptoms
were almost negligible until some other condition
led to the investigation of the digestive tract, as in
a patient with recurring lumbago which was found
to be due to a secondary growth in the bodies of the
eleventh and twelfth thoracic vertebre, originating
‘in a carcinoma of the descending colon. Of the
14 cases of carcinoma of the rectum the age at the
onset of symptoms varied from 37 to 75 years. These
took the form of a frequent desire to stool or diarrhea
THE LANCET]
in 11, constipation in 2, and epigastric pain increased
after meals in 1. Two only had noticed no blood
in the motion, & had suffered serious loss of weight,
and in 1 man pain with micturition was an early and
troublesome complaint. In the diagnosis the triad
of constipation more or less associated with diarrhea
and hsmorrhage was characteristic, but only half of
the patients with cancer of the colon complained of
serious constipation, and constipation might occur
in ordinary intestinal stasis. Bleeding from the
bowel occurred in 60 per cent. of the patients and
was not seldom ascribed to piles.
Amongst the general symptoms loss of weight and
ansmia were predominant. The anzsmia might be
severe in cases of carcinoma affecting the proximal
colon without much obvious blood occurring in the
motion; whereas in cases affecting the distal colon,
where blood and mucus were common, anæmia was
not a prominent symptom. In all cases rectal
and sigmoidoscopic examination should be carried
out. The patients might thus complain of dyspepsia
or general malaise usually with colitic symptoms,
constipation, diarrhea, pain, stoppage, or hzemor-
REVIEWS AND NOTICES OF BOOKS
° [APRI 24, 1937 989
rhage, but always a change in the character of the
motions. Dr. Patterson illustrated the radiological
diagnosis by a series of X ray photographs and
diagrams. In differential diagnosis the age factor
was one which had to be considered.
In regard to treatment full discussions from the
‘surgical point of view had been published in the
‘weekly medical journals during the last few years
by Sir David Wilkie, H. B. Devine, H. H. Rayner,
and E. K. Martin. In the present series excision was
carried out in 13 of the cases of carcinoma of the colon
and 2 of carcinoma of the rectum, Colostomy was done
in 15 and 10 cases respectively, while a short circuit
without removal was possible in 9 of the colon cases.
A consideration of the length of history with the
results of surgical treatment showed that if advice
had been sought earlier and a diagnosis made many
more lives could have been saved.
In the subsequent discussion Dr. R. W. LuxtTon,
Prof. MORLEY, Mr. RAYNER, and the PRESIDENT again
stressed the importance of early diagnosis and
attention to the commencing disturbances of the
bowel.
REVIEWS AND NOTICES OF BOOKS
Practitioners’
papEBEY, of Medicine . and
Surgery
Vol. XI, Hye, Har, Nose, and Throat. Supervising
Editor, "GEORGE BLUMER, M.A., M.D., David P.
Smith Clinical Professor of Medicine, Yale Uni-
versity. London: D. Appleton-Century Co. 1937.
Pp. 1153. 50s. (in sets only).
THis imposing volume has been compiled by over
forty American specialists, many of whom are well
known and respected in this country. It possesses
the merits and the defects of most of such compilations.
On the one hand, there are chapters by distinguished
authorities on subjects they have made especially
their own and, on the other, there is overlapping
and unevenness, with not a few omissions. Thus
no mention is to be found of inflation of the ear by
the method of Politzer, nor through the Eustachian
catheter in the treatment of recent catarrhal deafness,
and the technique of the introduction of the catheter
is nowhere described ; indeed, in the discussion of
acute catarrhal otitis media, Creighton Barker
_visualises an inflammation accompanied by fever,
pain, and usually perforation of the drum, rather
than the common “cold in the ear” associated with
deafness and fullness, for which inflation is valuable.
An instance of overlapping is the description by R. E.
Buckley of cancer of the larynx, followed by a chapter
on the same subject by Louis Clerf; in the latter
only the operation of laryngofissure is described,
while Buckley says that “the results of radium
therapy have been so poor that its further use in the
treatment of cancer of the larynx should be absolutely
discouraged.” The brilliant results obtained in
England by the introduction of radium according to
the fenestration method of W. D. Harmer and N. S.
Finzi might with advantage be more widely known
and practised in the United States.
S. J. Kopetzky has contributed a beautifully
clear and helpful exposition of the application of
physiology and pathology to the study of suppurative
lesions of the middle ear which, together with the
preceding chapter by D. M. Lierle and J. J. Potter,
forms an admirable basis for the understanding of
inflammatory processes in this region. Acute suppura-
tion of the ear is discussed in four separate chapters ;
the importance of the subject may be sufficient '
excuse for the lengthy treatment, but the mass of
reading is uninviting and curtailment should have
been possible. The section on diseases of the eye
is very complete. The scope of the book is not
intended to include descriptions of those operative
procedures for which the equipment of a specialist
is required; nevertheless those employed in the
treatment of cataract and glaucoma are fully discussed
and illustrated, as also is the operation of lateral
pharyngotomy for cancer of the laryngopharynx.
The work is not a text-book, but rather a collection
of excellent essays on these special subjects which
well deserves a place in the practitioner’s library.
Electricity in Therapeutics
By Harorb H. U. Cross, Ph.D., formerly Research
Worker at the Stanford University, California ;
Certificate Electro-Radiology, Faculty of Medicine,
Paris. With a Preface by Dr. GEORGE BOURGUIGNON
London: Crosby Lockwood and Son. _ 1936.
Pp. 378. 265s.
Tms book does not deal entirely with electrical
treatment. There isa chapter entitled “ The Elements
of Electro-diagnosis’’ and a considerable portion
of it is devoted to the chronaxie and its determination.
A short chapter has been written on ultra-violet
ray treatment, and there is a brief résumé of infra-
red ray therapy. This book has been written to
supply such technical information as will show
the student and practitioner the underlying electrical
and chemical principles of electricity in therapeutics.
It includes much more, however, than technical
information. Methods of subjecting patients to the
different physical agents and various ways of treating
disease by their means are also described. Dr. Cross
refrains from expressing his own views on the selection
or prescription of treatment but he describes a few
of the cases which he has treated. Considerable
attention is given to the galvanic current and its
therapeutic uses. The chapter entitled ‘‘trans-
cerebral ionization ” will be of especial interest
to British readers. This form of treatment was
introduced by Bourguignon. It is recommended
for long-standing cases of hemiplegia with con-
990 THE LANCET]
tracture. For cases of facial paralysis, especially
those with contracture, indeed, it is said to be a
“ sovereign remedy.” The section of the book devoted
to high-frequency currents is much smaller than
that concerned with the galvanic current and its
uses. Generators, electrodes, and accessory apparatus
are fully described, but only ten pages are allotted to -
the medical and surgical applications of high-fre~
quency currents. The work conducted in this country
on the diathermic treatment of the pelvic organs
does not appear to be mentioned, although there
is a description of Sloan’s method of treating cervicitis
and vaginitis by ionisation. The author also describes
the use of ultra-violet rays and quartz applicators
in the treatment of urethritis, erosion, vaginitis,
cervical catarrh, leucorrhea, and gonorrhea.
One form of treatment said to be used with
benefit in inflammatory conditions is not regularly
practised in this country. High-frequency currents
derived from a high voltage source are applied by
way of glass or quartz electrodes of various shapes
and sizes to the skin or introduced into such channels
as the nose, rectum, or vagina. The current is said to
exercise a ‘“‘ revulsive”’ action. The risk of breakage
of the electrode in situ is mentioned. Should this
happen the operator is instructed to keep the patient
calm and flood the canal with warm olive oil; to
remove pieces with forceps and reassemble as nearly
as possible to ascertain that all has been recovered.
There are three appendices. One is a selected
bibliography ; another contains a number of diagrams
showing the motor points of muscles and nerves
with descriptions of the action of the muscles; and
the third gives advice on the resuscitation of those
who have apparently. been electrocuted.
Kidney Pain
By J. Leon Jona, D.Sc., M.D., F.R.A.C.S.,
M.C.0.G., Hon. Assistant Gynecological Surgeon,
Women’s Hospital, Melbourne. London: J. and A.
Churchill, 1937, Pp. 95. 7s. 6d.
RENAL pain of unknown origin is very commonly
met with in practice, more especially among female
patients. It is therefore a subject of great practical
importance, and the object of this little book is
to bring before practitioners certain views on the
causation of obscure renal pain and on its treatment.
Dr. Jona has been working for the last ten years on
the physiology and pathology of the renal pelvis,
but unfortunately the outcome of his researches are
still too theoretical to be of much use to the busy
practitioner. It is obvious, however, that he has
read very widely on the subject and the extensive
bibliography supplied will be of the utmost use to
those concerned with this region. A better title for
the book might have been ‘Introduction to the
Study of Renal Pain,” for it will certainly provide
an admirable survey from which further fruitful
work may spring.
Enzyme Chemistry 3 /
By HENRY TAUBER, Ph.D., Consulting Chemist,
New York Medical College and Flower Hospital.
London: Chapman and Hall. 1937. Pp. 243. 15s.
Tms book will find a warm welcome in the libraries
of chemists, biochemists, and physiologists who
require an up-to-date summary of our knowledge of
the chemistry of enzymes and their mode of action.
Dr. Tauber deals mainly with the actual chemical and
physical nature-of the enzymes rather than with their
complicated action, and a book written on this aspect
REVIEWS AND NOTICES OF BOOKS
[APRIL 24, 1937
of the problems presented has been badly needed
for years. There are many works on such subjects
as the kinetics of enzyme reaction, and mathematical
treatises on the many relationships of enzyme to
substrate; but the worker who wants to find out
anything about the actual chemical nature of the
ferments themselves is faced with the need to make
an arduous search through the literature.
Even the most erudite among general biochemists
will get some surprises when reading through this
book. For instance, it may well come as news to
them that crystalline trypsin and pepsin have been
prepared, and that ferments such as carboxy-poly-
peptidases have been crystallised. Dr. Tauber has
undoubtedly provided a most useful addition to the
library of any worker whose interests are directly or
indirectly concerned with enzymes.
Complement or Alexin .
‘By T. W. B. Ossorn, University of Witwatersrand.
London: Humphrey Milford, Oxford University
Press. 1937. Pp. 116. 7s. 6d.
Dr. Osborn has done a useful service in bringing
together the available knowledge on the subject of
complement in the form of a brief and well-arranged
monograph. The work takes no new standpoint
nor does it bring forward any new facts of importance,
but it is obviously written with real understanding
of the subject, and if little criticism appears in the
pages, a good deal, we imagine, has been expended
on the omissions. As Prof. R. A. Peters says in his
introductory note, complement is a ‘‘ mysterious and
interesting °? reagent. It is also a very important
reagent in practical laboratory work, and all who have
to do Wassermann’s or other fixation test will profit
by reading this excellent account of its properties.
1936 Year
Syphilology
Edited by FRED M. WISE, M.D., Professor of
Clinical Dermatology and Syphilology, New York
Post-graduate Medical School and Hospital of
Columbia University; and Marion B. Svutz-
BERGER, M.D., Associate Professor of Dermatology
and Syphilology at the School. Chicago: Year
Book Publishers; London: H. K. Lewis and Co.
1936. Pp. 720. 12s. 6d. |
THE editors of this valuable publication, since
its inception as one of 10 similar year books (including
dentistry) in 1931, have adhered to the same pro-
gramme and classification. This volume has been
enriched by abstracts from discussions and papers
read at the ninth international congress of derma-
tology and syphilis held at Budapest in September,
1935, an event which must have made still harder
the selective duties of the editors. As in former
years they have themselves contributed an intro-
ductory essay on a subject of common therapeutic
interest. Last year they chose eczema; in this
issue they present a detailed survey of the treatment
of urticaria in its acute and chronic manifestations,
and any reader who has exhausted his armamen-
tarium in an obstinate case of that disease may
hopefully seek here some new measures for its allevia-
tion or cure. Among the more important extracts
are those from papers dealing with the control and
cure of syphilis, including two which present the
results of treatment by Mepharsen—the new trivalent
arsenical for which reduced toxicity is claimed. A
special feature has been made of the recent studies
and advances in the pathology of the virus diseases
Book of Dermatology and
THE LANCET]
REVIEWS AND NOTICES OF BOOKS
[APRIL 24, 1937 991
and those associated with disorders of the
hsmopoietic and reticulo-endothelial systems.
. The table of contents is divided into 14 sections
under which the editors have abstracted papers
dealing with mycotic infections, eczema, allergy and
immunology, drug eruptions, hematogenous derma-
toses, miscellaneous dermatoses, cancer, leukzemias
and allied conditions, chronic granulomas other than
syphilis, non-syphilitic venereal diseases, derma-
tological therapy, physical therapy, experimental
studies, and finally syphilis in all its various aspects.
As an addendum to some of the more important
communications, and where they do not altogether
agree with the conclusions of the authors quoted,
the editors have submitted criticisms or alternative
views, which will be found of considerable interest
and occasional assistance. Dermatologists owe a
big debt to the industry of those who have helped to
collect and collate the best of the new work on diseases
of the skin, and have provided such a comprehensive
and reliable annual.
1936 Year Book of Obstetrics and Gynecology
Obstetrics. Edited by Joserm B. DELEE, A.M.,
M.D., Professor of Obstetrics, University of Chicago
Medical School. Gynecology. Edited by J. P.
GREENHILL, B.S., M.D., F.A.C.S., Professor of
Gynecology, Loyola University Medical School.
Chicago: Year Book Publishers; London: H. K.
Lewis and Co. 1937. Pp. 704. 10s. 6d.
THE appearance of the 1936 number of this year
book reminds one of the continued and widespread
activities of Prof. DeLee who edits the obstetric
section of this book. His editorial remarks are
characteristically trenchant and add to the general
interest of his summaries of new work. Prof. J. P.
Greenhill is responsible for the gynzcological section,
which is no less well compiled. The volume is of
handy size and provides an admirable review of the
best of the year’s work in this specialty, chosen
liberally from all parts of the world.
Health of the Mind
By J. R. Rees, M.D., Director of the Institute
of Medical Psychology. London: Faber and
Faber. 1936. Pp. 230. 6s.
Dr. Rees has brought his book up to date by
the inclusion of a number of minor points in various
chapters. The volume is designed to appeal not to
the expert, but to the intelligent layman, the school-
master, and the spiritual guide. Technicalities are
cleverly avoided and the skill of the exposition,
aided here and there by diagram, makes many a
theoretical tangle seem simple. The chapter on
childhood is a sound display of common sense. For
those who tremble on the brink of suggesting psycho-
logical treatment for themselves or their friends this
volume will be a disarming invitation. Since its
issue the institute directed by Dr. Rees has reverted
to its former honoured name and in future will again
be known as the Tavistock Clinic.
Reactions of the Human Machine
By JoHN YERBURY DENT. London:
Gollancz. 1936. Pp. 288. 8s. 6d.
THis volume is frankly materialistic biology
and from the very beginning determinism is the
premise of the argument. Movement or reaction
is a special quality in living things and, having
admitted this special quality, it is not difficult to
Victor
build up a consistent dynamic structure of- the
organism of man in its individual and social reactions.
The argument in fact is so very consistent that
many apparently strange explanations fall into
their place in the general scheme of the book. In
many ways the author’s thesis is an extension of
the theories of Pavlov. It is with these theories
in view that the book should be studied. Those.
readers who look for consistency and fidelity to
biology in the study of mental medicine will find
much stimulation in its contents. Neurologists
in particular will look with favour upon it; some
few a a may be either irritated or
scornful, |
What Science Stands For
By Sir Jonn Boyp ORR, F.R.S., Prof. A. V. HIL,
Sec. R.S., Prof. J. C. Puur, O.B.E., F.R.S., Sir
RICHARD GREGORY, Bt., F.R.S., Sir A. DANIEL
Hatt, K.C.B., F.R.S., and Prof. L. HOGBEN, F.R.S.
London : George Allen and Unwin. 1937. Pp. 132.
5s.
SCIENCE represents the satisfaction of man’s
curiosity ; and in common life it stands on the one
hand for the addition of many facilities and con-
veniences to his material existence, and on the other,
for much of his intellectual and spiritual refreshment
and inspiration. The first consideration appeals
more to those who do not know by personal experience
what science is, the second to the initiates. Both
points of view are represented to various degrees in
the six essays of this symposium: all of them are
well worth reading and most of them are sufficiently
provocative ; the happiest expression of what seems
to be the real truth comes from the editor of Nature,
An Introduction to Medical Science
By Witt1am Boyrp, M.D., F.R.C.P., Proteasoy of
Pathology in the University of Manitoba. London :
Henry Kimpton. 1937. Pp. 307. 16s.
Prof. Boyd has written three good books on patho-
logy and he now adds a baby to the family. Despite
its title, it is an elementary text-book of pathology
intended for junior students, nurses, technicians, and
perhaps the lay public. It is not more attractive
than the average infant and while it is certainly not
bad it cannot unreservedly be called good.. In
places the writing is careless—e.g., in the account of
rickets. It may well be of use in its special field
until someone succeeds in the extremely difficult task
of composing a better semi-popular guide without tears.
1. A Doctor at Work and Play .
By Smney H. SNELL, M.D., B.S. Lond., D.P.H.
London: John Bale, Sons and Curnow. 1937.
Pp. 351. 12s. 6d.
2. Scalpel and Sword
By Sir James Exvziiott, M.D. Sydney: Angus
and Robertson. 1936. Pp. 215. 7s. 6d.
1. IN the first of these books, the late Dr. Snell
shows himself to have been possessed of the vigour
and simplicity characteristic: of the Victorian pro-.
fessional class. A Westcountryman who received
his professional education at University College
Hospital, he contrived to combine a busy professional
life with numerous outside interests and activities.
Freemasonry, travel, golf, sailing, fishing, farming,
and fox-hunting were some of the things he found
time for and, in common with other horse-lovers
and modern educationists, he found that a spirited
992 THE LANCET]
animal will sometimes go better in a snaffle than on
acurb. The book, illustrated with photographs and
abounding in anecdotes, is the straightforward and
colloquial chronicle of a life remarkable perhaps for
the quality and variety, rather than the rarity of
the experiences packed into it. The reader is left
with an impression of the author as an attractive
person, full of energy, kindliness, and the joy of
jiving.
2. Sir James Elliott writes with considerable
literary skill and his adventures are set against
a very different background. Educated at Edinburgh
and perhaps a shade condescending towards the older
universities he is delightfully reminiscent about his
former teachers. As a doctor he saw service with a
field hospital in the South African War and, during
the late war, was senior medical officer on the ill-fated
Maheno. Much of the book is concerned with an
interesting account of the manners and customs
of the Maoris and the author’s gift for happy phrase
is well exemplified in the chapter on America.
Snow on Cholera
Being a Reprint of Two Papers by John Snow,
M.D. Together with a Biographical Memoir by
B. W. RIcHARDSON, M.D., and an Introduction by
WavE Hampton Frost, M.D., Professor of Epide-
miology, Johns Hopkins School of Hygiene and
Public Health. New York: The Commonwealth
Fund; London: Humphrey Milford, Oxford
University Press. 1936. Pp. 191. 10s. 6d.
Tuis reprint of Snow’s classical papers on cholera
has been published under the auspices of the Common- `
wealth Fund (New York) by ‘“‘ Delta Omega,” an
American society of public health, to whose interest
we already owe areprint of William Budd’s Typhoid
Fever. In addition to the second edition of Snow
on the Mode of Communication of Cholera it
contains his interesting paper on Continuous Mole-
cular Changes, an oration given to the Medical Society
of London on its eightieth anniversary. The edition
also includes the memoir on Snow’s life by his friend
Sir Benjamin Richardson which was originally pub-
lished in the Ascleptad in 1887, and which is every-
thing that a brief biography should be. A short
introduction by Prof. Frost gives an informative
and just account of Snow’s place in the history of
epidemiology. The apparatus is completed by a
bibliography of Snow’s works and a frontispiece
portrait of Snow. The book is attractively got up.
It includes the coloured maps of the original second
edition (1854); typographically it is as near as
possible a reproduction of the original, and the
binding ‘and lettering are also reproduced. To the
discriminating reader these details will add much to
the enjoyment of owning and reading the book,
which has obviously been published as a labour of
love and is being sold at what must be below cost
price. We can hardly think of a better gift for any
young doctor interested in public health work than
this edition of one of the most interesting and inspiring
of the classics of hygiene.
Diseases of the Respiratory Tract
Eighth Annual Graduate Fortnight of the New
York Academy of Medicine. London: W. B.
Saunders Co. 1936. Pp. 418. 24s.
THis is a collection of lectures to post-graduate
students and practitioners by twenty-one authorities
on special aspects of respiratory disease. Such a
collection could not be comprehensive and the
lecturers have wisely chosen subjects rich in specu-
NEW INVENTIONS
[APRI 24, 1937
lative and controversial matter. The general standard
of the various papers is high and reference must
be made to one or two of particular interest. A
lecture by A. R. Dochez on the common cold gives
the recent evidence for the conclusion that the
causative organism is a filter-passing virus; in
the writer’s experience even after prolonged immuni-
sation there is no diminution in the number of colds
experienced, although there may be some decrease
in severity.
Other papers of particular merit are those on
bronchoscopy by Chevalier Jackson, and on bron-
chiectasis by J. B. Amberson. Recent views on the
pathology of pulmonary tuberculosis are expressed.
in two papers, the first by J. A. Miller on the evolution
of .pulmonary tuberculosis, and the second by
A. R. Rich on immunity in tuberculosis; the
latter insists strongly on the absence of any real
basis for the view that hypersensitivity (allergy)
is necessary for development of immunity. In a
paper on carcinoma of the lung Lloyd E. Craver
discusses the brilliant results which have recently
attended lobectomy and pneumonectomy in certain
cases of this disease, but he is careful to call attention
to the very small proportion of cases which are
suitable for this form of treatment. In many cases
the growth is inoperable when first discovered, either
on account of its anatomical position or because of
the early appearance of metastases. Of the remainder
a considerable number are not fit subjects for major
surgery either on account of age or general weakness.
In Craver’s experience internal or external irradiation
is here mostly the treatment of necessity rather than
of choice; although palliation of symptoms often
occurs he is doubtful if life is prolonged a these
measures.
NEW INVENTIONS
A NEW TYPE OF NEEDLE HOLDER
I DEVISED this needle holder primarily for use in
cleft palate operations in children, but it is equally
useful in all operations, in any situation where space
is limited and accurate suturing is essential. The
majority of needle holders were too massive and
cumbersome for the small needles employed. Apart
from this, when working in such a confined space,
one’s hand invariably tended to obscure the view of
the operation field. Owing to the pronounced
“cast off” in the handles, the needle is always in
view, and the slight curve in the jaws and the fineness
of their points enable even the smallest sizes—e.g.,
Lane’s—to be held securely in various positions.
The sutures can thus be inserted from any angle,
which is impossible with the ordinary types of needle
holders.
The needle holder has been made for me by Messrs.
Down Bros., London, 8.E.
G. L. Preston, F.R.C.S. Edin.
Honorary Surgeon to the Prince of Wales’s :
Hospital, Plymouth.
Era a ee ae. ee
‘
THE LANCET]
A MASTER OF EPIDEMIOLOGY.—CIRCULATORY COLLAPSE
[APRIL 24, 1937 993
THE LANCET
LONDON: SATURDAY, APRIL 24, 1937
_A MASTER OF EPIDEMIOLOGY
Tux classics of epidemiology wear better perhaps
than those of any other branch of medicine. The
student of epidemic disease may still find immediate
help and inspiration in the writings of Farr and
Bupp, MURCHISON and GRAVES, BRETONNEAU and
TROUSSBAU, or HirscH and CREIGHTON, and the
more his experience grows does he find them
instructive. This is not because epidemiology is
an unprogressive science; its advance has been
as spectacular as that of any specialty. That
good observation in the field of epidemic disease
is not readily superseded depends partly on the
fact that many epidemic diseases were more
common and more easy to study in bulk in the
past than now; but partly also on the circum-
stance that it was the disease rather than the
patient that was studied and the argumenia ad
hominem which tend to make the doctor a good
friend but a bad scientist were largely eliminated.
JOHN Snow has hardly yet been accorded a
place in the front rank of the masters of epidemio-
logy, but his famous treatise on cholera is a cameo
of medical writing and a model of epidemiological
inquiry. We welcome the cheap and elegant
reprint of the work reviewed on another page
which has been produced through the good offices
of the Commonwealth Fund and makes available
a story as interesting and instructive as any in
medicine. Cholera as a serious epidemic disease
had a brief and meteoric career in England. It
reached the country somewhere about 1830 and in
1854 it fell on London like a wolf on the fold.
Had it arrived half a century earlier it might
have caused a major national disaster; as it was
the fold was being watched over by such alert
shepherds as WILLIAM Farr, WILLIAM BupD, and
JoHN SNow. Within half a dozen years it was
attacked .and practically exterminated in this
country and foremost in the event was JOHN Snow.
Snow had studied cholera in Newcastle some ten
years earlier ; he knew his enemy and he achieved
its destruction in an astonishingly short time.
Within a few weeks from the outbreak he was
able to put on permanent and unshakable record
his thesis that cholera was a water-borne disease,
that the source of infection was the dejecta of
cholera patients, and that the materies morbi was
what we should now call a germ. SNOW was a
fine example of the naturalist doctor characteristic
of English medicine. He was in the best sense in
the “ Hunterian tradition.” A physician with a
busy practice, he yet could find time for intense
observation and for scientific work of the highest
quality. It is sometimes said that this is impossible
under present-day conditions, and research workers
demand whole-time facilities. It remains certain
that such men as HUNTER or SNow would have
succeeded in finding opportunity for their work in
the face of practically any difficulties, though
admittedly these men lived “ dedicated lives ” and
their successes were not won without material
and social sacrifices.
Snow was one of the pioneers of anesthetics and
he must have taken a large part in popularising the
use of anesthetics at childbirth for it was he who '`
gave Queen VICTORIA her first anesthetic and thus
set the fashion. He does not seem to have
benefited financially to any extent from this
practice, though all the fine ladies of the time
must have demanded the Queen’s anesthetist, and
would surely have been willing to pay substantially
for his services ; we are told by his friend RICHARD-
SON, however, that his income never exceeded
£1000 a year and this explains much. Snow
wrote some fifty papers. on medical subjects,
many of them on anesthetics, but his masterpiece
is the little treatise of some 140 pages, in which
he records his investigations of the London out-
breaks of cholera of 1849-54. The story reaches
its highest pitch of interest in the account of the
epidemic, perhaps the most severe in English
experience, which in 1854 caused over 500 deaths
in ten days in the very heart of the West End—
in the neighbourhood which now backs on the
Regent Palace Hotel. The story is known to
every student of epidemics—how SNow gratui-
tously took upon himself the task of investigation ;
how by ingenious and unremitting inquiry he
traced case after case to the Broad-street Pump ;
how the “widow of a percussion cap maker,”
retired in Hampstead, sent a messenger daily for
a bottle of water from the Pump as she preferred
it to the local waters; how she died, a unique
case in her salubrious neighbourhood ; how her
niece who visited her drank some of the treasured
water, returned to her ‘residence in a high and
healthy part of Islington,’ was attacked by
cholera, and died also; how the men of Mr.
Huggins’s Brewery, hard by the Pump, knew of a
better pump and all escaped—such are some of
the elements which makes Snow’s report of
perennial scientific and human interest. The story
has been retold by Dr. H. H. Scorr in his excellent
book, ‘‘ Some Notable Epidemics,” but this should
only whet our appetites for the original sources. The
appearance of a cheap reprint of SNow’s classic
will, it is hoped, gain many new admirers for this
“representative,” as RICHARDSON calls him, “of
medical science and art of the Victorian era.”
CIRCULATORY COLLAPSE
In a recent issue, when discussing the effects of
extensive local injury, we surveyed various theories
of the cause of secondary shock.’ These theories
assumed a loss of fluid with diminution in the
volume of circulating blood, and differed chiefly in
their explanation of how this loss was brought
about. It is generally taken for granted that a
total blood volume which is small in relation to the
capacity of the vascular systei is sufficient to start
the vicious circle seen in surgical shock, but this
disproportion between volume and capacity may
1 Lancet, April 3rd, 1937, p. 821.
994 THE LANCET]
well be an accompaniment rather than a cause of
the condition. Surgical shock may, for instance,
be due to some profound dislocation of function
in the central nervous system, of which vasomotor
incodrdination is merely one of the more serious
manifestations. S. WEIss, R. W. WurKmns, and
F. W. Hayners of Boston? have done work of
great interest in this connexion. By using sodium
nitrite they are able to produce a state of circulatory
collapse in which the condition of the subject
closely resembles that seen in shock ; but the state
is reversible in a matter of seconds. The subject
is placed in a horizontal position and given a dose
of nitrite which has little or no effect so long as
he remains lying down. After a few minutes he is
raised into a vertical, or nearly vertical, position,
‘with dramatic results. Yawning more and more
often, he develops sighing respiration, rest-
lessness, increased peristalsis, and warm and
then cold perspiration in rapid succession. The
skin becomes cyanosed and finally “ ashen grey,”
the pupils become dilated, and the subject of the
experiment becomes drowsy. Dimness of vision
and extreme muscular weakness are followed by
unconsciousness. This process takes about 20
minutes, but when the horizontal is resumed,
consciousness is immediately recovered and the
symptoms rapidly subside.
Quantitative observations show that the peri-
pheral blood flow, as estimated with the plethysmo-
graph in the hand, is diminished; the venous
pressure is less, the pulse-rate more rapid, and the
pulse pressure is diminished at the expense of the
systolic arterial pressure. Shortly before syncope
the blood flow through the hand falls to zero, the
venous pressure falls below the hydrostatic level
of the right auricle, the radial pulse disappears,
and the blood pressure is unobtainable. Then,
just when syncope is about to ensue, the pulse-rate
may suddenly fall from over 120 to less than 80
per second ; elimination of this drop by means of
atropine makes no difference to the other mani-
festations, and the investigators attribute it to
stimulation by anoxzmia of the cardio-inhibitory
centre of the medulla. Normal blood flow, venous
pressure, pulse pressure, and pulse-rate are promptly
restored by the horizontal position. Further
experiments lead to the conclusion that not the
arterioles, but the veins and venules, through loss
of tone and increased capacity, are responsible for
the sequence of events. It is claimed that
“ pooling ” of blood can occur in the systemic veins
as well as in the splanchnic area, and is accompanied
by reflex vaso-constriction on the arterial side.
The significant feature of these experiments is
the “ pooling.” of blood in such a way that it
can be quickly returned to the circulation, and the
clear demonstration, by first “ removing ” and then
restoring the blood, that interference with the
circulation is alone responsible for the symptoms.
There can be little doubt that, could the experiment
have been pushed further, secondary effects due to
anoxemia of the nervous system would have
supervened, while lack of circulation and vaso-
constriction in the periphery might well have led
2 J. clin. Invest. 1937, 16, 73 and 85.
PRINCIPLES OF MEDICAL STATISTICS
[APRIL 24, 1937
to a leakage of fluid through the anoxic capillary
walls and a state: of “irreversible ” circulatory
collapse. `
PRINCIPLES OF MEDICAL STATISTICS
In clinical medicine to-day there is a growing
demand for adequate proof of the efficacy of this
or that form of treatment. Often proof can come
only by means of a collection of records of clinical
trials devised on such a scale and in such a form
that statistically reliable conclusions can be drawn
from them. However great may be our aversion
to figures we cannot escape the conclusion that
the solution of most of the problems of clinical
or preventive medicine must ultimately depend
on them. Even those who pretend to despise this
method of approach find that any assessment
success or failure which is based on fact rather
than on opinion must nearly always be expressed
in some numerical form—e.g., when the medical
observer reports that he has treated so many
cases with a favourable result in such and such
a proportion, or the public health worker assesses
the attack-rate on a population inoculated against
some infection. But often, unfortunately, the
figures used are either insufficient in number or
documentation or too limited in their scope to
bear the weight of the interpretation that is placed
upon them. An additional difficulty is that few
medical men have been trained to interpret figures
or to analyse and test their meaning by even an
elementary statistical technique. We have reason
to believe that there is now a steadily increasing
demand among both clinical and public health
workers for some knowledge of that technique and
a realisation that it is not much good collecting
figures more or less haphazardly and then
to expect a professional statistician to draw
conclusions from them.
Acting upon this belief last year we invited Mr.
A. BRADFORD Hix, D.Sc., of the London School
of Hygiene and Tropical Medicine, to prepare for
our columns a series of short simple articles on
such methods as his experience of medical statistics
had shown him would be most useful in that
field. Dr. Hur’s first article appeared on Jan. 2nd,
1937, and his last will be found on p. 1001 of this
issue. He has succeeded beyond our hopes in
demonstrating some of the ways in which investiga-
tions can be planned and figures derived from
them can be analysed in order to yield fruitful
results. He has chosen examples from medical
publications to illustrate both the types of problem
with which the medical worker is faced and the kinds
of error he is most liable to make; and wherever
possible he has either avoided mathematical
presentation of his material or has led up to it so
skilfully as to rob equations and even square roots
of their traditional horrors. This consideration
for those who are not mathematically minded has
resulted in an exceptionally clear exposition of a
difficult subject and we have had many requests,
to which we are happy to accede, for the reissue of
these articles in book form. They will appear
shortly as Vol. 3 of THE LANCET post-graduate
series under the title Principles of Medical Statistics.
THE LANOET |
[APRIL 24, 1937 995
ANNOTATIONS
THE TREATMENT OF ASPHYXIA
NEONATORUM
THE gibe that it takes ten years to get a new
idea into a medical text-book and the rest of time
to get it out is not without point when applied to
certain methods .of treatment still recommended in
some places for the severe degrees of asphyxia
neonatorum. The Schultze, the Byrd, and the
Silvester methods are now generally regarded as
valueless for the purposes of initiating respiration in
an apnoic infant and are known to be potentially
dangerous, for their use may inflict trauma and cause
or aggravate shock. Mouth-to-mouth insufflation is
also of doubtful value; it may on rare occasions
save a life, but at the best it is an uncertain method
not devoid of risk. Unfortunately no very effective and
simple aaran Te to these unsatisfactory methods
has hitherto been suggested by their critics, and many
obstetricians have been content, after clearing the
thick mucus from the pharynx, to take no action
beyond keeping the infant warm, in the hope that the
shock from which it suffers will subside and that
the slow rise of carbon dioxide tension of its blood
will in a short time evoke an inspiratory effort.
More active intervention is advocated by Dr. R. A.
Wilson of New York, who on April 16th presented
to the section of obstetrics and gynæcology of the
Royal Society of Medicine the results of ten years’
investigation of the cause and treatment of asphyxia
neonatorum. The most difficult case to treat, he
said, is the infant which has made no effort to
breathe. To give oxygen and carbon dioxide by a
face-mask is useless, and even the Drinker respirator
is of so little avail that an attempt to use it may
waste valuable time. Attempts to distend the lung
alveoli by gas pressure are in Dr. Wilson’s view
dangerous, since experiment-has shown that pressures
up to 18 millimetres of mercury do not lead to
adequate lung expansion, although they may cause
rupture of the alveoli. A method recommended as
useful even if it does not immediately cause respiratory
efforts is intubation of the trachea followed by
insufflation of oxygen under low, and preferably
intermittent, pressure. But Dr. Wilson holds intra-
venous injection of respiratory stimulants to be the
most effective of the various means of stimulating
respiratory efforts. He said that alpha-lobeline and
Coramine are both active in this respect, but lobeline
is the safer drug; and he showed cinematograph
films, and graphic records of the respiratory efforts
of new-born infants obtained by a specially designed
spirometer, to demonstrate the remarkable effect of
lobeline in initiating respiration in apneic infants,
and in augmenting feeble respirations in newly born
children whose respiratory centres had been depressed
by morphine or by barbiturates previously given to
the mother. In barbiturate poisoning lobeline seems
to be much more effective than carbon dioxide.
Dr. Wilson said that alpha-lobeline could safely be
given to infants apparently stillborn in a dosage of
gr. 1/20. The foetal cord should be clamped 8 or 9
inches from the body and the lobeline solution
injected through a hypodermic needle into the
umbilical vein a few inches from the clamped end.
The cord should then be stripped with the fingers in
order to “‘ milk ” the fluid into the circulating blood.
The distal half of the cord should be emptied quickly
and then reclamped; the remainder should be
stripped at a slower rate, in accordance with the
infant’s needs and the response evoked. It usually
took 15 seconds for the drug to reach the respiratory
centre. The first effect was invariably the production
of a generalised spasm of the body of the infant,
often with opisthotonos. This spasm was followed
by vigorous respiratory efforts; until these started
the treatment should be conducted with the child ©
held in the head-down position.
Intravenous lobeline, while of the greatest value,
should not be the only remedy tried. As the result of
the experiences gained by Dr. Wilson and his
colleagues in the treatment of 340 cases of asphyxia
neonatorum, the following technique has been
evolved: (1) The infant’s mouth and pharynx are
immediately aspirated with a mucus catheter, in
order to remove the thick secretion and liquor which
often obstructs the airway. (2) The cord is clamped,
the vein injected with lobeline, the cord half stripped
and clamped again, according to the method described
above. (3) In severe cases a tube is passed into the
trachea by aid of a special laryngoscope, and the air-
passages are then insuffated with a mixture of
oxygen (80 per cent.) and carbon dioxide (20 per
cent.). The pressure of the gas should not exceed
5 mm. of mercury. (4) The remainder of the cord
is now slowly stripped, the child being held head
downwards. (5) After initiation of respiration, and
usually within two minutes’ time, the tracheal tube
is removed and replaced by a face-mask, through
which the oxygen-carbon dioxide mixture can be
continued, according to the needs of the case. Since
prolonged apnea may damage the respiratory
centre. treatment should be instituted with the
minimum of delay.
These recommendations command respect because
of the close study Dr. Wilson has given to the experi-
mental and clinical problems of asphyxia, and
because of the exact nature of his own clinical
observations. The methods suggested are not new,
but the clear definition of their scope and value,
which is the outcome of wide experience, has served
to remove many vague impressions. The way in
which lobeline is used is worthy of special note and will
doubtless be tried by obstetricians in this country.
PRURITUS ANI
THE subject of pruritus ani is one of perennial
interest and of no little importance both from the
sufferers’ point of view and also that of the medical
attendant who is asked to undertake the treatment
thereof. It is now well recognised that a large
proportion of cases of anal pruritus are caused by a
discharge at the anus. Many local conditions in the
anal canal or rectum may set up such a discharge—for
example, anal fissures or fistula, prolapsing hæmor- .
rhoids or polypi, and any form of proctitis or colitis.
The discharge dries up on removal or cure of these
causative conditions, and the anal irritation, which is
usually of a fairly mild type, soon disappears too. |
Severe idiopathic or essential pruritus ani, which was
the subject of observations by J. W. Riddoch in our
last issue, is to be regarded as a separate disease.
In Riddoch’s view “idiopathic pruritus ani is caused
by odema of the peri-anal skin following on stasis
in the external hemorrhoidal veins.” In a histo-
logical study of six cases evidence of cdema was
found, such as swelling of the prickle cells, poor
staining of the nuclei, and unusual prominence of the
intercellular channels. In the cutis there was also
obvious oedema, and this was not attributed to any
sort of irritant because of the absence of lymphocytic
996
THE LANCET]
infiltration. The sensation of irritation is known to
arise in the epidermis, and is a feature of urticaria and
other skin conditions in which edema commonly occurs.
Œdema often arises from local venous stasis, and
Riddoch produces clinical evidence of the way in which
stasis and congestion of the veins in the external
hzmorrhoidal plexus may be related to anal pruritus ;
he states that where this is present dilated anal veins
are often to be seen through a proctoscope in the lower
part of the anal canal. Riddoch suggests that
certain types of treatment have proved beneficial
because they have’ destroyed or sclerosed the veins in
the anal region.
this way as much as by section of sensory nerves,
and the injection of various solutions, such as
alcohol or hydrochloric acid, may act similarly ;
possibly too the injection of anesthetic solutions in
vegetable oils may have some effect, apart from the
immediate ansesthesia, by causing fibrosis and venous
obliteration. According to Riddoch’s theory the
beneficial effects which in some cases are obtained by
X ray treatment may be due to a destructive action
on the blood-vessels. Many observers have com-
mented on the improvement in pruritic cases which
often occurs after a submucous injection of a sclerosing
solution such as phenol in oil, and this may be due
to fibrosis of veins in the internal hemorrhoidal
plexus, and closure of the communicating veins
through which back pressure can take place on the
anal veins. When slight degrees of oedema (the pre-
pruritic state) are present, many factors such as
allergy, slight rises in temperature, or alcohol may act
on the skin vessels and produce irritation, whereas
the normal skin would not be affected.
Riddoch’s views at least provide a useful basis for
examination and treatment of the idiopathic type of
pruritus, and also offer a reasonable explanation why
so many different forms of treatment have, at various
times, been acclaimed as beneficial in this condition.
A patient with anal pruritus should certainly be
subjected to the careful routine of a complete rectal
examination: inspection, palpation, proctoscopy,
and sigmoidoscopy. The best method of circum-
venting anal venous stasis must be a matter of con-
sideration in each individual case. The treatment
of the internal hemorrhoidal areas by sclerosing
injections is likely to assume a greater importance in
cases of pruritus, and for the veins of the external
hzemorrhoidal plexus doubtless much may be done by
way of operation (excision of skin ridges or tags
with the underlying veins) or by injection of irritant
solutions which have been proposed from time to
time. These include alcohol, quinine-urea, hydro-
chloric acid, castor oil, phenol in oil, and the various
anesthetic solutions in oil, most of which, it may be
noted, contain benzyl alcohol.
HOSPITAL KITCHENS
THE importance of providing good, appetising,
well-served food for hospital patients was emphasised
by Miss R. Whitaker, principal of the Gloucestershire
Training College of Domestic Science, in a Chadwick
lecture delivered in London on April 15th. Failure
in the dietary department, she said, “delays con-
valescence and unfavourably moderates its complete-
ness.” The provision of suitable food is, however,
by no means simple. Good food, well cooked, may
suffer deterioration in its transport from the kitchen
to the bedside, and many cooks in institutions are
unfairly hampered by lack of the conditions in which
alone a satisfactory diet can be produced. Miss
Whitaker laid special stress on the necessity of well-
STAPHYLOCOCCI AND URINARY CALCULI
Thus Ball’s operation may act in,
[APRIL 24, 1937
planned kitchen offices, so that raw materials may
enter the building as near as possible to the stores,
and each item forming part of the meal may “ travel
steadily forward through the various processes of
preparation, with no backward movements and as
little cross-tracking of workers as may be, until the
finished product is assembled in the hot or cold
closets of the servery.” Not only must the large
apparatus be properly placed, but the small tools
should also be as far as possible within reach of the
worker, who should be able to sit at her duties by
the provision of knee-hole accommodation in her
table. Ventilation and lighting are important. Cross-
ventilation is essential, and alternative methods should
be available. The best lighting of a kitchen, Miss
Whitaker said, is literally the cheapest. Natural
light should be, admitted to the greatest possible
extent, while artificial light should be adequate,
without glare, and placed to fall upon the work and
not upon the worker. A combination of gas and
electricity, with the addition of steam, will probably
give the greatest efficiency in fuel.
STAPHYLOCOCCI AND URINARY CALCULI
THE etiology of urinary calculi is still an unsolved
problem. The part played by infection is, however,
well recognised and some modern authorities indeed
are even doubtful whether urinary lithiasis exists at all
unaccompanied by infection. H. P. Winsbury-
White, who has recently reviewed the subject,}
points out that this conclusion has been reached
chiefly as the result of improved technique, whereby
organisms may be found more readily in the urine
and actually identified in the nuclei of the calculi
themselves. These investigations have particularly
incriminated the staphylococcus. J. Swift Joly?
repeatedly emphasises the importance of staphylo-
coccal infection of the urine, and recently John
Hellström * has written a monograph on the subject
of staphylococcus stones.. This study is based on
90 cases, all observed personally by himself, thoroughly
investigated, and followed up for varying periods,
16 of them for more than ten years. Only cases in
which staphylococci were found in the stone without
a large admixture of other organisms are included in
the series. The stones were examined for cocci by
dissolving out the inorganic constituents with hydro-
chloric acid, and then either making smears or
cutting sections. Cultures from the urine showed
that by far the commonest organism was the Siaphylo-
coccus albus. It is estimated that about 14 per cent.
of all urinary calculi are due to staphylococcal
infection.
The treatment of these conditions is unsatisfactory
because the infection is so difficult to eradicate.
The stones themselves have mostly to be removed
by operation, either by themselves or with a kidney.
Hellstrém’s operative mortality was less than 1 per
cent., but his recurrence rate was 38 percent. The
percentage cured of both stones and infection was 32.
Seventeen out of the 90 patients avoided operation
by passing their stones; of these only 1 suffered
a recurrence, but 8 remained infected. It is
apparently even more difficult to treat the infection
than the stone. Acidification of the urine, vaccines,
. and most of the so-called ‘“‘ urinary antiseptics’”’ are
ineffective. Hellström obtained the best results with
neosalvarsan and also favours direct irrigation of the
renal pelvis.
1 Brit. J. Urol. 1935, 103.
2 Stone and Calculous Disease of Urinary Oras: London, 1929.
3 Acta chir. scand. 1924, 79, Suppl. 6.
THE LANCET]
The actual method of formation of staphylococcus
stones is not thoroughly understood. Many of the
factors concerned in stone formation in general are
probably at work, such as disturbances of the colloid-
crystalloid equilibrium of the urine. It is possible
that conglomerations of the cocci serve as nuclei
for the stones to form around; or the cocci may
act indirectly by providing a kind of protein that
upsets the colloid-crystalloid equilibrium. The large
masses of cocci found in some of the stones tends to
support the former hypothesis. Another factor may
be the effect of staphylococci on the pH of the urine,
for many staphylococci (especially S. albus) have the
power of forming ammonium carbonate from urea.
M. S. S. Earlam * and others have shown that by
no means all staphylococci associated with urinary
calculi have the power of splitting urea, and more-
over most patients with staphylococcus stones
have acid urine. Hellström observes, however, that
in all cases examined by him the staphylococci on
cultivation in urine turned it strongly alkaline, and
suggests that an artificial solution of urea is not a fair
substitute for the urine itself. He maintains also
that he has often observed a difference between the
reaction of the bladder urine and that of the urine in
the immediate vicinity of a renal calculus.
NATALITY AND MORTALITY IN THE U.S.A.
Two volumes corresponding to the annual reports
of the Registrar-General of England and Wales are
issued annually by the Bureau of the Census of the
United States. One deals with the year’s births, still-
births, and infant mortality, the other with the
statistics of the mortality registered. The reports
for the year 1934 have recently been issued. The
registration area, first established for deaths in 1880,
for births in 1915, has slowly but steadily widened.
For mortality statistics States have been admitted
only on the basis of approximately complete registra-
tion of deaths (at least 90 per cent. of all deaths):
and when the data have shown that the deaths are
recorded properly under adequate registration laws.
Texas, admitted in 1933, has been the last State to
satisfy these criteria. ‘The present reports therefore
relate, for the first time, to the whole of the United
States. Supplementary returns are also provided
for the territory of Hawaii, Puerto Rico, and the
Virgin Islands. In 1934 the estimated population
of the United States was 126,626,000 and the total
numbers of births and deaths registered amounted to
2,167,636 and 1,396,903, giving a birth-rate of
17-1 per 1000 inhabitants and a crude death-rate
of 11°0. The natural increase of population it will be
noted was rather more than three-quarters of a million
persons. The infant mortality-rate was 60 per
1000 live births and in addition 78,503 stillbirths
(3-6 per 100 live births) were notified. This enormous
mass of material is tabulated in these two reports
in considerable detail, attention being paid to such
factors as urbanisation, season, colour or race, sex
and age, and cause of death. Statistics are given of
plural births (there were in 1934 six cases of quad-
ruplets, all born alive), and of birth-rates by age of
mother, information we are still waiting for in this
country. In view of the public interest in road
accidents two special accident tables are included
in the mortality report. In 1934 just over 36,000
4 Brit. J. Urol. 1930, 2, 233.
5 U.S. Dept. of Commerce. Bureau of the Census, Mortality
Statistics, 1934. Thirty-fifth Annual Report. Pp. 329. $2.
Birth, Stillbirth, and Infant Mortality Statistics, 1934.
Twentieth Annual Report. TD: 211. $1.75. U.S. SOV eromieni
Printing Office, Washington, 1 1936
SURGICAL TREATMENT OF HYPERPIESIA
[APRIL 24, 1937 997
deaths were attributed to motor-vehicle accidents
in the registration area, an increase of over 5000
deaths above the average for the three previous years.
For those desirous of making an excursion into the
vital statistics of the United States study of these
two reports is essential.
SURGICAL TREATMENT OF HYPERPIESIA
Page and Heuer! describe a small series of cases
—l17 in all—treated for hypertension by bilateral
division of some or all of the anterior nerve-roots
dorsal VI to lumbar II. The grounds for this pro-
cedure are that it cuts off vasoconstrictor impulses
to the splanchnic area and this is followed by vaso-
dilatation in this area with a resulting fall of blood
pressure. That this is the immediate effect of the
operation seems clear. But in most of these few
cases at any rate the drop in blood pressure appears
to have been merely temporary, and at the end of the
period of observation (maximum 37 months) it was
seldom much lower than before the operation. The
chief improvement observed was in the subjective
symptoms, and as the authors say that a strong
element of neurosis was obvious in many of the
patients it seems likely that equal improvement
might have been attained by less spectacular means.
The operation in itself seems to have had no ill effect
upon the functions of the heart or kidneys, but it
does not appear from this series of cases that any
improvement in renal function is to be expected as a
result of the lowering of blood pressure. This is in
direct contradiction to results reported by Freyberg
and Peet? in 48 cases of hypertension treated by
bilateral section of the splanchnic nerves. In such
patients as responded by a considerable fall of blood
pressure these workers found decided improvement in
the renal function as measured by the concentration
and urea-clearance tests. But in this series again the
results of the operation were very variable, and as a
rule the blood-pressure level, after an initial fall,
showed a tendency to rise to, or even above, the pre-
operative figure. Such results, indeed, raise serious
doubts whether severe’ operations upon the nervous
system are a justifiable means of treating hyperpiesia.
CHRONIC MILIARY TUBERCULOSIS IN
CHILDREN
As long ago as 1845 Waller in Germany noted that
miliary tuberculosis of the lung is not always fatal ;
and radiography has now made it recognisable before
death. Dr. R. H. Fish ? is thus able to describe four |
cases with recovery (as well as six fatal ones) observed
at High Wood Hospital, Brentwood, which receives
all children with pulmonary tuberculosis requiring
treatment under the London County Council tuber-
culosis scheme. In the fatal cases the illness varied in
duration from 53 to 11 months from its demonstration
radioscopically. Four of the six showed undoubted
though temporary improvement, and post-mortem
examination of the tubercles, which contained live
tubercle bacilli, revealed all stages of healing. The
four non-fatal cases were similar to the others except
in their recovery. Persistent but mild pyrexia was
almost constant, but it was punctuated by occasional
rises, perhaps representing waves of bacillemia
arising from massive tuberculous glands in the upper
mediastinum. A slight cough was often present,
joan oe ie H., and Heuer, G. J., Arch. intern. Med. February,
2 Freyberg, R. H., and Peet, M. M., J. clin. Invest. January,
1937, p.
3 Arch. Dis. Childh. February, 1937, p. 1.
998 THE LANCET]
THH BLOOD PICTURE AFTER INDUCED FEVER
`
[APRIL 24, 1937
and sometimes a few rales, but no gross signs were
` superficial hyperszmia.
found in the chest.* Tubercle bacilli were occasionally
demonstrated in the sputum, but recourse to gastric
lavage and guinea-pig inoculation was commonly
necessary. The Mantoux reaction was usually positive
on using 0-1 c.cm. of 1 in 10,000 old tuberculin and
always in 1 in 1000 dilution. Radiography showed
the characteristically diffuse and mottled appearance
of the lung. In the four non-fatal cases, and some
of the fatal ones, extrapulmonary lesions were
coexistent.
In treatment, rest is of paramount importance,
and it must be continued until the stippling has
disappeared, which happens when the tubercle is
replaced by fibrous tissue. All these patients were
treated on open-air balconies, and Dr. Fish gave
them gold in the form of Solganal B, which he thought
beneficial. The prognosis proved as difficult in this
type of tuberculosis as in others, and cases apparently
of the worst type recovered.
RATIONAL SALINE THERAPY
THE intravenous injection of common-salt solution
has been recommended for a variety of conditions.
Some of the recommendations appear contradictory
—for example, the use of “ normal” or hypertonic
saline for cure of the anhydremia of shock and
hemorrhage and as a treatment for anuria in which
fluid-retention may be taking place. The occasional
efficacy of intravenous therapy can be explained by
blood analyses. Root.1 describes two cases in which
intravenous hypertonic saline restored the urinary
flow in patients with only one kidney. Both patients
had anuria with increasing nitrogen-retention and
low blood chlorides, one as. a result of vomiting and
the other from excessive sweating. After intravenous
therapy and restoration of the urinary flow the
blood chemistry became normal and recovery followed.
An example is given of the calculation of the chloride
deficit and the exact amount of salt solution to remedy
this. No doubt if these methodical analyses could be
‘conducted on all patients before the administration
of intravenous solutions, such brilliant results might
be achieved more often. There seems to be no very’
good reason why a vein should be preferred to the
alimentary canal for salt or fluid replacement,
especially if reasonably early blood analyses are done
to reveal the condition before it becomes acute.
If clinician and laboratory were always able'to work
more closely together in these circumstances many
lives would be saved.
THE BLOOD PICTURE AFTER INDUCED FEVER
THE account on p. 1007 of the congress on artificially
induced fever shows to how many different uses this
treatment is now being put in America. Its effect
on the hemopoietic equilibrium is thus of considerable
moment. F. H. Krusen has recently summarised 2 his
observations on a large group of patients. The
patient’s body was exposed from 3-7 hours in hot
circulating humid air varying from 145°-150° F., the
humidity being kept constant. Samples of blood
were taken from each patient immediately before and
immediately after each fever treatment. The disease
for which fever therapy was given appeared to be
without effect on the character of the response.
Similar changes were noted in both venous and
capillary blood, so it may be concluded that such
ehanges represent a fundamental alteration in hæmo-
1 Root, H. F., J. Amer. med. Ass. March 20th, 193
2"4mer. J. med. Sci. 1937, 193, 470. pater
poietic equilibrium and are not dependent upon
Average venous counts on
100 patients before treatment gave a leucocyte count
of 7100 per c.mm., while after fever the count was
11,300 per c.mm. This increase was dependent upon
an increase in polymorph cells. No change that was
significant was found in the Arneth count. The red
cell count was unaltered. The author believes,
therefore, that there is a true increase in circulating
white cells, since there is no evidence of concentration
of the blood and the white cell increase appears to
affect one cell type only. Rather more elaborate
studies of the same problem have been made by
Dr. M. M. Hargraves, who adds a note to Dr.
Krusen’s paper. Dr. Hargraves followed his patients
for 20 hours after the onset of fever with half-hourly
blood counts. He found a response so constant that
he characterises it as a ‘‘febrile hemogram.” There
is a post-febrile leucocytosis, the duration and extent
of which is an individual affair related to the duration
and height of the fever. The peak of leucocytosis is
dependent on a polymorphonuclear increase and often
goes as high as or higher than 40,000 leucocytes
perc.mm. At this stage the younger cells as shown
by an Arneth count are increased, evidence it is
believed of bone-marrow delivery rather than of
redistribution. As the polymorph peak declines, the
total count is sustained, at least to some extent, by
an influx of monocytes. The lymphocytes reappear
in normal numbers only towards the end of the period.
These figures, Hargraves suggests, confirm Krusen’s
observation which was correct for the time of
sampling but usually missed the peak of the response.
Apart from their own interest these figures emphasise
again how rapidly changes in the white cell count
occur, rendering single of = less value than serial
observations,
OBSTETRICAL EMERGENCIES
. Prof. Farquhar Murray’s idea of a local emergency
service for difficult childbirth is now bearing fruit.
It is some twelve years since he began to work out a
way of providing the accoucheur with the needed
assistance whenever the unexpected difficulty pre-
sented itself. In 1929 he advocated 1 the organising
of emergency services, especially in industrial areas,
and in 1935, with the coöperation of the medical
officer of health, he initiated such a service in
Newcastle-upon-Tyne, which was nearly the first of its
kind, something similar having been tried in Lanark-
shire two years previously. In that year a local
Newcastle journal gave a graphic account of how the
efficiency of the service was tested. Prof. Murray
with an accoucheur and the M.O.H. sent an
emergency call from a house in a Newcastle suburb,
and within 15 minutes of the call being made a
nurse was on the doorstep, followed in another minute
by the gynecologist, who had travelled three miles
and was only summoned after the first man on
the rota was found not to be at home. The procedure
is simply this: the doctor or someone acting for him
telephones to the maternity hospital where the outfit
is kept, asking for the service to be put in motion,
and giving name and address of patient and name of
consultant desired. The hospital rings up the con-
sultant named and if he is not at once available one
of the others on the panel of four takes his place.
He goes direct to the patient’s house unless this is
outside the five-mile radius, in which case he calls to
pick up the nurse and outfit. For local cases the
hospital telephones to a taxi rank and sends the
1 Brit. med. J. 1929, 1, 691.
adi i ëO eed et ë Ge ee oe
THE LANCET]
nurse and outfit direct to the patient’s house. The
agreed charges for Newcastle-upon-Tyne are: con-
sulting fee two guineas, operation fee four guineas,
nurse and outfit one guinea, taxi charges extra.
Outside Newcastle the service is now available in
Gosforth, Newburn, Tynemouth, West Hartlepool,
and generally throughout the counties of Northumber-
land and Durham. During the eighteen months it
has been in operation some 20 emergency cases
have been attended, in a number of which Prof. Murray
is assured that lives have been saved.
Just over a year ago a similar flying squad was
inaugurated at the Birmingham Maternity Hospital
by coöperation between its honorary staff and the
medical ‘officer of health, the underlying principle of
the scheme being to bring the resources of the hospital
to the patient’s bedside in case of serious obstetrical
complications where transport would be likely to
impair the chance of recovery. The equipment is
supplied by the public health authority and the
scheme in general is planned on the northern model.
The working has been found quite simple. The
practitioner in charge of the case sends two messages
—one to the consultant, the other to the maternity
hospital which is in close touch with the St. John
Ambulance Service. Within a few minutes a senior
nurse arrives with equipment which includes blankets,
hot bottles, bags containing surgical requirements,
and drugs appropriate for any. emergency. The
ambulance stays at the door in case the patient
should be in a fit condition to be moved, but in
practice it generally does no more than take the
apparatus and nurse back to hospital. During the short
period in which it has been in use the flying squad
has admittedly been instrumental in providing help
without which the parturient mother could not mens
come through safely.
THE JOURNAL OF THE UNIVERSITY OF
MANCHESTER
THE first issue of the Journal of the Universtty
of Manchester represents a venture which must be
successful. The journal will be recognised by all the
members of the university as forming a common bond
between the graduates, providing them with topical
“news and interesting personalia as well as information
on developments in university policy. If future
issues maintain the standard of No. 1, Vol. I, the
journal will be welcomed not only by those whom
it is specially designed to please, but by all interested
in university education. The recent growth of the
University of Manchester and the part to be played
in the future by university education are set out in
two opening essays by Sir Ernest Simon, treasurer .
of the university, and Prof. Godfrey Thomson, whose
Ludwig Mond lecture, delivered last autumn at
Manchester, is now reproduced. Prof. Thomson
closes with these words which all who take heed
to the meaning and needs of education will endorse :—
“The only hope for unity, permanent unity, among
mankind is through the rule of intelligence, through the
cultivation, by an education proper to each, of the
intelligence of all. The schoolmaster is right who considers
that his sole business is to lead his pupils to see truth
clearly, and who holds that that is in itself character-
training, and the only character-training the school may
lend itself to, if it is to refrain from serving party or class,
colour or race, or prejudice of whatever kind, but is to
serve civilisation and al] mankind.”
The university is the next stage to thè school,
and this broad social view is even more obvious in
university training. The new journal exhibits the
THE JOURNAL OF THE UNIVERSITY OF MANCHESTER
. Prof,
[APRIL 24, 1937 999
University of Manchester as a centre of liberal
progress and its graduates will welcome it. And
it is a present to them for it will be supplied without
charge to them and the friends of the university
on application to the Manchester University Press,
Wright-street, Manchester. .
“LYMPHATOLOGY”
A SYSTEMATIC study has been pursued for many
years at the anatomical institute of the University
of Kyoto into properties of lymph and the lymphatic
system for which subject they use the convenient
term “‘ lymphatology.” Recent results are recorded 1
in a series of papers numbered 76-101 by a group of
workers under the general direction of Prof.. S.
Funaoka. The rabbit has been the experimental
animal throughout, and lymph was obtained from
afferent and efferent trunks of the popliteal gland,
from the gland capsule itself, and from lymphatics
of liver and intestine by simple collection or perfusion.
In order to collect lymph at these sources special
techniques have been developed. Many of the
workers have exploited the method devised by
M. Watanabe under the guidance of
Funaoka by means of which all lymphoid tissue is
removed from popliteal glands and lymph is collected
in the shell of the capsule that remains behind. -
Lymph obtained by this means is referred to as
“ Brunnenlymphe” to distinguish it from that
obtained from afferent and efferent trunks. An
improved method for gaining access to the efferent
popliteal lymphatic has been devised by Y.
Yoshida. It consists in constricting the efferent
vessel together with the nutrient artery by means
of a ligature, till it is distended with stagnant lymph.
Then, when it is easily visible, a large-sized hypodermic
needle is passed into its lumen, a second ligature is
passed round the needle and the first is removed.
This manœuvre diminishes damage to blood-supply
in the gland and the danger of contamination of
lymph by cells and serum. A method for obtaining
liver lymph is described by Funaoka and S.
Sumiya. Various quantities of the lymph which was
obtained are given in a Table, but unfortunately
no mention is made of the time taken to collect
these amounts. In this respect the contribution by
K. Okamoto is especially interesting for he
gives the following details: the difficulty in obtaining
peripheral lymph depends upon the time of year ;
it is more difficult in April and at the end of October
(in Japan); by the “ Brunnenlymphe” method the
quantity collected in the first half hour varies from
0-3-1:5 c.cm., and the mean is 1-42 c.cm. per hour ;
the limb from which this flow was obtained was
normal, was not massaged, and the animal was
loosely held round the abdomen. Details such as
these are conspicuously lacking in the form in which
most of this Japanese work is available to European
and American readers, and they are of far greater
interest than tabulated results of scantily described
experiments.
Most of the contributions to these two sections
deal with chemical constituents of lymph under
normal conditions ; more than one author has sought
for ferments passing out of lymphatic glands and in
lymphocytes; a few have examined lymph for
immune bodies in various experiments; several
papers describe the morphology and characters
of cells in lymph; the vexed question of regenerative
capacity of lymph nodes is tackled by one author, and
X ray records of injected lymph vessels have been
1 Acta Sch. med. Univ. Kioto, 1936, 19, Fasc. I and II.
1000 ‘THE LANCET]
used in an examination of normal and retrograde
lymph flow.
Part II ends with a concise summary by Prof.
Funaoka of chemical investigations done at his
institute as well as elsewhere and his promise to
develop certain special themes in future volumes.
THE TAVISTOCK CLINIC’S APPEAL
THOSE who were associated with the institute
of medical psychology now situated at Malet-place,
W.C.1, in its early days at Tavistock-square, will
rejoice that the old name is to be restored. This
welcome change comes, however, at a time of severe
crisis for the clinic. It is one of the very few institu-
tions which gives psychotherapy to out-patients
suffering from neuroses and psychoneuroses and
provides post-graduates with opportunity to study
the various methods employed by its staff. It
promotes many courses of lectures and demonstrations
on mental health for medical and lay workers and
also maintains a child guidance clinic. All this work
is supported entirely by voluntary generosity ;
the medical staff are either unpaid or receive very
small honorariums.
The council of this excellent clinic are now faced
with serious shortage of money. A year ago they hoped
almost immediately to build and equip a hostel for
in-patients in the neighbourhood, but they received so
little financial support that they did not feel justified
in carrying out the plan. The lease of the present
hostel was due to expire in a few months but it has
fortunately been possible to arrange for an extension
until midsummer next year. This is, however,
only a respite and financial help is none the less
urgently needed. The council say in their annual report
for 1936 that unless the situation is promptly relieved
they will be forced to curtail the clinic’s work and
to abandon its promising extension. It would
be tragic if the development of the work of this
clinic were thus hindered. In many other countries
the problem of the mentally unfit is dealt with on
a much larger scale; for example, Vienna has a
dozen counterparts of the Tavistock Clinic. It
would be a veritable disgrace if this pioneer clinic,
which is even now quite inadequate in quantity
though not in quality to meet the needs of London
alone, failed to find support. It is doing fine work
and has large numbers of patients clamouring for
help. The council are making a special appeal to
the industrial community, and especially to large
employers of labour. There is every reason why
they should get a response, since one-third of the
incapacity of employed persons in this country
is attributed to functional nervous disorder; and in
addition, thousands of workers who are not actually
incapacitated have their efficiency much reduced
by neuroses, with an aggregate loss to the nation’s
industry, which is not easy to measure but is certainly
severe,
ETHYL STRYCHNINE AS A RESPIRATORY
STIMULANT
THE important uses to which a drug might be put
which had the power to exert a stimulating action
directly on the medulla need no demonstration.
Respiratory arrest during anesthesia may be
mentioned merely as one example. Experiments
which their authors believe establish the value of
ethyl strychnine as such a drug have now been
described by M. Aiazzi-Mancini and L. Donatelli}
They point out the striking difference between the
1 J. Pharmacol. March, 1937, p. 304.
THE TAVISTOCK CLINIC’S APPEAL
~ convulsive effect.
[APRIL 24, 1937
effects of strychnine and those of ethyl strychnine.
The former, which was at one time much recom-
mended for injection during surgical emergencies
associated with shock, has long been disapproved
of in these circumstances, the researches of Crile
having had much to do with forming the conclusion
that strychnine in spite of its stimulant power is
exhausting and dangerous when applied to an
acutely depressed nervous. system. The most
commonly employed restoratives for failure of
breathing are at the moment carbon dioxide, with
or without oxygen, Coramine, and lobeline. The
authors to whom we have referred believe that ethyl
strychnine may prove superior to these clinically,
as it has in their experimental work. Previous
observers working with strychnine have maintained
that respiratory depth is increased by injection of
the drug only if the stage of convulsion is reached.
Ethyl strychnine, on the other hand, is able to
stimulate the medullary centre in doses which do not
modify spinal activity. Moreover its toxicity to a
normal animal is only a twentieth of that of strychnine.
In animals under narcotics and anssthetics ethyl
strychnine was found to increase greatly the depth
of breathing, without having much effect on the rate.
In doses of 0:05 to 0:25 mg. per kg. of body-weight
the action is prolonged and unaccompanied by any
Undesirable symptoms were pro-
duced only if the drug was injected into a‘ vein.
The authors insist therefore that ethyl strychnine
should be used intramuscularly, or under the skin.
The doses needed to stimulate animals poisoned by
narcotic or anæsthetic were of course much greater
than those which stimulated respiration in the normal
animal.
MEDICINE STAMP DUTY
In the Budget the Chancellor of the Exchequer
has found the extra money he needed without acting
on the recommendations of the Select Committee on
Medicine Stamp Duties, which showed him how to
add £3,000,000 or thereabouts to the revenue. Thus
for the time being the report is shelved, but it is not
likely to be forgotten. “I am having the recom-
- mendations examined,” said Mr. Chamberlain, ‘* but
in view of the very complex issues involved and the
existing strain on the time of Parliament I am not
proposing to introduce legislation on this subject in
the Finance Bill this year.” Such a source of revenue
as exposed by the committee cannot be overlooked
indefinitely, but, in the meantime, other means of
keeping the traffic in proprietary medicines within
reasonable bounds may be explored.
WE rat to announce the death on April 18th
of Dr. Archibald Donald, emeritus professor of
obstetrics and gynecology in the University of
Manchester.
MEDICAL SERVICES IN U.S.S.R.—7528 million
roubles (nominally about £290 millions) is allocated from
the State budget of the Soviet Union for health protec-
tion in 1937, as against 5803 million roubles in 1936. It
includes an expenditure of 1000 million roubles on building.
The number of hospital beds in 1937 will be brought up to
‘619,800 as against 564,000 in 1936; maternity beds to
11,078 as against 6000. The public nurseries will be
extended in the urban areas to provide places for 609,000
children. as against 464,000 in the previous year, and in
rural areas to provide places for 570,000 children as
against 378,000. Sanatoriums and health resorts in 1937
will provide 95,000 beds as against 91,500 in 1936; while
the number of beds at the rest homes run by the trade
unions will be increased from 99,300 to 105,000.
THE LANCET]
[apriL 24, 1937 1001
PRINCIPLES OF MEDICAL STATISTICS
XVII—CALCULATION ,OF THE
CORRELATION COEFFICIENT
THE correlation coefficient, r, is most easily
calculated from the formula r = mean of the values
of (observation of x minus mean of the observations of
x) X (corresponding observation of y minus mean of the
observations of y) — standard deviation of x x stan-
a deviation of y. Or in the symbols previously
used,
_ Sum of values of (x — x) (y — y)
ic NOg Sy
The Ungrouped Series
Suppose, for instance, we have measured on
twelve persons their pulse-rate and their stature,
and wish to measure the degree of relationship,
if any, between the two by means of the correlation
coefficient. The twelve observations are given in
columns (2) and (3) of Table X a.
TABLE XA
i a e e a ee ee
er Zas = | : | Š =
ndi- | a82/ oa ah > j> 2
Aaa | wegl gel 7 | A Si] x | xb
EPRE A See cs cep
B35 |i | Ili = D
gu’ R | oa
x 1
(1) (2) (3)|. (4) (5) (6) | (7)| (8) (9)
1 62 | 68 | 3,844 | 4,624 |—10| —1| +10 | 4,216
2 74 |65! 5.476 | 4.225 |+ 2 —4| — 8| 4810
3 80 |78| 6.400 | 5,329 |+ 8 +4| +32 | 5,840
4 59 | 70 | 3481 | 4,900 |—13 +1| —13 | 4,130
5 65 |69| 4225| 4:761 |— 7| 0 0 | 4,485
6 73 | 66| 5,329 | £356 |+ 1| -3| — 3| 4,818
7 78 |69! 6084| 4.761 (+ 6 0 0 | 5382
8 86 | 70 | 7,396 | 4,990 |+14! +1] +14 | 6,020
9 64 |72| 4096| 5.184 |— 8' +3| —24 | 4,608
10 68 |71| 4624 | 5041 |— 4| +2| — 8 | 4,828
11 75 | 68, 5,625 | 4.624 |+ 3| -1| — 3| 5,100
12 80 | 67 | 6,400 | 4.489 |+ 8| —2| —16 | 5,360
Total 12 | 864 |828 | 62,980 |57,194 | oj of —19 |59,597
Mean |
values| 72 | 69 '5248°33/4766'17| — | — | —1°58 4966°42
|
|
The standard deviations can be found, as shown
before, by squaring each observation, finding the
mean of these squares, subtracting from it the square
of the mean, and taking the square root of the
resulting figure. The standard deviation of the
pulse-rates is therefore «45248-33 — (72)2 = 8-02
and of the height is +/4766-17— (69)? = 2-27.
The deviation of each individual’s pulse-rate from the
mean pulse-rate of the twelve persons is given in
column (6) and of each height from the mean height
in column (7). If there is any substantial (and
direct) correlation between the two measurements,
then a person with a pulse-rate below the mean
pulse-rate ought to have a stature below the mean
height, one with a pulse-rate above the mean rate
ought to have a stature above the mean height.
(If the association is inverse positive signs in one
will be associated with negative signs in the other.)
Inspection of the figures suggests very little correla-
tion between the characteristics. For the numerator
of the correlation coefficient formula we need the
product of the two deviations shown by each person.
These are given in column (8). Their sum is —19
and their mean is therefore —19/12 = —1-58.
The coefficient is reached by dividing this mean
product value by the product of the two standard
deviations—namely, 8-02 x 2-27, and gives a value
of —0:09. In other words in these twelve individuals
the pulse-rate and stature are not related to one
another.
In the example taken this is a satisfactory mode of
calculation because the mean pulse-rate and the
mean height are whole numbers and also the original
measurements are whole numbers; it is, then, easy
to calculate the deviation of each observation from-
its mean. But if decimals had been involved the
deviations would have been troublesome to calculate.
In that case it is easier to avoid altogether using
deviations and to multiply directly the pulse-rate
of each person by his stature, as in column (9),
applying a correction at the end to the resulting mean
value. The correction necessary is this: from thé
mean value of the products thus found we must
subtract the product of the two means—i.e., the
product of the distances between the points from
which we chose to measure the deviations and the
points from which we ought to have measured them.
In the example taken this gives 4966-42 — 72 x 69
= — 1-58, or the same value as was previously
reached by working with the real deviations from
the means.
This is the simplest and best method of calculating
the two standard deviations and the correlation —
coefficient between the characteristics in anything
up to 50-60 observations. With a larger series of
observations, finding the individual squares and
products becomes progressively more laborious and
it is better to construct a grouped correlation table.
The Grouped Series
* AS an example, we may take for each of a number
of large towns in England and Wales (1) a measure
of the amount of overcrowding present in a given
year, and (2) the infant mortality-rate in the same
year; we wish to see whether in towns with much
overcrowding the infant mortality-rate tends to be
higher than in towns with less overcrowding. We
must first construct a table which shows not only
how many towns there were with different degrees
of overcrowding but also their associated infant
mortality-rates.
Table XB gives this information. The town with
least overcrowding had only 1-5 per cent. of its population
living more than 2 persons to a room (this being used as
the criterion of overcrowding); the percentage for the
town with most overcrowding was 17:5. The lowest
infant mortality-rate was 37 deaths under 1 per 1000 live
births and the highest was 110. Reasonably narrow
groups have been adopted to include those maxima and
minima and each town is placed in the appropriate ‘“‘ cell ”’
—e.g., there were 5 towns in which the overcrowding
index lay between 1-5 and 4:5 and in which the infant
mortality-rates were between 36 and 46, there were 2
in which the overcrowding index lay between 10-5 and
13-5 and in which the infant mortality-rates were between
86 and 96. (If a very large number of observations is
involved it is best to make a separate card for each town,
person, or whatever may have been measured, putting the
observed measurements on the card always in the same
order; the cards are first sorted into their proper groups
for one characteristic (overcrowding), and then each of
those packs of different (overcrowding) levels is sorted into
groups for the other characteristic (infant mortality).
The cards in each small pack then relate to a particular
cell of the table.)
1002 THE LANCET]
Table X B shows at once that there is some associa-
tion between overcrowding and the infant mortality-
rate, for towns with the least overcrowding tend,
on the average, to show relatively low mortality-
rates, while towns with much overcrowding tend to
show high mortality rates. The table is, in fact,
a form of scatter diagram.
TABLE X B
Overcrowding and Infant Mortality.
Correlation Table
Example of
Percentage of population in private
families living more than two persons
Infant per room.
mortality- Total
rate.
1°5— | 4°5— | 7°5-— | 10°5—-| 13°5-| 16:5-
i 19:5
36- 5 ee ee ee 5
46- 9 1 ee ee 10
56- 10 4 1 wa 1 16
66- 4 7 5 2 18
76- 2 5 4 1 13
86— 2 2 2 1 7
96- 1 2 2 1 7
106—116 1 sa 1 a 2
Total .. 30 21 14 8 2 3 78
To calculate the coefficient of correlation we need
(1) the mean and standard deviation of the over-
crowding index; (2) similar figures for the infant
mortality-rate ; and (3) for each town the product
of its two deviations from the means—i.e. (over-
crowding index in town A minus mean overcrowding
index) x (infant mortality-rate in town A minus
mean infant mortality-rate). In other words we wish
to see whether a town that is abnormal (far removed
from the average) in its level of overcrowding is also
abnormal im the level of its infant mortality-rate.
In calculating the means and standard deviations
of the two distributions we can entirely ignore the
centre of the table; we have to work on the totals
in the horizontal and vertical margins. The method
is shown in Table X c.
TABLE XC
Overcrowding and Infant Mortality. Calculation of
Correlation Coefficient
Percentage of population in private families
living more than two persons per room.
Infant
mortality- =
rate. =
7°5— | 10°S5— | 13°5- 16°5— EX
R.U. |W.U 0 +1 +2 +3
36- -3 5
46- — 2 P AE 10
56- — l 1 (0) 1 (—3) 16
66- 0 5 (0)2 (0) ss se 18
76- +1 4 (0)1 (+1)1 (+2) A 13
86- +2 2 (0)2 (+4) 1 (+6) 7
96- | +3 2 (0). 2 (+6)1 (+6)/1 (+9) 7
106- +4 1(+4) .. Pe 2
116
Total 14 8 2 3 78
R.U.= Real units; W.U.= Working units.
For instance, we see from the right-hand totals that
in 5 towns the infant mortality-rate was between
36 and 46, in 10 between 46 and 56, in 16 between
PRINCIPLES OF MEDICAL STATISTICS
[APRIL 24, 1937
56 and 66, and so on. Of this distribution we want the
mean and standard deviation. As shown previously
these sums are more easily carried out in ‘ working units °”
instead of in the real, and larger, units. In these units
we have 5 towns with an infant mortality-rate of —3,
10 with a rate of —2, and so on. In working units,
therefore, the sum of the rates is +5 and the mean rate
is +5/78 = +0:06. The mean in real units is, then,
71 (the centre of the group opposite 0) + 0:06 x 10
(10 being the unit of grouping) = 71:6. To reach the
standard deviation we continue to work in these units.
Measuring the deviations from the 0 value instead of from
the mean there are 5 towns with a squared deviation of
(—3)2 and these contribute 45 to the:sum of squared
deviations ; there are 10 towns with a squared deviation
of (—2)2 and these contribute 40 to the sum of squared.
deviations.
In working units the sum of squared deviations from
0 is thus found to be 237. The mean squared devia-
tion from 0 is 237/78 = 3-0385 and from this, as
correction for having measured the deviations from
0, we must subtract the square of 0-06, the value
from which we ought to have measured the devia-
tions. The standard deviation of the rates in working
units is therefore the square root of 30385 —(0-06) 2 =
1-742, and in real units is 1-742 x 10 = 17-42.
We can now work in just the same way on the
distribution of overcrowding—there are 30 towns
whose overcrowding index in working units was
—2, 21 whose index was —1, and so on. This’ gives
a mean and standard deviation in working units of
—0Q-77 and 1-329, and in real units of 6-7 and 3-99.
In this there is nothing new; the process was given
in full in Section XVI.
We now need the product of the deviations from
the means for the numerator of the correlation
coefficient. This is easily reached by continuing
to measure the deviations in working units from the
0 values and making a correction as usual at the end.
For instance, there are 5 towns the deviation of which
is —2 in overcrowding and —3 in infant mortality. The
‘product deviation is therefore +6, and as there are 5 such
towns the contribution to the product deviation sum is
+30. Each of these values can be written in the appro-
priate cell (they are the figures in parentheses in
Table X coc). Their sum is +107 and the mean product
value is + 107/78 = +1-3718. These deviations in working
units were measured from the two 0 values whereas they
ought to have been measured from the two mean values,
+0:06 and —0:77; therefore as correction we must
subtract from + 1:3718 the product of +0:06 and —0-77
(as in the ungrouped series, the correction is the product
of the distances between the points from which we chose
to measure the deviations and the points from which
we ought to have measured them). The numerator to the
coefficient is therefore +1-3718 — (0-06 x —0:77), and
the denominator is the product of the two standard
deviations ; so that
_ +1:3718 + 0:0462
~ 1742 x 1329-
(It may be noted that as the numerator is in working
units, the standard deviations must be inserted in their
working units.)
= + 0-61.
There is we see a fair degree of correlation between
overcrowding and the infant mortality-rate, but at
the same time Table XB shows that with towns
of the same degree of overcrowding there are consider-
able differences between the infant mortality-rates.
The standard error of the coefficient is 1/Vn—=1=
1/V78—1= 0°11; as the coefficient is more than five
times its standard error it may certainly be accepted
as ‘‘significant.”’
The calculation is very much speedier with the
observations thus grouped and little change has been
THE LANCET}
BRITISH HEALTH RESORTS ASSOCIATION
[APRIL 24, 1937 1003
made in the values reached, as the Eon mene figures
show :—
, l Same 78
Grouped Soros observations
a of Table X B ungrouped.
Means—
Overcrow a e's 6°7 6°6
Infant mor ty oie 71°6 71°0
da: on goratu
are er a 3°99 3°74
Infant morte ty Es -IT 17°3
Correlation coefficient +0°61 +0°59
The regression equation is—
17-4
Infant mortality minus 71-6 = -+-0-61 i
3-99
crowding index minus 6:7) which reduces to—
Infant mortality = 2-66 overcrowding index +
53-78. (It must be noted that the values in real
units must be inserted in this equation.) In other
words the infant mortality rises, according to these
data, by 2-66 per 1000 as the percentage of the
population overcrowded increases by 1.
A. BRADFORD HiL.
(over-
SPECIAL ARTICLES
BRITISH HEALTH RESORTS
ASSOCIATION
A MEETING of the British Health Resorts Associa-
tion was held at Skegness on Saturday last. The
conference was well attended and the various advan-
tages that might be derived by the sick, the con-
valescent, and the public from the facilities offered
at the different centres in this country were
brought out. The congressists were the guests of the
municipality.
Lord Meston, the president of the association,
spoke of the inception of the movement and of its
development from a winter-in-England movement
into a body not only interested in presenting the
claims of British resorts on to the attention of the
medical profession and the public, but also in
promoting the study of the climatic and other con-
ditions which made these resorts suitable ; or perhaps
unsuitable, as health seekers at different times of the
year must have resorts selected for them. He pleaded
for greater support by local authorities, whose
interests the association was unselfishly serving, but
noted the steady improvement in hotels, to which |
he thought the action of the association had con-
tributed. Speaking from personal experience in
many countries, he held that the British hotels “ had
nothing to fear from comparison if like were compared
with like.” -
The chairman of the Skegness urban district council,
Mr. J. Crawshaw, presided at the first session, dealing
with
Industry and ‘the Health Resort
Mr. A. L. Peterson, managing director of the
Spirella Company of Letchworth, spoke as an employer
in a firm which had made complete arrangements
for the welfare of its employees. As most of the
‘users of health resorts, he said, were connected with
industry it was important for employers who desired
to be progressive should be told more of the advan-
tages of these resorts for the workers. He stressed
the point that, with payment for holidays, a move-
ment which was advancing, there would be great
opportunities for health resorts placed in proximity
to the centres of industry. He said that there should
be talks in the factories on how holidays could be
used so that holiday-makers could get the best
value out of them.
Mr. Ernest Bevin, general secretary of the
Transport and General Workers Union, said that
the provision of holidays with full pay for the
workers was one of the principal struggles of the
movement he represented. The different treatment
of staff, public servants, and others employed in
more favourable occupations, as against the actual
workers, formed a serious grievance. Since the war
the more enlightened employers were realising that
the granting of holidays with pay was not only an
advantage to the working person and his family
but to industry itself. Unpaid unemployment,
moreover, had risen periodically so that the whole
question of what might be termed the contractual
period for labour had been brought within the realm
of practical politics and the Government had now
set up a committee, of which he was himself a member,
to consider the whole problem,
THE AMENITIES OF HEALTH RESORTS
There was need for the creation of an industry to
cater for the holiday needs of the workers; there
should be a scientific study of the whole matter
and the provision of holidays for the workers would
open an avenue of employmént for thousands of
others. He held that the British health resorts had
not taken a sufficiently enlightened view to meet
the requirements that this new development would
entail. It had been demonstrated that a great set-off
against the cost of holidays to industry generally
was the decrease in sick leave and absenteeism.
The English climate was not an easy one for which
to cater, but the kind of shelter put up along sea
fronts, with a glass partition in the centre, was quite
inadequate to meet the weather changes and yet
these shelters were an absolute necessity if visitors
were to derive the benefit of the sea air. And when
holiday resorts were planned there must be a real drive
to secure a better standard of accommodation.
Although “hot and cold running water” in every
room was so readily advertised, in thousands of
houses, which the workers now have to use, the
accommodation was quite out of date; yet from
a health point of view, good accommodation and
bright surroundings were an even bigger contribution
to recuperation than medicine. Taking the British
seaside resorts generally, the municipalities had
spent more money and were superior to continental
resorts in the arrangements made to cater for the
pleasures of the people. But in accommodation
and cuisine they lagged behind, Here was a great
opportunity for municipal enterprise which would
be called for, since the extension of holidays over a
lengthened season would cause the question of
holiday centres or homes to be dealt with. These
could not be erected in every health resort, and if the
millions were to be catered for some development .
must occur. In many industries it was impracticable
for the whole of the workers to take their holidays
during the summer months and there were three
other periods in the year which offered opportunity
for catering, if correctly handled—i.e., late October,
Christmas, and Easter. The maintenance of our
health resorts would be largely dependent upon
catering for the masses. Amongst the so-called
1004 THE LANCET]
middle classes the idea was sometimes prevalent
that the masses were just vulgar people, and so cheap
and nasty accommodation was held to be good
enough. But the popular standards were rising and
time would show inadequate accommodation to be a
very short-sighted policy. The food-catering arrange-
ments must be improved ; people were used to better
fare both in homes and restaurants and would not
tolerate the stodgy, unappetising meals now set
before them.
PRESERVATION OF THE COUNTRYSIDE
- Mr. Bevin spoke earnestly on the need to preserve
the beauty of the countryside and coastline. “ With
the planning of the health resorts,” he said, “and
with improved architectural arrangements, due
regard must be paid to the preservation of the coast-
line and countryside. So many beauty spots are
spoiled by building speculators and others, whose
sole idea is to reap in Money in one form or another,
and many local authorities also succumb to the
desire to share in these developments. They do not
fully realise their responsibilities and do not sufficiently
exercise their powers of control. It must be
remembered that a holiday is not only for enjoyment,
to be effective it must also be cultural and health-
giving, and whilst you may bring prosperity to a
few citizens by allowing development to go on in
an haphazard manner, it is a short-sighted policy,
and local authorities may find themselves saddled in
a few years with burdens they should never have
undertaken. Local authorities should exercise a
strict control on the erection of buildings, whether
for pleasure, hotel, or housing purposes, and keep
them in conformity with the best architectural
standards and the traditions of the place, plus the
acceptance of modern ideas. Avenues, public gardens,
and vistas should be kept spacious and ample
space provided for recreation and games.”
He went on to plead for more attention to the
case of the children ;
was not only for the man, it was for the woman
also, and the family problem was a very serious
one, so that facilities for the children to play in
covered shelters during bad weather must be made.
He commended the action of those local authorities
who provided play centres on the beach, where the
younger children could be looked after by trained
nurses, allowing the mother to safely leave them
for a few hours. He advocated holiday camps for
children. The development of inland centres he
commended as preventing the coastal resorts from
being overcrowded and leading to a greater use being
made of our spas and hydros. Here he pointed
out that the preservation of the beauties of the
surrounding countryside and its historical features
would in the long run lead to and hold the business.
SUITABLE CONVALESCENT HOMES
Of the employment of health resorts to a much
greater extent for the provision of convalescent
treatment, Mr. Bevin said that trade unions, friendly
societies, approved and other societies had established
buildings and homes under their own management,
leading to a limited form of treatment and selection
whilst, at the same time, literally thousands of pounds
were being spent in convalescent benefit. The whole
arrangement was uneconomic and the fullest benefit
was not being derived. A codrdinated scheme, in
conjunction with our health resorts, for the munici-
palities and the societies to take a hand in really
planning convalescent home treatment was wanted.
BRITISH HEALTH RESORTS ASSOCIATION
the holiday, he pointed out,
[APRIL 24, 1937
For suitable arrangements for curative treatment
and a pleasant and restful vacation it would be a real
boon. But convalescent homes must not be developed
on institutional lines; they must be well appointed
and free from too many restrictions, while the rooms
should be large and airy, and cheerfully decorated.
The home should stand in its own grounds. He
added that although there were quite a number of
convalescent homes throughout the country for
men, the number provided for women was totally
inadequate.
Mr. Bevin concluded by asking for a Government
commission to examine the problem of planning,
equipment, and codrdination of health resorts. He
said: ‘I should like to see the Health Resorts
Association urging the Government to set up a Royal
Commission to examine the whole problem of planning,
equipment, and codrdination of health resorts.
The work of this Royal Commission could proceed
concurrently with that of the Holidays with Pay
Committee, so that as a rapid expansion of holidays
takes place we can get a great drive for public develop-
ment and so cater for what will become a very import-
ant and vital industry to this country. The Royal
Commission should not only take into account
the planning of the existing health resorts, but
also the problem of equipping such resorts. This
‘May have a very great bearing upon certain spots
-in the Special Areas. .
. . The trade unions who have
been working on this problem of holidays with pay
and now have the task of trying to weave it into our
industrial fabric have created as it were a raw
material for the development of our health resorts
far beyond the dreams of any of those who have been
engaged in the business in the past.”
THE HOLIDAY ATMOSPHERE
Dr. Leonard P. Lockhart, medical officer, Boots
Pure Drug Co., Ltd., opened with the following
wide definition of a health resort—‘ as I understand
it is any place where a holiday can be spent.” Hence it
followed that it should meet the needs either of the
person desiring a holiday or the person who is under-
going a routine treatment or resting for convalescence.
He drew sound distinctions between the holiday
maker and the patient, holding the holiday atmos-
phere to count most in most cases, and regretting that
people were not sent away more often as a prophy-
lactic. From personal experience he held that more
care should be taken to choose only the right cases
to be sent away, and he believed that in the con-
valescent home established by Messrs. Boots at
Skegness, money was spent on just those cases.
Holidays properly based on rates of pay would
reduce the sick absentees. He pointed to the value of
holidays being taken in family groups.
Mr. J. J. Hewlett, representing the Hotels and
Restaurants Association, disclosed some of the diffi-
culties experienced by the hotel-keeper, especially in
places with short seasons, reminding the audience
that hotels in Great Britain were handicapped as
those on the Continent were not, by Government
restrictions as well as by increasing rates and
taxes.
The chair was taken at the afternoon session by
Dr. A. D. F. Menzies, M.O.H. for Skegness, and the
session was devoted to the consideration of
Games, Sport, and Sea-bathing
The discussion was opened by Sir Kaye Le Fleming,
who said that he was not speaking as a member of.
THE LANCET}
the Government Advisory Council on Physical Educa-
tion, and was omitting from his, remarks any con-
sideration of nutrition, although attention to nutrition
was essential in any national attempt to raise physical
standards. Pleasure, he said, could not be fully
enjoyed without an education in its use; it was
relaxation after work and the re-creation of faculties
for work. The British were a games-loving people,
and games were the specialised ends of physical
education. Hence he would give a prominent place
in the betterment of physical culture to such sports
as tennis, swimming, and skating, which produced the
balanced mind in the balanced body, and would put
in a plea for deck tennis, a game which it was easy to
provide cheaply and which, as it took up little space,
could be played indoors. All these sports, he thought,
should be available for the mass of the workers, so
that they would have a chance to develop a sense of
pleasure in the fitness of their bodies. With regard
to bathing, he pointed out that there should be
attached to every bathing centre a building—call it
a gymnasium—not provided with any elaborate
apparatus, but where, while exercises could be
indulged in, music and opportunities for refreshment
were provided. In sea-bathing much of the advantage
was in the free exposure of the skin to the air and
the reluctance of the male sex in this direction must
be overcome; women had already got over it.’ The
medical profession would have to give more serious
study to the problems connected with physical
education. And with regard to Skegness, he held the
centre up to praise for the efforts that had been
made to supply the necessary amenities, adding that
such efforts must be made more freely at seaside
resorts.
Dr. Cove Smith said the new Government move-
ment in favour of physical education had come none
too soon. The kind of individual we want to produce
is the man and woman who és fit and feels fit. It
was no use in so developing gymnastics that we
produced‘ people with the muscles of a Sandow who
would die in the fifties with a fatty heart. The
problem was to find out how our spare time, of which
there would be more for many people, could be best
employed. Modern machine repetition work had
unbalanced the average worker, while artificial
inducements to exercise could not take the place of
exercise in the open air. He dealt with the technical
aspects of sea-bathing, the appreciation of which
was a comparatively new development. On the
authority of Fanny Burney he said its popularity
dated from the time when King George III took the
sea at Weymouth, followed by a bathing-machine
containing fiddlers who played ‘God Save the
King.” -
Dame Louise McIlroy attributed great virtues in
many gynæcological cases to seaside treatment.
Girls who had been accustomed to much active
exercise at school often fell into poor health when
they were deprived of this, and a visit to the seaside
with active exercise and bathing was of great value.
The same applied to many women in sedentary
occupations rather than to those whose work was
more active and sometimes really heavy. Middle-aged
women with tendency to fat were greatly benefited.
This country was behind the Continent in its health
resorts, but, things being equal, the avoidance of
long and tiring journeys, with language and customs
difficulties, must be remembered. The native doctor
could better treat the patient, understanding her
psychology and her home conditions, than a foreign
one could. It was a mistake to try to imitate con-
MEDICINE AND THE LAW
[APRIL 24, 1937 1005
tinental cooking. She supported Mr. Bevin’s plea for
more convalescent homes.
Dr. Menzies gave interesting\ figures about the
meteorology of Skegness. There was a low rainfall
and a high ultra-violet rate. The place was specially
good for post-operative cases and their best months
were April, May, and October. The tonic effect was
greater then than in the summer months. They were
proud of their children’s day nursery with its
trained nurses. They were fully alive to the import-
ance of accommodation at hotels, and had made a
survey last year which would show good results.
Their physical culture classes on the beach were
very popular.
Dr. H. Sanguinetti (London) referred to Prof.
Kestner’s recent work on the effects of sea air on
children and said it pointed out one way in which
doctors could take a greater part in the investigations
needed to place this subject on a thoroughly
scientific basis.
Mrs. McCrae, M.B. (London), from her experience
of child welfare work, strongly supported the claim
of the wife of the industrial worker for the benefits
of the seaside. These she could not get unless she
were at the same time relieved of much of her
maternal worries.
Lieut.-Colonel W. Byam, R.A.M.C. (ret.), chairman
of the Medical Advisory Committee of the Asso-
ciation, in moving a vote of thanks to the chairman,
said many sound ideas had been ventilated which
would receive the attention of his committee.
HOSPITALITY
In the evening the members of the conference,
along with members of the local council and their
ladies, were entertained at a banquet at the County
Hotel. -Lord Meston proposed the toast of Skegness,
to which the chairman of the council replied, giving
many interesting details as to the growth and
progress of the town. Councillor C. T. Jessap
proposed the health of the association, to which Dr.
Alfred Cox, the secretary, replied. The banquet,
which was enlivened by songs, was a pleasant
termination to a most successful conference.
MEDICINE AND THE LAW
Successful Claim against Widow of Doctor
THE litigation -in Connolly v.. Rubra forms a
menacing precedent for the medical profession.
A civil servant named Connolly dies of tuberculosis.
His right of action does not die with him. His
widow sues Dr. Rubra, who attended the patient, and
alleges negligence in diagnosis and treatment. Dr.
Rubra is himself too ill to appear in court; he dies
before the case is decided and damages to the amount
of £5000 are awarded against his estate. The Court
of Appeal declines to interfere.
Lord Justice Greer, delivering the unanimous
judgment of the court on April 7th, emphasised the
difficulty of the case. The original trial had taken
place before Mr. Justice Greaves-Lord “in circum-
stances of very great diffculty,” inasmuch as the
chief witness for the defence was not available. The
trial judge had to decide whether he should accept
the evidence of the plaintiff, Mrs. Connolly, as to
conversations she had with Dr. Rubra. As the Court
of Appeal observed, Dr. Rubra could not be called
1006 — LANCET]
to give his version of the facts; all that could be
done was to criticise Mrs. Connolly’s evidence by
reason of letters she had written and by reason of the
absence of corroborative entries in Dr. Rubra’s books.
Then there was another “very difficult question
indeed.” The plaintiff had to establish not only that
Dr. Rubra was negligent but also that his negligence was
the cause of shortening the life of the patient. Lastly
“the question: of damages was also one of great
difficulty.” It was difficult for Mr. Justice Greaves-
Lord to assess the amount; he must not fail to take
into account the common ‘risks of life to which all
persons, even if healthy, are subject. It was also
“very difficult for the Court of Appeal to interfere
with his judgment, even though they might happen
to think themselves that the award is rather on the
generous side.” The Court of Appeal was not entitled
to assume that the trial judge failed to take into
account the fact that Mr. Connolly was “ a frail and
chesty patient.” Unless the trial judge took into
account matters which he ought not to have taken
into account, or failed to take into account matters
which he ought to have taken into account, the Court
of Appeal would not upset his award. On the material
questions of fact, said Lord Justice Greer, the trial
judge, having to decide ‘‘ between a living widow and
a dead defendant,’ was entitled to make up his
mind on the evidence given by the widow, provided
that he took into consideration all the relevant
criticisms which could be made with regard to her
evidence,
It remains to summarise the observations of the
Court of Appeal on the issue of professional negligence.
Lord Justice Greer remarked that tuberculosis is one
of many diseases with which a general practitioner
commonly has to deal. If the doctor has any doubt
whether or not there are signs of tuberculosis, it is
his obvious duty to make further examination to
resolve that doubt and to make it clear that nothing
further can be done for the patient. A doctor who
is not over-confident of his own judgment will,
when he finds himself in a difficulty, call in an expert
and decide according to the expert’s views. To enable
the expert’s opinion to be of value it is not enough
to do what Dr. Rubra did at a later period—namely,
to take one specimen of the sputum and be content
with that if the result is negative; he must take
many specimens of the sputum and, in addition, he
ought to have an X ray examination and to watch
the patient to see whether he is progressing or going
back as time goes on, “Dr. Rubra unfortunately
did none of those things.” Ought he to have sus-
pected tuberculosis when he diagnosed bronchitis ?
It was here that.the widow’s evidence was crucial.
She gave evidence at the trial of interviews she had
with Dr. Rubra in December, 1930:
then told him of an effusion of blood from the patient’s
mouth in the summer holidays of 1929, of streaks of
blood in the sputum towards the end of 1930, and
of blood stains on his handkerchief. Believing the
widow’s evidence, the trial judge came to the con-
clusion that at the beginning of 1931, or at the end
of 1930, Dr. Rubra had shown such want of com-
petent and ordinary skill and care as justified the
claim for damages. There the case stands after an
attentive hearing and a judicial review with which no
doctor can quarrel. All must sympathise with Mrs.
Connolly and her children in their loss. Nobody
disputes the bona fides of the evidence for the plaintiff.
The state of the law, nevertheless, will cause the
medical profession grave misgiving. Does it not often
happen that the comments and statements made by
a patient’s relatives take on a quite different com-
MEDICINE AND THE LAW
she said she.
[APRIL 24, 1937
plexion when one hears the version given by the
doctor? Is it fair that the law should contemplate
a decision upon the evidence of one side alone, and
that a deceased doctor’s estate should be liable in
damages to the substantial amount of £5000 when,
had the doctor’s own evidence been available, the
plaintiff might not have succeeded in establishing
her case beyond doubt ?- The Court of Appeal saw
the difficulties of the case. If these decisions between
a living widow and a dead doctor have these heavy
consequences, a disturbing distraction will embarrass
the practitioner’s mind,
The Doctor’s Bad Debts
Though the Merseyside Medical Practitioners’
Association was formed to promote other and more
general objects than the mere collection of bad debts,
its efforts in the latter direction have attracted
publicity and may be imitated elsewhere. One news-
paper has stated that the Merseyside doctors estimated
that outstanding accounts owing by local patients to
medical men and dentists exceeded a total of £100,000.
The defaults are represented as being on an unusually
large scale. To prevent them from growing still
larger, the members of the association undertake to
furnish it periodically with lists of patients whose
accounts are long overdue. The debtors are given a
further chance to pay; if the chance is not taken
the names are placed on a “‘ defaulters’ list,” circulated
confidentially to members. The doctor or dentist
whose services are asked for by one of these defaulters
is thus in a position to request payment in advance.
This system simply applies to medical practice a
method of protection well known elsewhere. Bar-
risters’ clerks have their own ways of knowing the
firms of solicitors from whom no brief should be
accepted without the accompanying fee. London
shopkeepers are not entirely unarmed against
customers who habitually open accounts without the
means or intention to pay. Defaulters whom it is
necessary to place on a “ black list” are a nuisance :
having exhausted their credit in one direction, they
repeat the process in others. The plan adopted in the
Merseyside district will protect newcomers from being
imposed upon. Unless there is bad faith or breach
of confidence in its operation, it is privileged and
cannot give rise to libel actions. A doctor can
of course attend a patient on the understanding that
his service is gratuitous. In the absence of any such
understanding, he is entitled to be reasonably
remunerated for his professional work. He is cer-
tainly not obliged (unless there is some contractual
obligation on his part) to attend any patient who
chooses to send for him; nor is there anything to
prevent him from stipulating that his services shall
‘be paid for on a cash and not a credit basis.
A Mistake in Dispensing
At a Lancashire inquest on the death of a woman,
aged 60, during an operation shortly after the adminis-
tration of a local anezsthetic, it appeared that the
hospital dispenser had made a mistake. He had
been asked to supply a one-per-cent. solution of
procaine hydrochloride ; he had supplied not procaine
but percaine hydrochloride. The coroner explained
that, while procaine was a relatively harmless drug,
percaine was deadly in anything but therapeutic
doses. The patient had been in a serious condition ;
without surgical operation her expectation of-life was
limited ; but her death was due to the error. It was
easy, observed the coroner, to be wise after the
event. A verdict of “ death by misadventure” was
recorded,
THE LANCET]
ARTIFICIAL FEVER THERAPY
(PYRETOTHERAPY)
FIRST INTERNATIONAL CONGRESS
On March 29th at the College of Physicians and
Surgeons, Columbia University, New York City,
Dr. Allen O. Whipple, professor of surgery, Columbia
University, welcomed the delegates to the first
international congress of artificial fever therapy. Dr.
Pierre Abrami, professor of pathology, University of
Paris, replied, and messages were then read from Prof.
A. d’Arsonval and from Prof, Julius Wagner-Jauregg
who were unable to be present. Prof. @ Arsonval
referred to his interest since 1890 in the physiological
effects of currents of high frequency, especially the
painless rise in the body temperature which follows
the use of the diathermic current. His friend Ferrié
had actually used a medical type of apparatus for his
first trials of wireless at the Eiffel Tower. Nowadays
the position has been reversed and the wireless
industry was providing short-wave apparatus for the
physician. Prof. Wagner-Jauregg said that he first
began injecting tuberculin to produce an artificial
fever in cases of mental disease as early as 1891.
Since 1900 he had been concerned primarily with
general paralysis of the insane; some of his cases
treated over 20 years ago with tuberculin were still
in excellent health. He stressed the value of com-
bined fever treatment and chemotherapy, and
concluded by saying that it should not be the aim
of these combined methods to destroy the pathogenic
organisms in the body but to improve the resistance
of the organs and tissues against them, in order /
that the infection would eventually die away.
Over 100 papers was submitted at the congress,
of which 56 were actually read. A few of home are
summarised below.
PHYSIOLOGICAL EFFECTS OF FEVER TREATMENT
The first day of the congress was chiefly devoted
to the physiology and pathology of artificial fever,
and J. G. Gibson, I. Kopp, and W. A. Evans (Harvard
and Boston, Mass.) submitted a paper on changes in
blood volume during therapeutic fever. They found
that the diminution in plasma volume was closely
related to the intensity of sweating and weight loss.
Intravenous administration of fluids soon restored the
blood volume to normal. M. Pijoan, Gibson, and
Kopp (Boston and Harvard University) had investi-
gated the acid-base balance during therapeutic fever
and ascertained that if there was an excessive
dehydration a pronounced alkalosis might occur.
J. D. Hardy (New York) had studied the mechanism
of heat loss from the human body, and confirmed the
view that heat loss is due to radiation, convection,
and vaporisation, and depends largely on the environ-
ment. S. L. Warren (Rochester, N.Y.) contributed an
interesting paper on chloride balance in artificial
fever. The maintenance of a proper fluid intake
throughout the treatment was vital, especially when
long applications of from 10 to 24 hours were under-
taken. Under suitable conditions the water loss by
sweating might be compensated for by the ingestion
of between 200-300 c.cm. of fluid per hour. Salt
should only be administered when‘sweating diminished.
A. H. Dowdy and F. W. Hartman (Detroit, Michigan)
contributed a paper on the preparation of patients
for fever therapy with special reference to sedatives
and fluid intake. They advised the use of a carb-
amide sedative in preference to any of the barbituric
acid group. It should be given first the night before
CONGRESS OF ARTIFICIAL FEVER THERAPY (PYRETOTHERAPY) [APRIL 24, 1937
1007
the treatment and the last dose on the following
morning about one hour before treatment was begun.
During the treatment iced drinks of 0-6 pep. cent.
saline and 3-0 per cent. glucose were given orally.
RHEUMATIC FEVER, CARDITIS, AND CHOREA
On the second day of the congress the use of
artificial fever in a miscellaneous group of diseases
was considered. E. E. Simmons and F. Lowell Dunn
(Omaha, Nebraska) reported the treatment of 15 cases
of acute rheumatic fever for periods varying from
84 to 46 hours with temperatures of 103°-106° F.
Thirteen patients received complete relief from joint |
pain and swelling, two had relapses in from 2 weeks
to 2 months, and a third had a recurrence of chorea
21 months later. They believe that fever therapy
reduces the symptomatic activity of the rheumatic
fever and shortens the duration of the attack,
Three interesting communications on rheumatic
carditis and chorea were made by S. L. Osborne,
M. L. Blatt, and C. A. Neymann (Chicago, Illinois) ;
by Lucy Porter Sutton and Katherine G. Dodge
(New York); and by C. H. Barnacle, J. R. Ewalt,
and F. G. Ebaugh (Denver, Colorado). Osborne
and his collaborators had treated 25 children with
chorea, ranging in age between 4 and 16 years,
without encountering any difficulties. Nine cases
were very severe, 6 moderately severe, and 10 were
considered mild. The average number of treatments
given was slightly less than 4 and the average stay
in hospital less than 16 days. The choreic move-
ments ceased in 22 of the cases. Sutton and Dodge
have been using fever therapy since 1930 at the
Bellevue Hospital, New York. They first employed
injections of typhoid-paratyphoid vaccine; subse-
quently they have treated 50 cases of chorea with a |
radiant energy cabinet, the temperature maintained
was between 105° and 106° F. for from 4 to 5 hours.
Most patients received one or two treatments; early
cases, however severe, responded most quickly to
fever therapy. Altogether 400 cases were treated.
A preliminary analysis of 95 treated cases compared
with 75 untreated revealed a definitely lqwer
incidence of rheumatic manifestations, imcluding
polyarthritis and carditis,in the treated group. The
authors expressed their conviction that fever was
capable of cutting short an attack of chorea, that the.
presence of active carditis was not a contra-indication,
and that fever therapy might in fact be a valuable
therapeutic measure in rheumatic carditis. Barnacle
and his colleagues had treated 45 cases of rheumatic
carditis and chorea by physically produced fever ;
14 were severe, 29 moderate, and 2 mild. They
preferred daily fever sessions of only 24 hours’ dura-
tion at temperatures of 105°-105-4° F. The average
number of treatments given was 12-6, the average
total duration of fever 32-9 hours, and the average
time under treatment 22 days. All the patients
responded to fever therapy though there were three
recurrences. Nineteen cases had rheumatic carditis
and 12 of them showed a lasting improvement in
cardiac function.
RHEUMATOID ARTHRITIS AND NEURITIS
The communication of R. M. Stecher and W. M.
Solomon (Cleveland, Ohio) concerned the treatment
of acute non-specific infectious arthritis with artificial
fever. Their 20 cases all suffered from an acute form
of atrophic rheumatoid arthritis. Twelve patients
received prompt relief and apparent cure, while 8
were partially relieved. The course of the disease
was favourably modified in every case. Tempera-
tures of 105° F. were maintained for from 2-25 hours
1008 THE LANCET] CONGRESS OF ARTIFICIAL FEVER THERAPY (PYRETOTHERAPY)
with an average of 7:3 hours in the cases showing
complete recovery, and 5-30 hours with an average
of 17 hours in the patients who eventually experi-
enced only partial relief. Five out of 8 patients
showing radiological evidence of joint damage were
in the group which required longer treatment. The
authors interpreted their results as an indication of
the importance of prompt administration of fever
treatment in order to avoid or minimise joint damage.
A. E. Bennett and P. T. Cash (Omaha, Nebraska)
dealt with the relief of neuritic pain by employing
lower temperature levels and for from 2 to 4 hours’
duration. Out of 20 cases of sciatic neuritis treated,
16 were completely relieved by fever therapy com-
bined with epidural injections. Three out of 6 cases
of brachial neuritis were permanently relieved by
fever treatment alone. Four cases of toxic infectious
polyneuritis obtained complete relief as did 3 cases
of post-herpetic neuralgia.
DISSEMINATED SCLEROSIS
K. M. Walthard (Geneva) and W. Kerr Russell
(London) dealt chiefly with electropyrexia in the
treatment of disseminated sclerosis. In 4 of the
latter’s cases the gait deteriorated after treatment ;
in 5 there was no change ; and in 6 there was improve-
ment. Both authors stressed the difficulty of assessing
the value of fever therapy in a disease characterised
by natural remissions.
OPHTHALMOLOGY
J. S. MeGavie (Cincinnati, Ohio) presented a
preliminary report on 42 cases of various ocular
diseases. He had found that in gonorrheal oph-
thalmia the fever therapy seemed to increase the
amount of pus formed in the conjunctival sac following
the ' first and second treatments; thereafter the
discharge steadily diminished and smears became
negative in a short time. Seven cases of syphilitic
interstitial keratitis showed most impressive results.
Patients were generally able to keep their eyes open
after one or two treatments. A shorter course and
fewer permanent synechi® were noted in cases of
syphilitic irido-cyclitis. Treatment was given every
other day for 5 hours, temperatures of 105°-107° F.
being employed.
THERMAL DEATH TIME OF THE MENINGOCOCCUS
IN VITRO
Mary L. Moench (New York) had studied the heat
sensitivity of 15 strains of meningococci in vitro at .
temperatures used in fever therapy. A semi-solid
veal infusion agar was used for the cultures. At
temperatures ranging from 40°-42° C. all strains
except one showed reduction or cessation of growth
within 5-7 hours, the maximum reduction occurring at
41°C. and over. Dr. Moench considered fever therapy
to be worth trying as an adjunct to other treatment
in carefully selected cases of meningococcal infection
where serum therapy had failed or could not be used.
SYPHILIS
On March 31st six papers were devoted to syphilis.
A. Bessemans (Ghent) outlined his experiments with
hyperpyrexia. He found that the treponemata of
both rabbits and man rapidly became immobile
and disappeared after a temperature of 42° C. for
1 hour or 40°C. for 2 hours. L. E. Hinsie and
J. R. Blalock (New York) gave a survey of 12 years’
work in a paper on serology in general paralysis of
the insane; 326 patients were treated by one of
four different methods of treatment: malaria,
tryparsamide, and electropyrexia with and without
[APR 24, 1937
tryparsamide. The serological findings were analysed
at yearly intervals over a 12-year period. The most
favourable clinical and serological results were
observed in those patients who received fever therapy
followed by chemotherapy. For purposes of prog-
nosis, the authors advocated serological examination
three or four years after treatment had been started.
F. R. Menagh (Detroit, Michigan) had treated 90
syphilitic cases with hyperpyrexia combined with
chemotherapy ; more than a half showed improve-
ment, and nearly one-half of these had been treated
previously for an average of five years by chemical
means without success. Of the 45 cases of general
paralysis of the insane and 27 of tabes dorsalis the
best results were obtained in the early ‘cases with
minimal tissue damage. Perforating ulcers and
Charcot’s joints were favourably influenced as were
the 10 cases of optic atrophy. Ten cases of asymp-
tomatic neurosyphilis and meningovascular syphilis
did exceptionally well. W. M. Simpson and H. W.
Kendell (Dayton, Ohio) had formed the opinion from
a study of 34 cases of early syphilis under combined
therapy that artificial fever fortifies and intensifies
the curative action of chemotherapeutic agents.
Fever therapy alone or chemotherapy alone was
inadequate in a high proportion of control cases.
C. A. Neymann (Chicago, Ilinois) claimed that
electropyrexia had increased the percentage of
improvement in general paralysis of the insane by
21 per cent., and that the combined fever treatment
and chemotherapy cured most cases of early syphilis
promptly and permanently in one or two months.
GONOCOCCAL INFECTIONS
On March 31st C. M. Carpenter and Ruth A. Boak
(Rochester, N.Y.) dealt with the thermal death
time of 250 strains of gonococcus at a temperature of
41-5° C. (106-7° F.) The heat resistance of the
organisms varied from 6-34 hours, the mean being
16-1 hours. The figures for strains isolated from
patients and their consorts showed a close agreement,
S. L. Warren (Rochester, N.Y.) found that
87 per cent. of 100 consecutive cases which were given
fever treatment for a period equal to the thermal
death time of the isolated organism at 41:5° C. were
cured bacteriologically and clinically by the end of
the treatment. He considered that the thermal
death time test was a practical guide in determining
the length of the fever treatment necessary for each
individual patient. W. Bierman and E. A. Horowitz
(New York) described the method by which they had
treated 121 cases in the last six years, with success
in 113. They first raised the systemic temperature
by physical means and then applied additional heat
locally to the pelvic organs, generally with the
diathermic current, for a period of 7 hours. The
systemic temperature was kept between 105-5° and
106-5° F. for 12 hours, during 7-8 hours of which
the pelvic temperature was maintained at 109°-110° F.
One to three treatments were given, but the average
was only 1-4. One-third of the patients had sal-
pingitis and the pain generally disappeared during
the first treatment. F. A. Krusen, L. G. Stuhler,
and L. M. Randall (Mayo Clinic, Rochester) also con-
tributed a paper on combined systemic and local
heating in gonococcal infections ; 361 patients were
given 1698 artificial fever treatments at an average
temperature of 106:7° F. The average number of
treatments per patient was five. Forty patients who
proved refractory to systemic fever alone were given
additional local heat, and 86-5 per cent. then developed
negative cultures. Ten-hour sessions of fever were
given ; 92-5 per cent. of all the patients who completed —
THE LANCET]
their treatment had negative cultures. They believed
that often a single long session of fever, combined
where suitable with additional local heat, offered the
most satisfactory method of treating gonococcal
urethritis, cervicitis, and pelvic inflammatory infec-
tion. A. E. Belt and A. W. Folkenberg (Los Angeles,
California) found that 92-2 per cent. of their cases
were consistently free from organisms following one
10-hour session of fever.
E. H. Parsons, P. N. Bowman, and D. E. Plummer
(Denver, Colorado) compared the results of fever
treatment in male patients with those obtained by
injections, irrigations, and massage. They stated
that the number of cures in the fever-treated group of
acute prostatitis and complications was significantly
'greater than in the control group, and that the fever
cases only required a quarter of the time needed for
the controls. Acute prostatitis invariably dis-
appeared after one fever treatment. J. A. Troutman,
H. V. Stroupe, and D. J. Devlin (New Orleans,
Louisiana) described their experiences in the treat-
ment of 278 patients with gonorrhæœa; they found
that fever sessions of five hours gave early and
complete relief in cases of acute epididymitis, acute
arthritis, and acute prostatitis. T. G. Schnabel
and F. Fetter (Philadelphia, Pennsylvania) had
treated 136 cases of gonococcal infection with an
average of 44 treatments. Thirteen out of 15 cases of
gonorrheal vulvo-vaginitis were cured. Out of 93
patients with gonococcal arthritis 54 were cured and
39 improved. Comparing the arthritis cases treated
by fever with the controls, they found that fever
therapy appreciably shortens the period of hospitalisa-
tion and improves the prognosis. H. A. Freund and
W. L. Anderson (Detroit, Michigan) described the
recovery of a case of gonorrhæœal endocarditis treated
by artificial hyperpyrexia, and O. G. Hazel and W. B.
Snow (New York) a case of gonococcal septicemia
with purpura and arthritis which was successfully
treated in this way.
SOCIAL EVENTS
There was an excellent exhibition at the Waldorf
Astoria Hotel, New York, at which 11 firms demon-
strated their apparatus. On two evenings films were
shown dealing with the various methods of inducing
hyperpyrexia and the results obtained. On March 31st
New York physicians entertained the foreign guests
to luncheon. The congress banquet was held on
March 30th, when the French delegation conferred
the Legion of Honour on W. R. Whitney, C. F.
Kettering, W. M. Simpson, and W. Bierman, the
indefatigable secretary of this successful congress.
SCOTLAND
(FROM OUR OWN CORRESPONDENT)
EDINBURGH ROYAL INFIRMARY
THE managers of the Royal Infirmary have issued
an appeal for £200,000 to complete the cost of the
many extensions that they are making. An interest-
ing development is the return of the Maternity Hos-
pital to the Royal Infirmary, for in the year 1755
the first attempt to provide institutional facilities
for maternity cases was in an attic in the old Infirmary
in Infirmary-street. Forty years later a maternity
hospital was established independently on the site
of what is now the University Union, and in 1879
the present Edinburgh Royal Maternity and Simpson’s
Memorial Hospital was opened in Lauriston-place.
Since its opening the number of infants born within
SCOTLAND.—BU CHAREST
1
[APRIL 4, 1937 1009
the hospital has risen from 150 in the first year to
2500 during 1936. In addition, 950 cases were
attended to in their own homes in the district. No
fewer than 40 per cent. of the total births in Edinburgh
occurred under the care of this institution. It is
interesting, therefore, to note that the Maternity
Hospital is again to come under the wing of the Royal
Infirmary, and the new Maternity Pavilion, which
is to have 130 beds, should be ready for occupation
in 1938. An advantage of this new development is
that the Maternity Pavilion will be adjacent to the
present gynecological wards. p
A new nurses’ home providing for additional
accommodation for 300 nurses is also nearing comple-
tion. The radiological department has been equipped
with the most modern apparatus and new depart-
ments for orthopædics and neurosurgery are being
constructed. A new Dermatological Pavilion in
which the venereal diseases department is also
situated has recently been opened. In view of these
extensive recent developments it is not surprising
that the managers have some anxiety for the future
financial position of the institution.
UNIVERSITY HALL, EDINBURGH
To celebrate the jubilee of the opening of University
Hall a dinner is to be held in the North British Station
Hotel on Saturday, May 29th. A large number of
old residents of the various houses have intimated
their desire to attend, and it is hoped that any who
have not already done so, and who wish to come, will
write without delay to Sir Thomas Whitson,
21, Rutland-street, Edinburgh.
BUCHAREST
(FROM OUR OWN CORRESPONDENT)
MATERNITY AND CHILD WELFARE IN RUMANIA
THERE are at present 4000 qualified midwives
in Rumania, far too few for the country’s needs. .
Unqualified women who are not properly trained
have therefore to be employed in many districts
and since there are not enough doctors available
for consultation in difficult cases the mothers are not
very well served. Dispensaries dealing specially
with the protection of mothers and children number
167; most of these are managed by private charit-
able organisations with government subsidies. The
conditions for the conduct of labour are fairly
primitive in the villages, and the risk of infection
is great. Confinements are still often conducted in
a bed of straw, and in some remote parts of the king-
dom there are no professional midwives of any kind
handy and the labour is conducted by a member
of the family. For complicated cases, there are
22 maternity homes in the country in connexion
with hospitals or university clinics, and 20 smaller
ones are maintained by private charity. The Minister
of Public Health has declared his intention in
1937 to establish maternity homes in every county
hospital.
The infant mortality-rate is very high in Rumania.
According to Prof. Mezincescu, who is director of
the Institute of Hygiene and Public Health, the
rate for the last five years (1931 to 1935) has varied
between 174 and 192 per 1000 live births. This
high rate is attributed to the ignorance of the mothers
about the hygiene, feeding, and clothing of babies.
The care of infants is now to be taught to senior girls
at secondary schools and to university students.
In the villages also nurses will lecture to wives and
1010 THE LANCET]
to untrained midwives. Travelling clinics and dis-
pensaries already visit some villages twice a month
and it is hoped to extend this service to all counties
in the kingdom.
INTERNATIONAL CONGRESS OF MILITARY MEDICINE
AND PHARMACY
The ninth international congress of military
medicine and pharmacy will be held in Bucharest from
June 2nd to 10th. The aims of the congress, which
has been held in previous years at Brussels, Rome,
Warsaw, Paris, London, Hague, and Madrid, are
(1) to study practical methods of handling and
treating wounded and sick soldiers; (2) to maintain
good relations between the sanitary officers of various
nations; and (3) to arrive at certain international
conventions designed to lessen the horrors of warfare.
The committee entrusted with the organisation of the
congress consists of civil and military medical
members, and is presided over by Surgeon-General
Dr. Iliescu. The scientific programme includes the
discussion of six problems; the opening addresses
at each discussion will be given by representatives of
different nations, The organisation of sanitary services
in operation on the field and at sea will be described
by members from England and the United States.
Germany and Yugoslavia supply the principal speakers
on the transport, hospitalisation, and treatment of
gassed patients, and Swiss and Japanese delegates will
discuss the use of the different colorimetrical analyses
in the laboratory. Dentistry, with especial reference
to edentulous soldiers, is the subject allocated to Greece
GRAINS AND SCRUPLES `
J:
[APRIL 24, 1937
and Holland, while France and Turkey will supply
material for a comparative study of the alimentation
of sick and wounded soldiers in time of war and
peace. The organisation and functions of the
surgical service attached to mechanised units will
also be discussed.
The reports will be published in English, French,
German, Italian, and Spanish. Membership of the
congress is open to doctors, dentists, veterinary
surgeons, pharmacists, or administrative officers
attached to military, naval, or air force services.
The registration fee is 1000 lei (about 30 shillings),
which entitles members to receive official publica-
tions and to join in festivities arranged in connexion
with the congress. Further information can be
had from the secretariat-general, Institutut Sanitar
Militar, Bucuresti, II, Rumania.
TREATMENT OF ACUTE SORE-THROAT WITH BISMUTH
At a recent medical congress Dr. Mayersohn reported
experiences with the administration of bismuth in
acute sore-throat. He was induced to give a trial to
this practice by favourable reports published from the
university clinic of Rio de Janeiro. According to these
reports the symptoms of any kind of acute non-
specific sore-throat were greatly reduced within 8-24
hours by the application of one or at most two
intramuscular injections of bismuth. Dr. Mayersohn
had applied this method in his hospital and private
practice to 1180 cases with only 48 failures. Any
bismuth preparation containing 0-06 to 0-08 gramme
of bismuth in one dose is suitable for trial.
GRAINS AND SCRUPLES
Under this heading appear week by week the unfettered thoughts of doctors in
various occupations. Hach contributor is responsible for the section for a month;
his name can be seen later in the half-yearly indez.
FROM A TADDYGADDY
IV
“That it may please thee . . . to shew thy
pity upon all prisoners and captives.”
THE men who compiled the Litany had big hearts
and wide understanding. They thought of every-
body. Perhaps there was more time for thinking in
their day, when everybody was not in such a desperate
hurry to get somewhere, or do something else. Not
so long ago a wise bishop suggested, in the course of
a discussion on the alleged conflict between Science
and Religion, that what men should do was sit back
and consider the multitude of facts and alleged facts
accumulating all the time, and do a bit of sorting.
In other words, he asked men to sit down and think.
* * *
If they would do that it might be that they would
turn their minds to the problem of prisoners and
captives: to the tragic fate of those who have been
deprived of liberty, sometimes for years. I am
referring now to those unfortunates who, for this
reason or that, have been certified ‘“‘M.D.,” mentally
deficient, and confined in a colony for mental defec-
tives. What proportion of those confined and shut
up, I have wondered often, really are so mentally
afflicted that they need segregation for their own
safety or the safety of others ? I have made attempts
from time to time to do a little towards finding out,
and more than once I have been startled. I was
assured not so very long ago that, in the opinion of
an official person wielding considerable power, any
young woman, if poor, who produced more than one
illegitimate child should be regarded as morally defec.
tive and, if possible, certified and shut up. I was
assured, quite recently, by an official holding a position
of the first importance and power that in his opinion a
single act of childish sexuality was, in itself, a suff-
cient reason for keeping a boy of nineteen in a colony
for an indeterminate period. That boy had been
certified ‘‘ feeble minded ” in spite of the fact that
for two years he had kept his job to the complete
satisfaction of his employers, and had earned good
money. For two years, also, he had served
satisfactorily in the Territorials.
* * *
I have an uneasy feeling that there are powerful
people, officials with official mentality, who can see
nothing harmful in depriving young people of liberty,
solely because the young people do not conform to
their, often quite arbitrary, standards of intelligence or
conduct. Intelligence tests-are in favour to-day with
people with card-index minds. I submit they may
be, and sometimes are, exceedingly dangerous. Some
years ago I walked into a magistrates’ ante-room and
fired off a salvo of mental intelligence tests at the
two magistrates sitting there. I had no difficulty in
demonstrating to them that they were, according to
accepted standards, both mentally deficient. One
of them was the magistrate who did all the certifying,
after medical examination, of the alleged M.D.’s of
that district. They were annoyed. The certifying
one was quite cross about it, particularly when I
urged him to consider the moral of the experiment I
THE LANCET]
had tried upon him, It was no use. He was an ex-
schoolmaster, convinced that he had nee to learn
from anybody. į š Š
Do you remember the little cages, each with its
little bird, that used to hang in clusters outside the
shops and houses in Seven Dials? It was a depress-
ing spectacle. Unfortunately, very few of us ever
go and look at the captives in our mental homes, our.
colonies for mental defectives. Once a young person
is immured there he seems to be forgotten. He is
visited officially by officials and semi-official visitors,
but by how many non-official persons? For that
matter, what do most of us know about the inside
of any State, or municipal, institution ? I was struck
by the speedy return home from a municipal tuber-
culosis sanatorium of people who had gone there
filled with hope. I made inquiries. One reply was
suggestive: ‘‘It’s all so dull. There’s nothing to
do, and nobody seems to care. There’s a billiard
table we can use in the evenings, but the cues have
no tips. There are cards in the huts, but there’s
never a complete pack.” I went and had a look for
myself. The complaint was well founded. There
was nobody who seemed to care: nobody to whom
a patient could pour out his griefs, little or big.
* * ka
There has been much discussion concerning ‘‘ volun-
tary’? versus “municipal” in the hospital world.
So far as the purely business, the financial, aspect is
concerned, the ‘municipal’? advocates have it
every time. But, so far as the human aspect is con-
cerned, the “‘ voluntary ” advocates win hands down.
In voluntary institutions the inmates are not at the
mercy of officials: in State or municipal institutions
they are. That, I submit, is where a great deal of
trouble lies. We, members of the visiting staff of a
voluntary hospital, go in and wander about as we
please, talking to the patients, listening to their
grouses. We sense the spirit of the place. State and
municipal institutions, however materialistically effi-
cient, lack that human element. In mental homes,
in colonies for mental defectives, it seems to be
completely non-existent. The inmates are cut off
from contact with the outside world.
* * *
Is this all unduly serious for the ‘‘ Grains and
Scruples’’? page? I hope not. I am writing as a
Taddygaddy, a practising G.P., and I prefer to write
about subjects that concern my immediate job. The
unhappiness—particularly the preventable unhappi-
ness—of other people, especially young people, is
very much the concern of all of us. I feel in my bones
that all is very much not well in the officially run,
officially controlled, institutions in which young
people are kept captive. I am impelled to say that,
not merely because of my own observations, but
because of things said to me by other people of good-
will, notably a Roman Catholic priest of vast experi-
ence and the widest possible sympathies, who told
me so lately as to-day of his acute apprehension
and unhappiness concerning the fate of young
persons condemned to what amounts in practice to an
indeterminate sentence of deprivation of liberty.
ae * %
If I seem to finish up my series on a somewhat
bitter note it is because circumstances, quite recently,
have caused me to feel bitter—on behalf of young
people who are defenceless when confronted by the
stern arm of Authority. We doctors who practise
in and about back streets see much of the seamy side
of life. We do what we can to mitigate it but that
GRAINS AND SCRUPLES
[APRI 24, 1937 1011
is not very much. We can, however, give some sort of
publicity to abuses when we meet them—if we will.
That is why I have made this the concluding article.
It is very far from complete, for reasons which I
need not specify. I have been dealing recently direct
with Authority, which has been entirely kind and
considerate and courteous; but so far I have not
succeeded in persuading it to do anything. The
unfortunate confined weak ones for whom I have
been contending are still confined. So far as I can
see they are likely to go on being confined.
* J *
What is the matter with Authority? What is
wrong with the Official Person? There is, hung up
in one of our cathedrals—I think it is Chester—an
old poem whose message seems, somehow, not to
have reached the world of officialdom. This is how
it finishes :
Give me a sense of humour, Lord,
Give me the grace to see a joke:
To get some happiness from life
And pass it on to other folk.
That message, I submit, if accepted and acted
upon by us all would serve as solvent for many of
the anomalies and acts of seeming injustice that
perplex us. n n n
May I turn in conclusion to another old world
writer ? I open his book at random, and this is what
I light upon :
“ Mercy will soon pardon the meanest... .”
That is a sentiment which should appeal to us
who, as poor men’s doctors, see so much, know so
much, of conditions under which ‘‘ the meanest ” is
not pardoned. Rather is he not infrequently shut
away from the sight of men and, only too Perens
forgotten.
*.* This concludes the four articles by Taddygaddy.
Next month a Medical Economist will be responsible for
these columns.—ED. L.
INFECTIOUS DISEASE
IN ENGLAND AND WALES DURING THE WEEK ENDED
APRIL 10TH, 1937
Notifications.—The following cases of infectious
disease were notified during the week: Small-pox, 0;
scarlet fever, 1643 ; diphtheria, 942 ; enteric fever, 21;
pneumonia (primary or influenzal), 1464; puerperal
fever, 53; puerperal pyrexia, 124; cerebro-spinal
fever, 30; acute poliomyelitis, 1; acute polio-
encephalitis, 0 ; encephalitis lethargica, 4; dysentery,
18; ophthalmia neonatorum, 92. 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 April 16th was 3265 which included: Scarlet
fever, 879; diphtheria, 921; measles, 40; w hooping-cough,
526 ; puerperal fever, 16 mothers (plus 11 babies) ; : encephalitis
lethargica, 283; poliomyelitis, 1. At St. Margaret’s Hospital
there were 19 babies (plus 6 mothers) with ophthalmia
neonatorum.
Deaths.—In 123 great towns, including London,
there was no death from small-pox, 2 (0) from enteric
fever, 14 (0) from measles, 6 (0) from scarlet fever,
32 (11) from whooping-cough, 31 (9) from diphtheria,
54 (15) from diarrhoea and enteritis under two years,
and 112 (19) from influenza. The figures in parentheses
are those for London itself.
There were 2 deaths from enteric fever and 4 from diphtheria
at Liverpool. Four deaths from measles were reported from
Birmingham. Leeds and Middlesbrough each reported 3 fatal
cases of whooping-cough.
The number of stillbirths notified during the week
was 258 (corresponding to a rate of 34 per 1000
total births), including 38 in London.
1012 THE LANCET]
[APRIL 24, 1937
PUBLIC HEALTH
Mental Health in Scotland
THE number of insane persons under the General
Board of Control for Scotland in 19361 was less
by 103 than in the year before. The decrease is not
high in comparison with the total figure, which is
just under 20,000, but it is reassuring to see that the
number has not risen. There is a corresponding
small decrease in the average annual admissions to
institutions over the last five years. More and more
patients are now being treated in the observation
wards of poor-law hospitals and in nursing-homes,
and fewer patients with a good expectation of
recovery are being sent to asylums. Nevertheless,
the asylum recovery-rate remains as high as one-third
of the number admitted. The Mental Treatment
Act, 1930, does not apply to Scotland—a fact of
which one is reminded by the use throughout the
report of the traditional terms ‘“‘ asylum,” “ lunatic,”’
and ‘“‘ pauper ’’—but the Scots law allows voluntary
patients to be received into asylums, and the increase
in the numbers of voluntary admissions has been
steady and continuous. The Board, however, report
a steady accumulation of certified patients in insti-
tutions. The result of this accumulation is, they say,
that all asylums are now more or less fully occupied
and most of them are overcrowded. They suggest
that the problem could be partly met by providing
more observation wards and establishing out-patient
clinics to encourage early treatment still further.
The mere substitution of ‘f mental hospital” for
“asylum ” will not, they think, entirely remove the
inherent public dislike of institutions, and although
the problem of detention has to be met they regard
as much more urgent the problem of providing treat-
ment at a stage when it is likely to be effective.
They therefore strongly recommend to the directors
of all Royal Asylums the establishment of clinics
entirely apart from the mental hospital but under
the administration of its expert staff. Similar clinics,
both resident and out-patient, should, they say, be —
provided by local authorities in association with
general hospitals and supervised by expert psychia-
trists. Municipal authorities would probably need
an Act of Parliament to permit them.to set up these
new services. `
SHORTAGE OF STAFF
Scotland appears to suffer from shortage of staff in
much the same way as this country, with the result
that research and treatment are badly hindered. The
service therefore does not attract as many first-class
men as it should, for the medical officer is over-
burdened with routine duties and advancement is
slow and uncertain. A familiar vicious circle is thus
created. A further burden is thrown on the medical
staff by the absence, in many asylums, of lay officers
such as stewards, farm managers, and dispensers.
Not only, therefore, are the medical staff unable to
devote sufficient time to treatment within the asylum,
but they are unable (except in the large towns) to
carry out extra-institutional services in out-patient
clinics and observation wards. On the other hand,
the possibilities of guardianship are used fairly fully
and the system is working well. The reports of some
of the deputy commissioners throw an ee light
on its everyday realities.
1Twenty-third Annual Re opore of the General Board of
Control for Scotland. (Cm pears Edinburgh : H.M.
Stationery Office. 1937. Pp. 45. 1s.
Compulsory Pasteurisation of Milk
The logic of facts is directing more and more
attention to the need to extend control over the:
safety of the milk-supply of this country. For a
number of years milk has been a much discussed
article, but along two distinct though really interrelated
lines. The attention now paid to problems of
nutrition always leads to renewed emphasis upon the
nutritive value of milk and the need for more of it.
being consumed. For a great many years the medical
profession has emphasised that the milk consumed
in large areas of the country is a definite and
important factor in the spread of disease, and while
equally emphatic as to the nutritive value of milk,
submits that it must be safe milk. The existing legal
powers are demonstrably inadequate to solve the
problem. The very widespread outbreak of enteric
fever last year in certain seaside towns, spread by
raw milk, and other recent outbreaks also spread.
by raw milk in Doncaster and- elsewhere, show
how necessary and urgent is the problem of
adequate control. While the risk of the spread
of bovine tuberculosis can be removed by the
elimination of tuberculosis from our dairy herds,
experience shows that this is not yet a prac-
tical measure and at the best must take a great
many years to be made effective. The only satis-
factory way to render milk safe and yet not damage
its nutritive properties is by its efficient pasteurisa-
tion. Local authorities anxious to protect the people
for whose health they are responsible are now per-
ceiving the desirability of enforcing adequate heat
treatment of milk. Two of them—Glasgow and
Poole—have now under consideration a scheme of
obtaining powers to ensure efficient pasteurisation of
the raw milk distributed within their areas, and in
support of this movement their medical officers of
health have issued illuminating and interesting reports.
That coming from the public health department of
the corporation of Glasgow ? reviews the problem as
its affects Glasgow. The daily liquid milk-supply of
Glasgow is said to be about 71,543 gallons. Of this,
44-8 per cent. is pasteurised under licence, 39-5 per
cent. is given uncontrolled pasteurisation (including
a very little scalded or sterilised), 3-5 per cent. is
raw tuberculin-tested milk, while 12:2 per cent. is
consumed raw and ungraded. There are only 39
byres in the city, so practically all the milk comes in
from outside districts. Nearly all the milk (93 per
cent.) is distributed through the premises of wholesale
or large retail tradesmen, and only about 2 per cent.
is sold by the producer-distributor. On the cleanliness
side the figures show that more than half of the raw
milk sampled does not conform to a reasonable
standard. Other facts in the report show that
Glasgow is very well placed for an experiment in
compulsory pasteurisation and a scheme could be
operated with comparatively little difficulty. Since
such a large proportion of the city milk-supply passes
through milk depôts, most of which are of considerable
size, there are no inherent difficulties in requiring all
this milk to be efficiently pasteurised. The milk now
heated by uncontrolled pasteurisation is practically
all in such depéts and the plants could readily be
converted into pasteurisation plants of approved
type and working. The report also contains a fairly
2A Review of the Milk Supply of Glasgow in relation to
ee Tauon; By I. McCracken, M.B., D.P.H.,and A. M.
tewar
THE LANCET]
detailed review of the facts as to diseases spread
from contaminated milk and notes on pasteurisation
methods and practice.
In Poole compulsory pasteurisation powers are
being asked for in a parliamentary Bill in the form
of power to make by-laws :
“The Corporation may make byelaws for prohibiting,
regulating or controlling the sale or supply or the exposure
or keeping for sale or supply within the borough for human
consumption, or for use in the manufacture of products
for human consumption of milk which has not been
pasteurised and at all times securely protected against
contamination in such manner as may be prescribed
‘by the byelaws.”’ l
Pasteurisation is defined in the same terms as in
the Milk (Special Designations) Order 1936. The
medical offcer of health for Poole (Dr. R. J. M.
Horne) has also submitted a valuable report dealing
OBITUARY '
[APRIL 24, 1937 1013
with the dangers of raw milk and the need for these
powers to require pasteurisation. Such reports,
though they supply useful argument, cannot in the
space available review more than a small part of
the overwhelming evidence available in favour of
compulsory pasteurisation. Those interested will,
however, be able to consult many other sources,
including the authoritative report by the Committee
on Cattle Diseases to the Economic Advisory Council
and the several reports of the Peoples League of
Health.
We welcome the efforts of the corporations of
Glasgow and of Poole to carry out one of their
primary functions, the protection of their inhabitants
from the risk of milk-spread infectious disease, by
seeking to secure powers requiring the efficient
pasteurisation of the raw milk consumed within
their areas.
OBITUARY
JOSEPH FAYRER, Bt., C.B.E., M.D., F.R.C.S.Edin.
WE regret to record the death of Lieut.-Colonel
Sir Joseph Fayrer which occurred in Gullane, East
Lothian, on April 13th, in his 79th year. He was
-the second son of Surgeon-General Sir Joseph Fayrer,
famous for his gallant service at the siege of Lucknow |
during the Indian Mutiny, and author of the
Thanatophidta of India. i
Joseph Fayrer was born in 1859 and educated at
Rugby, Trinity College, Cambridge, and St. George’s
Hospital, where he commenced his medical studies.
‘Later he went to the University of Edinburgh,
where he took the diploma of F.R.C.S. Edin., later
graduating at St. Andrews as M.D. He went immedi-
ately into the R.A.M.C., entering in 1886 at the top
-of the list. He was stationed for a year at Edinburgh
Castle, and was then dispatched on foreign service,
where, following in the footsteps of his father, he spent
most of his time in India. His career there was that
of an energetic officer and he became specially marked
out for his administrative work in hospitals. On
returning to England in 1894 he was appointed medical
officer of the Royal Horse Guards, a post which he held
for three years. He then went to India for further
‘service until 1903, when he returned to England as
staff adviser and secretary to the P.M.O. of the
London Military District. At the expiration of
that post he became superintendent of the Duke of
York’s Military School, then situated in Chelsea,
where his energetic and sympathetic activities gained’
him large credit. He held this post for five years
when he went to China in charge of the Military
Hospital, Hong-Kong. In 1907 he succeeded to the
baronetcy, and while in Hong-Kong was appointed
in 1911 superintendent of the Edinburgh Royal
Infirmary, a position which he held for 13 years, a
period covering the years of the war. During the
war he was in command of the 2nd Scotch General
Hospital, Craigleith, and was made a C.B.E. in 1919..
He retired from the superintendency of the infirmary
in 1923 on the age limit. Both at the infirmary
and at Craigleith his charm of manner and capacity
for friendship assisted him in a marked way in the
discharge of his duties.
Sir Joseph Fayrer married Ella, daughter of the
late Colonel W. J. Mayhew, and leaves a widow,
+wo daughters, and one son who succeeds to the title.
A lifelong friend writes: ‘‘ At Cambridge and at
St. George’s Hospital Fayrer collected friends, and
‘throughout a long and varied career he showed the
same power. He had an alert attractive appearance
and a sympathetic manner, the outcome not of a
desire to please but of a willingness to be pleased.
He was a game player and a sportsman when official
duties gave him the opportunity. He always saw
the best side of the other man, and had a gift for
friendship. His death will be regretted by very
many.”
ROBERT LYALL GUTHRIE, O.B.E., M.D. Edin.
Dr. Robert Guthrie, whose death occurred on
April 13th, was the son of the late James Guthrie,
Hope Park, Broughty Ferry, Forfarshire. He was
qualified alike as doctor and barrister, commencing
with the medical profession, a connexion on which
he always insisted. He graduated in medicine at
the University of Edinburgh as M.D., C.M. in 1892,
and held several resident appointments. For a
time he practised at Bethnal Green, when he also
studied law. He acted as deputy coroner to the late
Dr. Wynn Westcott, and in 1897 was called to the
Bar at the Middle Temple. In 1903 he was deputy
coroner for the Eastern District of the County of
London, the post which he was holding in 1914.
During the war he was, at the outbreak, medical
officer to the 7th London R.F.A., later he was com-
mandant of the Fulham Military Hospital with the
rank of brevet major, and was then promoted lieut.-
colonel and took command of the Belmont Prisoners
of War Hospital. He was a successful administrator
in all these posts and for his services received the
O.B.E. After the war he resumed his duties as
coroner and in 1921 became coroner to the Eastern
District. As a coroner he was primarily a doctor
and refused to be diverted from what he held to be
his basic duty—namely, to find accurately the cause
of death. In his court one would frequently find cases
being decided plainly and simply which were likely
to have had far-reaching consequences—cases of
accidents at work, in docks or factories, where several
parties were interested in the issues. In these circum-
stances his kindly attitude and his commonsense
decisions received wide appreciation—appreciation
which led on one public occasion to Mr. George
Lansbury referring to him as the ideal coroner.
He was in addition a capable man of affairs, was
honorary treasurer of the London and Counties Medical
Protection Society, and medical adviser to the Law
Union and Rock Insurance Company.
Dr. Temple Grey writes: “Legal medicine has
suffered a distinct loss in the passing of R. L. Guthrie.
!
1014
There were united in him all the qualities which
go to make the best type of coroner: an up-to-date
knowledge of medicine, a sound grounding and grip
of the law, and much shrewdness and tact in the
conduct of an inquiry. Those who are not in close
contact with coroners and their work can have no
idea of the services rendered to the public by such men
as Guthrie. Of failing health for some years past,
one could not but admire the way he stuck grimly to
his task to the end.”
THE LANCET | ‘
Dr. Guthrie died at his home at Wimbledon in his -
70th year.
CHARLES COLES, M.D. Lond.
Dr. Charles Coles died suddenly on April 15th
at his home in St. Margaret’s-road, Oxford, where he
had lived in retirement for some years.. He was
the son of the late Mr. J. Coles of Uxbridge, and was
educated at St. Bartholomew’s Hospital, where he
distinguished himself as an athlete in football, cricket,
and tennis. He filled there the offices of house physician
and house surgeon, and was also house physician
at the Brompton Hospital for Consumption. He held
the Brackenbury scholarship at St. Bartholomew’s
and graduated as M.B. Lond. in 1890. Two years
later he took the M.D. degree, securing the gold
medal, and later was awarded the gold medal when
taking the M.D. degree in State medicine. For a
short time he was in practice in Leicester but gave
this up owing to temporary ill health, and entering
the public health service was in 1899 appointed
medical officer for the combined districts of Leicester-
shire and Rutland. In 1901 he was appointed medical
officer for the Oxfordshire united sanitary districts
and in 1911 county and school medical officer to the
Oxfordshire county council. His work for the county
council was never spectacular but was always sound.
It was not an easy task for the demand for an increase
in the scope of the public health services was difficult
to satisfy from the resources of an agricultural area.
In these matters he was always loyal to the county
council while yet retaining the respect and regard of
the medical profession.
Coles’s leisure time was spent in gardening and
in the study of the natural history of the country-
side, especially butterflies and birds. He had the
“ gardeners thumb,’ and plants flourished under
his care ;
garden he made roses bloom to perfection. He
would spend the greater part of the day after retire-
ment in his garden, and his great delight was to point
out to the occasional visitor the points of growth
and development of the different varieties and how
he had been able to produce the result. He had a
small greenhouse and grew roses in pots for early
blooms. He had also an extensive knowledge of
field botany.
He was of a retiring habit and did not make many
friends, but his friendship when given was real and
lasting. He leaves a widow, a son, and a daughter.
‘JOHN TAYLOR, M.D., Ch.M. St. And.
Muca regret was felt at the announcement of the
death on April 14th, at the age of 44, of Mr. John
Taylor, hon. surgeon in charge of the Orthopedic
Department, Dundee Royal Infirmary.
Mr. Taylor, who had been in poor health for about
two years, had been unable to carry on his practice
for some months. He graduated M.B., Ch.B. in
St. Andrews University in July, 1914, and a month
later went out to France before the majority of the
Expeditionary Force had left this country. He was,
OBITUARY
even in the poor soil of a north Oxford /
[APRIL 24, 1937
however, early invalided home and in 1916 was
appointed resident surgical officer in the Dundee
War Hospital. In 1917 he proceeded to the M.D. degree
and again went abroad on service, on this occasion
to Mesopotamia as surgical specialist. From that
field of operation he was invalided, but later became
senior medical officer in Bihar and Orissa. After
the war he continued in association with the Terri-
torial Force, in which he ultimately held the rank of
colonel and was A.D.M.S. to the 5lst (Highland)
Division. He was specialist in tropical diseases for
the Ministry of Pensions and surgeon to the Dudhope
orthopsedic annexe. When he rejoined the medical
school he acted successively as assistant to the
professor of .pathology and -lecturer in regional
anatomy at University College, Dundee. He was
appointed surgical tutor at Dundee Royal Infirmary
in 1920, later assistant surgeon, and finally ortho-
peedic surgeon. On his resignation in 1935 on account
of ill health he was appointed honorary consulting
surgeon. He was a fellow of the Association of Surgeons,
member of the Anatomical Society, and associate
member of the Orthopedic Society of Great Britain.
He gave much time to research and for ten years,
with Prof. Weymouth Reid and Dr. Stiven, carried
on investigations into the function of the pancreas.
His death is regretted among all classes of the
community in Dundee; he was known as an able
surgeon and a generous-hearted and kind friend.
DAVID SMART, M.B., C.M. Edin.
Dr. David Smart, who died suddenly on April 7th
at Bootle, was medical referee to the Shipping
Federation. A Scotsman born at Meigle, Perthshire,
he was educated at Dundee High School and the
University of Edinburgh, where he graduated as
M.B., C.M., obtaining at the same time the Buchanan
fellowship. He was for a period resident in charge
of the gynecological wards at the Edinburgh Royal
Infirmary and then went to Liverpool on appoint-
ment to the Smithsdown Road Institution, becoming
assistant surgeon to the Liverpool Hospital for
Women and the Toxteth Poor Law Hospital. At the
Liverpool Hospital for Women he met his wife,
Dr. Blanche Z. Smart, who was also a medical officer
at the institution, and for many years they were in
general practice in partnership. The war found
Dr. David Smart well equipped. He had already
given service to the old volunteers and when he came
to Liverpool continued his association with the
.territorial army by joining the 6th Liverpool Rifles.
He was associated with Dr. Graham Martin in raising
the Liverpool bearer company, whose members
were later transferred to the Ist and 2nd West
Lancashire Field Ambulances. During the war
he was Assistant Director of Medical Services to the
57th and 73rd Divisions, and retired with the rank of
Col. A.M.S. (T.). Dr. Smart was highly respected
and popular in the city of Liverpool and his death
is a subject of general regret in the city and in the
neighbourhood. The end was very sudden for he
collapsed and died while conducting an examination
of seamen at the Brocklebank dock,
NORMAN COLLUM PATRICK, M.R.C.S. Eng.,
D.P.H.
THE death of Capt. Norman Collum Patrick, took
place on March 24th in Belfast following a brief illness.
As chief medical officer to the Ministry of Home
Affairs of Northern Ireland, Capt. Patrick was an
outstanding figure in the profession and was every-
THE LANOET]
where respected for the devotion with which he carried
out his duties, and for his kindly and sympathetic
disposition. He was educated at Rossall and
Cambridge University and went for his medical
training to St. Bartholomew’s Hospital. After
qualification he served as dispensary medical officer
to the Glenavy district of Co. Antrim and subse-
quently was appointed tuberculosis officer for the
county. At the outbreak of hostilities in 1914
he volunteered for active service and served through-
POSTURAL DEFORMITIES OF THE SPINE
[APRI 24, 1937 1015
out the greater part of the war as Captain R.A.M.C.
attached to the 110th Field Ambulance, 36th Ulster
Division. After the war, when the Northern Govern-
ment was formed, his professional ability was
recognised by his appointment to the Ministry of
Home Affairs and later in his rise to the rank of
chief medical officer. His loss is deeply regretted
by his associates at the Ministry and by many who
found in him a loyal friend and a wise counsellor.
He is survived by his wife and one daughter.
CORRESPONDENCE
POSTURAL DEFORMITIES OF THE
ANTEROPOSTERIOR CURVES OF THE SPINE
To the Editor of THE LANCET
Sm,—The communication by Mr. Philip Wiles
published in your issue of April 17th comes at an
opportune moment when a national policy to improve
the physique of the people is being planned. Habitual
use of the body with any real increase of the normal
anteroposterior curves of the spine is undesirable.
Mr, Wiles states that voluntary control over the
movements that correct a postural deformity is
easily taught when adequate mobility is present.
In many cases, however, in view of the state of fatigue
of the anti-gravity muscles and the general lack
of responsiveness, it is not easy, in my opinion, to
get these muscles to maintain an improved position.
A period of reconstructive rest in bed for two or three
weeks may be necessary as a preliminary to exercises,
The mattress should be firm. The patient lies on his
back with a low pillow beneath the head and knees
and three times daily, for half an hour, after meals,
the thoracic spine is hyperextended by placing a
firm pillow beneath it, the hands being clasped behind
the head. This leaves the lumbar spine unsupported,
and exerts a slow, corrective leverage upon the whole
spine. It opens out the subcostal angle, and allows
the patient to be instructed in correct breathing.
The patient is then turned over, to lie face downwards
upon a pillow placed lengthwise beneath the trunk ;
hot fomentations may be applied to the spine for
15 minutes, after which the patient resumes the
first position described.
After ten days or so the improvement in the
mobility of the spine and in the pliability of the
' muscles may be quite astonishing. Now is the time
to begin spinal massage and instruction in a simple’
series of lying-down postural remedial exercises,
designed chiefly to teach the patient how to flatten
the lumbar spine and to contract the side-abdominal
muscles. Exercises in control are far easier to learn
when lying down. It is now in order to allow the
patient up for postural remedial training, the object
of which is to cause him to maintain an habitually
improved attitude in standing, sitting, walking, and
breathing. As a useful temporary makeshift until
the muscle-sense of proper balance is restored, a
light spinal back-brace to span the lumbar curve
is often worn; without it many quickly relapse into
bad habits of poor posture, and therefore no hesitation
should be felt in prescribing its use.
The order of treatment, then, is reconstructive
rest, remedial training, and support. The simplicity
and lasting efficiency of these methods I have often
proved in practice. They are not practised nearly
enough. One hears a great deal about the active
side of treatment, such as massage, exercises, and
so on, and far too little, in my view, of the opposite,
or passive, side which should precede and complete
the active side, Reconstructive, rehabilitating rest
and support are just as important as exercises as
a basis of restoration of correct use and function of the
body. When the three weeks’ period of rest is over,
the patient should still, for a considerable time,
have two half-hour periods of hyperextension on
the pillow daily. It is not a bad plan with slender,
physically delicate subjects to make a posterior
moulded plaster-of-Paris shell in which the patient may
lie at night, or for part of the night. In aggravated
cases it may be advisable to hyperextend the dorsal
spine for a time upon an angled ' Bradford frame.
In the process of training, it should constantly
be remembered that in all body actions it is the head
which leads in maintaining a proper static position.
If the head is stretched up tall, with the chin held in,
it causes the chest to be elevated and the diaphragm
to work properly ; it draws up the abdominal contents,
and gets the body forward on to the balls of the feet.
The fixed, -elevated thorax thus assists in affording
a strong basis of support for the action of the abdo-
minal muscles. These muscles, after all, have to be
allowed to assist the gluteal muscles in flattening the
lumbar spine.—I am, Sir, yours faithfully,
Edinburgh, April 16th. W. A. COCHRANE,
To the Editor of THE LANCET
Sir,—Your leading article last week on improve-
ment of posture provided a valuable commentary
on Mr. Wiles’s paper, with an appreciation of the —
protagonist of correct posture—Goldthwait of Boston
—not mentioned by Mr. Wiles. The phrase “ good
body mechanics ” first introduced by Goldthwait has
helped me very much to crystallise the generally
rather vague conceptions of what is to be gained by
physical exercises. Since seeing the results of his
theories applied in practice at the Robert Brigham
Hospital in Boston, I have taken the opportunity of
studying and correcting the bad mechanics of incorrect
posture at the Charterhouse Rheumatism Clinic. It
is especially in rheumatoid arthritis and in spondy-
litis adolescens (Marie Striimpel syndrome), and even
more so during the prespondylitic stage of bilateral
sacro-ilitis, that the very simple postural exercises
described by Goldthwait (1922, 1934) have proved of
immense benefit. I have adapted three for use, all
of which are performed lying on the back on the
ground or other plane surface. As you yourself
suggest, this is the position which provides the
necessary resistance to the flexors and support for
the (weaker) extensors.
1. Hands behind head, elbows pressed outward and
down, chest raised to the fullest extent. Breathe deeply
10-15 times, without lowering the chest. According to
Goldthwait and Loring Swaim, this produces full dia-
phragmatic breathing, empties the splanchnic veins, and
enlarges the abdominal cavity by widening the subcostal
angle.
5. When chest expansion is poor and the subcostal
angle narrowed, one hand is placed on top of the head,
1016
which is used as a fulcrum to pull on the ribs, first of
one side, then of the other, as deep breaths are taken.
3.: Hands to side, knees drawn up, the lumbar curve is
straightened by using the glutei and ‘‘rolling up the
pelvis ” (as stressed by Mr. Wiles). Maintaining this
position, each leg in turn is straightened, lowered, and
raised several times.
It is explained that these exercises are to encourage
a correct posture to be maintained at all times, In
Goldthwait’s words: ‘‘ Stand tall, head up, chin in,
chest high, abdomen flat, weight on balls of feet.”
These exercises take less than five minutes, and are
' far better than the usual ‘ physical jerks” which
occupy a long time, are extremely tedious, and are,
I believe, of little value for the purpose of keeping fit.
- I am, Sir, yours faithfully,
H. WARREN CROWE.
THE LANCET]
Harley-street, W., April 20th.
CYSTICERCOSIS AS A CAUSE OF EPILEPSY
To the Editor of THE LANCET
Smr,—In your issue of April 10th there is an
account of an interesting and instructive case of
cysticercosis (T. solium) which illustrates once more
the importance of X ray examination of the limbs in
the diagnosis of this condition, as calcification in
cysticerci in the skull is not often seen. The state-
ment, however, that ‘‘ Morrison (1934) has described
the only case where calcification of cysts in the brain
associated with epileptic convulsions has been found ”
is incorrect. Dixon and Smithers (1934) collected all
the cases of cysticercosis that they could trace as far
back as 1892, and in 1935 published a fuller account
of the condition in the R.A.M.C. Journal, in which
they brought the total of cases up to 79 (46 of which
had not previously been published). In this series of
79 cases 7 were found in which calcification in
cysticerci could be demonstrated in skull radiographs.
References to the original publication of these cases
are given below. -
Denny-Brown’s case was of particular interest in that
it is, I believe, the only case on record in the English
literature where calcified cysticerci were demonstrated
in the radiographs of the skull but not elsewhere in
the body,—I am, Sir, yours faithfully,
College-road, Dulwich, S.E., Aprili4th. D.W. SMITHERS,
REFERENCES
Roth, E. J. H. (1926) Brit. med. J. 2, 470.
Morrison, W. K EE Ibi,
Denny-Brown (193 A) Pree. a Soc. Med. 27, 667.
rA EN Tbid, 27,
F., and Sraithors, D. W. (1934) Quart. J. Med.
60 3. Two of these cases were diagnosed by H.
Micdonald Critchley.
MEDICAL EDUCATION OF WOMEN
To the Editor of THE LANCET
Str,—As long ago as 1934 THe LANCET mentioned
that a proposal to establish a medical school for
women at the West London Hospital was under
consideration by the University of London.
Dr. Norah Schuster, in your issue dated April 17th,
suggests that it might be of advantage to the West
London Hospital to take women as students and she
may be interested to know that the proposal is still
having the careful consideration of the authorities
both of the university and the hospital.
The creation of a new medical school is not an
easy matter and it is no fault of either the university
or the hospital that the women students of London,
as also of Oxford and Cambridge, are still finding
difficulties in getting vacancies in the London medical
schools for the clinical period of training. This
hospital can provide all the facilities necessary for
clinical training and has been an active post-graduate
centre for over forty years. But we cannot accept
Behrman, S
Dizon
OVER-TREATMENT OF GON ORRHŒA
` [APRIL 24, 1937
women students without the recognition of the
universities for whose degrees they are studying.
As far as the University of London is concerned I
think I can say that this recognition is only being
withheld until certain preliminary difficulties have
been overcome. Every effort is being made to solve
the numerous problems which are inherent in such a
‘project, but the machinery of university government
necessarily moves slowly and it is impossible as yet
to give any indication as to the date upon which the
change-over from post-graduate to undergraduate
teaching will be made.
In the meantime this college continues to make
its contribution to medical education as a post-
graduate school where increasing numbers of men and
women from all parts of the Empire avail themselves
of the excellent clinical material to be found in its
wards and out-patient clinics.
I am, Sir, yours faithfully,
MAURICE E. SHAW,
= Dean, West London Post- Graduate College,
April 17th. Hammersmith, London,
OVER-TREATMENT OF GONORRHEA
To the Editor of THE LANCET
Sir,—I should like to endorse the opinions expressed
by Mr. Nicholls in your issue of March 20th (p. 721)
and by Dr. Simpson (April 10th, p. 899) on the
over-treatment of gonorrhea.
A man of 26 who contracted gonorrhea three
years ago recently came under my care. He had
been treated at a clinic for one year, by a doctor
for another year, and by a second doctor for ten
months. There was a little mucous discharge free
from gonococci but with many diphtheroids. The
mucous surface of the anterior urethra was much
scarred from treatment with Kollmann’s dilator.
He was suffering from a non-gonorrheal urethritis
due to prostatic calculi.
There is no more useful method of treatment
than prostatic massage in the right cases and in the
rght amount, but much harm can be done. both
physically and psychologically if it is abused. If
the patients are being overtreated the number of
attendances at any one centre is unnecessarily
increased. Should treatment be reduced to reasonable
and proper proportions it might not be necessary
to delegate massage of the prostate to the unskilled
and sometimes rough hands of an orderly.
As regards women it is surely better for the woman —
with vaginal discharge to see a gynecologist first and
be sent by him to the V.D. department rather than,
as is customary at present, sent straight to the .
V.D. department to be sorted out. It is no doubt
of great importance for the young gynecologist
to learn to operate skilfully but it is no less part
of his vocation to diagnose and treat septic conditions
of the cervix. The gratitude of many thousands of
women is waiting to be earned by someone who will
tackle this difficult subject.
I am, Sir, yours faithfully,
London, W., April 15th. RICHARD ROPER.
LOCAL ANESTHETICS ON BLOOD-VESSELS
To the Editor of THE LANCET
Srr,—There is an inaccuracy which I would like
to correct in your report (THe Lancet, March 27th,
p. 756) of the discussion by the neurological section
of the Royal Society of Medicine on the nervous
sequels of spinal anesthesia. Questions were asked
by Dr. Wilfred Harris and from the presidential
chair about the vascular action. of 5 per cent.
procaine solutions. Actually my reply was to
the effect that while I used 10 per cent. procaine
THE LANCET]
TREND OF THE POPULATION
[APRIL 24, 1937 1017
during an air raid, for example, St. John Ambulance
solutions intrathecally I had no experience of solutions
stronger than 2 per cent. in the skin, and that such
solutions, in the absence of adrenaline, ‘‘ cobefrin,”’
&c., were vaso-dilator. The solutions used by my
students, in the practical classes, are 0:1 per cent.
‘solutions of procaine and percaine, with and without
0-001 per cent. adrenaline.
As suggested by Dr. Harris, I have since examined
the effects of 5 per cent. procaine (adrenaline-free)
both in and under my skin. Apart from the stretch-
ing of the epidermis by the solution no blanching is
produced, and considerable vaso-dilatation follows.
I have checked these observations on another subject
and a dental friend assures me that similarly 5 per
cent. procaine solution without adrenaline causes
no vaso-constriction and only a brief anssthesia
when injected into the gum. 7
I am, Sir, yours faithfully,
A. D. MACDONALD.
Department of Pharmacology, The University,
Manchester, April 15th.
‘WHAT IS OSTEOPATHY? ”
To the Editor of THE LANCET
Srr,—Even the more vocal of the medical opponents
of osteopathy are prepared to admit that certain
conditions of strain or fixation, which are often not
demonstrable on X rays, exist in the lumbar area.
These joint conditions are sometimes accompanied
by pain along the sciatic nerve or in the lumbar
muscles. That a similar condition may exist in the
cervical and upper thoracic areas and be accompanied
by pain in the arm or shoulder has received attention
in recent papers. It is equally an accepted fact that
these conditions often yield to manipulation. Now
the American-trained osteopaths are exceedingly
skilled in the quick specific movement of spinal
joints, and because of constant practice and teaching,
their dexterity makes the efforts of the average
orthopaedic surgeon look clumsy to a degree. Because
of this dexterity the osteopath obtains much more
satisfactory results in the long run, with less dis-
comfort to the patient, and without having recourse
to anesthesia nearly so often.
It is accordingly submitted that even if all the
other conditions which have benefited by osteo-
pathic treatment are discounted, the osteopaths have
contributed something to the art of medicine, and it
behoves the medical profession to see that those
among their members who set out to do manipulative
work acquire “a good pair of hands” by practice,
and by taking every advantage of opportunities of
seeing the work of experts at manipulation. It is
just as foolhardy to entrust the manipulation of.
cervical vertebra to a general surgeon as it is to
expect a radiologist to be able to perform a Wertheim
hysterectomy. .
I am, Sir, yours faithfully,
l W. HARGRAVE-WILSON,
Gloucester-place, W.. April 19tb.
AMBULANCES AND STRETCHERS
To the Editor of THE LANCET
Sık, —The question of standardising the size of
British ambulances is one which I think deserves
consideration. At present ambulances may be divided
generally into short and long. The short type (most
civil ambulances) is capable of carrying only short
stretchers—i.e., those with folding handles—while the
long type is capable of carrying stretchers with fixed
handles such as the Army and St. John Ambulance
stretcher. In times of national emergency it would
be most desirable that all ambulances should be
capable of carrying any type of stretcher ; otherwise
men, having collected a casualty, might find that
they could not load him straight into the ambulance
which had driven up. Delay is undesirable on such
occasions, and on all occasions the less a badly injured
man is shifted about the better.
As the vast majority of British stretchers to-day
are of the long type—Army, Air Force, St. John
Ambulance, and so forth—it appears desirable to.
encourage the production of long ambulances only,
which could be relied upon for the rapid collection
of all casualties at home or abroad. It is understood
that the London County Council have already moved
in this matter and our latest naval ambulances are
long. I feel sure that if this aspect of the matter was
brought to the notice of firms concerned, they would
advise their patrons accordingly when future orders
were being considered. And as other countries
suffer from the same difficulty, this should become a.
matter for international consideration ; for there can
be no question of international rivalry here,
I am, Sir, yours faithfully,
R. A. W. FORD,
April 17th. Surgeon-Commander, Royal Navy.
TREND OF THE POPULATION
To the Editor of THE LANCET
Sır, —Please allow me to make the following
comments on the valuable article by Mr. C. A. Gould
on p. 944 of your last issue. (1) The population
of England and Wales has indeed been ageing since
1870, but let no one overlook that this was due to
reduction in the mortality of the young. (2) Mr.
_ Gould says that the population will attain a maximum
of 40,800,000 about the year 1944; yet the Registrar-
General takes it to be more than that already. (3) It
is not a serious matter that trade should decline if
the amount of it per inhabitant increases. (4) The
splendid diagram usefully shows that, on the worst
estimate, the workers will outnumber the children
ând aged for a century; so Great Britain should
continue to have a high standard of living although
it may cease to be a dominating power. I may
add that if our farms become larger they will more
easily compete with the food from the sparsely
peopled countries, and if wages rise there will be
an increasing demand for home-grown produce,
Mr. Gould ignores the possible effects of migration,
but a relatively high standard of living would draw
from the Continent as many young workers as we
might choose to admit,
I am, Sir, yours faithfully,
Manor Fields, Putney, S.W., April 19th. B. DUNLOP.
PAGE NUMBERS ON REPRINTS
To the Edttor of THE LANCET
Sm,—From time to time I am the fortunate
recipient of reprints of papers which have appeared
in various periodicals. May I call attention to a not
uncommon fault in these reprints ? It is the omission
of the number of the first page of the article. I have
before me a reprint from a well-known scientific
publication. It gives the name of the journal, the
number of the volume, the number of the issue, and
the date of publication but no page. In a country
like this it is impossible always to get into touch with
a library to supply the omission, and in my editorial
work I find the impossibility of inserting the page
number a difficulty in carrying out properly the
Harvard system of references. |
I am, Sir, yours faithfully,
JAMES H. SEQUEIRA,
, Editor, East African Medical Journal.
Nairobi, Kenya, March 27th.
1018 THE LANCET]
[APRIL 24, 1937
PARLIAMENTARY INTELLIGENCE
CORONERS AND THEIR DUTIES
In the House of Lords on April 15th Lord Morris
said there was an increasing tendency among coroners
to moralise and lecture at inquests over which they
presided and he inquired whether steps could be taken
to curb this undesirable disposition by legislation.
Alternatively, he asked the Government if they would
consider the abolition of the ancient office of coroner.
In February, 1935, the then Home Secretary, in
response to popular clamour, had appointed a Depart-
mental Committee to inquire into the law and practice
relating to coroners. In the course of its report it
was stated :—
The tendency of some coroners to animadvert upon the
conduct of persons who have, perhaps quite incidentally,
come under their notice has frequently been the subject
of public comment. ... We consider that the practice
should be brought toanend. We donot, however, propose
any amendment of the law at present on this point. We
believe that the body of our recommendations, taken
as a whole, will tend to put a stop to this practice.
That pious hope unfortunately had never been
fulfilled. The present Home Secretary had also
quite recently expressed a similar hope that coroners
would have some regard to the recommendations
of that Committee. On the contrary, coroners
had paid no attention whatever to those recommenda-
tions, but were getting worse. For example, a
month or two ago the coroner at Greenwich had
publicly rebuked a minister of religion and lectured
him on his supposed duty. On March 28rd the
coroner for Tunbridge Wells, inquiring into the death
of a six-weeks’ old child, told the mother coram
populo this :—
This child was starved to death, but I am prepared
to believe that you thought you were doing the right thing.
I am prepared to put your complete failure down to
ignorance. You and your husband are both young, and
I hope you make a better job of it next time.
_ Lord Morris suggested that that was a piece Of
intolerable impertinence. It was time that a stop
was put to this kind of thing and that steps were
taken, if necessary by legislation, to check this
desire on the part of coroners to apportion moral
responsibility, an act that had nothing to do with
their proper function, which was solely to inquire
into the cause of death. At Harrogate a short time
ago the local coroner was inquiring into the death
of aman. According to the Yorkshire Post the son
of the dead man said: ‘‘I would like to make it
perfectly clear that my father was living a mode of
life which he was not accustomed to.” The coroner
remarked to the son of the dead man: ‘I know all
about that. You have the gentlemen of the press
here, and certain papers will thoroughly enjoy
spreading your family troubles all over the country.
If you will take my advice you will say nothing more.”’
Lord Morris said he thought that a man who could
so abuse his position as to make remarks of that
kind was quite unfit to occupy the post of coroner
and the sooner he was removed the better.
The coroner’s court was admittedly very old in
origin; it went back, he believed, to the thirteenth
century ; but that hardly seemed a reason why ‘it
should survive to-day. There was now an efficient
police force and the coroner served no useful purpose
whatever. He was merely a nuisance and an
expense; he cost the country, on an average, not
less than £220,000 per annum, which might be put
to a better use. The only possible case where inquiry
of this kind was called for was in suspected foul
play, and these could well be left in the hands of
the police. There was objection to that in some
quarters on the ground that the police might be
corrupt or negligent. He did not think that fear
was wellfounded; butacoroner’s inquest was certainly
a very indifferent safeguard against that danger,
if it be a real one. Leaving out these cases there
remained those of obvious suicide, motor accidents,
and so forth. Deaths due to road accidents could
very easily be investigated by the Ministry of
Transport, and railway accidents could be inquired
into—as indeed they were at present—by the concerns
in question. In almost all cases of fatal accident
to employed persons—taking the mining industry
for an example—these inquiries were now carried
out by experts, and the coroner’s inquests did not
throw any light on the matter at all. The coroner
was nothing but a paid public Paul Pry and the whole
thing was extremely un-English. The very expensive
but undoubtedly interesting travesty last year
when one of their Lordships was tried on a charge
of manslaughter was due entirely to the fact that the
noble Lord in question was committed for trial
there on a coroner’s warrant, and no magistrate
would have committed the noble Lord at all, since
there was not a tittle of real evidence against him.
He was convinced that there was a growing and
considerable volume of opinion in this country
which favoured the complete abolition of the coroner
and his inquest.
Lord SNELL said that the issue which Lord Morris
had raised- was not an unimportant one. They
expected public officials in this country to do their
duty according to their obligations to the State.
It was true that very few of them could resist the
temptation to advise another’ person when he was
in trouble, but they did not appoint public coroners
for that purpose. They had certain specific legal
duties to perform and when those duties had been
performed the coroners had done all that the nation
expected of them. The very worst moralist in the
world was the amateur moralist who knew practically
nothing about it and he thought that Lord Morris
had made the point that coroners should stick to the
job for which they were appointed and leave these
matters to the discretion of people whose knowledge
upon them was superior to their own.
The MARQUESS OF DUFFERIN AND AVA, Lord-in-
Waiting, said that Lord Morris had made so many
accusations that it was difficult to keep track of them.
For instance, he had said that the coroner’s court
was un-English. No habit or practice of this land
was called English until it had been sanctified by
custom for many years, but the coroner’s court
went back to 1276, and he thought that the noble Lord
would agree that this un-English custom had some
small roots in our land. He did not want to quibble,
but he must say on behalf of the Home Office, that
the words of Lord Morris’s question were extremely
misleading. So far as the Home Office were aware
there was no increasing tendency on the part of
coroners to moralise and lecture at the inquests over
which they presided. The press and the public
were very vigilant at the moment with regard to the
way in which coroners exercised their responsibility
and the Home Office would certainly have been
aware if coroners had in fact tended to spread them-
selves more in the last few months than they had
done in the past. Lord Morris had really only argued
from the cases which had come to his notice in the
public press, and, of course, the only cases which had
come to his notice were cases where coroners had
exceeded their responsibilities. He had given no
credit at all for the number of inquests, tens of
thousands of them, that were held in this country
in which the coroner had acted properly and rightly.
There were 3500 inquests held in London alone every
year. Lord Morris: What a waste of time. The
Marquess of DUFFERIN and AVA said it might be a
waste of time, but so far as he knew during the last
year no complaint of any coroner’s conduct at any
of these inquests had been made. At the same time
it was not for him to deny that on occasions the
privilege of the Coroner’s Court of Record might be
abused. There was, of course, a grave danger, and
THE LANCET]
it was all the graver because sometimes these lectures
and moralisations were directed at people or at
institutions who were not able to answer back and
might not even be present in the court or not
represented by people qualified to deal with the
intricacies of the law. He need hardly say that
the Home Office took the very gravest view of that
sort of attack. The Home Secretary recently in
the House of Commons had used what seemed to
him rather hard words. They made it quite clear
that in the view of the Government spitting on the
grave of the departed did very little good. The grave
could take care of its.own, but the living must be
considered. In the view of the Government, and,
of course, of Lord Wright’s Committee, a living man
had just as much right to have his reputation
protected as his liberty and it was just as wrong to
take away a man’s reputation without due process
of law as it was to take away his liberty. That
point was the occasion of a circular issued by the
Home Office in 1927 to all coroners in which the
Home Secretary made it clear that, as he had been
pressed to make a rule on the subject,
“He may say that where it is possible to secure the
attendance of a person whose conduct appears to be in
question, it is desirable that his presence should be secured
before censure is passed, and that he should be afforded
a reasonable opportunity of making any relevant explana-
tion. It need hardly be added that there is special need
for care, before publicly making adverse comments,
if the person concerned is likely to suffer thereby in his
profession or calling.
That circular was followed by the recommendations
of Lord Wright’s Committee, which were naturally
brought to the notice of coroners, and he firmly
believed that the mere publication of the Committee’s
report had done much to curb the habit to which
Lord Morris objected. The Committee expressly
said that on this particular point no legislation
was required. They expected that the legislation
that might follow from their report in regard to the
Disciplinary Committee and the Rules Committee
would be sufficient to attain their object. Lord
Dufferin assured Lord Morris that although the
programme of legislation was very full and he could
not possibly offer any concrete promise, at the same
time when opportunity offered the suggestions of
that Committee would probably be the subject of
future legislation. When that happened he was
rfectly certain that all the evils of which the noble
Lord had complained would be done away with.
The Government agreed with his noble friend in
so far as they deprecated coroners going outside
their. proper function. At the same time with the
Wright Committee, which was very definite on this
point, they could not possibly contemplate the
abolition of this ancient office.
DEFECTIVES AND VOLUNTARY
STERILISATION
On April 13th, on the motion that the Speaker do
leave the chair on the House of Commons going
into Committee of Supply on the Civil Estimates,
Wing-Commander JAMES moved the following
amendment :—
In the opinion of this House, the Government should
give further consideration to the potentialities of voluntary
sterilisation for hereditary defectives in accordance with
the unanimous recommendations of the Departmental
Committee that reported to the Ministry. of Health on
Jan. 8th, 1934.
He quoted a paragraph from the report of the
Committee on Scottish Health Services which he
said was a very strong body and the most recent
health committee to report. It said : ‘‘ In consider-
ing what measures should be taken to improve the
health of the people, we have to take into account
at the outset the question of heredity. Physical and
mental capacity has a basis in inheritance, and some
people, therefore, because of their hereditary constitu-
PARLIAMENTARY INTELLIGENCE
[APRIL 24, 1937 1019
tion, will be less fit, physically and mentally, than
others, no matter what is done by way of medical
care and improvement of environmental and other
conditions.” He (Wing-Commander James) invited
the Minister of Health to give his attention to the
need for further research into the problem of genetics.
The fact that the amendment was not completely
in agreement with the recommendations of the
Brock Report was not because he disagreed with any
of them, or would depart in any respect from them,
but was merely a matter of technical form. Mental
deficiency, which covered the largest number of
people concerned, had generally, in varying degrees,
a basis in heredity. In the Colchester inquiry it was
shown that heredity played the greater part or the
lesser part in the predisposition to mental deficiency
in approximately 91 per cent. of the cases examined.
In addition to mental deficiency, there were other
forms of hereditary disability, notably some forms of
blindness, which was much more directly hereditary
even than the average form of mental deficiency.
Most of the opposition to the idea of sterilisation
came from people who had not read the report of the
Brock Committee. That committee agreed with the
Wood Committee, which published a report in 1929
that there were in England and Wales about 300,000
defectives, and they gave it as their opinion that of
that number approximately 200,000 were fit for
community life, their degree of deficiency or defect
not being high enough to justify their being retained
in any form of institution. At present a very much
smaller proportion than one-third was in fact in
institutions or under care.
On Jan. lst, 1936, the London County Council
published a report containing the statement that the
London County Council Hospitals Committee was
responsible for the care of 27,730 persons of both
sexes. In an earlier report they stated that 30,000
beds were occupied by deficiency cases. They stated
further, in the 1936 report, that since 1920 there had
been an average annual increase of 603, and that
during the next few years they anticipated a net
annual average increase of 560 in the number of
persons for whom accommodation would have to be
provided. The increase recently was partly due to
the growth of population of the London County
Council area, The expenditure on such cases by the
London County Council during the last financial
year was £1,698,633. There was an enormous total
expenditure in connexion with this problem. He
did not suggest that if sterilisation were legalised
it would be an economy. In the long run that might
be achieved ; but it was not from the point of view
of economy that the Brock Committee recommended
sterilisation, or that anyone else should consider the
problem. Ifsterilisation were legalised, the immediate
effect would be small. But if any part of the present
enormous expenditure could be diverted to other
channels and social services, the community as a
whole would benefit. The Central Association for
Mental Welfare actively supported the ‘suggestion
that sterilisation should be legalised. A point in
opposition to this proposal was that the existence
in the community of persons who had been sterilised
would lead to a lowering of the standard of morality.
That point was examined and answered by the
Brock Committee. There was still a great deal of
misunderstanding about the nature of the sterilising
operation. Any doctors who might be present that
day would con the statement that the operation
was very simple.. In males it was trivial and wholly
unattended by risk and in females it was virtually
unattended by risk. It had no effect whatever on
the normal ordinary life and health and capacity
of the individual. It had nothing in common with
any of the operations used for the removal of any
giand. It in no way affected sex life or sexual
secretions. The only effect was that the sexual act
when performed did not result in fertilisation.
Another argument frequently used against the
recommendation of the committee that sterilisation
should be legalised was that a mentally defective
pr
1020 THE LANCET]
PARLIAMENTARY INTELLIGENCE
[APRIL 24, 1937
person cannot have full volition. That argument,
again, was dealt with extensively in the report.
Sexual sterilisation to-day for health reasons as
opposed to eugenic sterilisation was perfectly legal.
Every year hundreds of people in this country had
such operations performed either by private practi-
tioners or in general hospitals for reasons of their
own health. Most frequently this occurred with
women likely to be endangered by child-bearing.
But it was illegal for a person to be sterilised in the
interests of posterity—or it was probably illegal,
because it was not settled as a matter of case law or
statute law.
Of the 300,000 defectives estimated to bein England
and Wales, 200,000 at least cònducted their lives
in the ordinary way as members of the community
and for all other purposes save this were held to have
volition. Then there were people who had hereditary
disabilities. Was it to be said that they had not
complete volition ? There were also carriers, them-
selves sound, whose progeny might well suffer from
some congenital trouble. There was one point by
which the Brock Committee was very much impressed
—the position of the unfortunate normal child of a
defective parent. It was perhaps one of the most
telling arguments in favour of sterilisation.
One of the obstacles to this desirable reform arose
from the opposition of the Roman Catholic Church.
Fifteen years ago the whole question of sterilisation
was brushed aside as so improper, so unthinkable,
and so impracticable as to be unworthy of argument.
Public opinion had moved a long way since then,
and with it that great Church, which for generations
had moulded and directed so much of human thought
but which, he believed, had never in the long run
stood across the path of progress, had modified its
position. There was no reason why, if the Papal
authorities decided to do so, they should not with
perfect consistency change their attitude on the
subject. It was a matter of discipline only and not
of dogma. Since no responsible authority in this
country had ever advocated sterilisation being
anything but voluntary, and since, therefore, there
was no possible suggestion that it could be inflicted
on anyone, why should the Roman Catholic Church
deny to those who were not Roman Catholics a form
of relief which they desired ? There had been much
less opposition to the idea in the country than was
supposed, and particularly among the poorer classes,
who were the people who suffered most from the
proximity of defectives and comprised the class
which could not afford the use of nursing-homes,
there was a fervent demand for the legislation of
sterilisation. The present position was class legisla-
tion. Those who were well off could get themselves
sterilised if they wanted to, and those who are not
well off cannot do so.
Some of the more important bodies which had
Sir FRANCIS ACLAND, in seconding the amendment,
said that the more he had studied the question the
more convinced he had become that something ought
to be done without too long a delay. He emphasised
a point implicit in the whole campaign for voluntary
sterilisation on the lines of the Brock Report—
namely, that this campaign was not, as it had been
represented to be, the thin end of the wedge towards
compulsory sterilisation. It was the very reverse
and antithesis of the whole idea of anything com-
.pulsory. The proposal was not that anyone could
go and get himself or herself sterilised, but there
must be very careful inquiry and certification by the
two doctors, who were both specially approved for
the purpose, with an expert Ministry of Health
committee in the background in case the Minister’s
advisers were not satisfied with the medical reports
and certificates. That had this importance that in
three out of four classes who would be entitled to
apply for voluntary sterilisation under the Brock
Report, the certificates could only be given if the
practitioner were satisfied that the person applying was
suffering, or had suffered, from disability or disorder
deemed to be inheritable, or was a person deemed to
be likely to transmit defectiveness or disorder or
great disability to a subsequent generation. No ©
really honest opinion with regard to that could be
formed unless the practitioners concerned had had
access to the family histories of both of the past
generations and of the collaterals of the. persons
concerned. No one would give information if there
was any possibility that a person might be sought
out and compulsorily sterilised. Therefore the whole
machinery on which voluntary sterilisation rested,
which depended on the care and conscientiousness
and thoroughness of these reports, would be brought
to naught immediately any system of compulsory
sterilisation was introduced.
Mr. LoGAN said that the teaching of the Church
was that man was made to multiply, and there was
no getting away from that special ordinance. This
measure could not be applied unless it was made
compulsory. It was a very bad thing for medical
men to advocate sterilisation in view of the great
advances in science, and he suggested that people
would be doing better to give attention to raising the
standard of life for the worker.
Captain GUNSTON said that the Brock Committee
‘reported that “ The children of parents one or both
of whom are mentally defective are, on the average,
below the normal, and our inquiry shows that nearly
one-third of such children as survive are likely to be
defective, and more than two-fifths must be expected
to exhibit some degree of abnormality.’’ In the
face of evidence like that, it could not be said that
they ought not to take measure to reduce the number
of mental defectives born into the world.
Mr. PRITT said that this was a very fundamental
recently signified their support of the principle of `step to propose and further research was really the
voluntary sterilisation included the Royal College
of Physicidns, the Royal College of Surgeons, the
Society of Medical Officers of Health, the Mental
Hospitals Association, the Women’s Public Health
Officers’ Association, the County Councils Association,
the Association of Municipal Corporations, and many
others. He hoped that the Minister of Health would
be able to give some statement on what was being
done about the research recommended by the Brock
Committee, and incidentally by other bodies, such
as the Departmental Committee on Scottish Health
Services of 1936. There were now: many countries
abroad which had on their statute books and in
practice sterilisation laws. ‘Those countries included
Germany, the Scandinavian countries,and some British
Dominions. Those who advocated voluntary sterilisa-
tion did not for a moment suggest that it was going
to be a universal panacea or a substitute for othet
efforts. All they said was that for those who wanted
it administered under adequate safeguards, such as
were recommended by the Brock Committee, it would
be a most important and very necessary. weapon
in the armoury of preventive medicine.
proper course. He understood that on the whole the
results so far in the United States where voluntary
sterilisation had been seriously applied had been a
little disappointing from a statistical point of view.
The results in Germany really ought to be ruled out
entirely, because they had not been going very long,
and were obviously administered with such bad
motives and such reckless disregard of decency,
that it would not be fair even to use them as an
illustration of the abuses that might result in a
civilised country. |
Sir KINGSLEY Woop, Minister of Health, said that
an allegation had been made that there had been an
increase in the number of defectives in this country.
Of course it should be borne in mind that the number
of defectives under care increased as the general
population increased, and as the local authorities
became more efficient in ascertaining the existence of
defectives, but it could be said with authority that
there was no proof that the incidence of mental
deficiency in this country was rising. Reference
had also been made to what had been done by other
countries and he assured the House that, of course,
THE LANCET]
his Department and the Board of Control kept them-
selves fully informed of the progress made under
foreign statutes. But it could be said with accuracy
and truth that, at any rate up to the present time,
no results of significance could yet be assessed. For
instance, a system of voluntary sterilisation was
approved in Norway, and also in Sweden, in 1935.
Germany brought in a compulsory system of sterilisa-
tion in 1933. Although Denmark began a system,
as regards a limited class in 1929, again no useful
lessons could be learned from it. Members would
appreciate the importance, apart from the merits of
the case of taking public opinion wholly with them.
Sterilisation laws were in operation in several of the
United States, but, in some little use had been made
of them. In certain cases the law appeared to have
been enacted without any money being provided
to work them, but the real explanation of failure
in other cases was probably that the enthusiasm
of small groups secured the passage of legislation
for which there was me general demand and no
sufficient backing of public opinion.
Observations had been made in the debate which
would lead one to think that perhaps in certain cases
the treatment of people who unhappily suffered from
this terrible disease was, to quote one expression
used, ‘‘ very horrible.” He would like anyone who
came across a case of that kind to give information
at once. He shared the view of a good many people
of what a terrible tragedy it was, and what it must
mean to people concerned. But he. must testify
to the increasing provision, care, forethought, and
kindness displayed in these institutions. He would
not like it to go out that there was anything else
but tbe utmost consideration shown and large sums
of money spent to see that reasonable care and treat-
ment were given. Undoubtedly a great deal had been
done. For instance, only in 1934, in consultation
with the Board of Control, the Medical Research
Council appointed a new committee to advise and
assist them in promoting research into mental dis-
orders. Another committee of equal importance had
also been appointed by the Medical Research Council,
a committee on human genetics, because in spite of
the advances made in the biological study of heredity
and the application of the results it was felt that the
study of human genetics had been relatively neglected.
Under the sgis of this latter committee some very
interesting researches were now taking place at the
Royal Eastern Counties Institution at Colchester
by Dr. Penrose and his colleagues, and an important
examination of the hereditary characteristics in the
blood of mental defectives and their families was now
being made by Prof. Fisher and Dr. Taylor of the
Galton Laboratory, University College, London.
This work was being assisted by grants from the
Rockefeller Foundation. Dr. Slater at the Maudsley
Hospital, London, was also working on a large-scale
field of inquiry into certain different types of mental
disorder. Other work was also being carried on,
so that it would be seen that this aspect of the question
was not being neglected by the Government. o.
Wing-Commander JAMES asked if the Minister
could give an assurance that any funds needed for
research would also be forthcoming from the
Government ?
Sir KınasreyY Woop said that would be a very bold _
undertaking to give without consultation with the
Chancellor of the Exchequer, but, if a question of
money arose which he ee K. Wood) thought was
important, he would not hesitate to take it to the
Chancellor of the Exchequer. He could say from his
knowledge of many years now in connexion with health
work that there was no doubt that opinion was
growing in favour of sterilisation. When he came
back to the Ministry after an absence of some time
he saw the record of a deputation from the County
Councils Association and the Association of Municipal
Corporations in 1935. They represented a large body
of people discharging responsible duties in a wide field
of public and social work. Itwould have astonished a
great many peopleif such a deputation had taken place
PARLIAMENTARY INTELLIGENCE
[APRIL 24, 1937 1021
only two or three years before. But he could not
disguise the fact that opposition still remained,
and there was much conflict of opinion, particularly
on religious grounds. The medical profession were
by no means unanimous on the matter. If one asked
even the medical men that one knew in one’s private
circle there was not a great deal: of unanimity of
opinion. Resolutions of certain learned colleges had
been quoted, but he very much questioned whether
one would get anything like unanimity from the
British Medical Association.
Mr. THURTLE asked if it was not a fact that on
most matters one could not get unanimity in the
medical profession.
Sir KINGSLEY Woop said there were always small
minorities, and-one dealt with them as best one could,
but there would be found, he thought, in the British
Medical Association, a pretty steady and strong view
on most medical matters of the day. -He was
endeavouring to put fairly the other side of the matter,
and he doubted very much whether they would get
such a strong vote as would justify a Bill being
promoted at this moment. It was desirable that
ample time should be given for consideration and to
get public opinion developed, as he believed it was
developing. :
Wing-Commander James withdrew his amendment.
NUTRITION: ‘NEW GOVERNMENT SURVEYS
On April 13th, in the House of Commons,
Mr. Rowson said that there could be no doubt
that, there were many people in this country suffering
from a shortage of essential foodstuffs. The case
was proved and accepted that large numbers of people
were suffering from malnutrition. The Ministry of
Health was certainly the best department through
which they could act if they desired to improve condi-
tions among the people. They should extend as
.far as possible the drinking of milk and also give
advice on the right kinds of foodstuffs. He would
like to see through the health committees of the local
authorities a more widespread use of the valuable
food that was produced, and, if necessary, free
distribution among the child population. The
Minister of Health should do something with a view
to organising the better feeding of children in the
schools. He hoped the Minister and all Members
of the House would recognise that this was a problem
which must be faced. There was intense suffering
all over the country, and they ought to do their
best to remedy this terrible evil among the people.
Sir KINGSLEY Woop said he welcomed this
discussion because it came at an opportune moment,
and he seized the opportunity to call the attention
of Members to the publication of the first report of
the Advisory Committee on Nutrition of the Ministry
of Health. That was the most valuable document
on nutrition that they had had up to the present time,
and there could be no question as to the authority
of the committee, and its report was unanimous.
It served a very useful purpose at present in that
during the last year or two the question of nutrition
had not only been a subject of much discussion, but
one on which all sorts of confusing statements had
been made about the condition of the nation. The
committee said that a great deal of further information
on the facts must be obtained before they could reach
a final national policy on nutrition. The report was
particularly valuable in that it pointed out a number
of ways along which they could make many advances.
But while nutrition was an important side, it was only
one side of our national health problem. A man
. did not live by calories alone; the national health
did not depend only on vitamins, but on a steady
pursuit of many objectives, such as better housing,
the clearance of slums, maternity and child welfare,
the provision of more open spaces and physical
recreation. To-day no’ word was more often used
and abused than ‘‘ malnutrition.” Members should
read Dr. M’Gonigle’s book in which he gave a very
fair description of what malnutrition really meant,
1022 THE vasa) |
On their broad survey, the Advisory Committee
had come to the conclusion that the consumption per
head of most foodstuffs had increased since the war,
and the weakest thing to which they could point
in connexion with the national dietary was the
consumption of milk which is on a very low level in
` this country. The consumption per head-had slightly
declined since before the late war, Milk was the most
complete food known and that there was no single
- step which would do more to improve the health
and the resistance to disease of the rising generation
than a largely increased consumption of safe milk
by mothers, children, and adolescents. They found
that, on the average of the years 1934 and 1935 all
except a relatively small part of the population were
obtaining the full amount of calories which they
required. The national diet also contained enough
protein, provided the consumption of animal protein
increased, while that of vegetable protein remained
nearly constant, as the standard of living rose with
income. Sir Kingsley had asked each local authority
to review at an early date its arrangements under
the Maternity and Child Welfare Acts for the supply
of milk and other foods, in view of the importance of
securing that the diet of expectant and nursing
mothers should contain the proper constituents and
that the consumption of milk, especially by young
people, should be increased. Practically all local
authorities had already ‘made some arrangements for
the supply of milk, and many also for the supply of
other foods, but it was essential that this important
matter should be adequately dealt with throughout
the country.
He had also drawn the attention of the authorities
to the fact that there was to be no question of
the limitations. He had told the authorities that
he did not think it desirable to adopt any such
restriction, for instance, as limiting the supply of
milk to the last two or three months of pregnancy
only, or only to children up to the age of 18 months `
or 2 years, or in every case to a pint per day. It
was also very important that the scales of income
should not be framed so as to render it difficult
for any mother to take advantage of the authority’s
arrangements. Wherever possible efficiently pasteur-
ised milk should be provided, and that where this
was not practicable the medical officer of health
should approve of the source and quality of the
supply. He had also asked the authorities to consider
afresh the question of a properly organised system of
meals.
In some areas local authorities had hesitated on
grounds of financial stringency to develop these
services as fully as they desired to do, but the addi-
tional financial assistance afforded by the recently
passed Local Government (Financial Provisions)
Act provided a further reason for an early review
by the authority of existing arrangements. The
block grants to local authorities had just been raised
by £5,000,000 to nearly £50,000,000 a year and at
any rate the rearranged distribution gave a larger
share to the authorities whose need was greatest.
Therefore, he considered that many of them would
be able to continue and extend the work which they
were doing in the direction indicated by the Advisory
Committee.
The Advisory Committee had asked for certain
further information before they issue their next
report. The Minister of Labour was shortly to under-
take a family budget inquiry to provide the material
required for a revision of the basis of the cost of living
index. This was going to be incorporated in the
Ministry of Labour cost-of-living inquiry which |
would involve the collection of budgets from 10,000
families for one week, and from the large proportion
of those families for three other weeks, and also
supplementary budgets of personal expenditure from
wage-earning members of the families. They thus
hoped to be able to obtain the further information
asked for by the Advisory Committee. They also
proposed to make certain dietary studies which were
PARLIAMENTARY INTELLIGENCE
[APRIL 24, 1937
recommended by the Advisory Committee, some of
which would naturally take a considerable time.
Mr. E. J. WILLIAMS said that Dr. Somerville
Hastings, speaking recently of the inspection of
children under the school medical service, had said
that six minutes was taken to examine a school
child, and he had complained that it was quite
impossible to find out the flaws in a child’s health in
six minutes. Mr. Williams asked the Minister
whether something could not be done to give far
more accurate information as to school-children’s
state of health than we had at present. He hoped
what Dr. Hastings had said would be examined by
the Department, to see whether it was possible to
find out the actual physical state of a child in six
minutes, including the time in which a report had to
be written on the child’s condition. Yet the figures
presented in reports on the condition of school-
children in this country were dependent on such
scanty examination as that. They did not really
know the physical state of school-children, and with
such inadequate medical examinations they could
not hope to know it. The Minister should insist
that the school medical service was treated in a far
more scientific way than existed to-day.
Mr. A. V. ALEXANDER said that the policy which
the Government had adopted was not touching the
problem. The Minister seemed to take pride in the
fact that there was to be a further inquiry into famil
budgets. In the inquiries at Sheffield, Liverpool,
Manchester, Salford, and that of the British Medical
Association, they had an abundance of material
available about what dietaries cost the household
for the Government to take any necessary action
if they liked. It was simply a long-drawn-out
process of appointing inquiry after inquiry instead
of doing what was essential, enabling the people
concerned in one form or another, either by improved
wages, or by increased assistance or by adequate
scales for those who had recourse to public assistance,
to be able at least to purchase the minimum standard.
of food required to set up a proper basis of nutrition.
There was sufficient evidence already to show that
the increased cost of basic dietaries to-day was such
as to justify the special attention of the Government
n i income of the families which had to obtain the
ood.
Mr. R. S. Hupson, Parliamentary Secretary to
the Ministry of Health, replying to the statement
that the results of an examination of school-children
could not be of very great value because the time
taken for the examination was only six minutes, and
obviously it was impossible to have a proper examina-
tion in that time, said he was told that in fact the
time taken for the examination was not six minutes,
and that the examination of some of the children
took a longer time and that of others less time, the
average being six minutes, which was adequate for the
purpose. It was absurd for Mr. Alexander to say
that as a result of something the Government had
done the people in this country were seriously
prejudiced in obtaining adequate food. In some of
the reports of Lancashire medical officers of health
dealing with the health of school-children in Lanca-
shire, one of the most reassuring things which emerged.
_was that even in the boroughs in Lancashire where,
in view of the Iong-continued distress which many
of these boroughs had suffered one would have.
expected to find high rates of malnutrition and sub-
nutrition among school-children, actually one did
not find that. Anyone who knew Lancashire would
know of the great amount of unemployment and
suffering which St. Helens had gone through in
recent years. The medical officer of health of
St. Helens reported last year—and there was no
question here of averages—that out of a total school
population of 5797 who were examined he only found
eight individual school-children suffering from mal-
nutrition.
The motion that, the Speaker do leave the chair was
carried by 161 votes to 120.
ho a
=-
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PARLIAMENTARY INTELLIGENCE
[APR 24, 1937 1023
FACTORIES BILL IN COMMITTEE
Tum Factories Bill was further considered by a
Standing Committee of the House of Commons on
April 13th. Major LLOYD GEORGE was in the chair,
On Clause 65, which deals with the procedure at
‘inquests in the case of death by accident or industrial
disease in a factory,
Mr. MANDER urged that where a coroner directed
& post-mortem examination of the body of any
person whose death might have been caused by
accident or disease the various interested parties
should be entitled to be represented by a medical
practitioner. He said that there was considerable
anxiety on this point and it was the subject of a
recommendation in the report on the question of
coroners. Mr. SILVERMAN said he had had pro-
fessional experience very recently of a case which
threw a great deal of light on the point raised by
Mr. Mander. A man who had contracted silicosis
was granted a workman’s :compensation award
on the basis of total incapacity under the silicosis
scheme. After a considerable time the man died
‘and prior to the inquest there was a post-mortem
examination conducted by the surgeon who had been
requested to act by the coroner. The surgeon’s
evidence was that the man had died from silicosis
and a verdict was returned to that effect. He
(Mr. Silverman) understood that at the post mortem
portions of the lung were detached and sent, as was
the custom, to the Silicosis Board and some little
time afterwards there was a decision by the Board
that the man had not died from silicosis but from
tuberculosis accompanied by silicosis. Therefore
no compensation to the widow was payable. From
the decisions of the Board there was no appeal.
If Mr. Mander’s suggestion was agreed to in such
cases the widow would be represented at the post-
mortem and the inquest. Mr. LLOYD, Under-
Secretary, Home Office, said that it seemed undesirable
to deal with the post-mortem procedure in this Bill.
The Coroners’ Committee made various recom-
mendations on the subject which ought to be
considered as a whole. It was suggested therefore
that this matter should be left to be dealt with by
further legislation when it could be looked at as a
whole and in perspective.
The clause was ordered to stand part of the Bill.
On Clause 67 (Duty of examining surgeon to investi-
gate and report in certain cases),
Mr. LLOYD, replying to questions in regard to the
reason why the surgeons were designated ‘‘ examin-
ing surgeons” instead of ‘certifying surgeons,”
said he was informed that the surgeons preferred the
term ‘‘ examining surgeons.” He would look into
the matter in consultation with his advisers at the
Home Office before the report stage.
The clause was ordered to stand part of the Bill.
On Clause 68, which provides among other things
that, subject to certain exceptions, the total hours
worked by women and young persons in factories,
exclusive of intervals for meals and rest shall not
exceed nine in any day or 48 in any week; that the
period of employment shall not exceed 11 hours in
any day and shall not begin earlier than six o’clock
in the morning or end later than eight o’clock in the
evening, or on Saturday, one o’clock in the afternoon ;
and that where women and young persons are not
employed on more than five days in the week the
total hours worked may extend to ten and the
period of employment may extend to twelve hours in
any day,
Mr. RIDLEY moved an amendment providing
that it should not be lawful to employ a young person
under the age of 15 in a factory. He said that doctors
objected to the Clause as it stood because by it sleep
was denied and educationists did not want it because
by it education was denied. No one wanted the
clause except the bad employer.
Mr. DENMAN said that to the general proposition
that a young person below the age of 15 still growing
and developing should not become part of a machine
and work long hours still required under this Bill
he thought the whole Committee could almost
unanimously agree. But there was a real difficulty
here. The new Education Act did not come into
force until 1939 and therefore there would be a
year’s gap. While there was nothing to prevent
the children staying at school during that interval
they had to face the fact that they would leave
school in large numbers and if this amendment were
passed they would be prevented from getting into
the best available occupations at that age. He
agreed that they should strive for the time when
children would be kept at school and not be allowed
to go out into the labour market so early, but while
they were on, the labour market it would be a mistake
to decline to let them enter what were frequently
some of the best occupations.
After further debate,
Sir JoHN Spon, Home Secretary, said that the
Committee had now reached one of the really
important parts of the Bill. He had taken the view
from. the beginning that in some respects the measure
called for a change of drafting. Clause 145 (which
deals with general interpretation) as the Bill stood
stated: ‘‘ Young person ” means ‘fa person who has
attained the age of fourteen but has not attained
the age of eighteen.” They had to remember that
Parliament had passed a new Education Act and the
Factories Bill must be drafted in a form which
fitted the Education Act. Therefore the Govern-
ment had put down an amendment to add to
Clause 145 the following :—
‘“ But does not include any person whose parent is
required under or by virtue of the Education Acts, 1921
to 1936, to cause him (unless there is some reasonable
excuse) to attend school or to attend an alternative course
within the meaning of the Education Act, 1936.”
That, he thought, was the proper way in which to
ensure that the provisions of the Education Act
should be consistent with the factory law. Since
the Factories Bill was introduced the Committee
on Unregulated Occupations had reported and it
dealt, with various classes of young persons, including
van boys and others employed in connexion with
factories. The Committee recommended that there
should be regulation of the hours of work for young
persons employed in connexion with factories, docks,
and warehouses, It further suggested that it might
be possible to introduce that into the present
Factories Bill. As far as he (Sir J. Simon) could see
it ought to be possible to do that, and, if so, it would
stop an important gap. He was sorry that in the
circumstances he could not offer to do more in this
matter than he had said.
Sir ERNEST GRAHAM-LITTLE said that there was
one very important argument that had not been used
and that was in connexion with the diminution in the
number of children in the country. The capital
which the child population represented was the most
important capital that a nation could possess. Let
them make sure that they did the very best for that
capital which was possible. If they were going to
deprive children of adding to their education it
would be uneconomical and foolish.
The amendment was still under discussion when
the Committee adjourned.
Debate on the amendment was. resumed when the
Committee met on April 15th.
Replying to a number of speeches,
Mr. LLOYD said that there was no justification
for saying that in no circumstances could it be
regarded as beneficial for juveniles between 14 and 15
to go into factory employment. The Board of
Education had undertaken that in a circular which
they were issuing to local authorities they would
draw special attention to the importance of the
permanence of employment being regarded as one
of the considerations to be borne in mind in determin-
ing whether the employment was beneficial or not.
The proposal in the amendment would completely
hamstring the arrangements made under the new
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PARLIAMENTARY INTELLIGENCE
[APRIL 24, 1937
Education Act. It was not a practical proposal in
the interests of the juveniles and it cast an unjustifi-
able slur on factory employment as such.
After further discussion the amendment was
negatived by 32 votes to 22.
Mr. RIDLEY moved an amendment to the same
clause to make its provisions apply to all workers
in factories.
Sir J. Smon, in opposing the amendment, said
it was a novel proposal. It was a suggestion to
establish by law, for the first time in this country,
the maximum number of hours to be worked by a
grown man in a factory. In the past there had been
collective bargaining between the trade unions and
the employers and the law had only limited the hours
of work in relation to certain classes of people because
it was thought that they were in special need of
protection.
After a long debate the amendment was negatived
by 29 votes to 16.
The Committee adjourned.
HOURS OF EMPLOYMENT IN HOSPITALS
On April 14th in the House of Commons Mr. KIRBY
asked leave to bring in a Bill to provide for the
limitation of hours of work for persons employed in
or in connexion with hospitals and institutions
under the control.of local authorities. He pointed
out that the measure did not apply in any way
to voluntary hospitals or institutions of that character.
He and his friends would desire that it should cover
those voluntary institutions as well but they realised
the difficulties that a Bill ofthis sort might bring to
them and therefore they were deliberately excluded.
The Bill provided for a working week of 48 hours
for the outdoor staffs and in the event of urgency
or emergency those hours might be exceeded, provid-
ing that overtime was paid at the usual scales as
provided for in agreements between employers and
workpeople. So far as the indoor staffs were con-
cerned the Bill provided for 96 hours’ work in each
fortnight with the same provisions for overtime as
applied to the ordinary outdoor staffs. He thought
it would be generally agreed that so far as the nursing
and other indoor staffs were concerned it was desirable
that not too strict a line should be laid down in order
that the emergencies of the nursing services should
be provided for if necessary. With a 96-hours’
fortnight instead of a 48-hours’ week there would
be a much wider scope for the indoor staff in their
various duties and shifts than if it was confined
to a 48-hours’ week. He believed that provision
would be a special boon to the smaller institutions
and hospitals where they had a very small number
of personnel to deal with. The other provision of the
Bill was that every worker whether employed on
the indoor or outdoor staff should have a rest day
in every week—a full 24 hours off duty for every
calendar week worked.
The conditions in hospitals and institutions of
a similar character had been widely investigated
during the past two years, and those investigations
showed that there was chaos generally in the manage-
ment, which required rationalising and regularising
in a great number of ways and particularly in regard
to hours. At the present moment those people
who worked outside these institutions—motormen
and ambulance attendants—by reason of the fact
that they were in a trade union enjoyed better hours
and conditions of labour than many of the nursing
staff employed inside, and he was particularly
anxious that so far as the inside staffs were concerned
this Bill should become law very soon. He would
give the House two quotations from letters he had
received relating particularly to the conditions of
the nursing staffs in hospitals and institutions.
The first letter came from a national organisation
of a responsible trade union catering for this class
ofworker. Hesaid :—
“ Owing to the long hours, which are aggravated
particularly by split duties, or spread-over system, &
number of authorities are finding it almost impossible to
recruit adequate nursing staffs for their hospitals. The
most recent case I know of in this connexion is that of the
county council, whose chief officer reported that he
was unable to recruit the necessary number of nurses
to staff their hospitals and institutions, and that in fact,
at the present time they are short staffed.”
The other quotation was from a lady member of
a local authority. She said :—
‘“ The facts are that great difficulty is being experienced
at the moment throughout the country in inducing women
to enter institutional life owing to the prevailing condi-
tions. With regard to the nurses a very acute shortage
of entrants to the profession is being experienced especially
by municipal hospitals. It would be true to say that if a
serious epidemic occurred in London or in one of the large
provincial towns there would not be a sufficient staff
to man the hospitals.... The reasons given for this are
long hours of duty spread over insufficient leisure time and
so on.”
Leave was granted to bring in the Bill, which was
read a first time.
Mr. CLEMENT Davies presented the Magdalen
Hospital Bill, a measure to confirm a scheme of
the Charity Commissioners for the application or
management of the charity called the Magdalen
Hospital in the County of London. The Bill was
read a first time..
INSANITY AS GROUND FOR DIVORCE
In the House of Commons on April 16th the
Marriage Bill, as amended in Standing Committee,
was considered on Report.
Mr. TURTON moved an amendment to make the
grant of divorce on the grounds of incurable insanity
subject to a period of seven years instead ‘of five.
That period, he said, would be more consistent with
the present law and would also give a better safe-
guard to those who disliked giving divorce on these
grounds.
Commander BOWER, in seconding the amendment,
said this was one of the most difficult questions: to
deal with. It was difficult to find any medical men
who would give a definition of incurable insanity
or would definitely say that the condition of any
particular patient was incurable. This allowing
of divorce for insanity, whether considered’ incurable
or not, might in many cases have a most unfortunate
effect on a patient of unstable mind. Most important
of all was the question of those who had voluntarily
entered a mental institution. A voluntary patient
under Section 1 (5) of the Act of 1930 might leave the
institution, hospital, or home on giving 72 hours’
notice, or if he was under 16 such notice was given
by parent or guardian. They therefore had this
astonishing legal anomaly that a person who was
well enough to go out of an institution at short notice
under the Act was considered by the promoters of
this Marriage Bill to be so insane that he could be
divorced behind his back.
Sir J. WITHERS: No. There is a period of five
years and also there must be medical evidence.
Lieut.-Commander AGNEW said that not only
was medical opinion confused but public opinion
was in grave doubts on this question. When those
doubts existed the period necessary for granting
divorce for incurable insanity should not be less.
than for granting it for overseas desertion, which
provided for the presumption of death after seven
years,
Sir ARNOLD WILSON said that on behalf of the
promoters of the Bill he opposed the amendment.
The recommendation of the Royal Commission of
1912 on this subject was that five years should
be the period during which continuous care and treat-
ment should be applied before there could be judg-
ment on the matter of incurability.
Mr. CROSSLEY asked if the clause meant that no
decision could be taken by any medical authorities
about the incurability of a patient until he had been
in an institution for five years.
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PARLIAMENTARY INTELLIGENCE
[APR 24, 1937 1025
EEE
Sir A. WILSON said that was so. The conditions
were that not only must the patient be continuously
under treatment for five years, but he must also
after that be subjected to a medical examination
which in the opinion of the Court was sufficient to
prove that he was in fact incurably insane. Every-
thing that had been said in support of the amend-
ment justified the conclusion that doctors would
in future be increasingly reluctant to declare that
& person was incurably of unsound mind and that the
question of five years would be of less importance
than it was in 1912, As to the voluntary patients
he pointed out that they must have been continuously
under treatment without any interval. After a
very careful survey of the reports of the Board of
Control of the last few years, of the figures about
incurability, and of the very great efforts which were
being made with the aid of funds provided by the
Medical Research Council, the Rockefeller Trust and
others to extend the possible relief of insanity he
was confident that this clause was as safe as anybody
could make it, and that they would be ill-advised to
increase to seven years the period during which a
patient must be under continuous treatment. Out
of 100 possible recoveries only two took place after
the period of five years.
ter further debate, the amendment was negatived
by 141 votes to 48.
The further consideration of the Bill was adjourned.
NEW BLOCK GRANTS FOR SCOTLAND
IN moving the second reading of the Local Govern-
ment (Financial Provisions) (Scotland) Bill in the
House of Commons on April 15th, Mr. ELLIOT,
Secretary of State for Scotland, said that the Bill
had four main objects. First it fixed the amount
of the Exchequer contribution given by way of block
grant to Scottish local authorities for a period of —
five years. Secondly, it relieved local authorities
in Scotland of the payment of contributions under
Section 45 of the Unemployment Act, 1934. Thirdly,
it made provision for calculating the grant in future
fixed grant periods; and lastly, it amended the
formula on the basis of which the larger part of the
block grant was distributed among the local authorities.
With regard to the amount of grant in the next
five years the Bill proposed an annual sum of
£6,827,000 per annum, or £600,000 more than in the
previous grant period. In addition it proposed to
relieve local authorities of their liability to make
payments towards the cost of unemployment
assistance, which amounted now to about £745,000
er annum, Furthermore no account was taken
in arriving at this general Exchequer contribution
of the relief afforded to county councils by the taking
over of trunk roads, which amounted to about
£90,000 per annum, It would thus be seen that
the local authorities in Scotland would be better
off in the next fixed grant period to the extent of
£1,435,000 a year than at the present time, a very
substantial sum. The new formula was more heavil
weighted for unemployment and sparsity. The Bill
would give substantial additional assistance to the
areas which stood in greatest need of it. The total
additional relief amounted to nearly £1,500,000 and
over £1,000,000 would be devoted to the necessitous
areas. Substantial assistance would also be given
to the less needy areas.
After further debate, the Bill was read a second time.
MATERNITY SERVICES IN SCOTLAND
THE Maternity Services (Scotland) Bill as amended
in Standing Committee, was considered on Report.
Mr. LEONARD moved the following new clause :—
- It shall' be lawful for a local authority, in consultation
with the local organisation of registered medical practi-
tioners as referred to in sub-section (5) of Section 1 of
this Act, to publish annually a panel of registered medical
practitioners for the purposes of Section 22 of the Mid- -
wives (Scotland) Act, 1915, such panel to consist of
registered medical practitioners regularly practising
midwifery and to be made available to all certified mid-
wives practising within the area of the local authority.
He said the intention was really to give a lead to
local authorities.
; THERS, in seconding the new clause, said
that it simply sought to put into the hands of practis-
ing midwives a list of medical practitioners who would
be able effectively to assist them in any emergency
that they might encounter.
Mr. ELLIOT, Secretary of State for Scotland, said
he had every sympathy with the object of the new
clause, but in the schemes under the Bill there would
be full provision for the midwives to know where the
practitioners, and indeed the specialists, were.
The impression of his Department was that the
scheme would cover 80 per cent. of the confinements
in Scotland. The other 20 per cent. would not be the
poor people but the well-to-do who had their own
doctors and were in touch with the obstetric specialist
as well. It would not be left to the midwives to
pick a doctor from a casual list of practitioners -
which might or might not be issued by the local
authorities. It would be the duty of the midwife
to be in touch and to work with the woman’s own
medical attendant and if she did not know where
the medical attendant was, or where in his absence
some other practitioner could be found, then she
would be in fault under the new schemes. He
hoped the hon. Members who had put forward this
new clause would consider that their purpose would
be achieved in the schemes under the Bill and would
not press the matter. id
Mr. LEONARD said he was indebted to the Secretary
of State for his explanation and was willing to with-
draw the clause. |
The clause was withdrawn.
Mr. ELLIOT moved an amendment to the clause
providing that the medical schools and other mid-
wifery training bodies should have an opportunity
to make representations. |
This amendment was agreed to.
. Mr. WESTWOOD moved an amendment the purpose
of which he said was to strengthen the prohibition
of unqualified persons from acting. It was felt
that under this clause it would be possible for a
young medical student just entering on his studies
or for a temporary nurse just starting her training
to take control of a case. That was altogether
unsatisfactory. Both student and nurse ought to
be given a period of training of at least three years
before having the responsibility of dealing with
maternity cases. . |
Mr. ELLIOT said neither medical students nor
pupil midwives could now undertake a domiciliary
case until they had had a complete theoretical
course and adequate practical instruction, including
the delivering of women in labour, under qualified
supervision in an institution. The existing safe-
guards went further than the statutory form suggested
in the amendment. Under the rules of the General
Medical Council no medical student might under-
take practical midwifery until the last term of the
fourth year of his curriculum. Further, he would
point out that the whole matter was governed by
schemes and he undertook in scrutinising these
schemes to give his personal attention to them and
to ensure that no danger should arise of medical
students going out to cases earlier than the period
which hon. Members had put forward. He was
certain that the General Medical Council had no
intention of relaxing their rules, and it might well
be that their rules were stiffer. He did not want to
undertake that men should not go out under three
years’ training when the General Medical Council
said. that they should not go out until the last term
of their fourth year. He hoped the House would
consider that his suggestion was adequate to dea]
with the question of the training of medical students,
Mr. WESTWOOD said after the explanation of the
Secretary of State and the pledge he had given,
he was prepared to withdraw the amendment.
1026 THE LANCET]
_ Mr. WEstwoop said the right hon. gentleman’s
explanation on the training of the medical student
was quite satisfactory, but he thought the House
was entitled to an explanation with regard to the
training of the nurse. He moved an amendment
that midwives should have at least two years’
training.
Mr. ELLIOT said the full course of the midwives
curriculum under the rules of the Central Midwives
Board extended over only twelve months and there-
fore he did not think the amendment would be
possible in practice. The Central Midwives Board
contemplated an extended period of training, but
not, he thought, to the extent which would render
. this amendment practicable. Women who were
already registered nurses under the Nurses Registra-
tion Act qualified as midwives after a six months’
course, but being registered as nurses they had had
a long training already. He thought Mr. Westwood
had more in view people who were working for the
full course of the midwives curriculum under the
Central Midwives Board. Looking at the matter
from that point of view it would be difficult to start
amending by Statute the rules of the Central Mid-
wives Board. The Board tried to make sure that
no one should be asked to undertake this tremendous
responsibility without having gone through a course
which the responsible professional people thought
was a proper one. He would, however, be very glad
to look into the question whether there was any
loophole or gap by which comparatively untrained
persons could be faced with this very great responsi-
bility. His belief, however, was that that would
not and could not arise. If any safeguard was
necessary it could be secured in the schemes framed
in conjunction with the local authority and subject
to the approval of the Department.
Mr, MAXTON said the Secretary of State was
relying upon the appropriate professional organisa-
tions to see to this matter, but the evil they were
trying to combat had grown up under existing
professional organisations.
Mr. ELLIOT said that the evil to which the hon.
Member referred had been combated and was in
process of eradication under these professional
bodies. He thought the professional bodies were
tightening up their regulations almost every year
in regard to these things.
Mr. WESTWOOD said after the very clear explanation
and promise given by the Secretary of State he was
willing to withdraw the amendment.
The Report stage was concluded and the Bill was
read the third time and passed.
THE BUDGET
HIGHER INCOME-TAX AND NEW TRADE PROFITS DUTY
IN the House of Commons on April 20th
Mr. CHAMBERLAIN, Chancellor of the Exchequer,
introduced his Budget. He said that in spite of an
allowance of over £50,000,000 more for defence in
his last Budget a small surplus was anticipated.
Owing, however, to the recent acceleration of the
defence programme there was an actual realised
deficit of £5,597,000. If the defence expenditure
had not exceeded the Budget provision by £7,821,000
there would have been a formal surplus of nearly
£2,250,000 after applying over £13,000,000 of ordinary
revenue to debt redemption. The total revenue
for 1937-38 was estimated at £847,950,000 and the
total expenditure at £862,848,000, leaving a deficit
of £14,898,000.
Dealing with his proposals for changes in taxation
the right hon. gentleman indicated that steps would
be taken to deal with tax avoidance in regard to
‘bond washing” and one man investment companies.
The report of the Select Committee on the Medicine
Stamp Duties had been made public. He had had a
good many representations from various quarters
since the publication of the report and he was having
the recommendations of the committee examined
in the light of those representations. But in view of
PARLIAMENTARY INTELLIGENCE
[argit 24, 1937
the very complex issues involved and the existing
strain upon the time of Parliament he was not
proposing to introduce legislation on that subject
in the Finance Bill this year. (Cheers.)
Effect would be given from Jan. lst, 1938, to the
recent announcement by the Minister of Health
in regard to the abolition of the Male Servant Licence
Duty. The rate of income-tax would be raised by
3d. in the £ to 5s. and there would be a new graduated
duty on the growth of profits of trades and businesses
called the ‘‘ National Defence Contributign.’”’ Mr.
Chamberlain made it clear that professional profits
would be exempt from the new tax. The additional
3d. in the £ on income-tax, the new profits duty,
and the measures to deal with tax avoidance were
expected to yield an additional revenue of £15,150,000
this year, making a total estimated revenue of
£863,100,000. After taking account of a total
estimated expenditure of £862,848,000 there was an
anticipated surplus of £252,000. The aim of his
Budget, said Mr. Chamberlain, was on the one hand
to avoid a tremendous increase in tax burdens which
would’ check convalescence—hence the decision to
resort: to borrowing for defence purposes—and on
the other hand to make such increases as would
EAR feverish activity without inspiring an upward
rend.
In the House of Lords on April 15th the Education
(Deaf Children) Bill was read the third time and
passed.
In the House of Commons on April 16th the
Methylated Spirits (Scotland) Bill was read the third
time and passed.
QUESTION TIME
WEDNESDAY, APRIL l4TH
Human Nutrition in Tanganyika
Mr. Matuers asked the Secretary of State for the
Colonies whether he could make any statement as to the
departmental committee in Tanganyika on the subject
of human nutrition in that territory ; and whether that
committee would take into consideration the memorandum
by the International Institute of African Languages and
Cultures, pointing out the need of combining medical
and anthropological inquiry in respect of nutrition
problems.—Mr. OrmssBy-GorE replied: As the result.
of the circular dispatch published in 1936 as Colonial
No. 121, a Departmental Committee has been set up in
Tanganyika as in many other parts of the Colonial Empire
to study questions relating to human nutrition. Copies
of the memorandum to which the hon. Member refers
have already been sent to all African Governments, and
I have no doubt that the desirability of combining medical
and anthropological inquiry will be given full weight by
the Committee.
Mr. MatHers: Is there any actual guidance in the
dispatch referred to that inquiry should follow those
lines ?7—Mr. ORMsBy-GorE: Yes. This dispatch suggests.
certain lines, and I think the hon. Member knows a special
Committee of the Civil and Research Organisation here
are receiving replies as they come in from the various
Dependencies.
Unemployment and Sterilisation in Bermuda
Mr. GALLACHER asked the Secretary of State for the
Colonies whether his attention had been drawn to the `
recommendations contained in the report of the Select.
Committee appointed on Feb. 5th, 1935, to consider and
report on the existing state of unemployment in Bermuda ;
if he was aware that these recommendations provided for
compulsory sterilisation; whether it was proposed to.
give effect to these recommendations by means of legisla-
tion ; and, if so, whether he would intimate to the govern-
ment of Bermuda that the recommendations of the
Select Committee were objectionable and that the proposed
legislation should not be proceeded with.—Mr. ORMSBY-
GORE replied: The answer to the first and second parts
of the question is in the affirmative. As regards the
latter part of the question, I am informed by the Governor
THE LANCET]
of Bermuda that no action regarding compulsory sterilisa-
tion is contemplated.
THURSDAY, APRIL 15TH
Labour Exchange and Manchester Royal Infirmary
Mr. FiEemina asked the Minister of Labour whether he
had considered the objection submitted to him against his
proposal to erect a labour exchange adjoining the central
branch of the Manchester Royal Infirmary ; and whether
he still intended to proceed with the said building.—
Mr. ELLs Sutra, Mr. WEDGwoop BENN, and Mr. Emery
asked similar questions on the same subject.—Mr. ERNEST
Brown replied: I am now in consultation with the
First Commissioner of Works regarding certain proposals
recently made to me informally on behalf of the Board of
the Manchester Royal Infirmary, but until our inquiries
are completed, I am unable to make any statement.
MING: Has the Minister considered the serious
objection of the medical profession in Manchester on the
ground that this proposed building will gravely obstruct
the work that is being carried on in the central branch of
the Royal Infirmary 7—Mr. Brown: I am aware not
only of that objection but of some others which have been
put to me. I am also aware that for 15 years past the
great social service of the Employment Exchange in
Manchester has been carried on in a building that is
utterly unsuitable and not fair to the staff concerned.
Mr. Benn: Has the right hon. gentleman taken any
advice as to the public opinion in Manchester with regard
to this matter ? If not, will he be good enough to do so ?
Mr. Brown : I am well aware of the opinion in Manchester.
At the request of the representative of the Infirmary
I saw him privately and it is for that reason that I am
now doing my best to carry out the promise I made to
him that I would get consideration for this matter. Reply-
ing further to Mr. Benn, Mr. Brown said that some time
' ago he saw a very important body on this matter and heard
all the arguments over again. Mr. E. Smrru : Would the
right hon. gentleman also consider the alternative of taking
into consultation the Office of Works with a view to taking
over the site and suitably compensating the Manchester
Royal Infirmary ?
Mr. Brown : I prefer to make no statement about that
for the moment.
Hours of Employment of Young Persons
Mr. Parma asked the Home Secretary whether the
Government had considered the report of the Depart-
mental Committee on the hours of employment of young
persons in certain unregulated occupations; and what
steps they proposed to take.—Sir JOHN Simon replied :
Yes, Sir: I have been giving careful consideration to this
important report, and I am hopeful that it will be possible
to deal in the Factories Bill with the hours of the young
persons employed in connexion with factories, docks, and
warehouses whose inclusion in the new factory code is
recommended by the Committee. As regards the other
classes of young persons in whose case the Committee
suggested an extension of the Shops Act, 1934, it would
be necessary to introduce separate legislation which could
not be undertaken during the present session.
Deaths following Vaccination
Mr, Groves asked the Minister of Health the number
of deaths of infants due to vaccination recorded by the
Registrar-General in the last ten years.—Sir KINGSLEY
Woop replied: The number of deaths of infants under
‘one year of age classified to vaccinia or other sequelæ
of vaccination during the ten years 1926 to 1935 was 42.
MONDAY, APRIL 19TH
Medical Practitioners in Nigeria
Lieut.-Commander FLETCHER asked the Secretary
of State for the Colonies the number of medical prac-
titioners in Nigeria, and the proportion borne by this
number to the total population.—Mr. OrmsBy-GoRE
replied: The number of registered medical practitioners
in Nigeria, including Mandated Territory, on Jan. Ist,
1937, was 224. This number bears to the total population
a proportion of one medical practitioner to every 89,500
persons approximately.
L.C.C. HOSPITAL BUDGET
[APRIL 24, 1937 1027
TUESDAY, APRIL 20TH
Insurance Committees and Physical Training
Mr. KenneEpy asked the Secretary of State for Scotland
if he had considered a resolution adopted and sent to him
by the Kirkcaldy Insurance Committee complaining that
no representative of national health insurance committees
was included in the list of members who were to be
responsible for the organisation of the work of the National
Advisory Council for Physical Training and Recreation
for Scotland; and if this omission could now be rectified.
—Mr. Error replied: The answer to the first part of
the question is in the affirmative. With regard to the
second part the members of the Council were appointed
because of their personal qualifications and not as.
representatives of particular organisations. It is not at
present proposed to add to their number, but in the event
of further appointments being made the ‘possibility of
adding a member with special knowledge of national
health insurance work will be kept in view.
Ex-Service Man and Treatment for Tuberculosis
Mr. GEORGE GRIFFITHS asked the Secretary of State
for War whether he was aware that E. A. Wareham,
No. 6,912,364, was discharged from the Rifle Brigade
suffering from tuberculosis; that there was no trace of
tuberculosis in the soldier’s family; if he received any
treatment for the disease ; and whether the man received
a pension or a gratuity.—Mr. Durr Cooper replied :
Yes, Sir. Mr. Wareham’s case received thorough investi-
gation and treatment, including surgical treatment which
effected a considerable improvement in his condition.
He received a gratuity of £18 on his discharge from the
Army. I regret that as his disability was not caused by
his service; he is not eligible for a pension.
L.C.C. HOSPITAL BUDGET
UNDER this heading on March 27th we published
a statement of estimated expenditure by the London
County Council on their general and special hospitals
during 1937-38. It has been pointed out to us that
the figures we reproduced relate only to votes on
account, pending the Council’s approval of the
complete votes for the year. We now publish the
correct figures, as supmitved to the Council on
Tuesday last.
The estimated capital expenditure on general
and special hospitals during 1937-38 (excluding
provisional sums) is £551,000. The estimated expen-
diture on maintenance is £5,743,505, made up as
follows :—
£
General hospitals me ea T 3,298,750
Infectious hospitals .. is iW Sa 912,460
Sanatoria ws ba ss ss 217,920
Children’s hospitals au Ds da Je 372,225
Pathological laboratories . 61,635
Maintenance in hospitals other than thoso
provided by the Council,. aS 203,070
District medical service i 41,975
London ambulance service . 170,025
Staff .. a ie `. 198.895
Miscellaneous “expenses 17,495
Sanitary officers : wa s% ae 98,300
Public vaccinators .. 1,00
Diagnosis and treatment of venereal diseases 112,000
Maternity and child welfare 2,000
Midwives services . ; 4,770
Other public health services 985
The total net estimated expenditure for the year
(£5,395,820) exceeds the net estimated expenditure for
1936-37 by £212,670, the two principal items account-
ing for the increase being about £125,000 additional
expenditure on staff, and about £78,000 extra under
the heading of “ provisions, clothing, drugs, domestic
renewals, &c.”’
The estimates put forward by the mental hospitals
committee are £235,000 for capital expenditure and
£2,796,425 for maintenance.
1028 THE LANCET]
University of Cambridge
The title of the M.B. degree has recently been conferred
on Mrs. E. M. P. Wilson.
University of London
On May 3rd, 4th, and 5th, at 5 p.m., at University
College, Gower-street, W.C., Prof. H. Rein, director
of the physiological institute in the University of Göttingen,
will lecture on some economising mechanisms as a con-
dition of the body’s adaptation to increased activity.
Later in the month four lectures on the history of physiology
will also be given at University College: on May 18th
Mr. E. S. Russell, D.Sc., will speak on ancient biological
conceptions; on May 20th and 2lst Prof. Charles Singer
will speak on the emergence of modern physiological
doctrines ; on May 24th Mr. D. McKie, D.Sc., will speak
on the development of theories regarding combustion
and respiration in the eighteenth century ; and on May 25th
Mr. F. G. Young, Ph.D., will speak on the development
of certain aspects of metabolism during the nineteenth
century. These lectures will be at 5.30 p.m. The lectures
are open to all interested.
University of Aberdeen
A capital sum has been given anonymously to the
university for the foundation of a part-time lectureship
in psychopathology. It is a condition of the gift that the
lecturer shall not be an alienist and that his clinical work
shall be done at the Royal Infirmary. The sum of £500
has also been received from Lord Glanely to permit
research in rheumatism.
Royal College of Surgeons of England
The museum of the college will be open at the usual times
on and after Monday, April 26th.
Royal College of Physicians of Edinburgh
The council of the college will shortly award a Kirk
Duncanson fellowship for medical research. Its value will
be £300 for the first year. Further information may be had
from the secretary of the college, to whom applications
should be sent not later than June 30th.
Aberdeen University Club, London
The ninety-seventh half-yearly dinner of this club will
be held at the Café Royal, Regent-street, at 7.30 P.m.
on Thursday, April 29th. The chairman will be Sir
Peter Chalmers Mitchell, F.R.S., and the chief guest
Sir Benjamin Robertson. The hon. secretary’s address
is 51, Harley-street, W.1.
Child Guidance Council
Three fellowships in psychiatry, each of the value of £300,
are offered for half-time work at the London Child Guidance
Clinic, 1, Canonbury-place, N.1. Further information
may be had from the secretary of the council, Woburn
House, Upper Woburn-place, London, W.C.1, and the
closing date for receiving applications is May 10th.
Indian Medical Service 3
The annual dinner of the Indian Medical Service will
be held at the Trocadero Restaurant, London, on
Wednesday, June 16th, at 7.15 P.M., when Sir Rickard
Christophers, F.R.S., will preside. Tickets may be obtained
from the joint hon. secretary, Sir Thomas Carey Evans,
Hammersmith Hospital, L.C.C., Ducane-road, London,
W.12.
The Red Cross in Spain
The international committee of the Red Cross reports
that its appeal for funds and for gifts in kind for the
relief of the victims of the civil war in Spain continues to
meet with response from Red Cross Societies in all parts
of the world, but that considerably larger sums are required
to meet the appalling needs. The committee continues
to pay special attention to the question of help to prisoners.
Visits to prisons by Red Cross representatives are now
permitted in many localities and standardised parcels of
food and clothing are distributed. Prison hospitals have
been established, and some prisoners have been exchanged.
Contributions may be addressed to Sir Arthur Stanley
at 14, Grosvenor-crescent, London, S.W.1.
MEDICAL NEWS
[APR 24, 1937
Royal Sanitary Institute
A meeting of this institute will be held in the Rolls
Hall, Monmouth, on Friday, May 7th, when Dr. W. R.
Nash, medical officer of health for Caerphilly, and Dr.
William Panes, assistant medical officer of health for
Monmouthshire, will open a discussion on immunisation
in diphtheria. Mr. J. Jenkin Evans, sanitary inspector
for Monmouthshire, will also open a discussion on the
public health acts, and their implications in rural areas.
Institute of British Surgical Technicians
On Friday, April 30th, at 8 P.M., at the Welbeck Hotel,
Welbeck-street, London, W., Sir Weldon Dalrymple-
Champneys will give a lecture to this society on the
sterilisation of surgical ligatures. Tickets may be obtained
free on application to the secretary of the institute,
6, Holborn Viaduct, London, E.C.1.
Carey Coombs Memorial
The Carey Coombs memorial committee and the Bristol
Medico-Chirurgical Society have arranged for Mr. Laurence
O’Shaughnessy to deliver a lecture on the operative
treatment of cardiac ischemia on Wednesday, May 5th,
at 8.30 P.M., in the physiological lecture theatre of the
University of Bristol.
French Hospital, London
A clinic for the treatment of hay-fever and allied con-
ditions by ionisation is being opened at this hospital.
The treatment, which is free, is available to all who speak
French, irrespective of creed or nationality, and will be
given on Wednesdays at 4 P.M. (first attendance Thursday
at 2 p.m.). Further information may be had from the
secretary of the hospital, Shaftesbury-avenue, London, W.1.
Institute of Ray Therapy
This institute was established in 1930 at 152, Camden-
road, London, N.W. ' Its object is “ to provide every form
of electrical treatment for people of small means for
whom it would not otherwise be obtainable,” and it is
open daily from 2 P.M. to 9 p.m. During 1936 no less
than 106,460 treatments were given, and an appeal is
now being launched for £25,000 to increase the equipment
and enlarge the building. At a luncheon held last
Monday Lord Horder, the president, said that the work
done at the institute was now well known to doctors in
the neighbourhood and also outside it. Im many con-
ditions physical methods had largely superseded the bottle
of medicine in which patients had so much faith; but
physiotherapy could not be very satisfactorily undertaken
outside a clinic or an institution which provided up-to-
date equipment and nursing facilities and men and women
with expert training. The public needed a warning
against indiscriminate use of old-fashioned machines by
untrained people, which was really a form of quackery.
Lord Sempill, chairman of the board of governors,
explained that unless £25,000 could be obtained at latest
by the end of this year, the work being done at the
institute would have to be curtailed and patients turned
away. At general hospitals surgical and medical work
had to take precedence of electrical treatment, and
whenever space was urgently needed in a general hospital
the electrotherapy department was crowded out—partly
because it needed considerable floor space and a special
staff. The conditions treated at the institute included
rheumatism and kindred diseases; accident cases after
discharge from hospital; children’s diseases, such as
rickets, adolescent rheumatism, and enlarged glands;
skin diseases, nervous disorders, and diseases of the ear,
nose, and throat. The institute could and should be a
great centre of physical medicine in Great Britain, fit to
compare with the most modern and efficient in Europe
and America. It had grown, like all great movements,
from a very small beginning, but it had grown con-
tinuously in usefulness.
Other speakers at the luncheon included Miss Violet
Vanbrugh and Mr. Russell Howard, who is a member of
the medical advisory committee. The honorary physician
and medical director is Dr. William Beaumont.
-
THE LANCET]
Maternity Centre at Loughborough
A new maternity and child welfare centre has been
opened here by the mayor to mark the twenty-first year
of infant welfare work in the town.
Joint Tuberculosis Council
A series of intensive post-graduate courses are being
given under the auspices of this council by Dr. Peter
Edwards at Cheshire Joint Sanatorium, near Market
Drayton. The subject is modern methods of therapy in
tuberculosis of the respiratory system with special reference
to collapse therapy. The next course will be held from
May 25th to 27th, and there will also be courses from
Sept. 28th to 30th and from Nov. 23rd to 25th. Further
information may be had from Dr. William Brand, the
council’s hon. secretary for post-graduate courses, 8, Christ
Church-place, Epsom, Surrey.
Society for the Relief of Widows and Orphans of
Medical Men
A quarterly court of the directors of this society was held
on April 7th. The deaths of three of the members were
reported and five new members were elected. It was
announced that a donation of .£111 had been received
from the Bovril Medical Agency. A first application
for relief was received from a widow of a member who was
voted a yearly grant of £50 from the ordinary funds and
one of £25 from the Brickwell fund. The number of
widows at the present time in receipt of relief has now
reached a total of 60, which is the largest number to be
dependent on the society at any one time. The annual
general meeting of the society will be held on Wednesday,
May 19th, at 5 r.m. Membership of the society is open
to any registered medical man who at the time of his
election is resident within a twenty-mile radius of Charing
Cross. Full particulars may be obtained from the secretary,
at the offices of the society, 11, Chandos-street, London, W.1.
International Congress of Radiology
The fifth International Congress of Radiology will meet
in Chicago from Sept. 13th to 17th, under the presidency
of Dr. Arthur C. Christie (Washington). The international
executive committee of the congress includes Dr. C.
Thurstan Holland (Liverpool), Dr. Gösta Forssell (Stock-
holm), Dr. Antoine Béclére (Paris), Dr. Hans R. Schinz
(Zurich), Dr. Karl Frik (Berlin), Dr. Mario Ponzio (Turin),
Dr. Tamotsu Watanabe (Osaka), Dr. Heliodoro Tellez-
Plasencia (Santander), and Dr. Gottwald Schwarz (Vienna).
Dr. Russell Reynolds is chairman of the British national
group and may be addressed at 36, Harley-street, London,
W.1. More than 250 scientific papers will be read at the
five-day meeting; they will be delivered in the lecturer’s
own language and will be fiashed on screens simultaneously
in English, German, and French as the papers are read.
A scientific and technical exhibition will also be held.
The secretary of the congress is Dr. B. H. Orndoff, 2561,
N. Clark-street, Chicago.
Extended District Nursing Scheme for London
At a meeting held on April 19th under the chairmanship
of the Earl of Athlone it was recalled how Florence
Nightingale, in a letter to the Times on April 14th, 1876,
quoted an old woman who said, “They nurses is real
blessings : now husbands and fathers did ought to pay a
penny per week, as ’ud give us a right to call upon they
nurses when we wants they.’ Miss Nightingale thought
the old woman had put forward a sensible plan, and it
was the purpose of this meeting, held almost exactly
60 years later, to put it into practice by instituting a
Greater London provident scheme for district nursing.
It is hoped, wherever there are five or more people regu-
larly employed, to make it possible for them to subscribe
to the nursing service at the rate of a halfpenny a week
if they are not earning more than £6 a week. The benefits
will include free nursing care, subject to medical direction,
in the patient’s home for contributors and their dependents
and the loan of certain nursing appliances. Midwifery,
normal maternity work, and certain infectious diseases
are excluded. Lord Horder and Miss Mercy Wilmshurst,
general superintendent of the Queen’s Institute of District
Nursing, were among the speakers who. supported the
scheme. The executive committee may be addressed at
1, Sloane-street, S.W.1.
MEDICAL NEWS.—THE SERVICES
[APRIL 24, 1937 1029
Papworth Village Settlement
At the festival dinner of this settlement on April 20th,
over which the Duke of Kent presided, it was announced
that a sufficient sum had been raised to claim Lord
Nuffield’s provisional gift of £25,000. Mr. E. W. Meyerstein
has also given £20,000 towards building the new nurses’
home.
THE SERVICES
ROYAL NAVAL MEDICAL SERVICE
Surg. Capt. P. L. Gibson to President for course.
Surg. Capts. C. F. O. Sankey, O.B.E., to Victory for
R.N. Hosp. Haslar; W. H. Edgar, O.B.E., to Victory for
R.N.B.; and E. Moxon-Browne to Queen Elizabeth.
Surg. Lt.-Comdrs. F. Dolan to Drake for R.N.B. and
to Colombo ; and J. L. Malone to Pembroke for R.N.B.
Surg. Lts. I. C. Macdonald to Pembroke for R.M.
Infirmary, Deal; H. O’Connor to Arrow; W. H. C. M.
Hamilton to Falcon; T. A. M. Maunsell to President
for course and to Drake for R.N.B.; F. A. Crosfil to
London; R. V. Jones to Challenger; L. R. Norsworthy
and G. R. Rhodes to Drake for R.N.B.; B. O’Neill and
M. G. Ross to Pembroke for R.N.B.; P. G. Stainton
to Victory for R.N. Hosp. Haslar; F. P. Ellis to Pembroke
for R.N. Hosp., Chatham; W. S. Miller to Shropshire ;
A. J. Glazebrook to Ezcellent. and to Tedworth (on
commg.); J. G. Vincent Smith to Victory for R.N.B. ;
G. H. C. R. Critien to Broke; and W. Boyd to Cairo,
The entry of W. G. Smith, L.D.S., as Surg. Lt. (D)
(published in the Gazette of April 2nd) is cancelled. (Vide
Lancet, April 10th.)
ARMY MEDICAL SERVICES
Maj:-Gen. FitzG. G. FitzGerald, C.B., D.S.O., K.H.S.,
late R.A.M.C., h.p., retires on ret. pay; Col. A. E..S.
Irvine, D.S.O., late R.A.M.C., having attained the age for
retirement, is placed on ret. pay; Lt,-Col. S. W. Kyle,
from R.A.M.C., to be Col.; Maj.-Gen. H. H..A. Emerson,
D.S.O., late R.A.M.C., is apptd. Hon. Surg. to the King,
vice Maj.-Gen. FitzG. G. FitzGerald. o
ROYAL ARMY MEDICAL CORPS
Maj. F. S. Gillespie to be Lt.-Col.
Maj. R. J. Rosie is restd. to the estabt.
TERRITORIAL ARMY
Capt. D. S. Middleton to be Maj.
Capt. J. J. McEnery resigns his commn.
TERRITORIAL ARMY RESERVE OF OFFICERS
Capt. C. A. D. Mitchell, from Active List, to be Capt.
ROYAL AIR FORCE
Wing Comdr. R. S. Overton to R.A.F. Depôt, Uxbridge,
for duty as Medical Officer.
Flight Lts. R. E. Alderson to R.A.F. General Hospital,
Palestine, and Transjordan, Sarafand; R. A. Cumming
to No. 203 (Flying Boat) Squadron, Basrah, Iraq ;: and
J. R. Cellars to R.A.F. Station, Amman, Palestine.
Flying Offr. A. R. Sibbald is transferred to the Reserve,
class D.
Flying Offr. J. Conroy resigns his short service commn,
Flying Offrs. J. H. Lewis to No. 2 Flying Training
School, Digby ; S. Paul to No. 7 Flying Training School,
Peterborough ; and E. S. Sidey to No. 1 Flying Training
School, Leuchars.
Dental Branch.—Flying Offrs. promoted to rank of
Flight Lt.: I. St. C. Alderdice, O. F. Brown, J. H. G.
Fensom, S. Hill, R. A. Pepper, and W. A. H. Smith.
INDIAN MEDICAL SERVICE
Capt. K. M. Bharucha to be Maj.
Indian Medical Department.—The undermentioned
officers retire: Majs. (Sen. Asst. Surgs.) J. B. V. Braganza
and F. H. Foy; Lt. (Sen. Asst. Surg.) J. G. Johnstone,
O.B.E., on account of ill health.
1030
THE LANCET]
E 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, April 26th.
ntology. 8 P.M. Dr. David Stewart and Dr. W.
Lewinsky : A Comparative Study of the Innervation
of the Periodontal Membrane.
TUESDAY,
(Cases at 4 P.M.) clinica’ meeting
Medicine. 5 P.M.
at London Hospital, E.
FRIDAY.
A ie 8.30 P.M. Annual general meeting.
Ogilvie : Anterior Splanchnic Block. cwith
f A Clinical reports of cases will be given by Dr.
Ashley Daly, Dr. T. A. B. Harris, Dr. G. H. W. Keats,
Dr. W. S. McConnell, Dr. E. H. Rink, Dr. E. S.
Rowbotham, and Mr. H. W. S. Wright.
BRITISH PSYCHOLOGICAL SOCIETY.
THURSDAY, April 29th.—8.30 P.M. (London School of
Hygiene, Keppel-street, W.C.), Dr. William Brown:
Hypnosis, Suggestibili ity, and “Progressive Relaxation.
An experimental study.
ST. JOHN’S HOSPITAL DERMATOLOGICAL SOCIETY.
WEDNESDAY, April 28th.—4.30 P.M., clinical cases. 5 P.M.,
Dr. Godfrey Bamber: The Common Skin Diseases in
Children and their Treatment.
BIOCHEMICAL SOCIETY.
SATURDAY, May Iist.—2.45 P.M. (Department of Bio-
chemistry, University of Oxford), B. C. J. G. Knight:
The Nutrition of Staphylococcus aureus, Vitamin B;
and Nicotinic Acid. T. F. Macrae and C. E. Edgar:
Differentiation of the Vitamin B, Complex as it
occurs in Yeast. T. F. Macrae and C. E. Edgar: Some
past nological Effects of Lactoflavin. R. A. McCance
Masters: The Chemical Composition and the
Acid-base Balance of Archidoris britannica. W.T. J.
Morgan: Some Observations on the Specific Antigen
of B. dysenterice (Shiga). A. A. Levi and E. Boyland :
The Production of Dihydroxy 1 22.2 @. 2 G- dibenzan-
thracene from 1:2 :5:6- dibenzanthracene by Rabbits.
Lee and E. M. Widdowson: A Comparative
Investigation of Blood-urea Methods. . H. W.
Kinnersley and R. A. Peters: Observations upon
eo B, and Co- carboxylase. R. B. Fisher and
A. E.. Wilhelmi: A Micro-method for the Estimation
of EONA ; isher and A. E. Wilhelmi:
The Synthesis of Creatine in the Isolated Rabbit
Heart. R. Deanesly and A. S. Parkes: Influence of
Method of Administration on Effectiveness of Gonadal
Hormones. R. B. Fisher and F. Langford: A Method
or the Detection of Small Amounts of Guanidines.
. Walker: Bacterial Decomposition of Cellulose.
LECTURES, ADDRESSES, DEMONSTRATIONS, &c.
UNIVERSITY OF BIRMINGHAM.
THURSDAY, April 29th.—4 P.M., Prof. J. C. Drummond,
D.Sc.: The Chemistry and Physiological Significance
of Vitamin A. (William Withering lecture.)
ST. MARY’S HOSPITAL, W.
TUESDAY, April 27th. "—5 P.M. (Institute of Pathology),
Sir Almroth Wright, F.R.S.: The Manifold Fallacies
of the Statistical Method Applied in Clinica] Medicine.
gn N. POSTGRADUATE MEDICAL SCHOOL, Ducane-
roa
MONDAY, April 26th.—2.30 P.M., Dr. C. W. Buckley:
Arthritis.
WEDNESDAY.—Noon, clinical and pathological conference
(medical). 2 P.M., Dr. A. A. Miles: Agglutination
Tests as Aids to Diagnosis. 3 P.M., clinical and patho-
logical conference (surgical). 4 P.M., Mr. J. E. H.
Roberts: Surgery of the Chest. 4.30 P.M., Dr. W. E.
Gye: Experimental Cancer Research. |
THURSDAY. —2.30 P.M., Dr. Duncan White: Radiological
Demonstration. 3.30 P.M., Mr. A. K. Henry : Demon-
strations of the Cadaver of Surgical Exposures.
3.30 P.M., Col. L. W. Harrison : Gonorrhea in Women.
FRIDAY.—2 P.M. » operative obstetrics. 3 P.M., clinical
and pathological conference (obstetrics and gynecology).
Daily, 10 a.m. to 4 P.M., medical clinics, surgical clinics
and operations, obstetrical and gynecological clinics
one operations, refresher course for general prac-
ioners.
WEST LONDON oo POST-GRADUATE COLLEGE,
' Hammersmith,
MONDAY, pee 26th.—10 A.M. . Dr. Post: X Ray Film
Demonstration, skin clinic. 11 A.M., surgical wards.
2 P.M., operations, surgical and gynecological wards,
medical, surgical, and gynæcological clinics. 4.15 P.M.,
Mr. Arnold W alker : Obstructed Labour.
TUESDAY.—10 A.M., medical wards. 11 A. M., surgical wards.
2 P.M., operations, medical, surgical, and throat clinics.
z i P.M., Mr. Woodd Walker: Obstruction of the
‘olon.
WEDNESDAY.—10 A.M., children’s ward and clinic. 11 A.M.,
medical wards, P.M., gyniwcological operations,
medical, surgical, and eye clinics.
MEDICAL DIARY.—APPOINTMENTS.—VACANCIES
[APRIL 24, 1937
THURSDAY.—10 A.M., neurological and gynecological
clinics. Noon, fracture clinic. 2 P.M., operations,
medical, surgical, genito-urinary, and eye clinics.
FRIDAY.—10 A. M., medical wards, skin clinic. Noon, lecture
on treatment. 2 P. M., operations, medical, surgical, and
taras clinics. 4.15 P.M., Mr. Grant Batchelor :
ecture.
SATURDAY, May 1st.—10 A.M., children’s and cal
clinics. 11 A.M., medical wards, ee
The lectures at 4.15 P.M. are open to all medical practitioners
without fee.
FELLOWSHIP OF MEDI TIE AND Pee ee
MEDICAL ASSOCIATION, Wimpole-street,
MONDAY, April 26th, to SEE May 1st. D Gonow
HOSPITAL, Vauxhall Bridge-road, S.W. All-day
course in proctology.—MAUDSLEY HOSPITAL, Denmark-
hill, S.E. Afternoon course in Psychological Medicine.
NATIONAL HOSPITAL FOR DISEASES OF THE HEART,
Westmoreland-street, W.
TUESDAY, April 27th. —5.30 P.M., Dr. D. Evan Bedford :
Congenital Heart Disease.
HOSPITAL FOR SICK CHILDREN, Great Ormond-street,
THURSDAY, April 29th.—2 P.M., Dr. Donald Paterson :
Enlargement of the Lymph Glands. 3 P.M., Dr. R. T.
Brain: Investigation of Skin Diseases in Children,
Out- patient clinics daily at 10 a.m. and ward visits “at
P.M.
MANCHESTER ROYAL INFIRMARY.
TUESDAY, April 27th.—4.15 P.M., Mr. Geoffrey Jefferson :
Surgery of Intracranial Aneurysms, |
FRIDAY.—4.15 P.M., Mr. F. G. Wrigley:
of Ear, Nose, and Throat Cases.
GLASGOW POST-GRADUATE MEDICAL ASSOCIATION,
WEDNESDAY, April 28th.—4.15 P.M. (Western Infirmary),
Dr. Hugh Morton: Peptic Ulcer.
Demonstration
Appointments
BENISON, R. L., M.B. Camb., F.R.C.S. Eng., Surgical Registrar
at the Royal Northern "Hospital, London
BENTHAM, J. A., . Glasg., D.C.O. G., Senior. ‘Assistant to the
Medical Superintendent of the Liverpool Sanatorium.
BRODY, M. B., M.B. Sheff., Assistant Resident Physician to
Runwell Hospital, Essex.
CROSSLEY, A. J. F., M. . Manch., Assistant Medical Officer at
the Cheshire County Mental Hospital, Parkside.
FORBES, GILBERT, M.B., F. R. F.P.S. Glasg., F.R.C.S. Edin.,
Police Surgeon for Sheffield
LEECH-WILKINSON, A.,. B.M. Oxon. . F.R.C.S. Edin., Hon.
Assistant Gynrecologist and Obstetrician to the Royal
United Hospital, Bath.
McLACHLAN, A. E. W., M.B. Edin., D.P.H., Medical Officer in
charge of the Venereal Diseases Clinic at the General Hos-
pital, Newcastle-upon-Tyne.
MATTHEWS, ERNEST, Ph.D., M.Sc., L.D.S.R.C.S. Eng.,
Prosthetic Dental Surgeon to the Manchester Royal
Infirmary.
Payne, R. V., M. Chir. Camb., F.R.C.S. Eng., Hon. Surgeon
to the Maidenhead Hospital.
SHELLEY, URSULA, M.D., M.R.C.P. Lond., Hon. Assistant
ee to the Children’s Department of the Royal Free
osp
SMITH, J. C., M.B. Manch., L.D.S.R.C.S. Eng., Dental Surgeon
to the Manchester Royal Infirmary.
STRANG, JEAN, M.B.Glasg., D.O.M.S., Resident Surgical
Officer at the Birmingham and Midland Eye Hospital.
ee Surgeons under the Factory and Worksho moo: :
r. F. E. Hreins (Sudbury District, Suffolk); an
Pit (Swinton District, Lancaster).
V acancies
For further information refer to the advertisement columns
Alderley Edge, Ancoats Hosp. Convalescent Home, Great
Warford.—Hon. Visiting M.O.,
Aylesbury, Royal Buckinghamshire Hosp. —Second Res. M.O., at
rate of £150.
Bangor, Caernarvonshire and Anglesey Infirmary.—Sen. and
Jun. H.S.’s, £150 and £100 Ar decane
Barking Borough.—Asst. M.O.,
Bath, Royal Uniied Hosp =H. 5° ite Ear, Nose, and Throat
Dept., at rate of £150.
Beckenham, Bethlem Royal Hosp., Monks Orchard.—Cons, Surg.
Also Radiologist, 150 guineas.
Bedford County Hosp.—Second H.S., at rate of £150.
Birmingham City.—Res. Asst. M.O., £400.
Blackburn, Calderstones Certified I nstitution for Mental Defectives,
Whalley. —Deputy Med. Supt., £750.
Blackburn Royal Infirmary.—Res. H. S., £175.
Boston General Hosp.—Res. M.O., at rate of £150.
Brighton, New Sussex Hosp. for’ Women, Windlesham-road,.—
0.
Bristol General Hosp.—Third H.S., at rate of £80.
British Postgraduate Medical School, Ducane-road, W.—Three
Part-time Demonstrators in Clinical Medicine, "each £100.
Cardiff Royal Infirmary.—H.S8. to Ophth. Dept., at rate of £80.
Cardiff, Welsh National School of Medicine. — Jun. Asst. for
Medical Unit, £250.
Chesterfield and North Derbyshire Royal Hosp.—H.S. to Ophth.
and Ear, Nose, and Throat Depts., at rate of £150.
THE LANCET]
Coventry City.—Asst. M.O., £500.
cre ee Borough. — Asst. M.O.H. and Asst. School M.O.,
£50
Croydon Mental Hosp., Upper Pell ice arse —Asst. M.O., £350.
Doncaster Royal Infirmary and H.S., £175.
: Edinburgh Princess “m groaret Daep Hosp f om Crippled Children.—
e8. -
Edmonton, North ” Middlesex County Hosp.—Jun. Res. Asst.
M.O., at rate of £250.
Elizabeth Garrett Anderson Hosp., eee oe N.W.—Hon
Asst. Surgeon to aon: etd and Dept. Hon.
Physician to Children’s Dept. Radiolocist, £200. Also
Tatnologist for Dept. o Morbid Anatomy, Xe., £350.
al Devon and Exeter Hosp.—H.P. and H.S. to
Ear, Nose, and Throat Dept., each at rate of £150.
een County Hosp., Enniskillen. —Surgeon Superintendent,
l Lying-in Hosp., York-road, S.E.—Jun. Res. M.O. and
Anesthetist, at mate of £100.
Hornsey Central ’ Hosp., Park-road, N.—Hon. Consultants.
Hull Royal Infirmary. LH. P. to Sutton Branch Hospital, at rate
of £160. Also Second H.P. and Second Cas. O., each at
- rate of £150.
Ilford, King George Hosp.—Hon. Chief Asst. to Orthopædic
and Fracture Dept. Res. Surg. O. and Məd. Reg., £250
and £150 respectively. Also two H.S.’s, each at rate of £100.
Ree and District General Hosp —-Res. M.O. and Second
Res. M.O., at rate of £175 and £125 respectivel oe
PEER, City’ Isolation Hosp. and Sanatorium, oby-road.—
. Res. M.O., at rate of £300.
Leicester City’ Mental Hosp., Humberstone.—Locum Tenens
Asst. M.O., 10 guineas per week.
Liverpool and District Hosp. or Diseases of the Heart.—H.P., £100.
London Child Guidance Clinic, 1, Canonbury-place, N '— Three
Fellowships in Psychiatry, each £300.
County Council— Asst. M.O.’s, Grade I, £350. Also
Asst. M.O.’ 8, Grade II, £250.
ent General Hosp.—H.S., £175.
Maidstone, West. K
Manchester City.—M.O. for Maternity and Child ‘Welfare, £600.
Manchester, Crumpsall Hosp.—Res. Asst. M.O., at rate of £200.
Manchester, al Children’s Hosp., Pendlebury. “—Res, Surg. O.,
at rate of 150.
Manchester Royal Infirmary.—Jun. Asst. M.O., £350.
Manchester, Withington Hosp.—Asst. to Res. Surg. O. and
Asst. to Res. Obstet. Officer, each at rate of £250. Also two
Asst. M.O.’s, each at rate of £200.
Margate Royal pea ig (aed Hosp.—H.S., at rate of £200.
Norwich, Norfolk and Norwich Hosp. ——Res. Surg. 0., £250.
Nottingham Er Dispensary, Hyson Green Branch.—Res.
Surgeon,
Nottingham General Hosp.—H.S. to Ear, Nose, and Throat Dept.,
at rate of £150.
Plymouth, Prince of Wales’s Hosp.—H.S., at rate of £120.
Prenon County Mental Hosp., Whittingham. —Res. Jun. Asst.
_ Preston, Sharce | Green Hosp. —Med. Supt., £850.
Prince of Wales’s General Hosp., N.— on. Clin, Asst.
prance Beatrice Hosp., Earls Court, S.W.—Med. Reg., 50
guineas.
Princess Louise Kensington oe Jor Children, St, Quintin-
arenue, H .—Hon. Ophth.
Queen Mary’s Hosp. for Gi ad End. Stratford, E.—Hon, Asst.
Ophth. Surgeon.
Radium, Inatitute, Riding House-sireet, W.—Res. M.O., at rate
Royal Cancer Hosp., Fulham-road, S.W.—H.S., at rate of £100.
Also H.S. to Radium Dept., at rate of £200.
Royal Chest Hosp., City-road, E. C.—Res. M. O., at rate of £150.
Also H.P., at rate of £100.
Royal Free Hosp Gray’s Inn-road, W.C.—First Asst. m
dren’s De ect. at rate of £100.
Royal London thalmic Hosp., City-road, E.C.—Out-patient
Officer, 2100.
Royal Naval Medical Service. —M.0.’s
St. Bartholomew’s Hosp., E.C. A ‘Aural Surgeon.
St. Helen’s County Borough.—Asst. M.O.H., £500.
St. Thomas’s Hosp., S.E.—Asst. Pathologist, £450.
Salford City. eae Maternity and Child Welfare M.O., £250.
SANETI gaai Infirmary. —H.P., at rate of £125. Also Res.
Salvation Army, Mothers’ erik .» Lower Clapton-road, E.—Two
Jun. Res. M.O.’s, each £80.
Sheffield, Wadsley Mental Poep. —Asst. M. O., £350.
Simla, Medical Council of India. = Secretary, Rs. 1200-75-1500.
SONDO nr a Hosp.—H.S., £150.
South or Women, Clapham Common, S.W .—
Pond n i tor Gynecological Out-patients.
Stourbridge, Wordeley Public Assistance Institution.—Res. Asst.
Swansea County Borough m ental Hosp.—Asst. M.O.,
Swansea General and Eye Hosp.—Cas. O., at rate ar 160-2115,
allasey, Victoria Central Hosp.—Jun H. S., £150.
Petani General Hosp.—H.P. and Res. Asst. Pathologist, at rate
£150.
Winchester, "Royal Hampshire County Hosp.—H.S., at rate of
Wolverhampton Royal Hosp.—H.S.’s, at rate of £100.
Y a T Hosp.—H.S. to Eye, Ear, Nose, and Throat Dept.,
BIRMINGHAM HOSPITALS CONTRIBUTORY ASSOCIA-
TION — During the nine years of its existence this association
has collected and distributed £2,389,984 and its income
has risen from £156,000 to £381,000 while expenses do not
exceed about 5 per cent. There are about half a million
contributors.
[APRIL 24, 1937 1031
Births, Marriages, and Deaths
BIRTHS
CHILOOTT.—On April 7th, the wife of John C. K. Chilcott,
B.M., B.Ch. Oxon., of ‘Warmley, of a son.
CLARKE. On April 13th, at York, the wife of Major Ailwyn
Herbert Clarke, M.C., R.A.M. Č., of a son.
CUNINGHAM.—On April 10th, the wife of Dr. Ronald Cunningham,
of Londonderry, of a son.
HysLop.—On April 10th, at a nursing-home, Leeds, the wife of
Dr. W. A. Hyslop, of Settle, of a son.
MELLOTTE.—On April 14th, at Bentinck street, the wife of
Dr. James H. Mellotte, ofa daughter.
TICKLER.—On April 14th, the wife of Dr. G. M. Tickler, Little
Bradley, Thames Ditton, of a daughter.
WALKER.—On April 14th, at Welbeck-street, London, W.,
. the wife of C. . Walker, M.D. Aberd., of Oxted, of a
daughter.
VACANCIES.—BIRTHS, MARRIAGES, AND DEATHS
MARRIAGES
MADDOX—GILLESPIE.—On April 10th, at Upton Parish Church,
Chester, Denis Maddox to Anne Gillespie, M.B., Ch.B.E Edin.
YNE—BUTLER.—On April 15th, at St. John the Evangelist’s
Church, Notting Hill, W William John Fitzgerald Mayne,
M.D. din. -»» D.P.H. Belf., to Rachel Elizabeth Butler,
of Wonersh Hollow, Wonersh.
TAYLOR—HALL.—On April 16th, at St. Paul’s Church, Grange-
over-Sands, Major Ernest Charles Taylor, M.B., B.Chir. -
Camb., I. M.S. (retd.), to Amy Louise Hall, formerly of
Marlborough.
TODD—DEAKIN.—On April 10th, at the see. § Chapel,
Achimota, Gold Gast. Kenneth Waller Todd, M . Eng.
to Lucy Olive, only daughter of Charles Deakin and She late
Mrs. (Minnie) Deakin, of Shrewsbury.
WaRD—TootTH.—On April 17th, at Holy Trinity Church,
Brompton, Frederick Godsalve Ward, B.M., B. we Oxon.,
to Pamela Ada, only daughter of Mr. and Mrs. E. A . Tooth,
of Tilney-street, W.
DEATHS
BaTE.—On April 11th, at Goring-on-Thames, John Brabant
eu ie . Durh., West African Medical Staff, retired,
age
CoLES.—On April 15th, at Oxford, Charles Coles, M.D. Lond.,
late M.O.H. for Oxfordshire.
DONALD.—On April 17th, a Alderley Edge, Cheshire, Archibald
Donald, M.D. Edin., F.R.C.P. Lond., in his 77th year.
FAYRER.—On April 13th, at Suhane; Lt. O Sir Joseph Fayrer,
rt., C.B.E., M.D., F.R.C.S.E., R.A.M.C.
FULLARTON.—On April 17th, at Woodburn, Holon iburgi
Robert Speirs arton, M.D. Glasg., D.P.H. E and
Glasg., F.R.F.P.S. Glasg., Major, R.A.M.C. (T.), eed 70-
GREEN.—On April 12th, in St. Thomas’s Hospital, S.E., Charles
David Green, M.D. Lond., F.R.C.S. Eng., of Larrey House
Romford, aged 75 years. Dearly loved and devoted
husband, fat er, and practitioner. '
Alfred Herbert
JAMES.—On April 16th, at Morden, Surrey,
late of Crowthorne and KEvershot,
James, M.R.C.S. Eng.,
Dorset.
MARTYN.—On April 15th, Reginald Martyn, L.R.C.P. Lond., of
Exmouth, aged 72.
MEA DEN T PD mon ape 14th, at Barnstaple, Charles Meaden,
O’BRYEN. ae “April 16th, as a result of an accident, James
Wheeler O’Bryen, L.A.H. Dubl., L.R.C.P. Edin.
SPEAR.—On April 15th, sg Merrow, Guildford, John Augustus
Spear, M.R.C.S. Eng
N.B.—A fee of Ts. Gd. is kargt. for the insertion of Notices of
Births, Marriages, and Deaths.
INTERNATIONAL CONGRESS FOR PSYCHOTHERA-
PEUTICS,—The Danish and Swedish national groups of the
International General Medical Association for Psychothera-
peutics are arranging for the ninth international congress
to be held at Copenhagen from Oct. 2nd to 4th. On the first
day the subject for discussion will be psychotherapeutics and
general practice, on the second the teachability of psycho-
therapeutics, while the third day will be reserved for other
papers, discussions, and general business. Papers may
be read in German, English, or French, and anyone who
wishes to read one should notify the president of the
association, Prof. C. G. J ung, Kissnacht-Zirich, before
June Ist. The congress is open to all medical men ;
other psychotherapeutists and practical paychologists
may also take part at the invitation of the various national
groups. Dr. Oluf Briel, 2, Amagertorv, Copenhagen,
is secretary for the Danish group, and Prof. Poul Bjerre,
4, Engelbrektsgatan, Stockholm, for the Swedish group.
1032 THE LANCET]
[APRIL 24, 1937
NOTES, COMMENTS, AND ABSTRACTS
MEDICINE IN THE PHYSICAL LABORATORY
ONE of the primary concerns of the National
Physical. Laboratory is to give to industry the
scientific help it needs. The annual report for 1936
shows how much of its work has been directed to
that end. Many of the investigations, however, are
directly related to public health and medicine. One
important piece of work has resulted in the unifica-
tion of X ray and radium dosage measurements; a
difficulty of deep radiation therapy has been the
correlation of the dosage of these two kinds of radia-
tion. During the year two methods, one using
ionisation chambers, the other photography, have
been worked out so that radiation from the two
sources may be measured in terms of the rontgen,
the international unit. Another difficulty, arising
from the increasing power of X ray therapy installa-
tions, has been the protection of the medical observer
from stray radiation. An optical system which was
first studied because of its innate interest has been
found to provide means of viewing the patient while
he is separated from the observer by a thick
. protective wall.
X rays have been used for studying dental structure,
The main crystalline constituent of the enamel
proves to be identical with that of dentine, but while
the crystallites in the dentine are orientated at
random, there is a fibre structure in the enamel.
This structure is developed to a greater or less degree
in different enamels, a high-quality enamel being
associated, generally speaking, with a well-marked
fibre structure. It appears that calcification is more
conspicuous in the enamel the later the enamel is
formed in the life of the tooth.
The attack upon noise has been made on several
fronts. Loudness is essentially a subjective charac-
teristic of sound and the measurement of it, except by
direct comparison, has been unreliable in the past.
An objective meter which gives dial readings corre-
sponding to aural loudness has now been designed
and tested at the laboratory. It is free from all
suspicion of personal error and bias and has the
great advantage that it registers the loudness of
intermittent and impulsive noises which are so often
the cause for complaint. The meter has been used
to measure the noisiness of cars, lorries, buses, and
motor bicycles. Measurements have also been’ made
for the Home Office of instruments which might be
used as alarm signals in air-raids, and of road drills.
The silencing capacity of different kinds of floors
and partitions has been measured for the Ministry of
Health in connexion with the construction of flats
for the working classes.
During the winter 1935-36 observations were made
to determine the value of daylight illumination at
which clerical workers find it necessary to turn on
artificial light. The laboratory, in coöperation with
H.M. Office of Works, arranged that seventeen typists
in one of the large typing offices in Whitehall should
have their lights fitted with a device which, unknown
to them, recorded the time at which each light was
switched on and the illumination at the working
position at the instant of switching on. Although
the results showed a considerable spread, on average
the light was turned on when the daylight had fallen
- to a value of about 5 foot-candles. Another instru-
ment for measuring daylight has been devised for use
more particularly in deep rooms or rooms badly
provided with daylight; it should be of service to
public health departments having slum-clearance
schemes. The researches on illumination problems
have also been directed to the subject of glare.
The report mentions that the laboratory main-
tains equipment for testing the distribution of
radiation in limited spectral regions from sources
such as those much used in therapy recently. On
the other hand, many glasses have been examined
for the protection they afford to radiation of different
parts of the spectrum. Most of those against ultra-
violet light were found to be satisfactory, but most -
of those designed to satisfy the conditions laid down
for infra-red radiation failed by a large margin.
It is therefore probable that large numbers of
industrial workers are deriving from their protective
goggles much less protection than is believed desirable
and less than is certainly obtainable without any
sacrifice in the visibility of the work,
Among the routine undertakings of the laboratory
are the assaying of radium and the testing of clinical
thermometers; the latter must now be of a certain
thickness, have durable pigment on the scale, and
have other fixed characteristics if they are to conform
to the British standard specification and to receive
the ‘‘ Kew ”’ certificate. f
CONVALESCENT HOMES FOR CHILDREN
WITH RHEUMATIC CARDITIS
THE value of convalescent establishments for
children suffering from rheumatic carditis has been
much debated. It is pleasant to learn therefore,
from the annual report for 1936 of the Children’s
Heart Home, Lancing,. Sussex, that the results of
treatment at this home have been good. Two
members of the honorary staff of the Hospital for
Sick Children, Great Ormond-street, are consulting
physicians to the home at Lancing, which accom-
modates 70 children and provides them with education
satisfying the Board of Education. The average
length of stay of each child in 1936 was 100 days
(a period considerably shorter than that reported from
Birmingham and Broadstairs 10 years ago); the
preponderance of girls over boys was 140 to 111,
and the ages of the children received between 5 and
12. Otherwise the report includes no clinical details.
During the last 10 years so many new beds have
been set aside for the treatment of rheumatic disease
in childhood, that it is clear that sufficient material
must have accumulated for the publication of the
results of treatment, and, even more important, of
treatment plus after-care and of re-examination of
children returned to their homes. Ten years ago,
relapse after return home in some form (rheumatism,
carditis, or chorea) occurred in about one-third of the
children re-examined, and it is of cardinal importance
to know whether these figures have improved.
The cases under treatment at West Wycombe,
Lancing, and in even greater numbers at Carshalton
and Brentwood under the L.C.C. should by this time
be adequate to furnish the basis of a comprehensive
report which would be welcomed by all interested
in the problem presented by rheumatic carditis.
BOARD OF CONTROL.—The Board of Control, with
the approval of the Minister of Health, have appointed
a committee to advise upon questions arising in con-
nexion with scientific and ancillary mental -health ser-
vices which will include the following: Lord Radnor
(chairman), Sir Laurence Brock, Sir Hubert Bond, Dr.
A. A. W. Petrie, Dr. Adeline Roberts, Dr. C. J.
Thomas, and Dr. George Somerville. Mr. H. J. Clarke
will act as secretary. The Mental Treatment Act,
1930, empowered local authorities to provide for out-
patient treatment and for the after-care of mental patients,
and, subject to the approval of the Board, to undertake,
or contribute towards the expenses of, research in relation
to mental illness. An advisory committee was appointed
in 1931 but owing to the financial crisis its work remained
in abeyance, The primary function of the new committee
will be to advise the Board on the organisation and
encouragement of research, and other ancillary services
will be within its purview. On technical questions relating
to research, the committee will have the expert assistance
of members of the committee on mental disorders of the
Medical Research Council. i
THE LANCET]
[may 1, 1937
ADDRESSES AND ORIGINAL ARTICLES
THE PREVENTION OF
PULMONARY TUBERCULOSIS AMONG
ADULTS IN ENGLAND
IN THE PAST AND IN THE FUTURE *
By P. M. D'Arcy Hart, M.D. Camb., F.R.C.P. Lond.
ASSISTANT PHYSICIAN TO UNIVERSITY COLLEGE
HOSPITAL, LONDON ©
(Continued from p. 973)
Tue national tuberculosis scheme was designed
at a time when contact with open tuberculosis was
considered chiefly dangerous to children. While
precautions were advised for adults, doubts as to their
necessity were commonly expressed. During the
past decade or so, however, more attention has been
paid to the risks run by adults, and particularly by
young adults. This is evident from the opinions
‘of physicians to the London tuberculosis dispensaries,
cited by Bentley (1936c), who points out also that
the incidence of new pulmonary cases in London
during 1926-35 among child contacts examined was
l per cent., whereas among adult contacts examined
it was 7 per cent. |
It is obvious that exposure in some form is more
. dangerous than no exposure at all, for without
exposure there can be no infection; but we should
like to know the position of adults facing exceptional
exposure to contact, as compared with that of adults
encountering exposures of the kind met with in
ordinary life. Again, we should like to know whether
young adults run a greater risk from exposures than
do older persons; and to know the part played
by exposure incurred before adult life in the develop-
ment of progressive lesions later, compared with the
effect of exposure encountered actually during adult
life. And we should also like to know the comparative
risks run by adults who react negatively, and those
who react positively, to tuberculin.
What information is available ? Of late years much
work has been published upon the fate of adults
who are facing, or are about to face, exceptional
amounts of exposure. Among these: are home
contacts, work contacts, medical students, and
nurses.
Adults Exposed to Exceptional Degrees of
Contact
HOME CONTACTS
Using their comprehensive scheme of family
records, Opie and his co-workers have studied the
development of pulmonary tuberculosis in persons
of various ages after exposure to contact with this
disease in their homes in Philadelphia.
Persons apparently first so exposed to sputum-positive
cases at some date after the age of 15 developed progressive
lesions more often than persons similarly exposed to
sputum-negative cases, and still more often than persons
of corresponding age in the general population. The
annual attack-rate of manifest—i.e., clinical—pulmonary
tuberculosis, in the persons exposed to sputum-positive
cases, showed this excess at its maximum 4-5 years after
the commencement of the known exposure, while their
death-rate showed its maximum excess 2 years later.
With few exceptions these progressive pulmonary lesions
in persons apparently first exposed after the age of 15
*The Milroy lectures for 1937 delivered before the Royal
College of Physicians of London on Feb. 18th and 23rd.
593
In exposed children the radio-
graphic incidence of primary lung complexes increased
with the length of time after the commencement of the ex-
posure ; but in these adultsit did not, and from this it was
inferred that their adult-type lesions were due to exogenous
reinfection acquired, by contact, after the age of 15,
in lungs already the site of first-infection (see Opie,
McPhedran, and Putnam 1935, Putnam 1936). Since,
however, the tuberculin reactions before the commence-
ment of known exposure are unknown we cannot exclude
the less likely hypothesis that the adult-type lesions found
were due to endogenous reinfection (arising by blood
spread) from a first-infection focus that itself was acquired,
by contact, after the age of 15. For while the proportion
of persons that acquired first-infection during exposure
after the age of 15 might have been too small to cause a
significant gradual increase in the radiographic incidence
of primary complexes, it might still have sufficed to provide
the number of adult-type lesions found.
It is clear at least from these valuable observations
that exposure in their homes during adult life was an
important factor in the production of adult-type
progressive pulmonary lesions in these contacts.
And more recently these authors have brought
forward evidence of the greater danger of this house-
hold contact to adults than to children (Opie,
McPhedran, and Putnam 1936). |
Opie’s procedure was, in the main, to identify his
families by the primary case and to work forwards
from the commencement of known contact. The
opposite though more limited method has been used
by Lloyd and MacPherson (1936) at the Brompton
were of the “ adult ” type.
‘Hospital. They studied the case records of a. series
of clinically tuberculous young adults, aged 15-24,
so as to determine the time-relationships with the
termination of known exposure to any earlier case
in the home or elsewhere. In 40 per cent. of the
patients evidence was found of such an earlier case,
the majority (82 per cent.) having been in the home.
In 80 per cent. of the young adult patients with
evidence of an earlier primary case the onset of
their own disease was found to have been either
while they were still in contact with the primary
case, or within five years of termination of known
contact.
This work supports the view that home exposure
to clinically recognisable tuberculosis during adoles-
cence or adult life plays a large part in producing
tuberculosis among young adults.
THE POSITION OF MEDICAL STUDENTS
The incidence and extent of radiographic adult-
type lesions in medical students appears to be greater
during their clinical than their preclinical training.
Since the students are older during the clinical
course, and since the morbidity of pulmonary tuber-
culosis also increases somewhat rapidly with age
among young adults, assessment of the importance
of contact depends almost entirely upon comparison
with controls of the same age, which are very difficult
to obtain. However, comparing medical students
with a small series of dental and law students,
Hetherington, McPhedran, Landis, and Opie (1935)
did find a higher incidence of important adult-type
apical lesions in the medical students, suggesting
damage from exposure to contact in adult life during
their clinical training.
THE POSITION OF HOSPITAL NURSES: INFLUENCE OF
PREVIOUS TUBERCULIN SENSITIVITY
The position of adult contacts has so far been
discussed without reference to previous tuberculin
S
1034 THE LANCET]
DR. D’ARCY HART: PULMONARY TUBERCULOSIS IN ADULTS
[may 1, 1937
reactivity. This aspect of the problem has been investi-
gated in probationer nurses, a fair proportion of whom
come direct from rural districts which means that
many may be negative reactors on entry. Heimbeck,
working at Ullevaal Municipal Hospital, Oslo, found
that tuberculin-negative probationers, brought into
contact with open tuberculosis during their training,
ran a serious risk of developing lesions such as
pleurisy, erythema nodosum, and even meningitis,
attributable to tuberculous first-infection. These
lesions, as might be expected, did not occur so often
among those already first-infected, as shown by a
positive tuberculin reaction. Hence the original
“ negatives ” were at a disadvantage.
Heimbeck’s figures also appear to show that in
a given limited time the original negative reactors
developed serious adult-type lesions more frequently
than did the original positives. These lesions might
be explained as due to endogenous reinfection
arising by blood spread from a first-infection focus
acquired, by contact, during their training. Heimbeck
does not discuss this satisfactorily, but he does make
it clear that he attributes this second difference
between the fate of the originally negative but now
positive nurses, and that of the originally positive
nurses, to the previous possession of specific immunity
by the latter but not by the former. Hence the
original negatives appear again to have been at a
disadvantage. He supports his view by citing the
fate of nurses who became tuberculin-positive as.
the result of BCG immunisation. This was much
the same as the fate of those who were originally
positive without artificial immunisation.
It should be noted that the cases of manifest
disease described by Heimbeck among the originally
tuberculin-negative nurses of his series occurred
within a year of their becoming positive, the latter
change having usually taken place by the third year
of their training ; but for those who had not mani-
fested the disease within one year of the change from
negative to positive the subsequent fate was no
different from that of the originally positive reactors
(see Heimbeck 1936).
The appearance of troublesome accompaniments
to tuberculous first-infection in nurses who are
negative reactors to tuberculin before their training,
as found by Heimbeck, has been confirmed by several
authors. One of these (Mariette 1936) has also
provided tentative confirmation of the greater risk
of the adult type of disease appearing in this group
than in the group of originally positive reactors.
This second difference in fate is, however, in conflict
with Opie’s experience with medical students, among
whom no correspondence was found between the
occurrence of adult-type lesions and the original
tuberculin reactivity ; nor does it agree well with
Opie’s interpretation of the adult-type lesions in
his home-contact series as being due to exogenous
reinfection (see above). No final conclusion, there-
fore, can be reached until more information is
available.
A somewhat obvious suggestion as to the arrange-
ment of the results of work on this problem may be made
here. It is best to compare the fate, in a given period,
of the originally positive reactors not with that of all
the originally negative reactors, but with the fate of those.
originally negative reactors who have become positive
as a result of exposure. In Heimbeck’s work this would
make no difference to the figures, since all his negative
reactors changed to positive within three years of commenc-
ing exposure during their nursing training; but, since
such a change of reactivity does not take place 80
completely in all hospitals, the two above methods of
comparison are not necessarily identical.
Protection of Young Adults Exposed to
Exceptional Degrees of Contact
The following three principles might reasonably
be adopted for averting the possible danger to adults
who are, or are about to be, subjected to known and
perhaps intense or frequent exposure to open
tuberculosis.
(1) Known exposure to contact in adult life, both of
tuberculin-positive and of tuberculin-negative persons,
should be reduced to a minimum. (In the near future
this opinion may have to be modified to lay special stress
upon young adults, and especially on negatively reacting
young adults.)
(2) Adults, both tuberculin-positive and tuberculin-
negative, who are known to be in contact with open
tuberculosis should be kept under observation during
the Te of exposure. (This opinion also may have
to be modified to lay special stress upon young adults,
and especially young adults whose tuberculin reactivity
is known to have changed from negative to positive
as a result of the exposure.)
(3) After the termination of the known exposure, such
observation of adults (except perhaps those who have
retained their negative reactivity) should be continued
for some years.
How can these principles be eimpoaied in practice
in the near future? The following remarks are
restricted to young adults in the category under
consideration—namely, home contacts, work contacts,
medical students, and hospital nurses.
PRACTICAL MEASURES
For home and work contacts protection, both of
positive and of negative reactors, from the source
of potential infection is likely to remain the main
policy with young adults, as it is with children;
though of course it may unfortunately happen that
this source, whether in the home or at work, is only
discovered after one or moré secondary cases have
already occurred. Such protection of young adults,
like that of children, will become increasingly effective
as more expeditious diagnosis and removal of sputum-
positive cases for residential treatment becomes
practicable, as the sanatorium segregation of the
persistent sputum-positive case: becomes more widely
practised, and as further advances are made in the
schemes of after-care so as to reduce the contagion
of sputum-positive patients and so as to minimise
their chance of relapse into this infectious state.
Incidentally, such measures would help to meet
the growing objection of employees to the presence
of an infectious fellow-worker.
Here I may mention the growing interest in the earlier
recognition of infectiousness among persons with apparently
minor lesions in the lung. This mainly turns upon the
technical advances in sputum examination, such as
concentration of organisms, examination of stomach
contents, improved methods of culture, and examination
of “ morning saliva ”? (see Holmes 1936).
For medical students and nurses, protection from
known sources of potential infection by complete
avoidance of exposure is clearly unattainable. The
most that can be expected is the reduction of exposure
to the minimum by hygienic measures, though these
are perhaps more difficult to carry out in general
hospitals than in special tuberculosis institutions
(Joint Tuberculosis Council 1936).
If Heimbeck is right, however, we must be prepared
to regard negative tuberculin reactivity in young
adults exposed to contact with open tuberculosis
as indicating spectal disadvantages—namely, the
risk of clinical accompaniments to first-infection
and a greater risk of progressive adult-type pulmonary
THE LANCET]
SIR LEONARD HILL: PHYSICAL TREATMENT
[may 1, 1937 1035
lesions later. Special steps may therefore have to
be taken for the protection of negatively reacting
students and nurses, particularly if the proportion
negative at the commencement of clinical training
should increase.
One suggestion is to refuse negative reactors.
This course would be harder to follow with students,
who would already be half-way through their training,
than it would be with nurses, but even with nurses
a continuation of the present shortage of applicants
for posts at many tuberculosis institutions would
create considerable difficulties. If it were decided
eventually to follow such a drastic course with medical
students, the unfortunate man in his third year of
study would be compelled not only to pass an
examination in intellectual capacity to the satisfaction
of the anatomists and physiologists, and to pass
a test of mental fitness to the satisfaction of the
industrial psychologists, but also to pass a tuberculin
test to the satisfaction of the immunologists.
A less drastic though hardly more practicable
suggestion for the protection of those tuberculin-
negative probationer nurses who train at a general
hospital is that they should avoid the tuberculosis
ward, if such exists, until their reactivity has changed
to positive.
A third and much more promising suggestion is to
vaccinate these nurses with B C G, not allowing them
to be brought into contact with cases of tuberculosis
until their reactivity has changed to positive. The
reports of recent investigations upon BCG vaccina-
tion of tuberculin-negative infants (Wallgren 1934,
Kereszturi and Park 1936) and nurses (Heimbeck 1936)
have been distinctly encouraging.
Adequate observation, including periodic examina-
tion, during and for some years after the period of
exposure (see Jessel 1930, Lloyd and MacPherson
1936) should help to reveal such progressive pulmonary
lesions as do develop in spite of all protective measures.
The methods of carrying out such periodic examina-
tion will be discussed later.
The Contacts of Ordinary Life
Measures to reduce the amount of contact with
infectious cases, together with improvement in
housing and hygienic conditions, may be expected
to increase the proportion of children who reach adult
life without becoming tuberculin-positive. If a
negative reaction in a young adult should come to be
regarded as entailing a special risk in the face of
exceptional exposure, the question would arise as
to the risk run from exposures met with in the
ordinary circumstances of life.
This has been the subject of considerable specula-
tion. Indeed, it has already been suggested (Dahl
1933) that the recent retardation in the decline of
pulmonary tuberculosis mortality among young
adults in this country has been partly due to an
increased incidence of negative reactivity at this
age, with a corresponding reduction in immunity.
Such an explanation is, however, disputed by Bradford
Hill (1936), and would be untenable if, as appears
_ possible, the decline in mortality in this age-group
is Once more being resumed. As a matter of fact,
little is known of the present degree of tuberculisation
of young adults of the urban working-class population
of England, and still less of those of its rural] districts.
Certainly there seem to be insufficient grounds at
present for any special action to protect negative
reactors in particular in the population at large under
the ordinary circumstances of life. Nevertheless,
lest such a possibility be deemed fantastic, I may
cite the procedure in recruiting for the Japanese
navy, where, I am informed, only positive reactors
to tuberculin are accepted for service.
As to the future, we may hope that any danger of
producing a large proportion of adults in the general
population who would be open to the risks incurred
by peoples living under primitive conditions will be
offset by the fewer and smaller doses of infecting
bacilli likely to be encountered, by a higher standard
of living of the people, and possibly also by artificial
active immunisation.
At the same time it is important to have records of the
changing tuberculisation of young adults, and its relation
to changing morbidity and mortality. In particular, we
shall do well to keep a watch for the development of
classes or areas with a high incidence of adult negative.
reactors and a low incidence of pulmonary tuberculosis
cases, and other classes or areas where the opposite holds, |
in case the movement of persons from one class or area to
another may prove important, epidemiologically.
Conclusions Concerning Contacts
Contact with open tuberculosis has its dangers in
adult life as well as in childhood, and much of the
interest in the infectiousness of this disease is rightly
being transferred from children to young adults.
Preventive action in the future to protect adults
known to be in contact with open tuberculosis is
likely to aim—more than at present—at limiting
the exposure, at increasing individual resistance, and
at maintaining close observation for the early
detection of progressive lesions. Those who react
negatively to tuberculin may require special protec-
tion; they may need particularly close observation
should their reactivity change to positive as a result
of the exposure; or they may require artificial
immunisation. By a combination of preventive
measures such as these with the more general social
measures discussed earlier, we may confidently hope
that the benefit to the community from reduction
in the unfavourable consequences of tuberculous
‘infection will far outweigh any harm from loss of
immunity resulting from its diminished occurrence
(T'o be concluded)
THE RATIONALE OF CERTAIN METHODS
USED IN
PHYSICAL TREATMENT *
By Sır LEONARD Hit, M.B. Lond., F.R.S.
DIRECTOR OF RESEARCH AT THE ST. JOHN CLINIC AND
INSTITUTE OF PHYSIOAL MEDICINE
THE range of radiations that includes gamma rays,
X rays, ultra-violet and infra-red light, and the
high-frequency electric waves used in broadcasting
forms one great continuous spectrum of electro-
magnetic waves. The various regions of this differ
only in wave-length, the gamma rays being incon-
ceivably short and those used in radio being many
metres long. Still shorter even than gamma rays
are the cosmic rays that come from the universe with
great penetrating power and knock electrons off the
living substance of our bodies, with what effect,
if any, we do not know.
Radium
Radium emits (a) alpha particles or rays, which
are helium nuclei projected at high speed, and are
* A lecture given at the St. John Clinic and Institute of
Physical Medicine on Feb. 5th.
'
1036 THE LANCET]
completely absorbed in passing through the thickness
of an ordinary sheet of paper; (b) beta particles,
or rays, which are electrons travelling at high speed
and are stopped by 1 mm. of lead, or 0-5 mm. of gold
or platinum; (c) gamma rays, which are photons
with an average energy higher than that of X ray
photons ; those of the highest energy can traverse
many centimetres of lead.
The X rays are generated at voltages from 10-
1,000,000 kv, a range of wave-lengths extending from
2 to less than 0-05 A. (Angstrom units = 107 mm.).
The action of the soft X rays can be compared to the
beta rays of radium and that of the hard with the
gamma rays.
At first it was thought that rays of different
qualities were capable of producing different kinds
of reactions, but it is now known that the erythema-
producing effect on the skin does not differ whether
caused by gamma or by hard, soft, or very soft X rays.
Difference in magnitude of reaction is due to the
relative amount of energy absorbed per unit volume
of tissue. With equal amounts absorbed in equal
volumes of living substance the effects are the same
regardless of the penetrating power of the rays.
Thus gamma and X rays produce similar changes
in the chromosomes of the nuclei of ova and similar
mutations may arise—e.g., in the fruit-fly drosophila.
Dividing cells are those most sensitive to radiation,
and in producing an effect the rate at which the rays
are absorbed is very important. When a beam of
high intensity is absorbed the extensive ionisation
initiates destructive changes in all the cells; on the
other hand, the slight damage done by a beam of
low intensity can be repaired, and there may be no
result. Hard rays under appropriate doses may
injure the more sensitive tissues and leave others
unharmed. Thus by gamma rays of low intensity
the seminal epithelium alone is injured; with high
intensity the entire testis degenerates.
The erythema reaction of the skin is not a good
test of radiation. Minute living cells such as the
ova of drosophila or of the axolotl are much better,
failure to hatch out being the index. The very small
penetration of soft X rays and of ultra-violet rays
must be borne in mind. The radiation of one, or
of both kinds of germ cells, before fertilisation may
result in the production of monsters. Applied to
developing organisms irradiation effects the most
rapidly growing systems such as nervous, vascular,
reproductive, and renal. Irradiation inhibits pro-
cesses of regeneration in invertebrates in which
processes there is taking place active division of
cells. Ultra-violet rays are much less effective than
very low voltage X rays or cathode rays.
Repeated X ray irradiation of the skin swells the
connective tissue bundles, destroys cells, and thickens
the cutis with shrinkage of the skin. Similar changes
occur in the walls of the blood-vessels, leading to
occlusion; the epidermal cells swell and show
abnormal mitosis. Necrosis in the superficial layer
of the cutis and proliferation in the epidermis takes
place, and depilation may result. Ultra-violet, gamma,
and X rays alike produce dilatation of vessels, stasis,
diapedesis, and odema. Similar intensity of the
visible rays alone do not produce such destructive
effects on the skin. In frost-bite the rapid loss by
radiation produces the same sort of damage as
heat-burn does.
Exposure of the body to a massive dose of X rays
or radium, or the intravenous or oral administration
of a large dose of thorium or radium salts or of
radon, alike produce destruction of marrow and
lymphoid tissue, leucopenia, degeneration of epithelium,
SIR LEONARD HILL: PHYSICAL TREATMENT
[may 1, 1937
hyperemia of the intestines, cellular degeneration of
organs, and desquamation of epithelial linings, &c.
Infra-red rays produce flushing of the skin at the time
of exposure, ultra-violet rays after a latent period
of one hour or more. For X rays the latent time
is 2-5 days, and for the gamma rays of radium 2-3
weeks. The length of latency indicates the time that
secondary changes take to appear in the living cells.
EFFECT OF WEAK DOSES
The giving of salts of radium by the mouth or by
injection is dangerous. Iftaken by the mouth damage
may be doneto the mucous membrane of the intestines,
especially if the patient is constipated. When
injected 80 per cent. may be retained in the tissues,
principally in the bone-marrow, disappearing very
slowly. Thus deposits are formed from which
radiation may be emitted for a long time. A single
dose of radium salts equivalent to 0-5 mg. of radium
element can prove fatal. Several women died through
licking brushes when applying a luminous radium
paint to the dials of watches. The amount found
in their bodies varied from 0:01-0:08 mg. A rich
American citizen died through repeatedly taking,
in order, as he thought, to rejuvenate himself, a
solution containing 0-001 mg. of radium and meso-
thorium per ounce of water. The activity of the
emanation of radium declines to a half in 3-85 days,
and falls to less than 1 per cent. in a month. When
taken by the mouth 90 per cent. is given off by the
lungs in an hour, and so very little stays in the body
to form an active deposit. It is soluble gas and when
absorbed may reach every tissue, wherein in conse-
quence there will be a free action of the alpha rays ;
this is not the case when radon is applied in platinum
or other containers, which exclude these rays.
THERAPEUTIC USES
The unit of radon is a millicurie, the amount of
gas in equilibrium with 1 mg. of radium element.
For weak concentrations the Mache unit (M.U.) is used,
2,500,000 of which equal 1- millicurie. Some spa
waters are radio-active—e.g., Joachimsthal with
600 M.U. per litre and Baden-Baden with 100 M.U.
Artificial radio-active waters are prepared generally
with 8-30,000 M.U. in 1 litre as the daily dose. In
rats continual inhalation of radon in high concentra-
tion caused loss of weight, with leucopenia, enlarge-
ment of spleen, hemorrhages of the lungs and
glandular atrophy. It is claimed that small doses
have a stimulating effect upon cell activities and are.
inimical to morbid states. There is no statistical
evidence that spas with a high content give better
curative results than spas with a low one.
In a series of cases of chronic arthritis and hyper-
piesia treated with a concentration of 80,000 M.U.
in 15 oz. of water by Howitt, Pillman-Williams, and
Russ (1937) no benefit other than subjective was
found in the clinical condition, while no injurious
results were noted. There is no evidence that the
small quantity of radio-active material in certain
electrically heated pads is useful.
In a series of in-patients treated with much larger
doses—2,500,000 to 10,000,000 M.U. in 10 oz. of water
—no improvement was noted, except in two cases
of chronic gout ; more requires to be done to confirm
the effect observed even in these two cases. The
red cells fall in number when large doses are given,
a sign that the treatment is risky. We must bear
in mind that cancer of the lung occurs to a high degree
in miners who extract pitchblende, the ore from
which radium is obtained. Workers in X rays or
radio-active substances suffer from dermatitis,
THE LANCET]
particularly those who come in contact with tar or
paraffin, and skin cancer may result. They also
suffer from anzemia and leucopenia and necrosis of
the jaw bone. Sarcoma has resulted from a radon
tube left in the body. In handling radium lead
or tungsten alloy screens must be used, and the
period of work made short.
It has been shown recently that the two principal
chemical systems of cell life that supply energy—
respiration and glycolysis—are differentially attacked
by gamma radiation applied at body temperatures.
Thus tumour cells lose their power of using oxygen
during a period when glycolysis remains unaffected,
. but if the tissues are cooled to 10° C. or lower the
reverse happens. Normal tissues unlike tumour
cells do not use glycolysis as a source of energy,
except in a minor degree. When the utilisation
of carbohydrates by oxidation or by splitting processes
is inhibited by gamma radiation, nitrogenous products,
probably proteins, are broken down to supply energy
to the partially damaged cells (Crabtree 1936).
Glyoxalase, a ferment which was supposed to be
important in the series of reactions which result in
formation of lactic acid in cells is resistant to gamma
radiation. If a rat tumour is irradiated with a dose
too small to visibly affect it, and seven days later the
immediate subsequent transplantation of this tumour
is irradiated, and so on, the effect becomes cumulative.
The rate of growth and the percentage of successful
inoculations falls off (Cramer 1936). Such a small
dose then is harmful, not stimulating to tumour cells.
Ultra-Violet Light
The short ultra-violet rays penetrate so slightly
that their effects are limited to the epidermis and
superficial capillary loops of the cutis. The absorption
of products of the damaged cells causes a flush
first in evidence some hour or two after exposure.
The skin next day is sharply reddened; a section
of it shows that leucocytes have infiltrated among
the cells of the superficial layers; granules appear
in the cells round the congested capillaries. In thirty
hours the reaction is increased, nuclei of the superficial
cells stain dimly, and degenerated cells are to be seen.
The pigment layer .is disturbed and here and there
the cutis is separated from the epidermis. The
reaction now subsides, but the greatest swelling of
the connective tissue cells is seen on the third day.
The inner layer of the epidermis pigments as it and
the blood-vessels return to normal. The outer
layer desquamates.
One of the most important actions of the ultra-
violet rays is the production in the skin of vitamin D.
The vitamin is produced by activation of ergosterol,
present in minute amounts in the sebum. This is
brought about by the shortest wave-lengths of
sunlight of about 2900 A. These are absent in
winter and screened off by smoke pollution in cities.
Rickets can be prevented by suitable exposure of the
skin of infants and children to the sun or arc lights.
Vitamin D is also obtained by eating food such as
eggs, fish, and particularly liver oil, halibut oil being
especially potent. It is formed by the action of the
sun on green food of both land and sea. The milk
of cows contains the vitamin when they are fed on
grass, not when they are stall fed on oil cake and
grain. Some animals secure this vitamin by licking
or preening their fur or feathers, and carnivora
by eating fur or feathered animals. Vitamin A is
synthesised in animals from carotin, a common
pigment of green plants, carrots, &c: The B vitamins
are plentiful in green plants but even more so in
yeast grown in the dark. The antiscorbutic vitamin C
SIR LEONARD HILL: PHYSICAL TREATMENT
[may 1, 1937 1037
is developed not only in green plants but in citrus
fruit: and in germinating seeds; certain animals,
such as rats, can produce it in their own bodies.
Vitamins are destroyed by ultra-violet rays, but not
by that brief exposure that is required to form
vitamin D.
THERAPEUTIC USES
The antirachitic effect of ultra-violet light is exerted
by rays at 2530-3000 A. and very weakly by those
at 3130 A. The amount of energy of the shortest
wave-length in sunlight—about 3000 A.—which is
effective in preventing rickets is always very small.
Infusoria are killed about three times as quickly
with rays at 2800 A. as with those at 3000 A., while
those at 3130 A. have no effect. Hsemolysis is most
active at 2530 A. Erythema of the skin is produced
by 2900-3000 A. and also by 2530 A. where there is
a strong line in the mercury arc spectrum. These
latter rays penetrate the epidermis less deeply than the
3000 A. rays of sunlight, and the resulting pigment
is in consequence lighter in colour; thus the sun
browns the skin best. Patients who do not pigment
well, such as red-haired, freckly people, have to be
exposed to sun treatment with care. Protection
against ultra-violet light is secured by thickening
of the horny layer, and by pigmentation of the
epidermis. By giving doses that produce a mild
erythema once a fortnight, time is given for the
erythema and desquamation to pass off, and the
skin again becomes sensitive. The body can be
treated in four parts, thus if treatment is given twice
a week, exposure of any one part is given once a
fortnight. By this plan the length of exposure can
be kept short, for if the whole body is exposed each
time the skin becomes less and less sensitive, and
to produce an effect the exposure has to be made
longer and longer.
Health is stimulated by suitable doses of ultra-
violet rays, and immunity is said to be increased
against staphylococcal infections. Overdoses cause
fever, irritation, and depression, and are dangerous
to those who are fighting an active tuberculous
infection. The doses for such patients must be small
and carefully adjusted. The effect of absorption
of products of sunburn from the skin may be com-
pared with those of protein shock produced by
injection of milk or of the patient’s own blood.
Ultra-violet irradiation is one of the best means
of producing counter-irritation, and blistering doses
prove very useful in the treatment of sciatica, &c.
The irradiated skin is covered ‘with Elastoplast
bandage and left untouched till healed (Eidinow 1937).
Intense doses given‘ by the water-cooled mercury
lamp, or the water-cooled arc used in the Finsen
Institute heals lupus vulgaris by producing a reaction
in the skin. Light treatment is also valuable for
alopecia areata, eczema, psoriasis, acne, boils and
carbuncles, erysipelas and septic wounds, surgical
tuberculosis, and for wasting and rickety children.
It stimulates breeding in birds, mice, and monkeys,
and no doubt also in man. Good pigmentation of
patients is thought by A. Rollier to be a sign of wel- -
being, and for wounds Oscar Bernhard, the pioneer
in this form of treatment, uses the. Alpine open air
and sunlight.
Infra-Red Rays
The penetrating infra-red rays are of particular
value in addition to the ultra-violet rays—for there
seems to be no antagonism between ultra-violet and
heat rays. These penetrating rays relieve pain in
cases of sprain, &c., and by softening and making
supple rheumatic tissues enable curative movements
1038 THE LANCET]
and massage to be carried out. The long infra-
red rays are absorbed by the surface of the skin and
do not penetrate; they may raise the superficial
temperature from 32 to 41-44° C., while the tempera-
ture 10-25 mm. below the surface is not raised more
than a degree above body temperature, and then only
by conduction of heat. The temperature of the
surface rises quickly to a maximum, and quickly
drops when the irradiation ceases. On the other hand,
the short infra-red and red rays by penetrating may
produce a rise to 40° C. 25 mm. below the surface,
while the surface is raised only to 38°. In this case
the maximum rise and fall are reached more slowly ;
there is a drop of temperature from within outwards,
and this is accompanied by a feeling of refreshment
and relaxation. After insolation has ceased the
surface of the skin quickly falls in temperature, but
the deeper layers may take three-quarters of an hour
to fall. With the putting on of clothes after insolation
the effect may last for hours.
The heating of the blood and subcutaneous tissues
by the short infra-red and luminous rays is one of
~ the most important of curative effects (Sonne 1921).
Pigment in the epidermis absorbs and transforms
all the rays of sunlight into heat, and this in its
turn excites the nerve-endings and evokes sweating ;
thus overheating is prevented. A negro owing to his
pigment can have a thinner skin and so lose heat
more easily.
It must be kept in mind that infra-red radiation
that will not go through a thin layer of water will not
penetrate the epidermis. Thus only 0-5 per cent.
of the rays from a dark heater, 15 per cent. of
those from a carbon arc,and about 30 per cent. of
those from a tungsten arc and from the sun penetrate
l mm. of flesh. Oiling the skin by diminishing the
scattering of the rays increases the penetration of
the short infra-red and visible rays. The value of
a tungsten arc no doubt depends in part on the greater
number of penetrating rays coming from this source.
Sonne found during irradiation with the highest
endurable intensity that the surface skin temperature
rose to 43-8° C. with visible and to 45-5° with the
longer infra-red rays. With visible rays a maximum
temperature at 5 mm. depth was then 47:7°, and
with longer infra-red rays 41-7°. The amounts in
gram-calories per 8q. cm. per minute, which could
be borne by the skin, was 3-11 for visible, 1-79 for
shorter, and 1-33 forlonger infra-red rays. The visible
rays, except the red, are absorbed by the blood
in the cutis, and warm this ; the heat is then circulated
over the body. How the red and short infra-red
rays penetrate beyond the cutis is seen on placing
a glow lamp in the mouth and standing in front of
a mirror in a dark room. A red glow comes right
through the cheek, it does not do so in the case of a
negro, and only to a.small extent in the case of a
Japanese.
`I find that the long infra-red rays from dark
or dull red sources acting on the skin reflexly congest
and narrow the airways of the nose and lungs, an
effect which is set aside by cooling the skin with a
fan and in some people by rays from bright sources—
the antagonistic rays are in the short infra-red
region. The stuffiness felt in rooms heated by dark
or dull red sources is due to the action of the rays
on the skin, and the reflex action on the air tubes
and nasal sinuses, and has, in my view, nothing
to do with the chemical purity of the air. All rooms
so heated should be ventilated with enough cool
air to set aside the stuffiness. A greenhouse heated
by the sun feels stuffy compared with the open air,
because the sunlight is absorbed by the objects
SIR LEONARD HILL: PHYSICAL TREATMENT
[may 1, 1937
within and turned into dark heat, and this is trapped
by the glass, while there is no movement of cool
air. |
For infra-red treatment bright sources are best,
those which give off the more penetrating rays—
e.g., 1000 watt electric bulbs fitted with concave
mirror reflectors, or the clinical gas lamp. Eidinow’s
“ daylight” lamp gives relatively weak ultra-violet
rays coming from a tubular mercury-vapour are run
at low tension, together with plenty of infra-red rays
from a number of incandescent lamps, and itis a very
effective method of treating the whole body, as near
to that of sunlight as possible.
While ultra-violet rays burn superficially, heat .
may burn deeply ; such a burn must be treated with
tannic acid solution, which forms a sterile cover of
coagulated protein. Heat brings blood and lymph
to treated parts and softens the tissues; increased
circulation and tissue metabolism has a curative
effect on painful parts in cases of strain and
rheumatism. One of the best methods of applying
heat is by the paraffin-wax bath, heated to 130° F.
The paraffin solidifies at skin temperature and forms
a glove on the submerged part, which protects from
overheating, the vapour of sweat under the wax glove
acting as an insulator. The result is a local steam
bath, the part becoming flushed with blood and raised
in temperature. The body temperature may be
raised to 102° F. by immersion of the legs above the
knees. To chilblains, aching feet, and rheumatic
joints the paraffin bath gives great relief.
Short Waves
Beyond the infra-red is the high-frequency radiation
used in radio. The modern short-wave vacuum
tube oscillator has allowed a study of electric waves
as short as 1 metre ; it is not as yet possible to generate
any intensity of wave-lengths less than this. With
waves of 100-1 metre wave-length or 3-3000 million
cycles per second, and the living tissue put in the
field between condenser plates, and so subjected to
electrical stress, a displacement current results,
in which electrons in the molecules are stressed first
in one direction and then in another. Any free
electrons also tend to pass from molecule to molecule,
forming a conduction current, and the molecules
themselves, if bi-polar, tend to rotate in response
to the changing potential of the field. The result
is heating of the tissues. Artificial fever can thus |
be produced by putting the whole body, with exclusion
of the head, in the field of the high-frequency current.
The temperature may be raised to 105°F. in
60-80 mins. By so heating the body for some hours
gonococcal infection is destroyed. General paralysis
of the insane has been treated successfully by this
method in place of artificial production of malaria.
Local heating can be produced by the local applica-
tion of the electrodes—e.g., on either side of the face ;
the temperature in the mouth thus being raised to
102-103° F. an effect that cannot be produced by
hot bottles placed on either cheek, or by ordinary
diathermy. A local heating of the rectum can
similarly be obtained. Small tumours grafted in the
flanks of rats can be destroyed by the heating effects
of the field, with some damage also to the skin.
There is no evidence of any specific effect apart from
heat, for heart, cilia, and muscle-nerve preparations
of the frog put in the field and kept cold suffer no
change. If they are not kept coldsthey become
affected by rising temperature, brought about by the
high-frequency field just as when heated by any other
means. By intra-pelvic diathermy heat treatment
may be given with great advantage to certain cases
| .
THE LANCET] DRS. ANDERSON & LYALL: ADDISON’S DISEASE DUE TO SUPRARENAL ATROPHY [may 1, 1937 1039
of inflamed cervix or prostate, especially in gonor-
rheeal infection, and backache and rheumatic troubles
may also be relieved (Robinson 1929). In such case
the heat brings more blood and lymph to the treated
part, and increases metabolic change, and so produces
a curative effect.
Natural Sources
Exposure to cold in open-air treatment is effective
in stimulating body metabolism and appetite ;
still more so sea bathing, for the resting metabolism
may be increased by 50-100 per cent. in children
exposed to the open air, and 10 times while bathing
in the sea. Cold stimulates the nervous system and
drives the blood inwards, while heat flushes the
skin. Such to and fro changes promote health.
It is of interest to note that sterility has been produced
experimentally by keeping the testicles warm all
the time. The breathing of cool air promotes
evaporation from the respiratory membrane and
stimulates secretion and the flow of blood, thus
cleansing the membrane. The secretion of the
membrane is a defence against infection; cold air
widens the breathing tube, stimulates body activity,
and causes deep breathing, which occasions a natural
massage of the abdominal organs.
REFERENCES
Crabtree, H. G. a 936) Imperial Cancer Research Fund,
Cramer, W
Ten > rit mode Ts Jan. ae 1937, 16.
Howitt, Nan C., and Russ, S., Ibid,
"Toids 1 » 1072.
Robinson, O. A. (1 me . scand. p. 192.
ADDISON’S DISEASE DUE TO
SUPRARENAL ATROPHY
WITH PREVIOUS THYROTOXICOSIS, AND
DEATH FROM HYPOGLYCÆMIA
By IAN A. ANDERSON, M.B., B.Sc. Aberd.*
ASSISTANT IN. MEDICINE, UNIVERSITY OF ABERDEEN ; AND
ALEXANDER LYALL, M.D. Aberd., M.R.C.P. Lond.
LEOTURER IN CLINIOAL CHEMISTRY IN THE UNIVERSITY
THE patient, a single woman, was first seen on
August 28th, 1929, when she was 30 years of age.
At that time her history was that weakness, loss
of weight, prominence of the eyes, and swelling of
the neck had developed during the last three years.
She was a well-developed woman (height 5 ft. 4 in. ;
weight 9 st. 8 lb.) presenting the characteristic signs
of thyrotoxicosis. Her basal metabolic rate (B.M.R.)
of + 42 per cent. having confirmed this diagnosis,
she was referred for X ray treatment of her goitre.
On Nov. 6th of the same year, having had three exposures
to X rays, she weighed 10 st. 3 lb. and the tremors and
vasomotor disturbances had disappeared, but exoph-
thalmos remained. The B.M.R. was now +18 per cent.
On April 8th, 1930, after two further exposures to X rays,
her improvement was maintained, and the thyroid gland
was no longer palpable. Her weight was now 10 st. 4 lb.
and the B.M.R. + 20 per cent.
She was not seen again until Jan. 19th, 1936.
In the interval she had resumed her work as a typist,
and had remained in good health until 1935.
During the summer of that year she had become very
sunburnt ; the pigmentation did not fade subsequently,
but rather increased ; and in September she had a severe
attack of colicky epigastric pain, accompanied by vomiting,
pain in the back, and swelling of the eyelids. She returned
to work however, and between September, 1935, and
* Carnegie teaching fellow in medicine.
January, 1936, she felt quite well, although she was
rather easily tired, and the pigmentation of the skin
persisted.
In January, 1936, she began to have attacks of pain
and a sinking feeling in the stomach, accompanied by
nausea, these symptoms lasting for a few days at a time.
She also developed an aversion to salt or food the least
bit salty, and was more sensitive to cold weather than
before. When she was seen on Jan. 19th the pigmentation,
of the skin was striking. It was brown in colour, and pre-
sent on the face, lips, backs of the hands, areole, and
axilla. She now weighed only 8 st., but otherwise physical
examination revealed no abnormality. The pulse-rate
was 68, the blood pressure 120/90 mm. Hg, and the
B.M.R. —21 per cent. The blood chemical findings on
this occasion were: blood-urea 37 mg. per 100 c.cm.,
fasting blood-sugar 62 mg., and plasma chloride (expressed
as sodium chloride) 511 mg.f The urinary chlorides in
a sample taken at the same time as the blood sample
were 480 mg.
A diagnosis of subthyroidism was made, and also
a tentative diagnosis of Addison’s disease, in view of
the pigmentation, loss of weight, gastro-intestinal
symptoms, and slightly subnormal plasma chloride
level. The patient was put on thyroideum. siccum
(B.P.) one-quarter of a grain daily, the small dose
being given in view of the sensitivity of patients
with Addison’s disease to thyroid extract. Her
symptoms, after a short remission, became severe
again, and she was admitted to hospital on Feb. 26th,
1936, thyroid administration being stopped.
FIRST STAY IN HOSPITAL
The pigmentation had now become deeper, being presènt
over the abdomen and in the skin creases of the palmar
surface of the hands. Her weight was only 7 st. 2 1b.,
her pulse-rate was 104, and her blood pressure 88/64 mm.
Hg. Blood-urea 40 mg. per 100 c.cm., fasting blood-sugar
65 mg., and plasma chlorides 526 mg.
As her symptoms were not considered of extreme
urgency, she was at first kept under observation with no
special treatment, the blood chemistry being examined
daily. There was a slight improvement in subjective
symptoms during the first five days after admission, but
the plasma chloride level declined slowly, as is shown in
the Figure.
On March lst menstruation began, and the flow lasted
for four days, no blood samples being taken during this
time. On the 6th, two days after the period had ceased,
the patient complained of nausea, and began to vomit
after meals ; the plasma chlorides showed a further fall.
On March 9th her temperature rose to 101° F.,
and she developed dull abdominal pain, accompanied
by tenderness but no rigidity. As the plasma
chlorides had fallen to 479 mg. per 100 c.cm. the
blood-urea had risen to 67 mg., and the blood pressure
had fallen to 70/50 mm. Hg, treatment with supra-
renal cortical extract was begun, 5 c.cm. of Supracort
(Paines and Byrne) being injected intravenously
twice daily. No intravenous salines were given at
this time, but an attempt was made to commence
sodium chloride therapy by mouth. However, the
patient vomited salt given in formolised gelatin
capsules, and this treatment was abandoned tem-
porarily after one day.
In spite of the hormone injections, the plasma
chloride continued to fall for three days, being
438 mg. per 100 c.cm. on March 12th. The subjective
symptoms improved however, and the blood pressure
had risen to 94/66 mm. Hg by the 12th; the fall
in plasma-chloride concentration for three days
t Note on Methods.—Chloride estimations were made on
lasma throughout by the method of Van Slyke and Sendroy
1923). Blood samples were collected without stasis, but not
under oil, in small sample tubes which were practically filled
with blood ; separation of plasma and analyses were performed
at once. Blood-urea and b ood-sugar estimations were made by
the method of Maclean.
1040
THE LANCET]
DRS. ANDERSON & LYALL: ADDISON’S DISEASE DUE TO SUPRARENAL ATROPHY [may 1, 1937
after hormone therapy was probably due to dilution
of the blood, following hzemoconcentration during
the crisis, although no confirmatory hematocrit
estimations were made. That such dilution occurs
after hormone therapy in suprarenal insufficiency
is recognised from the work of Swingle and Pfiffner
(1933), Harrop (1933, 1936), and Loeb (1933).
On March 13th the plasma chlorides had increased
to 502 mg. per 100 c.cm. and next day salt therapy
was begun again, the patient taking 2 grammes of
sodium chloride in a cup of water thrice daily. This
method of giving salt caused much less nausea than
the formolised gelatin capsules, a fact noted also
by Kepler (1935) in recording the treatment of
Addison’s disease at the Mayo Clinic. Hormone
injections were discontinued on March 14th, and the
patient was now receiving 6 g. of sodium chloride
daily as the only special treatment. She was feeling
very much. better now, and was eating food with
relish. As her plasma chlorides only just reached a
normal level and began to decline again, the dose
of sodium chloride was increased to 8 g. daily, but
this did not prove sufficient to raise the plasma
chlorides to normal, and the dose was further increased
to 10 g. daily. The plasma chlorides quickly rose
to normal on this second increase in the dose of salt
and continued there during the rest of her stay in
hospital, and the patient noted a definite improve-
ment in her symptoms. Her strength and appetite
both improved, and she was now able to walk round
the ward. The cutaneous pigmentation decreased
in intensity, and her weight, which had fallen 2 lb.
since admission, began to rise.
To test the observation made by Blankenhorn and
Hayman (1935) that other sodium salts could be
substituted for sodium chloride without detriment
in the treatment of Addison’s disease, on March 25th
the patient was taken off sodium chloride alone, and
given 4 g. each of sodium acetate, sodium bicarbonate,
and sodium chloride thrice daily, this being equivalent
to 10 g. of sodium chloride in sodium content. This
treatment was continued for five days, during which
the plasma chlorides fell slightly, but kept well
within normal limits (see Figure) while the subjective
condition remained unchanged, thus providing a
confirmation of Blankenhorn and Hayman’s work.
During her stay in hospital, the patient showed
a strong tendency towards fasting hypoglycemia.
The fasting blood-sugar readings were :—
Jan. 19th ; si 62 mg. per 100 c.cm.
Feb. 27th até ee 65 4, p >”
»» 29th ale ie TE a ee 5
March 9th ; TEE e gs. Gs s
» loth .. va GI -ss as ji
Radiography of the abdomen revealed no evidence
of calcification of the adrenals. The lungs were
radiologically normal, and there were no signs of
tuberculosis elsewhere in the body. The B.M.R.
on March 2lst was —27 per cent. The patient was
discharged on April Ist, having been given instructions
to take 10 g. of salt daily.
SECOND STAY IN HOSPITAL
About a fortnight after leaving hospital on April Ist
the patient began to suffer from stiffness, and later
pain, in her knees, worst at night and in the morning.
Otherwise her health was satisfactory and she took
her salt regularly. During August and September
she received thyroideum siccum (B.P.) gr. 1 twice
daily. She had no vomiting or abdominal pain,
but her appetite deteriorated. On readmission on
Oct. 5th the pigmentation was somewhat lighter than
before ; the pulse-rate was 84, and the blood pressure
105/78. Both knees were held in semiflexion, and
movements were slow owing to spasm of the quadriceps
and hamstring muscles. Coarse joint crepitus was
felt on movement, which was painful. A radiogram
showed typical early osteo-arthritic changes in both
knees, but it was agreed that the joint changes could
not be held responsible for the extreme degree of
spasm present. The patient had always been a
difficult nursing case, but her irritability and intract-
ability had now much increased.
On the morning of Oct. 10th, five days after
admission, she became drowsy and confused. The
spasm of the leg muscles had increased, and the feet
were held rigid in an inverted position ‘with the toes
hyperextended. This spasm spread to the arm
muscles, masseters, sternomastoid, and respiratory
muscles; it was tetanic, with occasional super-
imposed twitches. The patient. was semiconscious,
responding only to painful stimuli, and her systolic
blood pressure was 65 mm. Hg. No cortical extract
was available, and 10 c.cm. of 10 per cent. calcium
levulinate solution had no effect on the spasm, which
increased in intensity. The blood chemical findings,
received about two hours after the first appearance
of the spasm, were: blood-urea 34 mg. per 100 c.cm.,
plasma chlorides 536 mg., blood-sugar, no reducing
substance present. As the peripheral veins were so
collapsed that intravenous injection was impossible,
100 c.cm. of 50 per cent. glucose solution was
administered by nasal catheter, and 8 minims of
1/1000 adrenaline solution injected intramuscularly.
The patient, who was deeply comatose by this time,
showed a dramatic response to this treatment.
Within 25 minutes of receiving the glucose she
regained consciousness and complained of great pain
in her knees. Instructions were given to continue
treatment with glucose and fluids by mouth. In the
early afternoon she was able to talk to her relatives
-but later in the day she became drowsy and relapsed
into coma. Adrenaline was injected without effect
and she died that night.
POST-MORTEM EXAMINATION
There was atrophy of both swprarenal glands, with
hyperplasia of the lymphoid tissue of the bowel, and to a
less extent of the lymph nodes throughout the body.
Both suprarenal glands were reduced to small flattened
pieces of tissue ; the left gland measured only 40 by 22 by
1:7 mm. The capsule and superficial arteries were clearly
seen, Microscopically, the glandular tissue had dis-
appeared, and only a few scattered cortical cells remained.
Some of these showed ‘proliferative activity and contained
two nuclei, while others were necrotic and undergoing
degeneration. The reticulum of the medulla with its
blood sinuses could still be made out, but only one or two
medullary cells were seen. The place of the glandular
tissue of cortex and medulla was taken by a small amount
of fibrous tissue, which was heavily infiltrated with
lymphocytes, amongst which there were a few macro-
phages and plasma cells.
The thyroid gland was of moderate size. Microscopically,
it showed extensive degenerative changes, with accumula-
tion of lymphoid tissue, an extensive fibrosis of the stroma,
and thickening of the walls of the blood-vessels. Residual
nodules of thyroid tissue remained, these being composed
of small acini lined by a single row of cubical epithelial
cells, many of which contained pyknotic nuclei and were
in the process of degeneration. Most of the acini contained
a small amount of deeply staining colloid. The liver
showed fibrosis of many of the portal spaces, which
contained giant-cells, and were surrounded by a ring of
lymphocytes. Some of the liver cells towards the central
vein showed. degeneration, and had pyknotic nuclei.
The parathyroid glands appeared normal.
Permission to examine the head was refused, so that the
pituitary gland could not be examined.
THE LANCET] DRES. ANDERSON & LYALL : ADDISON’S DISEASE DUE TO SUPRARENAL ATROPHY [May 1l, 1937 | 1041
Discussion
Cases of Addison’s disease associated with thyro-
toxicosis have only rarely been reported (Etienne
1910, Etienne and Richards 1926, and Chauffard
and Girot 1925, and Brenner 1928-29). As in the
present instance, the symptoms of Addison’s disease ©
have usually followed those of thyrotoxicosis.
The thyroid gland often shows pathological changes
in Addison’s disease although such changes as are
described show no uniformity. Crooke and Russell
(1935) described evidence of increased thyroid
activity—tubu-
lar, often
branched tubu-
lar, and rounded
acini, either
empty or con-
taining a little
coagulum, with
lymphocytic
infiltration.
Brenner (1928—
29) reported
fibrosis and
lymphocytic
infiltration of
the thyroid, the
parenchyma of
which showed
signs either of
increased or of
diminished
activity—-some-
times as much
diminished as in
myxedema, He
thought it prob-
able that the
changes in the
thyroid were due
to the same
cause as the
suprarenal
lesion, and not
secondary to loss
of suprarenal
function.
As would be
expected from
the pathological
changes in the
thyroid, the
B.M.R. is often
altered in Addi-
son’s disease.
It is usually
depressed—about —7 to —8 per cent. according
to Greene (1931). The case here recorded showed
a depression (—27 per cent.) as low as in a
fully developed case of myxcedema, and the
question arises whether the previous treatment
of the thyroid with X rays had made it more
susceptible to the degenerative changes which so
often accompany Addison’s disease.
Conversely, it may be asked whether the degenera-
tion of the suprarenal glands was in any way associated
with the previous Graves’s disease or with its treat-
ment with X rays. There is some experimental
evidence that the adrenal cortex inhibits the activity
of the thyroid. Thus Marine and Baumann (1921)
found that incomplete destruction of the suprarenal
cortex in rabbits with intact thyroids—but not in
600
on
(Sa
O
PLASMA
CHLORIDE
Na Cl. (mg. per 100 ccm)
D
O
A
gi
©
DOSE OF
CORTICAL EXT.
CORTICAL EXT(ccm)
On ROM WOON AO DW OO
DOSE OF
SODIUM CHLORIDE
Nall.(g.)
BLOOD UREA
oO
%
t
e
— aA o N
O O
W
on
`a
e
e
e
a
é
UREA (mg.
per 100 ccm.)
O
MARCH
> ı 3 5 7 9 |l 3 15 17 19 2i ?3 25 27 29 3i
Chart showing chemical findings in relation to treatment (first admission).
those with thyroids removed—cause a rise in body
temperature, and suggested that suprarenal
insufficiency might be the cause of thyrotoxicosis.
Koelsche (1934) showed that the suprarenal cor-
tical hormone inhibited the stimulating effect
of thyroxine on protein metabolism. On the other
hand, evidence is lacking that destructive lesions
of the thyroid affect the suprarenal cortex; if
they did, suprarenal insufficiency would have been
more often observed in the large numbers of
patients who have undergone thyroidectomy, or
radium or X ray treatment of the thyroid.
Apart from the
association of
thyroid disease
with Addison’s
disease, the
clinical history
of the patient
during her first
admission to
hospital pre-
sented two
other interesting
features :—
(1) She had a
strong distaste for
salt or salty food,
and it was very
difficult to make
her take salt until
she realised that
it made her feel
better. This con-
trasts with the
reports of other
observers. Thus
Snell (1934) and
Hanssen (1936)
both reported
cases with a crav-
ing for salt.
(2) The crisis
immediately fol-
lowed a menstrual
period. This rela-
tionship between
. Chlor. alone 4 g.each Sod. Chlor.
Sod.Chtor alone menstruation and
Sod Acet l increased severity
Bicart of symptoms in
Bennie Addison’s disease
has been com-
mented on by
Weller (1936), one
of whose patients
had monthly
attacks of vomit-
ing at the time
of expected, but
absent, menstrual
periods. The increase in suprarenal insufficiency is
presumably due to the added stress of the menstrual
period, which increases the need of the body for cortical
hormone.
OBSERVATIONS ON CHLORIDE EXCRETION IN
ADDISON’S DISEASE
In normal persons the excretion of chloride by the
kidneys is so controlled by the requirements of the
body that the concentration and the total amount of
chloride in the plasma and tissues is maintained at a
constant level. If the plasma concentration falls
below normal, the excretion of chloride in the urine
falls to a negligible amount. This is well shown in
a series of experiments by Aitken (1929) in which the
plasma-chloride concentrations of normal persons
were reduced by placing them on a salt-free diet and
s2
1042 THE LANCET] DRS. ANDERSON & LYALL: ADDISON’S DISEASE DUE TO SUPRARENAL ATROPHY [may 1, 1937
encouraging chloride loss by water-drinking and
sweating. When the plasma-chloride concentration
fell below 555 mg. of NaCl per 100 c.cm. the urinary
excretion of chloride reached the approximately
constant and negligible minimum of 5 mg. NaCl per
hour.
It is only rarely that the kidney excretes chloride
in anything but minimal amounts at levels of chloride
in the plasma below 530 mg. per 100 c.cm. Such
an alteration in what is usually called the ‘‘ chloride
threshold’? occurs in Addison’s disease, and
occasionally in diabetes mellitus and chronic nephritis.
In the latter diseases urinary chloride excretion
at subnormal plasma chloride levels, when it occurs,
is probably due to pathological changes in the renal
parenchyma. In Addison’s disease this chloride
loss is due to lack of the hormone of the suprarenal
cortex, one of the functions of this hormone being
the control of sodium metabolism and the distribu-
tion of body water (Harrop and Weinstein 1933,
Harrop 1936, Loeb, Atchley, Benedict, and Leland
1933). In the absence of the hormone, there is a
drainage of sodium, accompanied by chlorine, from
the body.
To demonstrate this loss of the power of the kidney
to conserve chlorides in Addison’s disease, observations
were made on our patient during her first admission
to hospital. On each occasion that a blood sample
was taken for estimation of plasma chloride, she
emptied her bladder fifteen minutes beforehand, and
then passed urine just after the blood sample had
been taken. The second specimen of urine was
assumed to represent the urinary chloride excretion
at the level of the plasma chloride found in the blood
sample. As can be seen from the accompanying
Table, urinary excretion of chloride continued for
CASE OF ADDISON’S DISEASE
Plasma Urinary
Plasma Urinary
chlorides chlorides
chlorides chlorides
(mg. NaCl per (mg. NaCl per
100 c.cm.). 100 ¢c.cm.).
Feb. 28th .. 534 .... 390 Mar. 7th .. 496 .... 470
» 29th .. 531 .... 360 a 8th .. 479 310
Mar. Ist .. 511 .... 290 a 9th .. 452 .... 270
~~ 5th .. 496 .... 700 » lith .. 438 .... 200
» Gth .. 488 .... 880 » 12th .. 502 .... 210
TWO CASES OF INTESTINAL OBSTRUCTION
Plasma Uripary
Plasma”: Urinary n }
chlorides chlorides
chlorides chlorides
enaa i
(mg. NaCl per , (mg. NaCl per
100 c.cm.). 100 c.cm.).
Pre-operative 467 .... Nil Pre-operative 470 .... 67
After opera-
tion— After opera-
12 hrs. .. 467 .... Nil tion—
oa ac Sree a5 12 hrs. .. 455 .... 60
Bo s: 452 2222 100 Of ardor cues 29
E oe 2 days .. 455 .... 16
a so DOO see. Loo as seats
8 » ae O13: .... 672 a a ate 19s
9 ” ee 580 a.o o 440 4 29 ee 557 e.e co 382
several days after the plasma-chloride concentration
had fallen well below the usually accepted minimal
normal level of about 530 mg. per 100 c.cm.
As a contrast to this case, similar observations were
made on a series of cases with high intestinal obstruc-
tion, vomiting, and hypochloremia. In both cases
presented in the Table, the urinary chloride concentra-
tion during the period of hypochloremia was very
low, below 100 mg. per 100 c.cm. As soon as the
plasma-chloride concéntration rose to above 530-
540 mg., chloride appeared in the urine in normal
amounts, confirming the observations of Aitken
(1929), mentioned previously.
a.
While such a loss of chloride-conserving power is
not specific for Addison’s disease, being sometimes
found also in nephritis and diabetes mellitus, it may
be of some value in the differential diagnosis of
Addison’s disease, especially in cases without pigmenta-
tion. In the absence of evidence of diabetes or renal
disease, the finding of a chloride concentration in the
urine of over, say, 200 mg. per 100 c.cm., when the
plasma chloride concentration is below the minimal
normal level of about 530 mg. per 100 c.cm., would
strongly suggest the presence of Addison’s disease.
SPONTANEOUS HYPOGLYCÆMIA IN ADDISON’S DISEASE
The striking terminal phenomena after the patient’s
second admission to hospital were the coma and
generalised muscular spasm, associated with severe
hypoglycæmia.
Similar symptoms in the course of Addison’s
disease have previously been reported. Thus, in
the first of the cases reported by Weller (1936) there
was drowsiness and spastic contraction of the right
arm, which Weller associated with the hypoglycæmia
noted in the patient during a previous admission to
hospital. In the sixth of the cases reported by
Hanssen (1936) there was an episode almost identical
with the symptoms shown by our patient.
The patient, a woman of 47, with Addison’s disease
of tuberculous origin, became confused and maniacal,
and developed paralysis of the right arm and a bilateral
extensor plantar response. Blood-sugar determina-
tions made during the course of this episode showed
values as low as 40 mg. per 100 c.cm., and the
symptoms cleared up after the rectal administration
of glucose. Hanssen suggested that the sudden
death which‘ sometimes occurs in Addison’s disease,
with no hemoconcentration or other blood chemical
findings characteristic of crisis, might be due to
spontaneous hypoglycaemia.
Investigation of suprarenalectomised animals has
shown that, in certain species at least, removal of the
suprarenal glands causes a profound disturbance in
carbohydrate metabolism. Britton and Silvette
(1932) have demonstrated that in the guinea-pig and
cat suprarenal insufliciency is accompanied by reduc-
tion in liver glycogen and blood-sugar, and that
animals dying of suprarenal insufliciency show
convulsive seizures similar to those observed in
insulin hypoglycemia. These authors consider that
the convulsions are related to the hypoglycemia,
which, in their opinion, is the immediate cause of
death. Similarly, Harrop and others (1935) have
shown that in suprarenalectomised dogs, maintained
either with cortical hormone or with salt, fasting
produces weakness and coma, associated with extreme
hypoglycsemia, but with no fall in plasma sodium or
chlorides and no rise in blood non-protein nitrogen, and
that glucose injection rapidly relieves the symptoms.
Recent work (Britton and Silvette 1934, Buell,
Anderson, and Strauss 1936) has shown that animals
suffering from suprarenal insufficiency have lost the
ability to form liver glycogen from injected glucose
or sodium lactate. The weight of evidence therefore
suggests that the suprarenalectomised animal develops
hypoglycemia because it cannot form liver glycogen
as a store to maintain its blood-sugar level. Since
anorexia is common in Addison’s disease, the failure
to form liver glycogen from endogenous sources
may well be the cause of the hypoglyczmia so often
noted in this disease, and may explain the occurrence
of coma in the absence of any changes in blood volume
or plasma electrolytes.
In our patient, the plasma chlorides and blood-
urea were both within normal limits at the time
i gine ei 2 at ate =
THE LANCET]
of the terminal symptoms, and thus two of
the characteristic blood chemical findings of an
Addisonian crisis were lacking. On the other hand,
there was extreme hypoglycemia, and we hold that
the coma and muscular spasm can be directly related
to the hypoglycemia. Although serum calcium
and plasma alkaline reserve determinations were not
carried out, the muscular spasm was obviously not of
the nature of tetany, since it was unrelieved by
calcium injection and the dramatic recovery of
consciousness and the disappearance of the spasm
after the administration of glucose and adrenaline
made the diagnosis of hypoglycemia certain.
It is less certain whether the fatal termination
in spite of glucose treatment can be attributed to
hypoglycemia, but Rabinovitch and Barden (1932)
have reported a case which seems to make this
opinion at least tenable. Their patient, a youth
of 17, suffered from spontaneous hypoglycemia,
due to replacement of the suprarenal medulla by
lymphoid tissue. He developed coma and spastic
contraction of the right arm, with a blood-sugar
concentration of 25mg. per 100 c.cm. Recovery of
consciousness followed continuous intravenous glucose
infusion, but the blood-sugar remained low despite
this treatment, and he finally relapsed into coma and
died. In this case the suprarenal cortex was com-
paratively undamaged, so that Addisonian crisis
can be excluded as the cause of death.
Summary
A case of Addison’s disease due to suprarenal
atrophy and preceded by thyrotoxicosis is described.
Death occurred in hypoglycemia.
It is suggested that simultaneous determinations
of the plasma chloride and urinary chloride concentra-
tions are of value in the diagnosis of early cases of
Addison’s disease.
We are indebted to Prof. Stanley Davidson for permission
to publish this case, and to Dr William Davidson for the
post-mortem report.
REFERENCES
Aitken, R. S. (1929) J. Physiol. 67, ae
Blankenhorn, M. A., and Hayman, J. M. (1935) Amer. J. med.
Brenner, O (1928-29) Quart. J. Med. 22, 121.
Britton, 8. w, aog ne: a, H. (1982) Amer. J. Physiol. 100, 701.
Buell, M. he peel T "A., and Strauss, M. B. (1936) Ibid,
Chauffard, A., and Girot, L. AS, quoted by Rolleston.
Crooke, A. C., 'and Russell, S. (1935) J. Path. Bact. 40, 255.
Etienne, G. (1 910), Etienne, D and Richards, G. (1926) quoted
by Rolleston.
Greene, C (1931) Proc. Mayo Clin. 6, 305.
Hanssen, po (1936) Acta med. scand. 89, 426.
Harrop, G. A. 1936) Ball. Johns Hopk. Hosp. 59, 25.
Soffer J., Nicholson W. M., and Strauss, M. B.
(1935) J exp. Med. 839.
— and Weinstein, A. *(1933) Ibid, 57, 305.
Kepler are J. (1935) Arch: intern. Med. 56 109:
Bornea e, G. A. ee Mayo Clin. 55.
mnie pose an W., Benedict, É. M., and Leland, J.
DT ep 57, 775.
Marine D and Eon h, J. ee anes J. bes sae 57, A
Rabinovitch, J., and Barden, F. W. (1932) Amer. . med.
Rolleston, H. D. (1936) The Endocrine Glands in Health and
Disease, London.
Snell, A. M. (1934) Proc. Mayo Clin. 9, 303.
Swingle, W. W., Pfiffner, J. J., Vars, H. M., and Parkins, W. M.
so) Science, 77, 58.
Weller. T . (1936) Arch. intern. Med. 77, 275.
TORBAY HOSPITAL.—LEHight acres of land on the
western side of this hospital have been purchased.
Accommodation is being provided for another 22 patients
and a public appeal for the funds has brought in enough
to liquidate the amount due to the contractors. About
£6600 has been obtained from the contributory asso-
ciation. The out-patients’ attendances reached 36,718,
over 10,000 more than three years ago.
DR. COOMBS AND OTHERS: DIETARY CONTROL IN URINARY INFECTION [may 1, 1937 1043
TREATMENT OF URINARY INFECTION
THE IMPORTANCE OF DIETARY CONTROL
By HERBERT I. Coomss, B.Sc. Oxon., Ph.D. Camb.,
M.D. Harvard
CHARLES H. CATLIN, M.B. Birm., D.A.
AND
DorotHy READER, M.B. Birm.
(From the Bocheniec Laboratory, The Queen’s Hospital,
Birmingham)
Many of the methods of treating urinary infection
have necessitated some control over the reaction of the
urine. A satisfactory degree of alkalinity can usually
be produced by the administration of sodium
bicarbonate or potassium citrate provided adequate
dosage is employed, but acidification has always
been much more difficult to achieve. Control of the
acidity of the urine became important with the
introduction of the use of hexamine, but strict control
has only been attempted since the adoption of the
ketogenic diet and mandelic acid treatment.
When hexamine was first used, the somewhat
obvious agent acid sodium phosphate was generally
employed to acidify the urine, and this drug has had
a wide vogue ever since. Some doubts however
were cast on its efficacy as early as 1913 (Henderson
and Palmer), and since the work of Haldane (1921)
the administration of ammonium salts, such as the
chloride, nitrate or, more recently, phosphate, has
gained favour.
Diet, apart from drugs, also markedly influences
the reaction of the urine, ‘and can, if suitably arranged,
nullify or reinforce the action of drugs.
KETOGENIC DIET
In 1931 Clark investigated the effects of giving
patients a diet containing a large quantity of fat
but the minimum of carbohydrate. This lack of
carbohydrate causes incomplete combustion of the
fat, with the result that certain acids, of which
-hydroxybutyric acid is the most important, appear
inthe urine. These acids fulfil two purposes, they make
the urine acid and they act as bactericidal agents.
Very satisfactory results were obtained by this
method but the diet is extremely unpleasant and
many patients have difficulty in tolerating it. In
order to eliminate the troublesome dietetic régime
attempts were made to administer the ($-hydroxy-
butyric acid by mouth, but it was found, as expected,
that it is completely oxidised in the body and does
not appear in the urine. Rosenheim (1935), however,
discovered in mandelic acid an excellent substitute
which can be given by mouth and yet escape oxidation
and appear in the urine in sufficient quantity to be
effective. With this drug the need for a low pH
still exists, and it is probable that many failures of
mandelic acid treatment are due to the inadequate
acidification of the urine. Some investigators have
thought that a modified ketogenic diet might serve to
lower the pH of the urine sufiiciently for the mandelic
acid to be effective. Actually unless this type of
diet is imposed with the utmost rigour and care it
has no effect whatever on the reaction of the urine,
even comparatively slight variations from the strict
régime rendering it entirely valueless.
OTHER DIETARY MEASURES
There are, fortunately, other dietetic methods of
changing the reaction of the urine which are easily
tolerated.
1044 THE LANCET]
For the past thirty years considerable knowledge
of the mineral content of foods has been available
but seems to have been given little practical applica-
tion. Nearly all foods contain acid- or alkali-
producing elements in varying proportions, so that -
after oxidation there remains an ash having a pre-
ponderance of acidity or alkalinity. Sherman and
Gettler (1912) investigated the composition of many
foods and, by estimating the sodium, potassium,
calcium, magnesium, sulphur, phosphorus, and
chlorine content, were able to calculate the excess
of acidic or alkaline radicals present (see Table).
Table showing Acid-base Balance of Foods
Equivalent acid or alkali per 100 grammes edible foodstuff.
ALKALI-PRODUCING FOODS
Normal Normal
Foodstuff. alkali Foodstuff. alkali
(c.cm.) (c.cm.)
Almonds. 11:3 Horse- ree aie te (SOO
Apples.. e. .. 34 Jelly .. ce . 36
Apricots .. .. .. 72 Leeks . 71
Asparagus .. . 13 Lemons 4'8
Bananas as eS ae! COA Lemon juice 4°6
Beans, dried ze a dE Lettuce TT
y fresh string 5'6 Limes . 11°5
Beets .. ; 11°1 Maple syrup 12°5
Blackberries 3°5 Milk, cow’s, whole 1°8
Cabbage .. 4°3 a s skimmed 1:7
Cabbage grecns . 2'8 » ” condensed 4'3
Cantaloupe 152 s» goat’s .. 59
Carrots is 10:9 „ human . 08
Cauliflower . wer. 53 Molasses . 316
Celery . : ce eee Ro Mushrooms.. ©. P4
Cherries, red. oe 56 Musk-melon . 7S
Chestnuts .. .. .. 12°6 Olives .. . 48°0
Chocolate es 7'9 Oranges . 61
Cider .. 3°5 Orange juice . 57
Citron .. os 9°9 Parsnips . . 11°4
Cocoa . ea 5°7 Peaches; fresh . 58
Coconut, dried .. 2°3 Pears .. . 3I
i fresh 2'2 Peas, dried. ; 27
Cream we we. we -FA Pineapple ae «cae 69
Cucumber .. -. 1°3 Potatoes .. .. .. 82
Currants, dried . .. 16°6 Pumpkin .. .. .. 15
fresh .. .. 4°9 Radishes .. .. . 4°7
Currant juice 5°33 Raisins we Che: te Zee
Dandelion .. 18°8 Rhubarb... .. 9°2
Dates .. 12°6 Spinach ees ee 22°9
Endive gi 11°4 Strawberries š 6°7
Figs, dried . 28°4 Tomatoes . 53
» fresh. e eo 94 Turnips ae ee ND
Grape-fruit. . se ee 4°) Turnip tops . 18°9
Grape juice.. ws 29 Watercress.. - 1173
Grapes Sre 3'8 Water-melon “gee O2
Hazel-nuts . 5'4 Whey : se ‘ae. 82
Honey we 9°5 Wine, average ee eae 2
Jams have approximately two-thirds the values of the corre-
sponding fruits.
l ACID-PRODUCING FOODS
Barley, pearl
« “OL Meat— '
Bread, white .. .. 65 Bacon .. .. .. 78
wholemeal .. 6'8 Beef.. .. .- .. 10°0
Cake, plain.. - 43 Chicken .. .. .. 10°7
Cheese... .- .. « 76 Ham, boiled .. .. 10°0
.Clamse, round .. . 4'1 » Mediumfat.. 84
soft long.. - 69 » medium
Cornflakes .. .. . 54 enone 8'3
Corn (maize), sw eet . - 23 » smoked 9'6
Crackers .. .. 96 Liver a” ee L
Doughnuts... wel. T3 Pork, lean - 10°0
Egg, white.. - 63 Veal.. .. «- 10°8
» whole.. Pe ae | Meat peptone a ae -035
» yolk .. 32°6 Mustard i Mee, eb TO
Fish— Oatmeal .. .. .. 16°3
Cod, salt.. 12°7 Oysters ae CES 10°5
Haddock. . 8°5 Peanuts g ‘ 4°]
Halibut .. .. 93 Rice, brown 9°3
Herring, smoked .. 10°0 » puffed . .. 90
Mackerel. : sa (eS » White... .. .. 90
Salmon, fresh. .. 11°0 Spaghetti .. .. .. 97
5 tinned ss 10°77 Walnuts .. .. x 7°8
Sardines . te os ES Wheat, bran . 10°5
Smelts š ©. 8&7 » germ .. « 19°3
Flour, white ; 11°1 » puffed .. - 110
š wholemeal 111 es saredded ©. 12°2
Lentils, dried .. .. ie i whole .. .. 135
Macaroni .. ..
Cranberries, plums, prunes.
NEUTRAL FOODS
Butter, cornflour, fresh peas, lard, onions, sugar, tapioca,
vegetable oils.
The above Table is compiled from several sources but
is calculated almost entirely from the sodium, potassium,
DR. COOMBS AND OTHERS : DIETARY CONTROL IN URINARY INFECTION
[may 1, 1937
magnesium, calcium, sulphur, phosphorus, and chlorine
figures given recently by Sherman (1932).
Their results were expressed in terms of the number
of cubic centimetres of normal acid or alkali available
from 100 grammes of each food. The residue resulting
from oxidation within the body is excreted by the
kidneys and intestine, and thus tends to influence
the reaction of the urine. With most foods the
effect on the urine is exactly as the ash analyses
would lead us to expect, but a few fruits—i.e., plums,
prunes, and cranberries—act as acid-producers in
the body in spite of yielding an alkaline ash. This
apparent anomaly is explained by the fact that these
fruits contain appreciable quantities of benzoic
acid which escapes oxidation in the body and is
excreted in the urine in conjugation with glycine
as hippuric acid.
METHODS OF INVESTIGATION ~
A number of healthy men and women were placed
on acidogenic and alkalogenic diets similar to those
shown herewith.
AOIDOGENIO DIET
Breakfast.—Porridge or cereal with sugar and cream.
Bacon and egg, bacon and kidney, or fish. Bread and
butter.
Lunch.—Meat, chicken, or fish, or omelette (cheese or
savoury). Stewed prunes and cream. Bread and butter.
Cheese and biscuits.
Tea.—Minimum of tea with sugar and cream. Bread
or toast with butter, or egg or sardine sandwiches.
Supper.—Meat or fish or cheese. Bread and butter.
Walnuts. Minimum of coffee with cream and sugar.
ALKALOGENIC DIET
Breakfast—Half grape-fruit or orange with sugar.
Mushrooms and tomatoes on minimum of toast. Mixed
fruit—dates, apples, or bananas. Tea with milk and sugar.
Midmorning.—Glass of milk with apple or banana.
Lunch.—Vegetable soup (celery, tomato, parsnips,
turnips, onions, &c., but no meat stock, barley, or lentils).
Green salad (tomato, cress, lettuce, cucumber, celery).
Date and almond salad; baked apple, stewed fruit and
junket, or raw fruit.
Tea.—Tea with milk and sugar.
vegetable salad or fruit salad.
butter.
Supper.—Vegetables en casserole (onions, carrots,
turnips, tomatoes, &c.). Potatoes. Stewed fruit and
cornflour mould, raw fruit or almonds and raisins. Coffee
with milk and sugar. Golden syrup may be taken with
any meal.
Green salad, raw
Minimum of bread and
The urine was collected at two-hourly intervals
throughout the day and the pH of each specimen
determined colorimetrically with as little delay as
possible, The essential features of the acidogenic
diet are the inclusion of meats, fish, bread, cereals,
cheese, butter, and eggs, with plums, prunes, and
cranberries as dessert. All of these foods have a
comparatively low water content so that it was easy
to arrange that subjects on this diet had a low urinary
output. On the other hand the main articles of
food in the alkalogenic diet—namely, potatoes,
milk, fruit, and vegetables—all contain a large
quantity of water and this makes it somewhat difficult
to ensure a very low urinary output. Fortunately,
as explained below, this is not of great consequence.
RESULTS
The results of an experiment on a healthy male
are given herewith (Fig. 1) and similar results were
obtained with several other individuals.
It will be seen that a normal person can render
his urine relatively alkaline or markedly acid merely
THE LANCET] DR. COOMBS AND OTHERS: DIETARY CONTROL IN URINARY INFECTION [may 1, 1937 1045
by suitable selection of his food. It is clear that the
attainment of an acid urine by the administration
of drugs would be far more difficult in a person on a
vegetarian diet than in one on a mixed diet. In
order to test this point further the urine of individuals
on an alkalogenic diet was collected and sufficient
normal hydrochloric acid added to each sample to
bring the pH to 5:3. On the average the total
volume required to be added to the 24 hours’ output
of urine was about 75 c.cm. which is equivalent to the
daily dose of ammonium chloride usually prescribed
namely, 4 grammes. It can thus be seen that, in
a patient eating a vegetarian diet, this dose will only
be effective in producing a highly acid urine under
ideal conditions. As shown in Fig. 1, however, it
is possible to maintain the reaction of the urine
below 5-3 by diet alone. If drugs are used the diet
will reinforce their effect.
Experiments were carried out to ascertain the
effect of the ingestion of various amounts of water
on the reaction of the urine. It was found that
dilution of urine with distilled water in vitro has very
little effect on the pH. Urine of pH 5, even when
diluted tenfold, which is far outside usual physio-
logical limits, generally changes to pH 5-2. Moreover,
in the experiment shown in Fig. 1 the subject restricted
his fluid intake during all days on the acidogenic
diet with the exception of Nov. 3rd. On this day
large quantities of fluid were taken but it will be seen
that the effect on the reaction of the urine is not
very great. Even this small decrease of acidity
is of importance, however, and patients on an
acidogenic diet should restrict their fluid intake as
much as possible not only to achieve the maximum
acidity but, more important, to keep the urinary
concentration of mandelic acid, or other antiseptic
which may be prescribed, as high as possible. When
alkaline drugs are being administered the small
ACIDOGENIC
=
ALKALOGENIC DIET
PH OF URINE
A on D ~
on oO on on
, z=
o
m
-=
3
NOVEMBER
oranges and
PRACTICAL APPLICATION
' The above facts were demonstrated on several
patients. Allowing them their own selection of
diet and placing no restriction on “acid fruits”
such as
| ACIDOGENIC DIET ———>
lemons it was TS
found that the
average pH of
the urine was
5-5 or even 6
under the usual
dosage of man-
delic acid
preparations. t0 il 12 3 14
On correcting DAY IN HOSPITAL
the diet the pH FIG. 2.—The effect of an acidogenic diet
a on the e of a patient receiving man-
could be main delic acid. Before the diet the average
tained below pH was 5'8. Each day began at noon,
5-3 These just before lunch. Up to and including
> ; the tenth day in hospital the patient
facts are illus- selected his own diet. On the following
trated by the days an acidogenic diet was given.
following case.
pH OF URINE
An otherwise healthy male, aged 22 years, complained
of severe pain in the right loin. During the next fort-
night he suffered intermittently from this pain and had
a widely swinging temperature. He then passed a small
stone and noticed that his urine was cloudy. Alkalis were
administered for the next month but without effect. He
was referred to hospital and placed on the usual dosage
of a well-known preparation of mandelic acid containing
phosphates as an acidifying agent. During the next
ten days it was noticed that the average reaction of the
urine was about 5:8. On the tenth day of his stay in
hospital the urine was collected at three-hourly intervals
throughout the day and night. On the eleventh and
subsequent days the patient was given an acido-
genic diet. No other alteration was made in the
treatment and the satisfactory change of the reaction
of the urine is shown in
ACIDOGENIC DIET Fig. 2.
The above results show
that the reaction of the
urine can be much in-
fluenced by the diet both
in normal persons and in
patients suffering from
urinary tract infections.
It would seem expedient,
diet in all cases where
the maintenance of an
FIG. 1,—Effect of acidogenic and alkalogenic diets on the urine of a healthy male. Each day ; : : ‘
began at 8 A.M., junt before pe Toat 7 DYOR eres ane eres eu thè pemp lots cei se or ise a Wa 18
ment for reasons of space. ine is drawn at pH 5'3 and reactions above and below S importance. n man
line are shaded. On all days when an acidogenic diet was taken fluid was restricted except oh) Ae sas i of e
on Nov. 3rd when large quantities of fluids were taken. This has the effect of slightly raising Cases t control oO €
the pH. It will be noticed that about 40 hours of an acidogenic diet were required on Nov. diet need not be rigid,
13th and 14th to “ wash out ” the effect of the previous ten days’ alkalogenic diet. After ligh é ; hich
this the pH of the urine did not rise above 5'3 except for 2 hours on Nov. 15th, when it slight modifications whic
rose to 6'3.
effect of dilution on the reaction of the urine can
be disregarded, as clinical experience seems to show
that a marked diuresis is essential in the treatment
of cases in which these drugs are used.
It will be noticed that there is very little evidence
of acid or alkaline “‘ tides’ in the above results, but
on some occasions unexplained variations of pH
occurred at approximately similar times of the day.
These variations were probably connected with the
habits of the individual. There is no doubt that the
usual acid or alkaline “ tides’? must be dependent,
to a great extent, on the activity of the individual,
the times at which meals are taken, and especially
on the nature and quantity of the food ingested.
are hardly noticed by
the patient often being
sufficient. It has been found that a strict alkalo-
genic diet can be taken for long periods without
inconvenience. <A strict acidogenic diet, however,
may sometimes result in slight gastric discomfort,
but this, together with the slight dyspnea which
often occurs, may be a manifestation of the acidosis
and therefore inevitable. |
SUMMARY
(1) Urine can be rendered and maintained relatively
alkaline or highly acid by administration of diets
composed of alkali- or of acid-producing foods.
(2) Modifications of diet for this purpose are often
useful in the treatment of urinary tract infection.
therefore, to adjust the -
1046 THE LANCET]
(3) A table of acid- and alkali-producing foods is
presented.
ee
Clark, A. ee 1) Proc. Mayo Clin. 6, 605.
Haldane, J. B. S. (1921) J. Physiol. s3, 265
Henderson, L. J., and Palmer, W. W. (2913) J. biol. Chem.
Rosenheim, M. L. (1935) Lancet, 1, 1032.
puer man, H.C. (1932) Chemistry of Food and N utrition, 4th ed.,
ew
ork.
— and Gettler, A. O. (1912) .7. biol. Chem. 11, 323.
JAUNDICE COMPLICATING PNEUMONIA
WITH SPECIAL REFERENCE TO JAUNDICE WITH
CHOLAMIA AND ITS TREATMENT
By C. ALLAN Brirou, M.D. Liverp.,
M.R.C.P. Lond., D.C.H., D.P.H.
' SENIOR PHYSICIAN, NORTH MIDDLESEX COUNTY HOSPITAL
JAUNDICE is not a common complication of pneu-
monia. Amongst 860 cases of lobar pneumonia and
broncho-pneumonia in the last three years at the
North Middlesex County Hospital only 2 were recorded
in which severe jaundice was thought to be a direct
complication of pneumonia. One is described in this
paper and in the other the patient died shortly
after admission. A slight icteric tinge is seen more
often, and Elton (1931) has shown that latent jaundice
as manifested by the van den Bergh reaction is almost
constant in pneumonia.
Many workers have investigated the cause of
jaundice complicating pneumonia. Preti (1932)
concludes that in pneumonia bilirubin may be formed
in the lung itself and by entering the circulation
may give rise to clinical jaundice. Chierici’s (1932)
findings, too, suggest that during the stage of red
hepatisation bilirubin is formed outside the liver in
the pneumonic focus. Mangeri (1931) was able to
increase the bilirubin content of the blood in animals
by injections of blood into the air-passages. Bruni
(1929) thinks that jaundice in pneumonia should be
classified as secondary acquired hemolytic jaundice.
. Pisani (1930) concludes from a study of 9 cases of
visible jaundice in a series of 54 cases of pneumonia
that jaundice can be caused by toxic damage to the
liver parenchyma, by venous stasis in the liver
_ and by increased haemolysis and also by angiocholitis
' due to penetration of pneumococci to the bile- ducts.
Cases of jaundice due to the last cause have been
recorded by Lemierre and Abrami (1910) and by
“Ardin-Delteil (1909). Jaundice may also be due to
causes unassociated with pneumonia and, indeed,
a case has been recorded (Lambert and Secretan
1932) in which it followed pneumonia and was due to
an aneurysm of the hepatic artery pressing on the
common bile-duct. Harris (1927) using dye tests
showed that high temperature itself did not influence
Jiver function and concluded that liver insufficiency
in pneumococcal pneumonia was due to an accom-
panying toxemia which damaged the liver. There
was no alteration in liver function in advanced
phthisis indicating that structural changes in the
lungs did not play a part in producing liver
inefficiency.
Anyone who sees many cases of pneumonia knows
that cases with jaundice fall into two clinical groups
—first, those in which the jaundice is slight and
of no particular importance, and secondly, those in
which it may herald a fatal issue. In a recent paper
Coope, Osborn, and Pygott (1936) concluded that
while some patients with pneumonia could suffer
DR. C. A. BIRCH: JAUNDICE COMPLICATING PNHUMONIA
_ [may 1, 1937
some liver damage and yet survive, nevertheless an
-~ increase of bile in the blood stream did indicate a
disturbance of liver function with a worse prognosis.
Alexander (1927) says :—
“ A slight degree of jaundice often exists and is of no
particular importance. When jaundice is marked it has
been stated by many observers that it indicates a bad
prognosis. It is usually due to a duodenal catarrh leading
to obstruction of the bile-duct, but it is possible that in
some of the most severe cases ‘the jaundice is dependent
upon the hemolytic action of the pneumococcus. Unfor-
tunately very little treatment is available in the latter
type of jaundice.”
In the present paper I am concerned chiefly with
jaundice of serious nature. Such cases are recognised
clinically by the associated symptoms of cholæmia
and not by any special laboratory test. The clinical
picture of cholæmia is not very clearly defined in
pneumonia since it is complicated by the symptoms
of the causal condition.
In diseases primarily affecting the liver such as
acute necrosis the first symptom of cholæmia or
failure of liver function is usually intense malaise.
The patient is irritable and later apathetic. His
skin is dry and muddy. The pulse-rate rises and
there may be slight pyrexia, then anorexia, vomiting,
jaundice, and constipation appear. In the final
stage the patient is incoherent and delirious and
has a subnormal temperature. Convulsions may
occur. Sometimes there is air-hunger from acidosis,
and also diarrhea and tympanites. Leucine and
tyrosine crystals may be found in the urine after
alkalinisation. Hamatemesis may occur, and the
general hemorrhagic tendency associated with acute
destruction of liver tissue has been called ‘‘ pseudo-
hemophilia hepatica’? (Whitby and Britton 1935).
PATHOLOGY
It is well known that the liver is susceptible to
many toxins and that its cells are very prone to show
necrosis. In acute infectious diseases such as pneu-
monia cloudy swelling is an early change. In severe
infections including pneumonia actual necrosis of liver
cells occurs. Hurst and Simpson (1934) described a
boy suffering from a myopathy who died,of broncho-
pneumonia complicated by jaundice. The histological
changes in the liver were cloudy swelling and slight
fatty changes, and in addition parietal zonal necrosis
showing swollen granular cells containing karyolytic
and pyknotic nuclei. Autolytic changes occur rapidly
in the liver after death but in some cases of uncom-
plicated pneumonia in which it was possible to
examine the liver within a few hours of death and
in which autolytic changes were minimal definite
necrotic changes were found. When severe jaundice
complicates pneumonia therefore we may assume
that some hepatic necrosis is present.
TREATMENT
Although the outlook in cases of cholemia is
usually considered to be hopeless I think that there
is reason for not adopting a fatalistic outlook. Under
treatment recovery may occur and the essential points
in such treatment are the administration of glucose,
insulin, and calcium, plus measures to combat circu-
latory failure.
Glucose.—The administration of glucose in liver
disease is a well-established form of treatment, since
it is known that the liver parenchyma is protected,
if incompletely, from the action of toxins when it
contains a good store of glycogen. Davis and Whipple
(1919) proved that the immediate nutritional- state
influenced the effect of potential liver poisons by
THE LANCET]
showing that the destructive action of chloroform
on the liver was intensified by previously with-
holding food. Newman (1928) showed that a series
of cases in which jaundice followed chloroform
administration had all been prepared for operation
by starving and purging.
In order to protect the liver glucose should be given
in large doses. Satke (1933) recommends up to
100 c.cm. of a 10 to 20 per cent. solution of dextrose
intravenously but even this amount would seem to be
too small. Some idea of the amount required may
be obtained from the experiments of Mann and
Magath (1922). These workers showed that dogs
after complete hepatectomy developed twitchings
and other evidence of hypoglycemia which could be
relieved by the injection of glucose at the rate of
0:25 g. per kg. body-weight per hour. A patient
with severe cholemia is comparable to a dehepatised
animal and if he weighed 70 kg. he would need,
on the basis of 0-25 g. per kg. per hour, 620
grammes of glucose in 24 hours.
If the patient is able to swallow it is easy to
administer large amounts of sugar by mouth in the
form of fruit drinks and barley-sugar. It is difficult
to give much glucose by the rectum since solutions
which are hypertonic—i.e., stronger than 5 per cent.
—-are absorbed with difficulty and cause irritation.
In very ill patients glucose must be given parenterally
and this is best done by the intravenous injection
of a 30 per cent. solution warmed to body tempera-
ture. If pure dextrose is dissolved in distilled water
and autoclaved for twenty minutes it can be given
quite safely by the intravenous route. It is true
that such a solution has been used to cause thrombosis
of varicose veins but there is no danger of thrombosis
in the arm if some normal saline is injected before
removing the needle. In the case described below
no symptoms occurred which could be attributed
to lowering of intracranial tension by the hypertonic
glucose.
Dextrose given intravenously immediately raises the
blood-sugar above the renal threshold and hence some
dextrose is lost in the urine. MacLachlan, Kastlin,
and Lynch (1932) found that patients with acute
lobar pneumonia could be given 25 per cent. glucose
in normal saline continuously by the intravenous
method and that it was utilised at the rate of 50—60 g.
per hour. If it was given slowly enough no glucose
appeared in the urine. Incidentally the above workers
concluded that glucose was of no value in the treat-
ment of pneumonia and if this is true any good
effects in cases of pneumonia with jaundice must be
ascribed to its ability to combat the liver condition.
Wilder and Sansum (1917) found that if glucose was
given intravenously at a rate more rapid than 0:35 g.
per pound body-weight per hour some was excreted
in the urine. This would allow a ten-stone man
about 166 c.cm. of 30 per cent. glucose per hour.
This slow rate of injection is not always practicable
and I have found that in normal persons not more
than 5 g. of å total amount of 50 g. in 50 per cent.
watery solution given intravenously at a rapid rate
are lost in this way. More is probably lost in patients
with liver disease but not sufficient to vitiate this
form of administration. :
Insulin.—Experimental work concerning the effect
of insulin on the carbohydrate metabolism of the
liver is somewhat contradictory. It seems probable,
however, that insulin favours the storage of glycogen
in the liver when plenty of dextrose is available. It
has been shown that glycogen will accumulate in
the livers of depancreatised dogs but that the rate
of glycogen formation is greatly accelerated if insulin
DR.-C. A. BIRCH: JAUNDICE COMPLICATING PNEUMONIA
' [may 1, 1937 1047-
is given and it is probable that the deposition of liver
glycogen is in large part due to the action of insulin.
Umber (1922) used insulin and glucose in 38 cases of
subacute yellow atrophy with 4 deaths. In one
case a biopsy of the liver was performed and showed
swollen pale granular liver cells containing bile-
pigment and fat globules in the Kupffer cells. Icterus
was severe and death seemed imminent. Thirty
units of insulin twice a day and a rich carbohydrate
diet were followed by a cure.
Calctum.—Minot and Cutler (1929) were able to
produce acute hepatic insufficiency in dogs by the
administration of carbon tetrachloride and the toxic
manifestations shown by the animals closely resembled
those of cholemia in human beings. They also
showed that dogs could be protected against the
effect of carbon tetrachloride by the administration of
calcium and also that dogs with early symptoms could
be cured by calcium therapy. They concluded that,
while it was improbable that the pathological lesions
caused by the continued action of hepatic poisons
could be prevented by calcium, acute hepatic intoxica-
tion was unquestionably beneficially influenced by
calcium. Cantarow (1933) says he has used calcium
therapy in two patients with subacute yellow
“ atrophy ”? with “ brilliant and dramatic results.”
He recommends 10 c.cm. of 10 per cent. calcium
gluconate intravenously. The folowing are the
details of a case of cholæmia complicating lobar
pneumonia treated by glucose, insulin, and calcium.
The rarity of the condition and consequent lack of
opportunity for further trial prompts me to record
the details of treatment of a single case.
CASE RECORD
A man aged 44, a taxi-driver by occupation, .was
admitted to hospital on Dec. 9th, 1933, having been ill
for four days with chills. and pains in the left chest.
Tomp., 100° F.; respirations, 32; pulse-rate, 120;
blood pressure, 160/80. Pleural friction heard in the
left axilla and ample evidence of consolidation at both
bases. On the 10th 300 c.cm. of air was injected into
the left pleural cavity with rapid relief of pain. On
the 12th slight jaundice appeared. He was given
250 c.cm. of 30 per cent. glucose and 50 units insulin
intravenously. On the 13th he was deeply jaundiced.
The temperature had fallen to 98° F. by lysis. The pulse-
rate was about 110 and regular, Blood pressure 110/60.
The heart sounds were distant. There was no evidence
of fluid in the pleural sacs. He was in a state of constant
delirium. The van den Bergh reaction was prompt
direct positive. Bile-pigment and salts were present
in the urine and the fæces were coloured. Another
intravenous injéction of 250 c.cm. of 30 per cent. glucose
and 50 units insulin was given. |
On Dec. 14th he appeared moribund. He vomited a
little and was comatose, The general appearance and
odour were those usually associated with dying patients.
The odour may have been the ‘fostor hepaticus ”
described by the old clinicians, On this day he received two
intravenous injections of 560 c.cm. of 30 per cent. glucose
with 100 units insulin and 10 c.cm. of 10 per cent. calcium
gluconate intravenously. He also had five intramuscular
injections of 1:7 c.cm. Coramine. On the 15th he seemed
a little better though jaundice was still marked and he
was comatose for long periods. At 2.30 p.m. he received
250 c.cm. of 30 per cent. glucose and 50 units insulin intra-
venously and at 10.30 p.m. 540 c.cm. of 30 per cent.
glucose and 50 units insulin and 10 c.cm. of 10 per cent.
calcium gluconate intravenously.
On Dec. 16th he was much dehydrated and showed
evidence of circulatory failure and was given 560 ¢.cm.
of 5 per cent. glucose in saline from a Crookes’ ampoule.
At 8 p.m. 400 c.cm. of 30 per cent. glucose and 60 units
insulin were given intravenously. He was extremely
drowsy and seemed to be dying. Sugar was present in
the urine. On the 17th he received a total of 600 c.cm.
| 1048 THE LANCET] |
_of 30 per cent. glucose and 120 units insulin intravenously.
. On the 18th he seemed better and again received intra-
venous injection 600 c.cm. of 30 per cent. glucose and
200 units insulin. On the 19th he was able to take
500 c.cm. of 30 per cent. gluco$e diluted in lemonade by
mouth during the day. On the 20th he refused 30 per
cent. glucose by mouth but took about 500 c.cm. of a
10 per cent. solution of glucose in 0:5 per cent. sodium
chloride iced and flavoured with lemon juice. He was
also given 420 c.cm. of 30 per cent. glucose and 100 units
insulin intravenously.
On Dec. 2lst he was given 360 c.cm. of 30 per cent.
glucose and 100 units insulin intravenously. By this
time he was very much improved and no further intra-
venous injections were given. He was able to take
small amounts of food by mouth. He was seriously
dehydrated and took considerable quantities of the
glucose saline drink. The jaundice gradually disappeared.
He was discharged on Feb. 15th, 1934, after a stay of
nine weeks,
On Jan. 9th, 1934, the levulose-tolerance test was
carried out. The fasting blood-sugar was 126 mg. per
100 c.cm. Fifty grammes of levulose was given by mouth,
and after one hour the blood-sugar was 144 mg. and after
one hour it had fallen to the fasting level indicating a
normally functioning liver.
The accompanying Table shows the amounts of
glucose, insulin, and calcium used.
Table showing Treatment
Glucose
Date : . Calcium
in ee eee gluconate, Other treatment.
Dec 30 % . ? i 10 % s
c.cm. c.cm
12th 250 50 — —
13th 250 50 = —
14th 560 100 10 —
560 100 — —
15th 250 50 — —
540 50 10
16th 400 60 — 560 c.cm. 50 % glucose
in Rora saline intra-
venously. l
17th 300 60 — —
300 60 — —
18th 300 100 — —
300 100 —
19th — — — le ian a % glucose
y mouth.
20th 420 100 — —
21st 360 100 — 500 c.cm. 10 % glucose
by mouth.
Total 4790 980 20 —
A single example can never be used to prove the
value of any form of treatment and every clinician
has seen apparently hopeless cases recover. A
nihilistic attitude in such cases is not justified and
while it is impossible to be sure that death would have
occurred without the treatment used or to refute
the view that recovery would have occurred without
any treatment, I suggest that the treatment used had
a beneficial effect.
SUMMARY
The causation of jaundice complicating pneumonia
is discussed. The theoretical reasons for treating
jaundice and cholemia with insulin, glucose, and
calcium are stated, and a case is reported in which
such treatment was successful. -
I am indebted to Mr. Ivor Lewis, medical superintendent
of the North Middlesex County Hospital, for permission
to publish the notes of this case.
REFERENCES
Alexander, J. B. (1927) Practitioner, ae 234.
Ardin-Delteil (1909) Trib. med., Paris, 11, 168.
Bruni, G. (1929) Clin. méd. ital. 60, ATA
Cantarow, A. (1933) Calcium Metabolism and Calcium Therapy,
Phila adelphia. p. 183.
Chierici, A . (1932) Rif. med. 48, 1944.
(Continued at foot of next column)
PROF. LANGMEAD & DR. DONIACH : PERNICIOUS ANASMIA IN AN INFANT
Harris, B
[may 1, 1937
PERNICIOUS AN/MIA IN AN INFANT
By F. S. Lanemeap, M.D., F.R.C.P. Lond.
PROFESSOR OF MEDIOCINE, UNIVERSITY OF LONDON; AND
I. DontacH, M.D. Lond.
ASSISTANT PATHOLOGIST, DEPARTMENT OF PATHOLOGY,
- ST. MARY’S HOSPITAL -
THE existence of pernicious anæmia in infancy is
disputed by many authorities for it is difficult to
find authentic cases and it does not fit in with the
present concept of the stiology of this disease. The
question arises whether there is any place for liver
therapy in the primary anzmias of early life.
Bachman (1936) has recently reported a case of
macrocytic hyperchromic ansmia in an infant and
reviewed 16 similar cases described since 1909.
The recent cases were quickly cured by liver and
remained well without any further treatment.
Laboratory investigations showed that the majority
had a normal icterus index and low gastric acidity.
_ There was a history of infection in most of the infants.
He put forward the view that the cause was dietetic
combined with a low gastric acidity due to infection.
His own case, an infant nine months old with a
previous otitis, had a blood count with a colour-index
of 1°11, the hemoglobin being 83 per cent. The icterus
index was normal; the stomach secreted only a little
acid in response to histamine. Liver treatment
brought about a reticulocyte response of 8 per cent.,
and when a normal blood picture had been restored
the free acid in the stomach rose to within normal
limits.
Parsons and Hawksley (1933) gave the following
criteria for the diagnosis of pernicious anæmia in
childhood: “In addition to megalocytosis there
should be a high indirect van den Bergh, marked
poikilocytosis, almost always an absence of free
hydrochloric acid in the gastric juice, and a reticulo-
cytosis with liver extract.” The case described
below fulfils these criteria.
CASE REPORT
The patient, aged 13 months, was admitted to the
medical unit at St. Mary’s Hospital in October, 1936.
He had been vomiting for three weeks, and he was under-
weight and backward in development. He was very ill
and looked as though he was going to die. Weighing
6} Ib. at birth he had been breast fed until 7 months old ; ;
from then till 13 months he was fed on diluted cow’s
milk with the addition of white bread, orange juice, and
two teaspoonfuls of Virol a day. His first teeth erupted
at 7 months and he sat up at the same period. He has
(Continued from previous column)
Coope, R., Osborn, H. A., and Bete F. (1936) Lancet, 2, 1079.
Devi: . C., and W ipple, QG. H (19 19) Arch. intern. Med.
612.
Elton. N; W. (1931) J. Lab. clin. Med. 17, 216.
. R. (1927) J. clin. Invest. 211, 4.
Hurst, ae F., and Simpson, C. K. (1934) Guy's Hbap. Rep. 84, 173.
Lambert, Ga, and Secretan, W. B. (1932) R. Berks. Hosp. ” Rep.
N A., and oot P. (1910) Pr. méd. 18, 82.
MacLachian, W. W. G-, Kastlin, G. J., and Lynch, R. (1932)
ae. J. med. Sci. 184, 511.
Mangeri, S. (1931) peti. path. Anat. 86, 375.
Mann, . C., and Magath, T. B. (1922) Arch. intern. Med. a T
Minot, A. S. S., and Cutler, J. I. (1929) Proc. Soc. exp. Biol.,
(1928) Lancet, 1, 1012.
Pisani, 1 ¢. Cigs) Riv. clin. Med. 31, 1148.
S) Policlinico, 39, 283.
(1933) Wien. med. Wschr. 83, 1172.
Umba, On (1922) Klin. Wschr. 85.
Whitby, L. E. H., and Britton, tal ka C. (1935) Disorders of the
Blood, London, p. 277.
wider, R. M., and Sansum, W. D. (1917) Arch. intern. Med.
THE LANCET]
one brother and two sisters all in good health. His
mother thought that he was a dull baby compared with
her others. His parents and grandparents are alive and
well.
On examination the infant had an extreme waxen pallor.
His heart was considerably dilated, a widespread systolic
murmur being heard in the chest, maximal at the lower
end of the sternum. The veins in the neck were engorged,
the liver edge was palpable halfway between the costal
margin and the umbilicus, and the spleen could be easily
felt. The anterior fontanelle was widely patent and
showed much pulsation.
Laboratory investigations.—The icterus index was 17:6
units. The Wassermann reaction of the ‘blood was
negative. There was no occult blood in the feces. An
examination of the stool for fats showed: total fats
35-6 per cent., soaps 28-4 per cent., fatty acids 3-5 per
cent., neutral fats 3:7 per cent. There was no free acid
in the gastric Juice. A blood count showed :—
Red cells -.- 2,550,000 Leucocytes ee Da N
Hæmoglobin .. 50% ahs aa , A e
Colour-index .. 0'98 Large mononuclears. . 1%
Eosinophils .. : 5%
Basophils ae Sis 0%
The red cells showed marked anisocytosis and poikilo-
cytosis; they were strongly eosinophilic with but slight
polychromasia. One nucleated red cell was seen in the
film. The polymorphonuclears had many lobes to their
nuclei, and platelets were almost absent from the film.
The reticulocyte percentage was 1:3.
These results suggested that the child was suffering
from an anzemia due to lack of the hemopoietic principle.
Treatment and progress.—In view of his extreme illness
we did not experiment, and he was given liver extract
rather than any preparation containing Castle’s extrinsic
factor. He was treated with intramuscular injections
of Campolon (2 c.cm. every day). This resulted in a
reticulocyte response of 19 per cent. and a clinical improve-
ment. A blood film taken at the time showed considerable
polychromasia and 3400 nucleated red cells per c.mm.,
Iron was added to his diet in the form of iron and
ammonium citrate gr. 3 three times a day. The blood
count rose within a month to 5,000,000 red cells and 90 per
cent. hemoglobin, the colour-index being 0:9. The
RETIC|RB.C Hb -
Bolg liolcameoron IRON at ag
25| 5 |100 ABC, esI-
20| 4/80 =
1S} 3|60
10| 2) 40
3o 7 4 QA 2 5 2 9 26
NOV. DEC.
FIG. 1.—Chart showing reticulocyte response to campolon and
rogress of the patient in hospital. Retic.=reticulocytes.
RBC. =red blood-cells. Hb. =hsemoglobin.
film showed numerous platelets, an increase of eosinophils,
and slight anisocytosis and poikilocytosis of the red cells.
The improvement was maintained, the child putting on
over 3 lb. in three months.
including marmite and orange, juice. The course was
however slightly marred by attacks of coryza. Fig. 1
represents the blood counts in chart form and shows his
response to treatment. There was no free hydrochloric
acid secreted in the gastric juice in response to an injection
of histamine three months after the patient had been in
hospital. The blood count at the time was normal and
the patient was discharged.
DISCUSSION
A Price-Jones curve (Fig. 2) was drawn from a film
taken before any treatment had been instituted.
He was given a mixed diet, .
PROF, LANGMEAD & DR. DONIACH: PERNICIOUS ANEMIA IN AN INFANT [may l, 1937 1049
The megalocytosis and microcytosis, the values of
© and v resemble the pernicious anzmia
curve seen in the adult. As a result of his age and
gastric anacidity it is reasonable to suppose that the
child’s iron storage was deficient. The hyperchromic
anzmia was probably superimposed upon a previous
microcytic iron deficiency anæmia of infancy. The
mean diameter of 7-4 u in the Price-Jones curve may
well have been a shift to the right of 1 u from a previous
È o 8 S
NUMBER OF RED CELLS
N
Oo
3 4
10 li
5 6 7 8 9
DIAMETER IN MICRONS
FIG. 2.—Price-Jones curve before treatment began.
6-4u. Castle and Minot (1936) state that “the
typical macrocytic blood picture of pernicious anemia
may be modified by the presence of a complicating
deficiency of iron to a normocytic or mildly hypo-
chromic type.” It will be interesting to see whether
the patient remains well without liver therapy or
whether he will need liver for the rest of his life,
- The case appears to be one of pernicious anæmia
‘in an infant modified hæmatologically by a probable
initial iron deficiency by virtue of the patient’s age
and deficient gastric acidity. One of the most
striking features of the case was the excellent reticulo-
cyte response to liver treatment.
SUMMARY
A case of pernicious anzemia in an infant is described,
which fulfils the criteria of Parsons and Hawksley
for this diagnosis in that his anemia was hyper-
chromic with a megalocytosis of 6-8 per cent., his
icterus index was 17:6 units, his red cells showed
considerable poikilocytosis, he secreted no free
hydrochloric acid in response to histamine, and he
had a reticulocyte response of 19 per cent. to campolon
when his red cell count was 2,000,000 per o.mm.
He was treated with liver and iron and discharged
from hospital clinically well and with a normal
blood picture.
We wish to thank Dr. W. B. Henley, assistant to
the medical unit, who has carried out the chemical
investigations,
REFERENCES
Bachman, A. L. (1936) Amer. J. Dis. Child. 52, 633.
Castle, W. B., and Minot, G. R. (1936) Pathological Physiology
and Clinica] Deséription of the Anæmias, Oxford, p. 49.
2 araonn n: G., and Hawksley, J. C. (1933) Arch. Dis. Childh.
RoyaL HOSPITAL, WOLVERHAMPTON. — Expenses
at this hospital during the last year have increased
but contributions have kept pace with them. New
extensions are proposed, consisting of a semi-base-
ment and three storeys, planned so that in the future
two or three more storeys can again be added if required.
The semi-basement is to be made into a swimming-bath
and a gymnasium for the nursing staff and resident officers
and the first two floors will each accommodate thirty beds.’
1050
THE LANCET]
‘RELAPSING STAPHYLOCOCCAL
SEPTICEMIA
ASSOCIATED WITH CIRRHOSIS OF THE
LIVER AND SPLENOMEGALY
By F. A. Purtyipes, M.D. Camb.
_ ANAISTHETIST TO THE EVELINA HOSPITAL FOR CHILDREN 3;
LATE SENIOR CLINICAL ASSISTANT TO THE HOSPITAL
FOR SICK CHILDREN
THE following case appears to me to be of consider-
able interest, and I therefore venture to report it.
The patient, a well-developed man aged 29, serving
in the Navy, had severe jaundice, which varied
considerably during the period of observation.
HISTORY
When at Dartmouth in 1922, at the age of 15, he was
told that he had a thrill in his pulmonary artery, and was
not allowed cross-country runs, though he played all
games, including rugger, squash, &c. 1927: had a
febrile illness associated with hematuria; radiograms
negative for stone. December, 1928: in Mediterranean,
sent to Naval Hospital at Malta, diagnosed as rheumatic
fever; hand, elbow, shoulder, and right arm only affected ;
profuse sweating. March, 1930: kick on right shin at
rugger ; abscess followed, which was drained and healed
quickly. 1932: at this time he was first noticed to be
yellow. -
Apparently from 1930 to 1933 he was playing rugger,
squash, tennis, &c., and was in good health. August,
1933: in sick quarters at Shotley, pain right shoulder ;
temperature 99° F.; treated with salicylates. September :
transferred to R.N. Hospital, Chatham; very yellow in
face, and right shoulder very painful; negative reaction
to test for tuberculosis; right shoulder immobilised ;
pyrexia. Prolonged sick leave on account of stiff shoulder.
August, 1934: febrile attack. January, 1935: again
injured right shin, again with abscess formation. March :
febrile. October: in hospital at Aden; febrile for a few
days, yellow.
He was apparently afebrile from October, 1935, to
March, 1936, having treatment for stiff right shoulder.
March, 1936: right arm manipulated; he became much
more jaundiced. April: he started gastric symptoms—
“indigestion,” pains after meals, jaundiced.
There was no history of alcoholism or venereal disease.
EXAMINATION
The liver, which was not enlarged, was easily palpable
below the costal margin. The spleen was enlarged and
hard, and descended to the level of the umbilicus. There
was a rough systolic murmur maximal over the left inter-
costal space, with well-marked clubbing of the fingers.
No Osler’s nodes were observed. He had old arthritis
of the right shoulder for which massage and mild movement
had been given. The humerus could be moved some
30° before movement of the scapula was evident. No
pain, heat, or swelling was present in the shoulder-joint,
but all muscles were wasted and deltoid movement was
very limited. The abdomen was somewhat distended,
which was in part due to the splenic enlargement. Old
scars were present on the right shin.
INVESTIGATIONS
Van den Bergh reaction.—June 29th:
direct 5:0 units. Icteric index 30.
Urine (Dr. W. J. Griffiths),—Urobilinogen not increased ;
bile, a trace; bile salts absent. Centrifuged deposit
shows neither red cells, pus cells, nor casts.
Blood examination (June 29th, Dr. J. Bamforth) :—
Red cells 3,840,000 Leucocytes 5900
80%
positive and
Hæmoglobin .. Polymorphonuclears 60%
C.I. ia Ei 1°04 Lymphocytes 33%
(confirmed by Hyalines .. ae 0'59%
repetition) Eosinop bils | 2%
No malarial parasites. No abnor leucocytes.
J uly . lst: platelets, 180,000 per cm.; reticulocytes,
2:4 per cent.
DR. F. A. PHILLIPPS : RELAPSING STAPHYLOCOCCAL SEPTICEMIA
[may 1, 1937
Serum found to be jaundiced. Sachs-Georgi reaction
negative. Agglutination against Brucella melitensis and
abortus was negative in all dilutions. Fragility of red cells,
hemolysis started at 0:4 per cent. (slightly more resistant
than normal).
TREATMENT AND PROGRESS
At this period he was given Pernemon Forte 5 c.cm.
intramuscularly twice a week with ferri et ammon. cit.
gr. 20 t.d.s., p.c. per os.
After his return home he continued to suffer from attacks
of pyrexia at approximately fortnightly intervals, the
temperature varying from 104° F. on occasion to 100°,
the usual duration being for two or three days. The first
of these attacks occurred in May, 1936, from which time
they recurred throughout the course of the illness.
Blood examination.—On July 5th Dr. W. C. Carnegie
Dickson made an examination of the blood during a
pyrexial attack, the count of which did not differ fuatonally
from the previous one of Dr. Bamforth’s, the colour-
index being 1:3; polymorphs: 78-3 per cent. There
was a moderate degree of anisocytosis with general
increase in size to 9 or 104%: no appreciable poikilocytosis ;
no nucleated corpuscles or polychromasia. No malarial
parasites, spirochetes, or kala-azar parasites were seen.
Severe leucopenia; eosinophils absent; blood-platelets
scanty. Brucella and abortus negative; fragility normal.
Wassermann reaction negative. Gonorrhea complement
fixation, slightly more deviation than with normal.
Urine.—(non-catheter specimen): on ordinary agar,
blood-agar, &c., a growth of Staphylococcus aureus ;
in fluid 'media a very occasional streptococcal chain.
Blood cultures.—Primary cultures and a series of sub-
cultures at 16 and 26 hours showed no growth, but at
50 hours showed a pure growth of S. aureus. These °
cultures were made during a febrile attack, two cultures
made on the 6th (pyrexia subsided) showed no growth
at 56 hours,
Van den Bergh reaction.—Positive immediate direct ;
indirect also well marked (25 mg. per litre of serum).
Sedimentation test normal.
Consultation.—On July 17th the patient was seen by
Sir Maurice Cassidy, Prof. J. W. McNee, and Dr. P. Manson-
Bahr in consultation, when the question of tropical
disease was fully discussed and eliminated. As a result
of these deliberations cholecystography and a levulose-
tolerance test were carried out. At the same time a
radiogram of the great trochanter of the left femur was
taken, as persistent pain was complained of with slight
swelling.
Radiography.—The cholecystography, by Dr. W. H.
Coldwell and Dr. F. M. Allchin, was completely negative
as dye did not enter, while the femur showed a small
area of rarefaction with a sequestrum in its centre.
Levulose test (Dr. Griffiths, July 27th): The blood-
sugar curve after 30 g. of levulose was, within the accepted
limits of normality, as follows :— `
Before test 0'117% 90 mins... .. 0117%
30 mins. 0:135% 120 „ °sé .. 0109%
6U =", 0:139%
A further blood count showed little difference from the
previous ones, but the colour-index was 0-9.
During the months of August and September the patient
continued to receive injections of pernsemon once a week.
He showed some slight improvement as evidenced by
diminution in size of the spleen, less jaundice, and a
lowered height of pyrexia in the attacks..
On Oct. 17th, although he was not feeling well, he went
out to dinner, and during the night developed a tempera-
ture of 103° F. with gastric symptoms which persisted,
and on Oct. 21st he was transferred to St. Thomas’s
Hospital for further investigation.
A blood count (Dr. Bamforth) on this date showed :
red cells, 25,400,000 ; haemoglobin, 56 per cent.; colour-
index, 1:09 per cent.; leucocytes, 5600. Reticulocytes
very scarce—not more than 1 per cent. Fregility of red
cells started just below 0-4 per cent. (more resistant than
normal). No eosinophils in 200 leucocytes counted. A
number of red cells showed polychromasia and a few
cells showed basophil stippling, both constituted a small
percentage of the cells.
THE LANCET]
Blood cultures taken on the same date gave numerous
colonies of S. aureus in’ pure culture, while cultures of the
sputum on Oct. 22nd gave an overwhelming growth of the `
same organism. On Oct. 24th and 26th he received
intravenous injection of 40 c.cm. of staphylococcal anti-
toxin daily, after a preliminary testing with 0-1 c.cm.
and on Oct. 25th 2 c.cm. of pernemon forte. The rest
of the treatment was symptomatic.
The patient’s pyrexia persisted, the jaundice markedly
increased, and he died on Oct. 27th in coma.
POST-MORTEM EXAMINATION (DR. J. O. OLIVER)
Disease.—Staphylococcal septicemia, osteomyelitis, and
cirrhosis of liver. Examined Oct. 27th, 1936. Age 30.
Weights of body and viscera.—Liver, 51b. 20z.; kidneys,
left 174 oz., right 17 oz. ; heart, 17 oz. ; spleen, 2 lb. 12 oz.
Report.—There was a quantity of slightly blood-stained
fluid in the abdominal cavity. Straw-coloured fluid
distended the pericardial sac. Large numbers of firm
adhesions were present all around the gall-bladder and the
main biliary duct.
The liver showed an extreme degree of waltlobalny
cirrhosis with dilatation of all the larger bile channels of the
liver. The gall-bladder itself was distended with con-
centrated bile. There did not appear to be any obstruction
of the bile-ducts other than that which might be accounted
for by the adhesions referred to above.
`The heart was grossly dilated on the right side, and
on the left side generally hypertrophied. A minute open-
ing was present at the position of the foramen ovale, and
this opening was valvular in type, suggesting a possible
passage of blood from the left to the right side of the heart,
There was a small pyzmic abscess in the wall of the
aorta about 1] in. above the aortic valve and this had
ruptured into the aorta itself.
The left lung was semi-collapsed with some exudate at
the base and a number of small pyæmic abscesses scattered
throughout the lungs. The right lung was congested
and œdematous.
The kidneys were extremely large and showed many
small pysmic abscesses running along the course of the
blood-vessels.
The spleen was large and showed some septic reaction
in an organ which appeared to have been previously
enlarged.
The left femur: a small superficial softened area was
found in the bone in front of and below the great
trochanter.
The brain showed congestion and cedema only. The
sinuses showed no apparent infection in the ethmoid or
frontal cells. |
CLINICAL AND LABORATORY NOTES:
1051
There was no macroscopic thrombosis of the splenic or
portal veins.
A photomicrograph of a part of the liver is shown in
the Figure, and Prof. McNee has kindly given me his
opinion of the section: ‘‘ This slide shows very typical
advanced cirrhosis in a fairly active stage, with much round-
celled infiltration.”
[may 1, 1937
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COMMENT
Some points of particular interest in this ca3o
appear to be as follows: 1. The prolonged duration,
probably a period of 8 years, with intermittent
exacerbations of a staphylococcal infection. 2. The
association of the above with multilobular cirrhosis
of the liver, and considerable splenic enlargement.
3. The uniformly high colour-index. 4. The normal
levulose test in spite of the advanced cirrhosis.
5. The presence of a pyæmic abscess in the wall of
the aorta,
My thanks are due to the many doctors who have
carried out the numerous investigations for the use of
their notes, and especially to Sir Maurice Cassidy for his
kind criticisms and help with this report, to Prof. J. W.
MeNee for his opinion on the slide, and to Dr. J. O. Oliver
for his account of the findings at autopsy.
CLINICAL AND LABORATORY NOTES
ACUTE SACRO-ILIAC STRAIN
A PERSONAL EXPERIENCE
By R. Y. Paton, M.B. Camb., F.R.C.S. Eng.
SURGEON, ROYAL NATIONAL ORTHOP/EDIC HOSPITAL ; CONSULTING
ORTHOPZEDIC SURGEON, LONDON COUNTY COUNCIL
As I was digging in my garden the other morning
and endeavouring to turn over a particularly resistant
portion of clay soil, I experienced a sudden acute
pain in the lower part of my back on the right side
and on trying to straighten myself up was unable
to do so.
It was with difficulty that I was able to walk a few
yards to the house and with even more difficulty to ascend
the few steps necessary. Walking was extremely painful
and I could do so only with the right hip and right knee
slightly flexed. On sitting down I found it very hard to
get into a comfortable position and impossible to cross the
right knee over the left without great pain. There was great
tenderness over the upper portion of the right sacro-
iliac joint and there was pain down the back of the right
thigh and on the outer aspect of the right calf. Ten grains
of aspirin made not the slightest impression on the pain.
When the telephone rang it was with great difficulty
that I levered myself out of a chair and walked the few
feet to it.
After about an hour the pain was still as bad; so I
thought I must attempt some form of self-manipulation, as
I had relieved so many people in similar conditions by
manipulation. I stood up as straight as I could with
my legs abducted and my feet externally rotated. With
my arms widely abducted I rotated my trunk towards
the left and then suddenly, and as vigorously as I could,
rotated my trunk round to the right as far as it could go.
There was a sudden audible snap and the pain down the
leg had completely gone. I was able to move perfectly
freely again; I returned to the garden and completed
my digging, and then I proceeded to pull a heavy roller
all over the lawn without any discomfort or disability.
The next day, apart from a slight ache in the right sacro-
iliac region, there were no other symptoms whatsoever,
all movements being perfectly free and painless.
Cases of acute sacro-iliac strain are common and
their relief by manipulation is well known. The
customary manipulation is to rotate the pelvis
forwards with the shoulders fixed, at the same time
using some down-pressure on the pelvis. This mani-
È
1052 THE LANOET]
pulation can be done easily without an anesthetic
if the attack is of very recent onset, but later requires
a general anesthetic. The movements which I
carried through in my own case were intended to
reproduce this rotary movement as far as possible,
and results show that they were successful.
I hope this small note will prove of use to any
medical colleague who finds himself similarly smitten.
PULMONARY CDEMA FOLLOWING THE
ADMINISTRATION OF ESERINE
By W. E. Cooke, M.D. Liverp., F.R.C.P. Lond. and
Edin., D.P.H.
DIRECTOR OF THE PATHOLOGICAL DEPARTMENT, WIGAN INFIRMARY
THE increasing frequency in the use of eserine in
renal sympatheticotonus as well as the unusual
fatality prompt this note.
A female, aged 19, was operated upon. for subacute
appendicitis in August, 1936. In January, 1937, she
returned to Mr. J. B. Oldham with right renal colic.
` During the renal investigations it was noticed there was
definite delay in the emptying of the right renal pelvis
ROYAL SOCIETY OF MEDICINE: UROLOGY
[may 1, 1937
and the condition was diagnosed as renal sympathetico-
tonus. Immediate renal sympathectomy was considered
unjustifiable, the patient sent home and her family doctor
advised to inject 1/50 of a grain of eserine if attacks of
colic recurred. She resumed her occupation, apparently
well, until March 6th, 1937, when returning from work
she had an attack of pain in the right flank. She walked
into her doctor’s waiting-room and lay on a couch. One-
fiftieth of a grain of eserine was administered hypo-
dermically. In a few seconds the patient was seized with
intense respiratory distress, becoming increasingly urgent,
and blood-stained frothy mucus poured from her mouth.
She was given 1/100 of a grain of atropine but she died
in about fifteen minutes after the eserine injection.
Autopsy.—The pupils were midway between contraction
and dilatation. Therewas a band of adhesions anchoring
the cæcum to the anterior abdominal wall. The pelves of
both kidneys were injected and the bladder contained a
little purulent urine. The larynx, trachea, and bronchi
contained blood-stained frothy mucus. The lungs were
voluminous and heavy, pitted on pressure, and on section
poured out blood-stained serum. All the other organs
were normal.
The above are the facts of the case, and comment
seems unnecessary unless it is to point out the possible
untoward effects of eserine and that, although atropine
was administered, the course of the pulmonary edema
remained unchecked.
MEDICAL SOCIETIES
ROYAL SOCIETY OF MEDICINE
SECTION OF UROLOGY
Tars section held its annual general meeting in
London on April 22nd and 23rd under the presidency
of Mr. BERNARD WARD (Liverpool).
Closed Prostatectomy
Mr. CLIFFORD Morson opened a discussion on the
Harris operation and its modifications. The most
important modification that he himself had intro-
duced was the substitution of a longitudinal for a
transverse incision, and the elimination of the postero-
lateral sutures in the reconstruction of the bladder
base. He objected to such sutures because of their
nearness to the ureteric orifices. For Harris’s
lateral sutures he substituted a figure-of-eight suture
which he believed to be more effective in closing the
cavity. Only if the urine was not sterile or if he was
dissatisfied with the hemostasis did he omit primary
closure of the bladder. Mr. Morson then gave his
reasons for preferring the Harris to all other tech-
niques in prostatectomy. He did not wish to justify
it simply because of the mortality-rate—for mortality-
rates were deceptive unless at least 500 operations
had been done—but because it eliminated many of
the dangers and complications following prostatectomy,
shortened the period of convalescence, and added
to the patient’s comfort. Both reactionary and
secondary hemorrhage were uncommon after it, and
the stay in hospital was reduced by at least a fort-
night. Moreover the Harris technique diminished
what he termed the remote mortality of prostatectomy
.—i.e., deaths occurring some six months after the
operation as a result of the strain to which patients
had been subjected.
Mr. W. W. GALBRAITH (Glasgow) stated that in
27 out of 29 cases he had closed the bladder. In
his opinion some of the opposition to the Harris
technique was due to the fact that the principles
laid down by Harris were not followed; especially
was this true of preliminary treatment. But the
fact that he, Mr. Galbraith, favoured the technique
did not mean that he felt that it should -be carried
out in every case. Selection was necessary, and in
this selection the state of the cardiovascular system
was of very great importance.
Mr. TERENCE MILLIN said that the chief modifica-
tion he had made in the original Harris technique
was to substitute Lumbe’s method of bringing down
the posterior trigonal flap for that of Harris. As
a precautionary measure he also placed two temporary
“funk” silk sutures on the bladder and brought
them out of the abdominal wound. If it became
necessary to open the bladder because of hemorrhage,
the sutures made this easier.
Mr. C. A. WELLS (Liverpool) advocated the trans-
verse incision employed by Harris, because he felt
that it encouraged better healing. As a safety-
valve he used a small suprapubic tube closed by a
spigot. Through this the bladder could be washed
out if need be. |
Mr. A. H. Jacoss (Glasgow) was surprised that no
speaker had mentioned that severe complications
might follow the Harris technique. He himself had
had two cases of serious pelvic cellulitis. In one
of these the patient had died and post mortem an
abscess was found posterior to and communicating
with the prostatic cavity. This did not mean that
he would not employ the Harris technique; but
he felt it necessary to point out that its complications
might be more serious than previous speakers had
suggested.
Mr. Morton WHITBY called attention to the
importance of pre-operative treatment. He had
devised a two-way catheter by means of which
continuous irrigation might be carried out.
Mr. E. W. Ricwes preferred a transverse to a
longitudinal incision on the ground that his patients’
comfort was thereby increased and convalescence
shortened. Cases must be selected for the Harris
operation, and he thought that when death occurred
it was usually due to some systemic cause such as
embolism or cardiac failure. As an anesthetic he
THE LANCET}
liked a combination of a low spinal analgesia, followed
by gas-and-oxygen with an abdominal field block.
Perurethral Operations
Mr. KENNETH WALKER read a paper on the treat-
ment of prostatic obstruction by perurethral methods,
He recalled that he had introduced a similar dis-
cussion as long ago as 1925. His mode of presenta-
tion would however be very different on this occasion.
In 1925 it was necessary to plead for a method that
was in its infancy—and in a none too healthy infancy.
Now the child had grown so lusty and rampagious
that in some parts of the world it was necessary to
plead not for perurethral methods of treatment but
for the parent operation of prostatectomy. He would
therefore assume the attitude of a critic rather than
of an apologist, dealing especially with the complica-
tions and disadvantages of perurethral resection.
In his experience the main disadvantage was sepsis.
Some of this sepsis was inevitable and due to the
fact that the operator left behind coagulated tissue
which formed an excellent nidus for organisms.
Because of this there was a present tendency to turn
again in the direction of Young’s cold punch, using
coagulation merely for sealing-off bleeding points.
But some of the sepsis was due to the trauma of
instrumentation. An electrotome was not an easy
instrument to pass and in cases of involution of the
genital tract, where the urethra was small, it was
easy to damage the tissues. Another fruitful source
of infection was probably opening up the space of
Denonvilliers by perforating the trigonum. Mr. Walker
concluded by discussing what cases were suitable
for resection, Perurethral methods were particularly
indicated in minor enlargement of the prostate and
for patients in whom there were complications that
made prostatectomy too dangerous.
Mr. R. H. O. B. Rosrnson described the technique
employed at the Mayo Clinic. Two instruments
were in use there, the Bumpus and the Thompson
punch. Both instruments were difficult to handle
because they were of the direct-vision type. They
had the advantage, however, of causing less damage
to tissues. He employed these methods at
St. Thomas’s and with satisfactory results.
Mr. F. McG, Loueunane called attention to the
danger of resecting prostatic tissue on either side of
4 or 8 o'clock. Where he had disobeyed this rule
he had had infection of the cave of Retzius.—Mr. H. P.
WINSBURY-WHITE did not believe in massive resections
but in removing only five or six fragments.—Mr.
MILLIN preferred Young’s punch for fibrous prostates
because of the danger of pelvic cellulitis. In carci-
noma and cases of post-prostatectomy obstruction
the McCarthy resectotome gave excellent results.—
Mr. JOHN EVERIDGE recalled a case where, in attempt-
ing to get the loop above a large lateral lobe in a
bladder that could not be distended, the wall had
been perforated. He said that in order to avoid
hemorrhage a cut could not be made too slowly.—
Mr. RicHes pointed out the advantage of infiltrating
the prostate, before resection, with 0:5 c.cm. of
adrenaline in 10 c.cm. of Percaine solution, This
materially reduced hsmorrhage. If clot-retention
occurred after operation the glycerin of pepsin treat-
ment gave excellent results.
Spinal Injuries and the Bladder
Sir Joun THOoMSON-WALKER on April 23rd
read a paper on injuries to the spinal cord affecting
the bladder. Before the late war, he said, it was
taught that injuries to the lumbar swelling and
cauda equina were followed by distension of the
ROYAL SOCIETY OF MEDICINE: UROLOGY.
[may 1, 1937 1053
bladder and overflow. Experience during the war,
however, showed that after such injuries periodic
reflex micturition was soon established, the bladder
learning to contract at intervals and to empty itself
more or less satisfactorily. The chief problem
during the war had been the avoidance and treatment
of sepsis, 80 per cent. of spinal cases dying of ‘‘ surgical
kidney.” He would therefore like to discuss how this
appalling death-rate could be avoided. Four methods
of treatment for the retention following spinal —
injuries were possible.
(1) Non-interference—i.e., allowing the distended
bladder to empty itself by overflow.
(2) Emptying the bladder by abdominal pressure.
(3) The use of an in-dwelling catheter.
(4) An immediate prophylactic cystotomy.
The chief disadvantage of non-interference was
that the rule that a distended bladder should be
emptied by the passage of a catheter was so ingrained
in the medical profession that during the transit
of the wounded from the front to England, some
doctor was bound to pass a catheter. Emptying
of the bladder by pressure on the abdomen could
only be carried out by someone skilled in this method
of treatment. Spasm of the sphincters made it
sometimes very difficult and rupture of the bladder
had been reported. The chief complication that
had arisen in the war from the use of an in-dwelling
catheter was sloughing of the floor of the urethra
at the penoscrotal junction. Personally he had
advocated immediate prophylactic cystotomy as
the best method of overcoming the peril of sepsis.
While this did not prevent cystitis it removed the
conditions favourable to the upward spread of
sepsis—namely, infection associated with retention.
What was required most in order to solve the problem
was continuity not only of observation but also of
treatment.
Sir ALFRED WEBB-JOHNSON thought that an
authoritative statement that a catheter must never
be passed in the presence of a spinal injury would
save many lives. He suggested that the right
combination of treatment might turn’ out to be non-
interference at the front and early cystotomy at the
base hospital or when the patient reached England.
Mr. KENNETH WATKINS (Manchester) confirmed
the fact that cases of spinal injuries in civil life did
not die of urinary sepsis. This was probably because,
whereas most civil injuries were injuries to the `
cauda equina, most war injuries were at a higher
level,
Mr. EVERIDGE described a case of spinal injury
in the dorsolumbar region that had been successfully
treated by early cystotomy.
Undescended Testis
Prof. GREY TURNER, in a paper on the treatment
of the undescended testicle, said that up till 1927 he
had made very little effort to save a misplaced
testicle and had usually performed orchidectomy.
Since then, however, he had’ adopted a more con-
servative attitude. He was sceptical about a testicle
ever descending spontaneously after the third year —
of life. Some authorities considered that the best
period of life at which to begin hormone treatment
was at about nine; he himself was of the opinion
that eleven or just before puberty was the time of
election for operative treatment. This would allow
of patients having a preliminary trial of gonadotropic
hormone. In discussing operative . technique, he
laid emphasis on the importance of immobilisation
of the cord as high up as possible. The chief obstacle
1054 THE LANCET] NORTH OF ENGLAND OBSTETRICAL AND GYNECOLOGICAL SOCIETY
to a testicle being brought down was not shortness
of the vessels but adhesions between the vas and the
peritoneum.
Mr. W. McApam EccLes urged that the term
“ undescended testicle’? should be abandoned in
favour of “imperfectly migrated” testicle. Much
had still to be learnt about this subject, and he felt
that the greatest help would be obtained from the
experience of medical officers to schools.
Mr. T. W. Mrimpriss gave the post-operative records
of 80 cases treated by the Bevan technique at
St. Thomas’s Hospital. Only half of these operative
results could be said to be satisfactory. Better
results were noted with the transeptal technique and
although there were as yet an insufficient number of
cases available, it looked as if the Keetley-Thorek
technique was going to give the best results of all.
He was sceptical of the action of gonadotropic
hormone.
Dr. RonaLtp Smita (Rugby School) said that
imperfectly descended testicle was extremely common
amongst schoolboys. Contrary, however, to Prof.
Grey Turner’s belief, a very large number of these
testicles descended spontaneously before puberty.
He therefore recommended that all cases be left
till puberty before an operation was undertaken.
NORTH OF ENGLAND OBSTETRICAL
AND GYNECOLOGICAL SOCIETY
A MEETING of this society was held in Sheffield
on April 2nd with Dr. J. W. BRIDE (Manchester),
the president, in the chair.
Labour Obstructed by Foetal Bladder
Dr. F. J. BURKE (Liverpool) gave an account of a
case of dystocia due to over-distension of the feetal
bladder.
The patient, a multipara aged 29, went into labour
at 9 P.M. on Jan. 27th, being about 35 weeks’ pregnant.
At midnight the head and hands of the foetus were born
but there was no further progress. When admitted to
hospital she was having strong pains and was acutely
distressed. ‘The fundus reached to midway between the
umbilicus and the ensiform cartilage, and no fcetal heart
could be heard. A fcetal head and two hands were protrud-
ing through the vulva. The foetal neck was long and the
cervical spine was fractured—no doubt through vigorous
traction by a practitioner who had been called in by the
midwife. The thorax was found tightly plugged in the
maternal pelvis, and an incision was made through the
foetal chest wall. A large quantity of fluid escaped
and delivery was soon completed. The fœtus weighed
6 Ib. and was considerably elongated, with the abdominal
wall in large folds; there was also bilateral talipes equino-
varus. Post mortem the bladder in its collapsed condition
measured 6 in. by 4 in. and had hypertrophied walls.
Both ureters were dilated and the kidneys enlarged.
The urethra was patent, a small catheter passing without
difficulty.
Dr. Burke said that several similar cases of disten-
sion of the foetal bladder with patency of the urethra
had been described, and he quoted those of Savage
and Crawford and Jeficoate. Neuromuscular dys-
function was the usual explanation of the failure
of the foetal bladder to empty itself. He also wondered
what part was played by the fotal kidneys in the
production of liquor amnii, Gaylord Bates had
pointed out the frequent association of oligo-
hydramnios and fetal renal anomalies. The bio-
chemical studies of Makepiece Smith and Carroll
strongly suggested that the liquor amni was a
[may 1, 1987
transudate which, in early pregnancy, was in isometric
equilibrium with maternal and fetal blood, but
in late pregnancy was hypotonic because of the
addition of fæœtal urine. On the other hand, there
was evidence that the footal kidneys did not subscribe
to the liquor amnii. Phloridzin injected into the
mother could be readily detected in the foetal tissues,
but it was rare to find even a trace of sugar in the
liquor amnii. ,
The PRESIDENT said that the condition seemed
always to be associated with obstruction to the
urethra, and that he supposed it was more common
in the male fœtus.—Mr. J. E. STACEY referred to the
elongation of the cervical vertebræ and the talipes
equinovarus, and wondered whether the condition
was associated with any spinal lesion.—Dr. BURKE,
in reply, said he had no doubt that the elongation
of the cervical vertebrae was produced by trauma,
Adenomyoma Causing Intestinal Obstruction
Mr. A. GouGcH (Leeds) described a case in which
an adenomyoma was responsible for acute intestinal
obstruction.
The patient, aged 42, had never been pregnant. She
had had gradually increasing constipation for six months,
culminating in complete obstruction. The day before
Mr. Gough saw her, she had had absolute constipation
as regards both feces and flatus, and had vomited once.
Her general condition was quite good, and there was a
tense rounded swelling in the hypogastrium the size of
a four months’ pregnancy. On vaginal and rectal examina-
tion a hard fixed mass was felt behind the uterus and
involving the upper part of the rectum. On opening the
abdomen the rounded swelling was found to be a chocolate
cyst of the left ovary. There was much indurated tissue
involving the cervix and the upper part of the rectum.
A diagnosis of adenomyoma was made, and later confirmed
by histological examination. A colostomy was performed,
after the bulk of the disease had been removed, including
both ovaries and the uterus. A fortnight later, Mr. Gough
was able to start making a way through the obstructed
bowel, by passing gum elastic bougies up the rectum.
These were followed later by rectal tubes passed from the
colostomy downwards. In a fortnight the passage had
been dilated to ł in. The colostomy was closed in stages
by the use of an enterotome., Six days later the bowel
was dissected from the abdominal wall and the wound
closed. Some leakage occurred but within three weeks
the fecal fistula had closed.
Mr. GouGH said that an acute obstruction due to
an adenomyoma must be very rare indeed.—The
PRESIDENT said it was quite clear that the adeno-
myoma was in the bowel wall, and not merely in
the rectovaginal space.—Prof. LEYLAND ROBINSON
(Liverpool) remarked that the case showed how
important it was that a gynecologist should have a
knowledge of general surgery.
Dr. GLADYS Kay gave a demonstration of X ray
films taken of pregnant women during the ante-
natal period. The PRESIDENT, Prof. A. M. CLAYE
(Leeds), Mr. J. E. Stacry (Sheffield), and Mr. T. F.
Topp (Manchester) took part in the discussion.
SALFORD ROYAL HosPITAL.— Extensions and altera-
tions to this hospital, though not quite finished, were
opened on April 12th. The ceremony took place in
the new Bernhard Baron orthopedic department, for .
which the trustees of the late Mr. Baron have given
the sum of £3000. The erection of a new casualty
department and the enlargement of the out-patients’
accommodation have been made possible by a donation
of £8000 from the Lancashire and Cheshire Miners’ Welfare
Fund. The hospital’s deficiency on capital account now
stands at £24,498,
- THE LANCET]
[may 1, 1987 1055
* REVIEWS AND NOTICES OF BOOKS —
Diseases of the Nose, Throat, and Ear
A Handbook for Students and Practitioners. By
I. Smson Harr, M.B., Ch.B., F.R.C.P.E.,
¥.R.C.S.E., Surgeon to the Royal Infirmary,
Edinburgh (Department for Diseases of Nose,
Throat, and Ear). Edinburgh: E. and S&S.
Livingstone. 1937. Pp. 422. 10s. 6d.
Mr, Simson Hall has tried to explain the essential
features of disease of the throat, nose, and ear within
the compass of a very small book intended for the
student and the busy practitioner. It is due to
the clearness of his thought and style that he has
achieved a considerable measure of success, though
the result would have been still better had he allowed
himself a little more space. A very short account
- of the anatomy of the region is given before each
section, and the usual methods of examination are
described. But in many cases the picture presented
of the commoner clinical types of a disease is not
adequate to enable the practitioner to recognise it
and make a diagnosis. This is especially notable
in the section on diseases of the larynx, where the
description of tuberculous laryngitis can give the
reader no idea of its usual aspects. The flask-shaped
arytenoids, ‘“‘turban” epiglottis, and the early
unilateral infiltration of the cord are not mentioned ;
no help is given in the paragraph on the diagnosis of
this disease, and of the diagnosis of syphilitic laryn-
gitis it is merely said that this is usually made by
means of the Wassermann reaction. We must
protest, too, against the statement that the routine
method of combating dysphagia in tuberculous
laryngitis is the free use of cocaine.
The best part of the book is that which deals
with diseases of the ear, where the description of
acute otitis and its complications is particularly
lucid. When discussing the use of drugs, accurate
doses and concentrations might usefully have been
given. Boric and iodine powder is recommended for
aural suppuration, but the proportions of the mixture
are not stated in the text or in the appendix. Carbolic
acid at a strength of 4 per cent. is advised in the
acute stage of otitis media, but whether in aqueous
solution, with a syringe or as drops, is not mentioned.
In the short appendix on formuls, ear drops of
carbolic acid in glycerine are given at a strength of
5 grains to 2 ounces, or about one-half per cent.,
an unusually weak solution, and under Blegvad’s
drops the proportion of cocaine is not stated. We
point out these errors of detail, because they are
important in a book intended for use in a doctor's
practice, and because we hope that they will be
corrected in a subsequent edition. On the whole
the teaching is clear and definite and the advice
given is so sound that the work should have an
established place among the smaller text-books on its
subject.
Biological Laboratory Technique
By J. BRONTE GATENBY, B.A., B.Sc., D.Phil Oxon.,
M.A., Ph.D. Dubl., D.Sc. Lond., Professor of
Zoology and Comparative Anatomy, Trinity College,
Dublin University. London: J. and A. Churchill.
1937. Pp. 130. 7s. 6d.
OWING presumably to the variability of the
materials used there is no such thing as a standard
result obtained when making a microscopical prepara-
tion of a given tissue with a given procedure and
reagents. The worker must get to know his materials
by experience, and he obtains his results by a process
which he can demonstrate but can rarely explain.
If microscopy is, like cooking, an art, most books
on microscopical technique have the same limitations of
function as do books on cookery. Prof. Gatenby’s work,
however, should be valuable to teachers and to those
who are beginning research mainly because he gives
hints on just those minor but important points of
detail which are generally omitted from text-books.
An original and particularly useful chapter is the
one dealing with methods of observing the structure
and behaviour of the living cell, for the sight of a
living cell is a -lamentably rare experience for
the average student of histology. The section
which provides an introduction to the technique of
microchemical testing will also be welcomed.
The title of the book is somewhat misleading since
it deals solely with microscopy.
Recent Advances in Orthopedic Surgery
By B. H. Burns, B.A., B.Ch., F.R.C.S., Ortho-
pedic Surgeon to St. George’s Hospital; and
V. H. Erus, M.A., B.Ch., F.R.C.S., Orthopedic
Surgeon to St. Mary’s Hospital. London: J. and A.
Churchill. 1937. Pp. 296. 15s.
THE authors of this excellent little book emphatic-
ally state that it is not intended to be a text-book
but only a discussion of views held to-day on certain
orthopedic subjects. Nevertheless, they survey a
very wide field and contrive to compress into a small
space an enormous amount of valuable information.
They achieve this by a rigid economy in words
without sacrificing clearness, by careful choice from
a laborious study of the literature, and by the
avoidance of unnecessary detail. They have inter-
preted ‘“‘advances”’’ in its widest sense—implying
not only additions to knowledge but also the
standardisation of ideas and methods previously in
use. The acceptance, for instance, of Allison and
Ghormley’s classification of arthritis does not bring
new knowledge, but does certainly introduce order
out of chaos. Some knowledge on the part of the
reader is assumed, but the appeal is not only to
orthopaedic surgeons.
Subjects of interest to general surgeons and to
students such as chemistry of bone, bone tumours,
acute and chronic osteomyelitis, tuberculous joints,
and coxa vara, to mention only a few are included,
and at the end of each chapter a carefully chosen
bibliography of the more important works are
appended. When an article, book, or discussion at
a medical meeting has seemed to be particularly
significant, it is summarised and made the subject
of a complete chapter. It will be generally agreed
that the article on that obscure subject “‘ the painful
shoulder ”? is particularly valuable. Few students
will have the time or inclination to read Codman’s
admirable work, and the authors have rendered a
service in summarising it so excellently.
The writing of a book on recent advances is an
opportunity of reviving good ideas that run the risk
of being forgotten, and it is surprising that no reference
is made to Krida’s: work in connexion with the
importance of correcting the anteversion of the neck
of the femur in the treatment of congenital dis-
location of the hips. The omission is the more
surprising since in the X ray which is reproduced to
show a result of a shelf operation, the head of the
femur is anteverted by about 70 degrees. Apart
1056 ae LANCET]
REVIEWS AND NOTICES OF BOOKS
[may 1, 1937
from this everything seems to have been included
which can be interpreted as an advance during the
last five years, and placed in its proper perspective.
The book is small and easy to handle, and contains
ample and well-chosen X rays and diagrams. It
fills a long-felt gap, and should find its place on the
bookshelves of surgeons interested in bone and joint
disease. It is a book that will be easy to keep
up to date, so that it should become a standard work
for those studying for higher qualifications.
Fundamentals of Human Physiology
Fourth edition. By the late J. J. R. MACLEOD,
M.B., D.Sc., F.R.S., late Regius Professor of
Physiology in the University óf Aberdeen; and
R. J. Seymour, M.S., M.D., Professor of Physio-
logy, Ohio State University, Columbus, Ohio.
London: Henry Kimpton. 1936. Pp. 424.
10s. 6d.
To revise even a small book which is twelve years
old is a heavy task. Prof. Seymour has done it well ;
this work remains a reliable exposition of the
fundamentals of human physiology, and as befits
an introductory text-book, includes adequate informa-
tion on anatomical and chemical points. It leaves
no part of the subject untouched, having chapters
not only on the special senses, but on subjects such
as immunity, nutrition, and hygiene. Physiology
is therefore presented in perspective, an important
feature for the student who wishes to understand
its scope and main principles without reading too
widely. The editor states that the section on
metabolism has been cut down by half and that on
the endocrines expanded ; but nutrition, digestion,
and metabolism still cover a hundred pages,
while the ductless glands are given only fifteen.
The balance of the book thus needs attention in this
direction if it is to represent modern physiology in
miniature. It may be conceded, however, that
the present arrangement accords sufficiently with the
title, and in a work of this size sins of omissions
must not be treated too seriously.
British Journal of Surgery
THE April issue contains the following papers :—
CARCINOMA OF THE MALE URETHRA, with report of a
case. By Henry Mortensen (Melbourne). The rarity
of the condition is noted and its association with persistent
stricture requiring repeated dilatation. Suspicion should
be roused when dilatation is unsatisfactory and there is
@ persistent discharge of blood from the urethra. Squamous
metaplasia of the epithelium occurred in the case reported.
Fat EMBOLISM: report of a-case, with review of the
literature. By A. J. Watson (London). A fatal case is
recounted. The origin of the fat emboli—either from the
medullary fat or by aggregation of the fat emulsion of
the plasma—is discussed. The symptoms may be pul-
monary, with fat in the sputum, or systemic, with delirium,
and fat in the urine.
PYELOGRAPHY IN RENAL HypatTips. By R. Campbell
Begg (Wellington, N.Z.). The characteristic deformity
of the pyelogram can decide the side, nature, and site
of the lesion. In the absence of hydatids in the urine it
differentiates hydatid disease of the liver, spleen, or
perirenal region from that of the kidney.
MULTIPLE VuLous PaPILLOMATA OF THE GALL-
BLADDER. By F. R. Brown and D. F. Cappell (Dundee
and St. Andrews). Cholecystectomy was performed
for acute cholecystitis, and multiple calculi were found.
A CasE OF RUPTURED ANEURYSM OF THE SPLENIC
ARTERY WITH RECURRENCE. By Clifford G. Parsons
(Birmingham). Rupture occurs first into the lesser sac,
and only secondarily into the general peritoneal sac.
Operation stands more chance of success in the first
stage. In the case described ligature ‘of the artery and
splenectomy were followed by recovery. The recurrence
was fatal, owing to technical difficulties of the operation,
ONE-STAGE LOBECTOMY FOR HYDATID DISEASE oF
THE Lune. By A. L. d’Abreu (Cardiff). The cyst was
subpleural and probably on the point of rupture into the
pleural cavity. There had been symptoms for 42 years.
The patient, aged 60, made a splendid recovery with
primary healing of the wound.
EFFECT OF BRACHIAL PLEXUS BLOCK on PaTIENTS
SUFFERING FROM SECONDARY TraumaTIC SHOCK. By
H. J.. B. Atkins (London). It was hoped to protect
patients with severe injuries of the upper limb from the
nervous impulses causing secondary shock. The resul
of the block was a large fall of blood pressure. This
is attributed to the general action of the local anesthetic,
independent of the site of injection.
FIXATION OF THE HIP-JOINT BY MEANS OF AN EXTRA-
ARTICULAR BoONE-GRAFT: late results. By Hugh C.
Trumble (Melbourne). A strong tibial graft is implanted
between the ischial tuberosity and the upper end of the
femoral shaft. The results in 8 cases of tuberculosis
- of the hip are encouraging. The tuberculous process
has healed or is quiescent, and many of the patients have
returned to their original occupations.
TREATMENT OF FRACTURED PATELLA BY EXCISION:
a study of morphology and function. By R. Brooke
(Chichester). The author thinks the patella has no useful
function. Experiment on the cadaver shows that extension
is more effective in its absence; andin 30 cases of fractured
patelle removal has been followed by rapid recovery of
full function,
_A NOTE ON THE EXTENSION APPARATUS OF THE KNEE-
JOINT. By W. Hey Groves (Bristol). The insertion of
the quadriceps tendon is shown to occur almost indepen-
dently of the patella. The importance, in operations
of repair, of preserving and suturing the lateral expansions
of the quadriceps is noted.
SomE REFLECTIONS ON GastTrostomy. By E. S. J.
King (Melbourne). Experience of 50 cases has led King
to set down principles that should guide the surgeon in
the choice of operation and in subsequent feeding. Atten-
tion is drawn to the advantages of solid food.
EXPERIMENTAL LESIONS OF THE RABBIT’S APPENDIX.
By A. Q. Wells (London). Gangrenous appendicitis
followed ligature of the appendicular vessels and the
meso-appendix. Obstruction of the lumen of the appendix,
associated with a lesion of the mucosa, caused appendicitis
and death. Obstruction of the lumen alone caused muco-
cele. Ligature of the root of the appendix and of the vessels
caused atrophy of the appendix, without inflammation.
INTESTINAL STRANGULATION : THE HISTAMINE CONTENT
OF THE PERITONEAL EXUDATE FROM STRANGULATED
InTEsTInaL Loors. By Ian Aird and W. K. Henderson
(Edinburgh). An 8-inch loop of lower ileum was isolated
in a rubber bag. The histamine content was tested by
the effect of extracts on blood pressure of atropinised
cat, on rat uterus, and on virgin uterus and ileum of guinea-
pigs. The total content amounted to as much as 4 mg.
Although this amount is large, histamine is not to be
regarded as the sole lethal factor in the exudate. Its
bacterial origin is not wholly accepted.
EXPERIMENTAL OBSERVATIONS ON THE SPREAD OF
CARCINOMA BY THE BLOOD STREAM, with special reference
to the difference between the portal and systemic routes.
By David H. Patey (London). A dilute emulsion in
saline was used of the Brown-Pearce tumour of the scrotum
of rabbits. Injection into the portal system of rabbits
in 41 cases was followed by visceral tumours in 7. Similar
injection into a systemic vein gave visceral tumours
in 30 out of 44 cases.
Basis OF TREATMENT OF VASOSPASTIC STATES OF THE
EXTREMITIES: an experimental analysis in monkeys.
By P. B. Ashcroft (London). Theimmediate and late effects
of pre- and post-ganglionic division of the sympathetic
nerve-supply to the limbs was studied by skin temperature
records. Post-ganglionic division was found to produce
a great increase in adrenaline sensitivity and an increased
sensitivity to cold. It is suggested that this may account
for ‘‘recurrences’”’ after operations of sympathectomy
on the upper limb, and that pre-ganglionic section is a
better operation.
THE LANCET |
THE LANCET
LONDON: SATURDAY, MAY 1, 1937
INJURIES OF THE FACE
Few of us reach maturity without having on
some occasion suffered acute embarrassment from
the consciousness of a facial lesion—be it only a
scratch or mole or pimple. An assurance that
others have not noticed it is offensive rather
than comforting, for the oriental expression which
identifies “face” with self-esteem implies but
little exaggeration of the normal attitude. More
serious and permanent lesions, whether congenital,
such as cleft lip or nevi, or acquired, such as
tissue loss or distortion after a wound or accident,
can indeed inflict such mental trauma that the
development of plastic surgery to its present
high level is of far more than esthetic value.
Bram, BROWN, and Byars, in a recent study of
injuries of the face, note that a conviction of
deformity may even persist despite the most
perfect repair, and that unless it is wisely handled
may destroy the value to the patient of any
operative measure. It is of the utmost importance,
then, to avoid procedures immediately after any
injury which will increase the final scarring.
Often the plastic surgeon is more embarrassed
by the scars of primary sutures or by the results
of immediate débridement than he is by the
direct effects of the injury. On the other hand,
in fractures of the face delay may be even more
dangerous from the cosmetic point of view, than
immediate repair by one who is not an expert,
since, according to these authors, once solidification
occurs satisfactory reposition of bones of the
face is nearly always impossible. In their article
on prognosis in plastic surgery, GILLIES and
Mow.rm ? take a different view, holding that
where there is no skin lesion demanding immediate
treatment accurate reposition of the bony frag-
ments may be facilitated by waiting for a week
or so to allow swelling to subside. The position
of the fragments can then be more readily ascer-
tained by palpation and their replacement more
exactly controlled. It must be remembered,
however, that the procedure must depend on the
degree of specialised experience of the surgeon
and that the American authors are addressing the
general rather than the expert plastic surgeon.
In treatment of injuries of the soft parts, the
first rule is not to sacrifice tissue. A great deal
of faith can be placed in the vitality of flaps of
facial tissue. In certain types of injury to the soft
parts primary suture is also important. Blair,
Brown, and Byars cite four in particular: In the
“trap-door ” flap with a narrowly bevelled edge,
delay in suturing the thin edge into position may
1 Blair, V Brown, J. B., and Byars, L. T. (1937) Surg.
Gynec, Obstet. Pea
358.
2 Gillies, H., ‘and Mowlem, R. (1936) Lancet, 2, 1411.
INJURIES OF THE FACE
[may 1, 1937 1057
lead to its crumpling up in the scar, with an obvious
cushioning of the tissue beyond it. Careful reposition
of torn pieces of ear, again, may be the only chance
of preventing distortion. Narrow, double-surfaced
flaps, as at the border of the lip, ear, or eyelid,
if left hanging are apt to become. so twisted as
to be unusable in a subsequent repair. Finally
it is recommended that all cuts and tears of the
skin of the nose and its cartilage be immediately
closed with sutures as this may be extremely
difficult to do later on. In this connexion we
may note that in a recent publication another
American surgeon, J. EASTMAN SHEEHAN,’ deals
with the repair of cartilaginous defects of the
nose in very great and useful detail, though his
views on the utilisation of cartilage in preference
to bone for the restoration of major losses of the
bridge line do not correspond with modern British
practice. In the nose immediate reduction of bony
and cartilaginous displacements of the parts is
advisable, for a late replacement may be a formid-
able procedure. There is a difference of opinion
among experts as to the value of intranasal packing
in retaining the reduced fragments. Blair, Brown,
and Byars use a metal splint in cases which do not
remain reduced without difficulty. They draw
attention to the importance of nasal injury in small
children. The possibility of distorted growth of
the septal cartilage resulting in later life should
be remembered, even after injuries that at the time
seem trivial. ‘Their practice is to explain the
position to the parents and obtain consent to make
forcible pressure on the bony ridge from within
so as to straighten any bend in the septum.
The value of coöperation with the dental surgeon
in all fractures of the jaws is well recognised in this
country. Often the repair is primarily an ortho-
dontic problem. The two methods now employed
are interdental wiring and the dental splint.
Almost any fracture with sufficient displacement
to require splintage must be compound. Ordinary
. wire buried in the jaw will in most cases result in
osteomyelitis and bone loss. Possibly the passage
of wire through the alveolus of the fragment with
fixation to an adjacent tooth is a safer method
since the wire can be recovered in a week or two.
The involvement of the tooth socket in a fracture
of the jaw is a complication which needs attention.
If necessary, drainage must be provided by an
external incision under the border of the bone right
up to the slit that enters the socket. The edentulous
jaw presents its own problems, but they can often
be met satisfactorily by use of the dental plate or
plates. But if the case is seen early such heroic
measures are seldom required. It is essential to
remove any teeth which lie either in or very near
to the fracture line since they will act as foreign
bodies; the open sockets thus created usually
supply sufficient drainage. The importance of
avoiding through-suturing of the skin with thick
sutures of silk or silkworm-gut should be impressed
on all casualty officers. When -horse-hair sutures
removed in 48 hours or so are obviously insufficient
3 Plastic Surgery of the Nose. 2nd edition. By J. Eastman
Sheehan. London: Humphrey Milford, Oxford University
Press. 1936. Pp. 186. 38s.
\
1058 ‘THE LANCET]
to retain the tissues in accurate apposition, much
can be done with subcuticular stitching which is
nowhere more valuable than on the face. © Sub-
dermal interrupted sutures of very fine silk may be
inserted in deep wounds if the ends of the suture
are left protruding from the corner of the wound
to allow of the knot being subsequently discarded.
Adhesive plaster is often better than any suture,
and injuries of the lips can sometimes be repaired
from the mucous surface with adhesive plaster
to hold the skin edges. It is sometimes unwise
to bury catgut in the lip and the repair may be
effected by fine silk or silkworm-gut for skin and
fine catgut for muscle and mucous membrane.
HYPERTONIC SUCROSE
INTRAVENOUS injections of a hypertonic solution
of dextrose—or sodium chloride—are commonly
employed in the treatment of states of raised
intracranial pressure. The fall in the intracranial
pressure which results from such an injection
has been measured in experiments upon animals
and by direct manometric observations in humans ;
the reduction of pressure has been found to be more
conspicuous when the pressure is considerably
above normal. This form of treatment is not always
successful in effecting clinical improvement, and
it is well recognised that after a short interval of
time a relapse is liable to occur which may leave
the patient in a more serious state. There is
experimental proof that such relapses are due to a
reactionary rise of the intracranial pressure at
times to a figure above its former value. This
reactionary rise indeed constitutes a serious draw-
back to the method of treatment, although
repeated injections may be given to obviate it.
If sucrose is substituted for dextrose, hypertonic
solutions are found to possess a similar osmotic
property of reducing the intracranial pressure,
but without the objectionable reaction. Following
the intravenous injection of hypertonic dextrose,
there occurs an increase in the quantity of hydro-
lysable carbohydrate in the cerebro-spinal fluid
which is not observed if sucrose is employed.
It is likely that the mechanism of the reactionary
rise in the intracranial pressure depends on this
alteration in the composition of the cerebro-
spinal fluid and consequently of its osmotic
pressure. Hann, RAMSEY, and KOHLSTAEDT
have recently published a short review of this
subject of “ osmotic therapy,” with special refer-
ence to the treatment of cases of brain injury.
In a series of twenty-five such patients, they gave
single or repeated doses of sucrose, usually 100 c.cm.
of 50 per cent. solution. Their experience leads
them to consider sucrose a valuable substitute
for dextrose, causing an effective reduction in the
intracranial pressure with freedom from untoward
after-effects. They record in detail the notes of
three cases treated in this manner. The injections
noticeably improved the patients’ colour, respira-
tory rhythm, and state of consciousness, and
reduced the systolic and diastolic blood pressures.
1 Hahn, E. Vernon, Ramsey, Frank B., and Kohlstaedt,
Kenneth G. (1937) J. Amer. med. Ass. 108, 773.
THE SHORTAGE OF VETERINARY SURGEONS
[way 1, 1937
The authors consider that criteria such as these
are as dependable as the unequivocal information
obtained by spinal manometry. They note that
in the unconscious patient, the too frequent
injection of hypertonic solutions may lead to
dangerous dehydration, owing to ‘the resulting
diuresis. We would add that intravenous therapy
should not be resorted to indiscriminately in cases
of injury to the brain ; some of these cases have an
abnormally low intracranial pressure, a state which
might be aggravated by this form of treatment.
THE SHORTAGE OF VETERINARY SURGEONS
In the April issue of the Veterinary Journal
a special educational number, there are points
of great interest not only-to boys seeking a career
and their parents or advisers, but to all practi-
tioners of medicine, from their position as guardians
of the public health. Here the two branches of
medicine, the human and the veterinary, play
individual and combined parts, and any shortage
in the total number of the veterinary body may
reflect seriously upon the joint efforts. For the
diseases of animals which are communicable to
man are far spread in their evil influences. In
this country anthrax, glanders, and rabies are now
fortunately rare if terrifying spectres. Their
eradication is mainly due to the control exercised
by the veterinary department of the Ministry of
Agriculture and Fisheries over their respective
sources of origin, bovine, equine, and canine.
It is to be hoped that we shall never again in
this country have to fear these terrible menaces
to man; but this security depends upon the
continuance of the present keen veterinary inspec-
tion at each port where animals are allowed to land,
as well as on quarantine laws and those governing
the importation of animal products. Efforts
directed towards prevention of the spread to
humans of brucella infections and of foot and
mouth disease must also be recalled. In the
inspection of meat for human food the man
who must by virtue of his training know most
about the matter is the veterinary surgeon. He is
the one best qualified to detect disease in the food
animal before slaughter and to guarantee the
soundness of the flesh when dressed for human
consumption. And in the present fight against
tuberculosis, which is an uppermost theme in
every mind, the medical man works with the
veterinarian; and only through such collaboration
can measures of prevention be considered or a
successful conclusion to endeavour be anticipated.
The editor of the Veterinary Journal draws
attention to the shortage of veterinary surgeons
throughout the country and the difficulties which
exist in obtaining the help of qualified assistants.
This is to be attributed largely to the openings
existing in the Colonies, and the recently formed
Veterinary State Service, whose most urgent duty—
the eradication of the tuberculous cow—absorbs
many workers. It is necessary to bear constantly in
mind the fact that every year between 2500 and
3000 deaths of children under 5 years of age are
traceable to the drinking of tubercle-infected milk.
THE LANCET]
If reliance is placed upon many published state-
ments there are some million tuberculous cows
in Great Britain and Ireland, while in many districts
the dairy herds are infected to the extent of from
30 to even 60 per cent. As recently as last Tuesday |
Lord Dawson reminded the House of Lords, in
connexion with the present need for pasteurisation
of milk, that the decline in mortality from bovine
tuberculosis had not kept pace with that from the
human form of infection. If an intensified effort
to eradicate the tuberculous cow is a great task
before the veterinarian we are reminded how
varied and important are the other directions
in which his services are required in the promotion
and protection of public health. The shortage of
qualified vetermary surgeons is therefore a matter
of real concern. The young man entering the
RADIOTHERAPEUTIC HOSPITAL DEPARTMENTS
{way 1, 1937 1059
veterinary profession to-day will find that he has
joined a service which is increasingly needed and
valued ; the whole world counts on his help.
But the more this is so the more evident is it that
the educational course must become increasingly
comprehensive, and the tests to be satisfied grow
harder. An extension of the curriculum has already
been made, and university courses are running
concurrently with those connected with the prac-
tising diplema, but the danger of discouraging
candidates by insisting on too prolonged and
arduous a course of study must be borne in mind.
Students entering the veterinary profession now
will command better material rewards than has
been possible in the past, as there are almost
limitless possibilities of promoting the welfare of
the human as well as the animal kingdom.
ANNOTATIONS
RADIOTHERAPEUTIC HOSPITAL DEPARTMENTS
THE assumption which pervades the official memo-
randum on provision of radiotherapeutic departments
in general hospitals just issued ! is that any discussion
in general terms as to the place of surgery, X ray
and radium therapy in the treatment of cancer is
obsolete. In about 40 per cent. of the cases of
malignant disease admitted annually to hospitals the
tumours are in the so-called ‘‘ accessible ’’ organs, the
term “‘ accessible’’ being used to define those which
are most amenable to treatment by radiation, or a
combination of it with surgery—viz., uterus, mouth,
skin, and breast. Radiation methods are also being
tried with varying degrees of frequency and success:
for a proportion (here estimated as about 10 per
cent.) of the patients with cancer in other regions.
Since much can be done in the way of palliation by
radiation methods, no sharp distinction can be
drawn between cases treated with or without hope
of permanent benefit. The need for facilities for treat-
ment by both forms of radiation methods—radium
and X rays—as well as for operative surgery in a
general hospital which claims to give an adequate
cancer service is now recognised, and the problem is
narrowed to the calculation of the size of hospital
which may be expected to yield enough cancer
patients to make reasonably full use of radiation
facilities. Lieut.-Colonel Smallman, who has compiled
this memorandum for the Ministry of Health, estimates
this at a hospital of the order of 300 beds of which
some 30 to 40 might be expected to be required by
cancer patients of the “ treatable’? types. The
necessary provision of radium for a hospital of this
size is put at about 1:0 gramme of radium and, for
deep X ray therapy, two or three tubes working at a
voltage of 200-250 kilo-volts; and two model lay-
outs for a department of this order are detailed with
plans. Provision of larger masses of radium for
distance therapy by so-called bombs is omitted from
. consideration, as being in a stage of development
which makes it suited only to the larger centres.
But attention is given to the choice, training, and
organisation of a unit which will provide the necessary
team-work in the absence of a director—still very
dificult to find—who is expert at all three branches
of treatment, and is able also to supervise the follow-up
‘Cancer: Memorandum on Provision of Radio-therapeutic
Departments in General Hospitals. By A. B. Smallman, C.B.E.,
D.s.0., M.D. Rep. publ. Hlth med, Subj., L No. 79.
London: H.M. Stationery Office. 1937. Pp. 32.
onid.
7d.
` desirable.
department and the collecting of records in suitable
form. Apart from the internal organisation of centres
which will make an efficient cancer service available
throughout the country, arrangements must be made
for ,cases of cancer admitted to the smaller hospitals
to be transferred to those with radiation facilities
without undue delay when such transference seems
The difficulties to be surmounted before
this sort of scheme can be got into working order
are fully recognised by Colonel Smallman, and a
study of his discussion of the issues involved will
convince those who have the responsibility for
hospital services that there is no excuse for delay in
organising a network of fully equipped centres to
serve those districts which still need them. In a
preparatory note Sir Arthur MacNalty acknowledges
the courtesy of a number of physicians and surgeons
who have made useful suggestions after considering
the memorandum, which he believes to represent a
consensus of authoritative medical opinion on the
subject of radiotherapeutic hospital departments.
THE ROYAL SURGICAL AID SOCIETY
THE Royal Surgical Aid Society in the course of
75 years’ activity has provided well over a million
patients with urgently needed surgical appliances.
It has since the opening of the century received
Royal patronage and the occasion of the Coronation
is being taken to make a departure which should lead
to an extension of its valuable services. The plan
of work is that the patient obtains a certificate from
a surgeon of fitness for aid and then collects from
subscribers to the Society the number of letters of
recommendation specified as necessary. An annual
subscription of half a guinea, or a life subscription
of five guineas, entitles the subscriber to two recom-
mendations per annum, the number of recommenda-
tions increasing in proportion to the amount of
subscription or donation. That is the existing
method, but, in order to mark the event of the Corona-
tion, the committee of the Society propose to issue
double the usual number of recommendations in
respect of all special “ Coronation donations” during
the month of May. The increase in the number of
those whom the Society can help which should result
will mean a boon to many sufferers, for the applica-
tions for aid are always far in excess of what can
be dealt with. Study of the annual report for 1936
reveals something of the extent and importance of
the Society’s work. During that year 27,156 patients
1060 ‘THE LANCET] `
THE BLOOD GROUPS IN AFFILIATION CASES
[maY 1, 1937
obtained help through the Society, and the appliances
supplied totalled 35,263. Requests received from
the distressed areas were so numerous that a special
fund was created to deal with them, and a successful
appeal was launched enabling special grants to be
made to all authorised distressed area cases.
A valuable aspect of the work of the Royal Surgical
Aid Society is that, while relieving much distress,
it enables the benefactories who would otherwise
be chronically handicapped to lead normal and useful
lives. The annals of the Society are full of such
promising histories, and every day applications
are received where similar fortunate issues might
be anticipated. In the L.C.C. housing estates
preference is being given to tenants having delicate
families, who thus form fields where surgical equipment
is sadly needed. The Surgical Aid Society hopes in
the Coronation year to receive support enabling it
to help every suitable case from these areas.
THE BLOOD GROUPS IN AFFILIATION CASES
THE discovery of four, and later of twelve blood
groups provided means of differentiating to some
degree between the blood of different persons. Ever
since it was discovered that the group characters
are inherited according to unvarying rules, jurists
have considered using this knowledge’ in the
determination of affiliation suits. In most civilised
countries the law requires the father of an illegitimate
child by a single woman to contribute to its main-
tenance. Accusations of paternity are difficult to
prove and the law of this country is satisfied with
credible evidence by the mother corroborated in
some material particular, provided that the evidence
of the man does not refute it. A method of reaching
greater certainty is therefore desirable.
The Medico-Legal Society discussed on April 22nd,
under the chairmanship of its president, Mr. Ainsworth
Mitchell, the practical and legal possibilities of using
blood groups in evidence. Dr. G. Roche Lynch
explained the nature of the twelve groups formed
by combinations of the agglutinogens A, B, M, and N.
He explained that almost all the original weaknesses
of the laboratory methods have been recognised and
abolished and that in experienced hands the tests are
as nearly infallible as any scientific tests can be.
Dr. David Harley expounded the rules by which the
blood characters are inherited, and maintained that
they are so completely authenticated as to be
absolutely trustworthy. They state, shortly, that
a child cannot inherit a blood character not possessed.
by either parent, and, moreover, that an O child cannot
have an AB parent and vice versa. Mr. D. H.
Kitchin .pointed out some of the difficulties in the
way of the legal exponents of the tests. Their cost,
he said, puts them beyond the means of the poor
men who are usually the defendants in afliliation
proceedings. He had little doubt about the need
for them, and strongly opposed the view, which is
held even in some legal quarters, that the law only
requires reasonable proof that intercourse has taken
place at the proper time, and not proof of biological
paternity. It is common knowledge that women of
easy virtue who find themselves pregnant not infre-
quently choose the man who is most likely to be able
to afford the maintenance of their child. At present,
as Mr. Kitchin pointed out, a bench of magistrates
has no power to order the woman to undergo the
test, nor even to refuse her application because she
will not. If all three bloods are typed and the results
acquit a man, he still has to pay a considerable
fee to the pathologist to come and give evidence,
It is not possible yet to say what the attitude of
magistrates is likely to be towards blood-group
evidence, for it has only been brought before them
once or twice and then has never pointed to an
acquittal. There is no doubt, as Mr. Kitchin said,
that the first case in this country in which non-
paternity is definitely established will be very interest-
ing and important. If the bench were to refuse to
acquit the man an appeal would lie to quarter sessions
and thence to the Divisional Court, and an opportunity
would be given for a full argument of the validity
of the tests in a court. Their establishment in one
or two conclusive cases would pave the way for
the legislation which would be necessary before
they could attain their rightful place in the administra-
tion of the Bastardy Acts. It would be necessary to
place some compulsion on the mother; as Judge
Earengey, K.C., put it, the bench should have power,
if the mother refused her codperation, to grant an
indefinite stay of the proceedings. It would also be
necessary to provide that, unless one of the parties
particularly desired the oral evidence of the pathologist,
his certificate should be conclusive proof of the result
of the test. Further, it would be necessary, to get
the full value from the tests, to give the magistrates
power to have them done at the public expense,
The most important feature of the discussion was
the strong support of the movement by Sir Travers
Humphreys, whose position and reputation as a
judge of the King’s Bench Division give his opinion
authority. He said that the whole legal profession
would welcome the blood-group tests if they were
shown to further the cause of justice. He saw no
real difficulty in saying in an Act of Parliament that
a woman shall, if the court so direct, submit to a
simple, painless operation. He also considered that
the bench should have power to appoint an expert
to do the test, just as a High Court judge is now
allowed, under the New Procedure, to appoint an
expert to report on any matter of scientific difficulty.
Both he and Sir Ernest Graham-Little considered that
the future of the blood-group tests in law depended
very largely on the agreement of the medical profession
that they are trustworthy.
THE PROMOTION OF LACTATION
THE influence of various hormones upon lactation
is being studied closely at the present time from
several aspects, of which that represented by agri-
culture is of great economic and commercial impor-
tance. S. J. Folley at the National Institute for
Research in Dairying, Reading, has shown in con-
junction with F. G. Young 1 that prolactin, one of
the many hormones derived from the anterior lobe
of the pituitary, can greatly increase the production
of milk. Two dairy shorthorned cows in declining
lactation were used for the experiment. One
received 15 daily subcutaneous injections of 1 gramme
of prolactin in 50 c.cm. of water; the other was
given similar injections of distilled water. The
cow receiving prolactin developed an increase in
milk yield, rising to a maximum of 30 per cent.
above the original daily yield. The percentage of
fat in the milk remained unchanged while the injections
were being given, while the percentage of non-fatty
solids in the milk was considerably increased during
this period and for some time afterwards. Folley
has also studied the effect of cestrogenic hormones on
lactation.? Four Guernsey cows were given injections
of oestrone, partly in solution and partly suspended
1 Chem. Ind. Rev. 1937, 56, 96.
2 Biochem. J. 1936, 30, 2262.
THE LANCET]
in warmed castor oil, supplemented by a small
amount of a solution of “ dihydro-follicular-hormone
benzoate ” in sesame oil (the Progynon B Oleosum
forte prepared by Messrs. Schering). The injections
were intramuscular and preceded by a control period
of at least 14 days, and the following calculations
were made for successive three-day periods: mean
daily milk yield, mean daily production of milk fat,
mean daily production of milk non-fatty solids,
mean percentage of fat in milk, and mean percentage
of non-fatty solids in milk. The results showed
that estrogenic hormone injections were always
followed by a considerable diminution in milk yield.
The inhibition was temporary and was obviously
correlated with a transient but considerable increase
in the level of cstrogenic hormone in the blood.
An attempt was made, by giving to one cow simul-
taneous injections of the cestrogenic hormone and
prolactin, to determine whether the inhibition is
exerted primarily on the anterior pituitary or whether
it is a direct effect on the mammary gland; unfor-
tunately the results were inconclusive. The effects
of the estrogenic hormone on the composition of the
milk were remarkable, suggesting that the treatment
had conferred upon the mammary gland the power
to synthesise milk constituents at a higher rate than
before treatment. An increase in concentration
of solids in the milk secreted lasted for two or three
months. These investigations have an obvious
interest for those concerned with promoting the
breast-feeding of infants, though the direct applica-
tion of the results of such studies to the human
subject would not be easy especially in view of the
superstitions which have accumulated round the
subject of breast-feeding. P. J. Greenway,’ who is
the systematic botanist at the East African Agri-
cultural Research Station in Tanganyika Territory,
has recently recorded some interesting observations
on the artificial induction of lactation in women by
administration of various concoctions both by mouth
and by local injection. He records over a dozen
plants which have a reputation in the territory
. as galactagogues, and there seems little doubt: that
some activity in the breast even of women who would
not otherwise be lactating can be induced by their
use. Greenway suggests that the plants he mentions
may have some action on the hormones which control
lactation.
THE EFFECT OF VENOUS STASIS ON BONE
REPAIR
THE acceleration of bone growth in conditions of
venous stasis, clinical as well as experimental, is
discussed by Herman E. Pearse and John J. Morton 4
in the first issue of a new American journal which
we have already had occasion to notice.5 The asso-
ciation between chronic cardiac and pulmonary
disease and bone changes in the fingers—the well-
known club-fingers—has long been recognised, and
Pearse and Morton mention various local circulatory
changes associated with hemangicctasis, arterio-
venous aneurysm, and meningioma which have been
held responsible for overgrowth of bone. They have
conducted experiments on dogs by which they claim
to have demonstrated a direct acceleration of bone
repair in artificially-produced defects in the fibula
by ligature of the popliteal vein. These experiments
were first described in 1930, but since they were
challenged by J. A. Key and F. Walton, further
3 E. Afr. med. J. nebrnaiy, 1937, p. 346.
4 Surgery, 1937, 1, 106
6 Lancet, Maron i3th, "1937, D. 640.
THE CHEMOTHERAPY OF STREPTOCOCCAL INFECTIONS
[may 1, 1937 1061
work has been undertaken. Pearse and Morton
have now done 28 experiments on dogs’ fibulæ, and
these have shown an increase in the rate of healing
in 25 on the side with venous congestion. The
progress of repair is controlled by X ray examination.
Great care is necessary to maintain the continuity of
the periosteum, as failures in bony union occur if
muscle is allowed to interpose between the fragments.
Bleeding is avoided by approaching the fibula through
the plane of the intermuscular septa, and care is
needed to distinguish the popliteal vein, which it is
intended to ligature, from the lesser saphenous vein.
The requirements laid down by Pearse and Morton
for these experiments are that post-operative splinting
shall be avoided, that functional disability shall be
minimised, and that damage to the circulation shall
be absent. Failure to reproduce their results are
attributable, in their opinion, to some imperfection
of technique. They have found, however, that repair
of bone in young animals is so rapid that it is
difficult to accelerate it further, and this also may
account for certain anomalies. The object of this
study was to explain the clinical results reported by
other observers, and to suggest that venous stasis has
a place in the treatment of fractures in the human
subject.
THE CHEMOTHERAPY OF STREPTOCOCCAL
INFECTIONS
A FLOW of literature dealing with the therapeutic
use of Prontosil and sulphonamide is now in full |
current. What is more particularly needed at the
present stage is guidance on such matters as dosage,
the type of preparation to be used, and the effect to be
expected in different types of infection by Strepto-
coccus pyogenes. A solid contribution on these lines
is made by Long and Bliss! of the Johns Hopkins
Hospital, Baltimore, who have treated 70 cases
of such infection involving various parts of the body. .
Among these there were 4 deaths, two being cases
of Ludwig’ 8 angina, one a septicemia in extremis,
and: the fourth an infant with peritonitis. The
recoveries included 22 cases of erysipelas and cellu-
litis, 27 of acute infections of the upper air-passages,
including 8 of scarlet fever, 9 cases of otitis media,
and smaller numbers of septicemia, puerperal fever,
and other miscellaneous conditions. Long and Bliss
are convinced of the efficacy of the treatment. They
have used both prontosil injections and oral sulphon-
amide; their dosage is heavy (up to 5 grammes of the
latter daily), and they report few signs of toxic
action, including only three examples of sulphemo-
globinemia. That an adequate concentration of
the drug can be maintained continuously in the
blood and tissues by present methods of administra-
tion is indicated by the useful work of Marshall,
Emerson, and Cutting,? who have studied the absorp-
tion, in-vivo distribution, and excretion of sulphon-
amide given either by injection or by the mouth.
This is a straightforward pharmacological study of a
kind which is apt to find a too belated place when
enthusiasm for a new remedy outstrips the orderly
progress of its study. The investigations, which were
carried out in dogs, show that whether the drug is
given by the mouth, by subcutaneous injection, or
intravenously, a high concentration is maintained in
the blood for six hours and diminishes only slowly,
owing to the very gradual onset of elimination in the
urine. It was likewise shown that a concentration
351.
1 Long, P. H., and Bliss, Eleanor A. (1937) Arch. Sunn: 3
. O. KEE
2 Marshall. 'E. K., Emerso on, K., and Cutting, W
J. Amer. med. Ass. 108, 953.
-1062 THE LANCET]
equivalent to about half that existing in the blood is
attained in the cerebro-spinal fluid, a fact of great .
importance in relation to the possible treatment of
streptococcal or meningococcal meningitis.
Another aspect of research’ on these drugs is
concerned with their effect on bacteria other than
streptococci. It will be recalled that Dr. G. A. H.
Buttle and his colleagues recently reported in this
journal è experiments from which it appears that
sulphonamide has a remarkable action, in mice, on
infection by typhoid and paratyphoid bacilli, and
lesser degrees of effect in infection by a number of
other bacteria. Among these was the pneumococcus,
and the findings in connexion with
organism were distinctly less encouraging than those
reported by Rosenthal.4 There is a discrepancy
here which has yet to be explained, and for the time
being a proper inclination would be rather to accept
the results of the more experienced workers in this
field. On the whole it seems advisable for the present
not to build serious hopes on these wider explorations :
there is no shorter road to discredit of any drug
than its indiscriminate use. Sulphonamide cannot be
expected to do everything, and the detailed knowledge
of antiseptic action which has been accumulating for.
years all points to a curious specificity among the
most active agents we possess, some bacteria being
highly susceptible and others comparatively resistant.
Now that effective chemotherapy is shown to be
possible in at least one bacterial infection, it may
be that altogether other chemical weapons will be
forged with which to combat others.
INSTITUTE OF CHILD PSYCHOLOGY
Too much stress is sometimes laid, in psychological
work with children, on the prevention and treatment
of neurosis—i.e., on pathology rather than on
normality. The Institute of Child Psychology believes
.in an approach based upon an intimate knowledge
of all aspects of childhood, a direct study of the
children themselves. Its staff have worked out some
interesting methods peculiar to the Institute for
treating children suffering from all kinds of disturb-
ances of their emotional life, from chronic physical
disorders, from maladjustment at home or at school,
and from educational difficulties. One of their most
successful methods is play therapy. They are
concerned to make their methods available for other
centres and to standardise them for general use.
The report for the past year says that great progress
has been made in classifying and consolidating these
methods and there is evidence that much interest
is being aroused in them. The staff also accumulate
the knowledge they acquire about the reaction of
children to life. In May the first number of the
Institute’s News Bulletin appeared, and the bulletin
is now self-supporting at a nominal annual subscrip-
tion. Two group discussion meetings were held and
courses of public lectures were well attended. During
the autumn, members attended a course of lectures
by Prof. R. G. Collingwood on the study of fairy
tales. The Institute sends its play therapists to a
special clinic at the West End Hospital where
children are treated for night terrors, anxiety, speech
difficulties and other disorders of health and conduct.
A special department treats children individually
instead of in groups and provides useful training for
physicians who wish to learn the psychotherapy of
childhood, Children are examined for physical ail-
ments in a medical department and an effort is made
Pra March 20th, 1937, fig
ê Rosenthal, S. . (1937) Publ. Hlth , Wash. 52, 192. -
INSTITUTE OF CHILD PSYCHOLOGY.—JOHN BLAND-SUTTON
this.
[may 1, 1937
to give them the treatment they need. The educa-
tional department collects and codrdinates school
reports, arranges special coaching and studies the
relationship between emotional inhibition and freedom
to use the intélligence. The social worker dealt
last year with 130 cases, including the heavy work
of after-care, and of finding suitable help for children
who could not be treated at the Institute. Another
department cares for the physical re-education of
children by rhythmic exercise. Parents are welcomed
at the institute, which recognises their importance
in the child’s problems and encourages them to deal
with their own. A generous donor has promised to
buy the Institute a larger house as soon as it can
find a suitable building.
THE PHOSPHATASES
THE phosphatases are assuming a steadily increasing
significance in several departments of physiological
and medical research and papers on the subject are
multiplying rapidly. As usual these find their way
into a wide variety of journals, not all of which are
readily accessible to medical workers. Mr. S. J.
Folley, Ph.D., and Prof. H. D. Kay} of the National
Institute for Research in Dairying, Reading, have
performed a useful service by summarising in tabular
form what is known about the properties of the
various phosphatases, their distribution in mammalian
tissues and fluids, and the changes which they exhibit
in natural or experimental disease. They have
compressed a great deal of information into a sur-
prisingly small space and their review should be very
helpful to anyone who is seriously interested in these
enzymes,
JOHN BLAND-SUTTON
AS a supplement to the Journal of Obstetrics and
Gynecology of the British Empire for the April
issue there is published a biographical essay on
John Bland-Sutton written by his colleague and
close friend, Sir Comyns Berkeley. The story,
admirably told, wanted telling in detail, because
Bland-Sutton’s career—his successes and set-backs,
his friendships and animosities—was sometimes
puzzling even to his friends. This record, a full and
moving one, while setting out in a coherent manner
its subject’s personality, gives interesting pictures of
professional and hospital organisation at the different
epochs. Cooke’s popular private school of anatomy
was flourishing in the ’seventies, and Bland-Sutton .
attended it and was invited to be the demonstrator.
But he refused the post, tempting to an impecunious
student, and offered himself, with 100 sovereigns
in a bag, as a perpetual student at Middlesex Hospital.
He joined as a prosector, for his work at Cooke’s
school had been thorough, and throughout all the
earlier stages of his career at Middlesex he was
teaching and coaching his contemporaries. This
precocious position as instructor explains the simplicity
and directness of his writings and public utterances
—he had taught himself to give prominence only
to the things that mattered, and to provide explana-
tions that could be followed at once. He won all
the prizes at the hospital for which he competed
but was unable to take a house surgeon’s post, because
not only was it an unpaid appointment but it neces-
sitated the disbursal of a fee. He became instead
assistant curator of the hospital museum, and worked
so well that he was offered more important posts of
a similar kind. These he refused, concentrating
1 The Phosphatases, Tabulee Biologices Periodice (W. Junk,
The Hague), 1937, 12, 268-279.
THE LANOET]
on his aspiration to the surgical staff of the hospital,
This materialised, and Bland-Sutton’s election as
assistant surgeon was noticeable for two things.
First he had never been an interne, and secondly, he
was actually the first man trained at the Middlesex
Hospital to be elected to the surgical staff of the
hospital, the practice hitherto having been to draw
for the staff from other and larger schools.
Bland-Sutton’s life was epitomised in an obituary
notice in these columns. The fuller chronicle will
be read with pleasure, for not only is the story a very
interesting one, but a vivid picture is presented of the
changes that have taken place in medical education
and hospital organisation since Bland-Sutton was a
student.
THE MEDICAL ANNUAL
WE always welcome the Medical Annual,! and
it continues to deserve its welcome. It is in the main,
of course, a set of summaries of the previous year’s
most important practical papers in the world’s
medical literature, prepared by a number of able and
distinguished contributors. But it avoids, with
conspicuous success, the dull stodginess of most
volumes of abstracts. This is partly because its
contributors are free to select, being under no obliga-
tion of comprehensiveness, and partly because they
know and understand the readers for wHom they
write—namely, those general practitioners who are
still willing to learn what is new and good in medicine
and eager to give the benefit of it to their patients.
The result is, in most of the articles, an easy clear
and friendly style, closer to conversation than to the
language of the text-book, and this, with the
reviewers’ skill in presenting new things in their
relation to what is already familiar, gives the manual
a character and an atmosphere of its own; it is not
merely a work of reference—one can enjoy spending
an evening reading straight through it. The editors
have the impression that last year was a year of
steady advance in many fields, without spectacular
achievements, and they remark that the tendency
continues for the clinical and the laboratory aspects
of medicine, no longer incompatibles, to become
properly compounded in the doctors mind and
practice. That process is no doubt slow, but it needs
judgment and a sense of proportion, qualities which
make-the Medical Annual’s own contribution to it
a very useful one,
THE TREATMENT OF ADDISON’S DISEASE
DESPITE great advances in our knowledge of
the function of the suprarenal glands, the treatment
of Addison’s disease remains very unsatisfactory.
This is the more depressing since both the preparation
of the cortical hormone, and the discovery of the
role of salt, held out great promise of therapeutic
application. The reasons, however, are not far to
seek. In the first place, as Borst and Viersma ?
point out, failure is naturally to be expected if the
Addisonian syndrome has been caused by generalised
tuberculosis which in itself would ultimately have
proved fatal. A second difficulty to which they
also allude has been the failure of manufacturers
to supply
hormones. A third difficulty is the seemingly manifold
action of the cortical hormone or hormones, This
* Medical Annual, 1937. Edited by H. Letheby Tidy, M.A.,
M.D. Oxon., F.R.C P., and A. Rendle Short, M.D., B.S., B.Sc.,
FR-OC tk Bristol John nent and Sons. London: Simpkin
Marsha Da 105:
a Borst, J. G. G., and Viersm: t, H. J. (1937) Acta med. scand.
127
THE TREATMENT OF ADDISON’S DISHASE
cheap, standardised preparations of the
[may 1, 1937 1063
is brought out by Grollman® and by other investi-
gators. The arterial blood pressure, inorganic salt
metabolism, carbohydrate metabolism, renal function,
absorption from the intestine,‘ resistance to infec-
tions, hzemorrhage and toxins all seem to be impli-
cated: and no one knows at present the relative
amounts of the hormone or hormofes required to
restore each or all of these functions to normal.
Add to this the possibility of variations in the
patient’s own resistance or reaction, and the explana-
tion of the therapeutic failures is complete. The
case described by Dr. Anderson and Dr. Lyall in our
present issue illustrates the difficulties that attend
treatment. This patient, who had been rescued from
almost certain death from collapse and salt deficiency `
in March, 1936, by cortical hormone and salt, died,
apparently from spontaneous hypoglycemia, in
October of the same year.
It is clear that once the diagnosis of Addison’s
disease has been made the prognosis must still be
guarded, It is also clear that haphazard treatment
is never likely to be permanently successful, and
that the best hope for these patients lies in making
a full investigation of their syndrome at frequent
intervals, and in varying their treatment from time
to time in accordance we the findings.
THE BRITISH ASSOCIATION
NOTTINGHAM is the place, and Sept. lst-8th the
time, of this year’s meeting of the British Association.
The president is Sir Edward Poulton, F.R.S., and
his inaugural address will deal with the history of
evolutionary thought as recorded in the meetings
of the association. Medical men who preside over
sections are Prof. F. A. E. Crew (Zoology) and Dr.
E. P. Poulton (Physiology); Prof. H. Hartridge,
F.R.S., will give a public lecture on illusions of
colour. Among very many subjects of interest to
medical men are: chemistry and medicine, the changing
distribution of population, the contribution of
physiology to the health of the individual and the
community, tests for colour defect, recent advances
in genetics and cytology, problems of child guidance,
air-conditioning, high-altitude flying, and the relation
of grass to the national food-supply. Mr. H. G. Wells
presides over the section of educational science
and will speak on the informative content of education.
Further particulars and the provisional programme
may be had from the secretary at Burlington House,
London, W.1.
THE annual meeting of the British Medical Associa-
tion will open at Belfast on July 16th, under the
presidency of Prof. R. J. Johnstone, F.C.0.G. . The
council of the Association have recommended that
Dr. Colin Lindsay be elected president for next
year’s meeting which will be held at Plymouth.
3 Grollman, A. (1936) The Adrenals, London.
* Verzár, F., and McDougall, E. F. (1936) Absorption from the
intestine, ondon,
THE Roriz Eye HOSPITAL.—A clinical society,
has been organised in connexion with this hospital.
The next meeting of the society will be held on Tuesday,
May 4th, at 6 P.M., at the hospital, when Dr. T.
Rowland Hill will read a paper on ‘“neuromyelitis
optica,” illustrated by cases. All medical practitioners
will be welcome. For further particulars apply to
the hon. secretary, J. Minton, Royal Eye Honpital,
Southwark.
1064 a LANCET |
[may 1, 1937
SPECIAL ARTICLES
ALUM-PRECIPITATED TOXOID IN
DIPHTHERIA PREVENTION
By J. C. Saunpers, M.D.N.U.I., D.P.H.
MEDICAL OFFICER OF HEALTH, CORK
THE work to which these notes relate was under-
taken in order to test the possibility of immunisation
by a single injection and may be regarded as a sequel
to previous work (Saunders 1932) in which multiple
doses of alum-precipitated toxoid (A.P.T.) were
used. The reactions experienced were discussed in
a subsequent article (1933), and arising from the
fact that in a series of 579 children four sterile abscesses
had developed, it was deemed advisable to suspend
the issue of this prophylactic while further laboratory
investigation was carried out with a view to pro-
ducing a purer A.P.T., which would be less liable
to cause unpleasant reactions and (if possible) free
from the liability to produce abscesses. The A.P.T.
used by us up to this point was that produced in
the Wellcome Research Laboratories according to
the method of Glenny and Barr (1931). Personally,
I was quite satisfied with the results obtained,
particularly in the immunising efficiency of the
product, but those in respect of reactions were not
regarded as so satisfactory by the laboratories and
the result was the temporary suspension of supplies. —
PRESENT PROCEDURE
The period covered by this earlier work was from
June, 1931, to December, 1932, and it was not until
December, 1934, that further supplies of A.P.T.
were received. A description of the method of
preparation will appear in another communication
from the Wellcome Laboratories. *
The period covered by the present work extends
from that date to December, 1936, and the pro-
cedure adopted was as follows :—
1. Children under 7 were not subjected to a preliminary
Schick test. They received 1 c.cm. of A.P.T. on the first
visit and were instructed to attend again in five weeks for
test.
2. Children over 7 received, on first visit, concurrent
Schick and Moloney tests. The dilution of toxoid used
for the Moloney test was 1 in 100 and readings were made
in three to four days afterwards. The disposal of these
cases was as follows: (a) Schick negative—no treatment ;
(b) Schick positive and Moloney negative—1 ec.cm. of
A.P.T. (retest in five weeks); (c) Schick positive and
Moloney positive—l1 c.cm. of floccules (T.A.F.) repeated
in two weeks and retest in five weeks.
All prophylactic injections were
subcutaneous route.
given by the
The majority of children under 7 are susceptible
to diphtheria and it was felt that the exclusion
of the preliminary test reduced injections to the
minimum. Indeed the great virtue of immunisation
by A.P.T. reposes in the claim that it is possible to
protect children by a single dose, and if this claim can
be substantiated a big advance has been made.
In my experience no method involving the use
of multiple injections can hope to achieve complete
treatment for all cases attending, and it will be
found that when the final tabulation is made con-
* The materials used by us throughout were supplied by the
Wellcome Research Laboratories, Beckenham, and Iam indebted
to Dr. R. A. O’Brien, the director, for supplies sent gratis in
the earlier stages of the investigation. Four different batches
were used, the Lf,value of which varied from 20 to 50.
siderable leakage has taken place. In our case failures
to complete treatment varied from 32 per cent.
in 1932 to 8-8 per cent. in 1933. In 1935—the first
complete year in which A.P.T. was used—the leakage
was calculated to be only 0:72 per cent. A defection
rate of 32 per cent. is serious and any scheme charac-
terised by such figures must be written down as a
failure. The main, if not the only, cause of such
failures is the objection inherent in so many people
to hypodermic injections, and the reduction of such
injections to the lowest possible minimum is there-
fore most desirable, especially if it can be shown.
that there is no reduction in the degree of protection
conferred.
The group dealt with here comprised originally
3189 children, including 398 who were found to be
negative to the preliminary Schick test and did
not require treatment, and 634 others who received
treatment but failed to come for the final Schick
test. There is, therefore, a residual group of 2157
who received treatment and were Schick-tested after
it, and it is this group which is concerned in the
analyses which follow.
Results of Treatment
It was decided in the first instance to review
the results of the Schick test as a whole without
any reference to the period that had elapsed between
treatment and test, and the result is set out in
Table I. With regard to the first age-group (0-2
years) it has to be stated that the great bulk of the
TABLE I
Final Results of Schick Tests after Treatment
| Schick test. Proportion
Seca Casos: negative
Positive. | Negative. | (per cent.).
0-2 .. | 446 | 7 | 439 | osa
2- 4 889 5 884 99-4
4— 6 516 5 511 99-0
asi oe 2 222 99°1
fig 2 5 61 93°9
Over 10 16 1 15 ! 33
= Total .. | 2157 | 25 | 2132 | 97
children were over 18 months, as it was only in
exceptional instances that we treated children under
this age. The proportion of negative reactions varied
from 99-4 per cent. (in the 4-6 group) to 93-1 per
cent. (over 10), but in the latter group the number
of children is so small that the resulting figures
become unreliable. Taking the group as a whole,
it is found that after treatment 98-7 per cent. of
the cases yielded negative reactions, which is at
least as good a result as could possibly be hoped
to be obtained with any prophylactic of the multiple
injection type.
The question, of course, arises about the Schick
conversion rate—i.e., the proportion of cases that
have been converted from Schick positive to Schick
negative. As stated above, primary tests were not
performed in children under 7, who comprise the great
bulk of the cases, and consequently a direct answer
cannot be given in their case; but it is possible
to adduce at least approximate figures. Since 1929
over 4000 children in Cork have been subjected
THE LANCET]
ALUM-PRECIPITATED TOXOID IN DIPHTHERIA PREVENTION
[may 1, 1937 1065
TABLE JJ—-RESULTS OF SCHICK TESTS AFTER TREATMENT
Analysed according to Interval between Treatment and Testing
RESULTS OF SCHICK TESTS.
Age- 5 weeks. 6 weeks. 7—9 weeks. 10-12 weeks. | Over 12 weeks.
grou Cases. N Do oe ee a.
p i j : l
Per | Per | | Per Per Per
Pos. |. Neg. ' cent Pos Neg. | cent. | Pos. | Neg ; cent Pos. | Neg. | cent. | Pos. ! Neg. | cent.
Neg | Neg | | Neg Neg Neg
0- 2 446 7 | 188 | 964 | — 93 | 100 — . 55 |100 — | 33 | 100 | — 70 | 100
| :
2— 4 889 2 335 99°4 1 198 ' 99°4 1 134 99°2 — , 85 100 1 132 99°2
4- 6 516 3 199 98°5 2 100 98°0 — 69 | 100 — 40 100 — 103 100
6— 8 224 1 92 98°9 — 38 | 100 1 33 | 970 — 19 100 — 40 100
! i |
8—10 66 4 29 | 87°8 — 14 | 100 1 6 857 — 4 100 | — 8 100
Over 10 16 1 ie a ee a ee — 1 | 100 | — 4 | 100
Total 2157 | 18 849 | 944 | 3 | 443 993 3 | 301 | 990 | — | 182 | 100 | 1 | 357 | 99°4
to the primary Schick test and it has been found
(Ann. Rep. 1935) that the proportion of positives
has varied from 78-2 per cent. in 1929 to 44 per
cent. in 1935. Differential analyses (according to
age-groups) have been made since 1932 and the
proportion of positive reactors in 0-5 years group has
varied from 88-4 per cent. in that year to 66-6 per
cent. in 1935, and the corresponding variation in the
5-10 years group from 60:1 to 49-5 per cent. We
may assume, therefore, that about 66 per cent.
of the 1851 children who comprise the first three
groups of our present series—i.e., 0-6 years—were
positive before treatment. This gives us a hypo-
thetical group of 1224 Schick-positive children
of whom (from Table I) 17 remained positive
to the secondary test. Thus we have a conversion
rate of 98-6 per cent., which is the same figure as the
proportion of negative tests yielded by the whole
group.
A further analysis was made according to the
period elapsing between treatment and test. The
result is shown in Table II. In all cases an effort was
made to get the children to attend for the test at
the end of five weeks ; 849 of them did so. It will be
noted that no less than 94-4 per cent. were negative
at the end of this relatively short period. If one
excludes the two last groups (8 years and upwards)
in which the figures are again very small the result
is even better, the proportion of negatives then
varying from 99-4 to 96-4 per cent. This is important.
It indicates a very high conversion rate in a very
short time. As we proceed to the longer time periods
we note a more or less progressive improvement
in which the ‘proportion of negative reactions is
never less than 99 per cent.
These results are much better than we had pré-
viously experienced with toxoid-antitoxin (three
injections), the highest negative rate being 89-5 per
cent. at a ten months interval (1932), and better also
than those obtained in a group of 1081 children
treated by us in 1933-34 with potent formol-toxoid
(two injections). In this case the proportion of
negatives on retesting was 96-8 per cent. (work not
published). The nearest approach we have had to such
figures was with the earlier batches of alum-toxoid
that I previously reported (1932), but in that case
multiple injections were used. It would hardly
be surprising if such figures as these now reported
induced, some degree of scepticism and, indeed, more
than once during the course of this work I have
felt inclined to call in question the potency of the
toxin used for the Schick test, but any uneasiness
on that score was allayed by the results of the primary
tests which were carried out concurrently. The
reactions which presented themselves were in every
way normally developed among this class. The
great majority of the readings were made by myself
and such as I did not see were read by my assistant,
Dr. P. F. FitzPatrick, who has had considerable
. experience in this work.
OTHER WORKERS’ RESULTS
It is clear, therefore, that in this area a single
dose of A.P.T. has been very effective as an immunising
agent, and it remains to be seen how the results
obtained compare with those in other places. Some
of these are shown in Table III.
Isabolinski, Judenitsch, and Lewzow (1935) also describe
interesting results obtained in guinea-pigs in which the
treated animals were found to be resistant to 600 m.l.d.
of diphtheria toxin. Kositza (1935), comparing the results
obtained with toxin-antitoxin, formol toxoid (F.T.), and
A.P.T. (seo Table IIL), concludes that A.P.T. gives a higher
percentage of immunity than F.T. in eight to nine wecks
after treatment, but that the immunity conferred by the
latter is more enduring. Leach (1935) describes the results
of field immunisation carried out in rural districts in
Austria and experiments to determine the relative merits
of different antigens. He believes that unless ‘“ depdt ”
material is present even high value toxoid has inferior
immunising powers. It was found that 60 per cent. of the
antigen was eliminated by the kidneys in twelve hours.
This author’s findings confirm the earlier work of Glenny
(1930) and are confirmed by those of Schmidt-Burbach
(1936) who describes experiments on groups of guinea-
pigs which were immunised in parallel with crude formol- .
toxoid, Al (OH), formol-toxoid, and A.P.T. (prepared by
the method of Glenny and Barr (1931) ). The latter two
antigens were found to be much superior to F.T. and the
better results are ascribed to the absorption of the antigen
and its slow subsequent release during immunisation.
_ According to this author both the alum preparations gave
rise to fewer undesirable reactions than crude toxoid.
In regard to animal experiments special reference has
to be made to the important work of Faragó (1935a) in
which is described the results of inoculation of guinea-
pigs with A.P.T. and the subsequent operative removal
of the indurated tissue and its reinjection into other
guinea-pigs. By this method the author was able to show
that even thirty-eight days after injection such tissue
gave evidence of containing antigen. Estimations of the
alum content of the tissues at the site of injection showed
that the content remains practically unchanged for thirty-
two days after injection. The longer the time the antigen
was left in situ the longer the antitoxin titre is maintained
at high level. These results suggest that an antigen
1066 ‘THE LANCET]
ALUM-PRECIPITATED TOXOID IN DIPHTHERIA PREVENTION
t
[may 1, 1937
injected in relatively insoluble form serves as both primary
and secondary antigenic stimulus or indeed, rather,
acts as a continuous stimulus. Elsewhere (1935b) the same
author describes field work in Hungary with A.P.T.
on a large scale (see Table iil).
TABLE III
Effect of A.P.T. (Single Dose)
Original | Interval Immun-
No. ity-rate
Authors Age. Schick before
treated status. testing. T
Baker and Gill 1414 — Not kn. | 2— 3 ms. 99
(1934).
McGinnes and 2000 —
Stebbins (1934). | approx.
an
Walker (1934). | A 135 | 6-18 ms.| Not kn. |
Positive. 2 ms. 90
id lyr
B 165 7—12 yrs.| Positive.
C 770 | Under | Not kn.
6 | 100
yr.
D 992 1-6 yrs. ”»
2-
m
í 2 wks. 60
Keller and A 23 — — 4 95
Leathers (1934). le? 100
B 53 — — Similar. Similar.
Isabolinski, 245 — Positive.| 63 wks. 96°8
Judenitsach, and
Lewzow (1935).
Murphy (1935). 131 — — 5 ms. 93°1
Haine (1935). 1160 |5-14 yrs.; Not kn.| 9 wks. - 90
Naughten, A 130 — Positive. — —
White, and B 240 — Not kn.| 2 ms. 90-95
Foley (1935). :
Underwood 152 — Positive! 1m. 83°6
(1935).
Kositza (1935). | A175 — Positive. nae ms. 91°4
B 335 — ae 8-9 wks. 86°3
Faragó (1935). 2652 — — 2 ms. D
lyr. (of 2379)
kn.= known.
ms.= months.
The authorities so far quoted have expressed favour-
able opinions in regard to the value of A.P.T., but not
all observers have been so favourably impressed.
Frazer and Halpern (1935) in comparing the antitoxin
response to one dose of A.P.T. and three doses of
unmodified toxoid found that the response to the latter was
distinctly greater than to the single dose of A.P.T. In
the A.P.T. group, after 10 weeks 62 per cent. had more
than 1/100 unit of antitoxin per ec.cm. Whereas of the
toxoid group 91 per cent. had more than 1/100 unit per
c.cm. After 1 year only 19 per cent. of the A.P.T.
group remained above 1/100 unit (cf, findings of Faragé
referred to above) while 91 per cent. of the toxoid group
remained above that level. Lai (1935) obtained only
62-6 per cent. conversion rate after 5 months in 359
_ previously Schick-positive children, but, in this case, it
is possible that the poor result was due to using an antigen
of low immunising power (9 Lf). Pansing and Schaffer
(1936) investigated the duration of immunity in groups
of children who had received a single dose of A.P.T. In
the first group 462 positives were retested 28 days after
inoculation and 84 per cent. were found negative. The
second group consisted of 445 positives retested after
60 days in which 86 per cent. had become negative. The
third group comprised 549 children who had been given
l c.cm. of A.P.T. and subsequently found Schick negative,
They were retested at the end of 2 years and 42-2 per
cent. only were found to be still Schick negative. In a
smaller series of cases Parish (1936) compared the results
after two injections and one injection respectively of
A.P.T. In the former case an immunisation rate of
100 per cent. was obtained as compared with 64 per cent.
in one instance and 81 per cent. in another in the case of
single dose A.P.T. He draws attention to the low natural
Schick-negative rate (17-5 per cent. to 20 per cent.) in the
communities with which he* was dealing and considers
that such communities are not suitable for treatment
by the single-dose method. Recently Bousfield (1936)
drew attention to an extremely low conversion rate
(37 per cent.) obtained by him in a small group of children
` treated with 1 c.cm. of A.P.T.
It is possible that the explanation of the discrep-
ancy that appears to exist in the findings of different
workers with A.P.T. may be found in differing
natural immunity rates. Variations may also be due
to differences in the ‘antigenic quality” of the
preparation and in the strength and purity of the
antigen. There certainly has been a striking change
in the natural immunity level of children in Cork
over a number of years.
Of 1170 children (all ages) submitted to primary Schick
testing in 1929-30 there were 78-2 per cent. of positives,
whereas in 1934 when 1474 were similarly tested the
proportion of positives had fallen to 44 per cent.
Differential analysis according to age-groups carried out
since 1932 has shown all groups to be affected in the
change, but it has been most pronounced in the 0-5 years
group (88:4 per cent. to 66-6 per cent.). In the group
over 10 years the proportion has declined from 37:7 per
cent. to 30:3 per cent.
For some reason, therefore, the natural immunity
rate of children in this area has been considerably
raised and now stands at a comparatively high
- level which, according to the views of Parish and
others as set out in a leading article in the British
Medical Journal (1935), is a favourable indica-
tion for the use of A.P.T. by the single-dose method
and may possibly explain why we have obtained
such good results by this method in Cork. But
it does not explain the comparable figures obtained
in many other areas as outlined above and I am
inclined to believe that those who have had a con-
siderable experience of A.P.T. in actual field work
will probably continue to use it among suitable
groups of children.
EFFECT ON DIPHTHERIA IN CORK
In my original article on the subject (1932) I
expressed the opinion that alum-toxoid (A.M.T.) was
superior to toxoid antitoxin mixture (T.A.M.) in the
prevention of diphtheria, that it induced immunity
more rapidly, and that in epidemic periods, when
rapid induction of immunity is essential, it was the
best antigen. Our experience of epidemic diphtheria
in Cork has afforded a unique opportunity of testing
the truth of these assumptions and I believe they
have been verified by the facts. Reference to the dia-
gram makes what follows easier to comprehend.
It is a graphical record of diphtheria notifications
(by quarters) from 1925 to the end of 1936, showing
the introduction of T.A.M. in June, 1929, A.M.T.
in June, 1931, and continued until December, 1932,
when it was temporarily suspended. F.T. was intro-
duced in March, 1933, and finally A.P.T. in December,
1934, Although there was a considerable abatement
in the severity of the epidemic after 1931 the real
decline set in in 1935 and is clearly shown in the
graph. In my opinion the main factor here was the
large number of children (particularly of pre-school
age) whom we were able to immunise by the single-
dose method. Very similar figures to these were
adduced by Prof. B. Johan at the second Inter-
national Congress for Microbiology in London in
July, 1936, in relation to diphtheria incidence in
Hungary. He showed tables and diagrams illustrating
the pronounced reduction in the incidence in certain
areas after the introduction of A.P.T. Prof. Johan
advanced as one of the reasons for the failure of
anatoxin to stem the tide of epidemic diphtheria
in the affected regions the fact that quite large
THE LANCET]
proportions of children failed to present themselves
for subsequent treatment after the first injection
(see Lancet, 1936, 2, 277), This will probably have been
the experience of most people using the multiple--
dose method. It certainly has been ours in spite of
intensive following up. In the present series no
less than 34 ;
children failed to
come for the final
test. This repre-
sents the consider-
able proportion of
22-3 per cent. and
in a scheme in-
volving more than
one injection such
cases would have
to be written off
as failures go far
as induction of
280
240
mixture
4
NOTIFICATIONS
immunity is con-
cerned.
respect, therefore,
it is clear that
A P.T WARES 40
an important
adyance in diph-
theria prophylaxis 1925 1926 1927 1928 1929 1930
and if it can be
shown that a
reasonable degree
of protection is induced by a single dose, this prophy-
lactic should play an especially important part in
combating epidemic diphtheria when rapid and
widespread protection becomes an urgent necessity.
Reactions
The reactions experienced with this lot of A.P.T.
have been definitely less than with the older batches
used some years ago, and this is especially so in regard
to abscess formation. Our procedure was to instruct
parents to report again in the course of three or
four days if there was any anxiety on the score of
sore arms or general sickness. Very few of them did so.
In addition, when the children reported for the
TABLE IV
Analysis of Reactions
| | Type of reactions.
| | =|
Age- 9 a Oo | 45 re g a
group.| 2% : al C p ais .
è E g/ 8) eraro eS
: fy ge fat D Faj Py
9 © D unl 2
| A} se] mS A
o-2 446| 20 | 44] 6 | 13; 4! 09] 3 | 62
|
2-4 889| 56 | 62] 33 | 37i 12 | r3 |101 | 11°3
4-6 516| 42 | 81| 36 | G9) 21 40} 99 |170
6-8 224 19 | 84] 18 | 80| 14 | 6-2 | 51 |227
8-10 | 66 12 |181| .8 [121 | 9 ,136 | 29 | 45°4
|
10 and
over 16 1 jy 61| — | — | 2 5122] 3 | 18-7
Total.. 2157 150 ! 6'9 | 101 | 4°6 | 62 | 2'8 |313 | 14°5
Schick test specific inquiries were made on these
two points and where positive histories were forth-
coming further more careful questions were put
about the nature and extent of the reactions and
from the information thus gained Table IV was
ALUM-PRECIPITATED TOXOID IN DIPHTHERIA PREVENTION
Multiple Injections
Toxin- antitoxin
TW
AA ECT
me OT ANAT A
CM
Notifications in Cork City before and during immunisation with different agents.
[may 1, 1937 1067
constructed. The standards used were those adopted
previously when using alum-toxoid :—
1. Slight.—Local reaction not exceeding 1 in. in diameter,
either with or without slight malaise.
2. Moderate.—Local reaction 1-4 in. in diameter with
or without malaise.
3. Severe. — Any
local reaction ex-
ceeding 4 in. in
diameter with or
without general
reaction,
It is necessary
to allude again to
the fact that in
this area these
reactions are not
regarded in the
serious light that
they appear to be
in England, and
consequently the.
findings must be
taken with a cer-
tain amount of
reserve, especially
when reliance has
had to be placed
on the views of
parents, but it has
nevertheless been
remarkable what a very large proportion of
mothers have been quite emphatic on the point
that there were no reactions. It will be noticed
that records of reactions of all sorts total 14-5 per
cent. and that approximately 7 per cent. were
mild, 5 per cent. moderate, and 3 per cent.
Single
Injection.
Alum-Precip¢-
Toxoid
Formol
Toxoid
Alum
Toxold
} 1
AS
1931 1932 1933 1934 1935 1936
severe. It will also be noted that the tendency to
TABLE V
Relation of Moloney Tests to Reactions
Case with reactions,
and proportion of
Moloney negatives (M.ve).
Age- 8 5 ie : Test
group S © : 2 S failed.
O/B |3]/s!i fis] se] ¢s
SF lig ego e
a |e E Alala
6- 8 224 75 | 19 6 | 18 14 3 |14 (18'6%)
8—10 66 62 | 12 | 10 8 9 9 |27 (43°5 %)
10 and
over 16 16 1 1| — | — 2 2 | 3 (187%)
Total 306 | 153 | 32 | 17 | 26 | 13 | 25 | 14 | 44 (281%)
develop reactions was more marked in the older
groups in spite of the selection of cases through the
Moloney test. These results are a distinct improve-
ment on those obtained in the earlier investigation
(Saunders 1933) in which it was shown that reactions
were experienced in as high proportions as 36 per
cent. and 56 per cent. with different batches. In
5 cases, in all of which the reaction was classed as
“ severe,” late development was noted. That is,
the first signs of inflammation were not noted until
6 or 7 days after the injection. Mottling was a
characteristic feature of the inflammation in these
cases. In 5 cases swelling, without inflammation,
was noted. In these there was uniform swelling
of the subcutaneous tissues of the outer aspect
1068 THE LANCET]
of the upper arm but no sign of inflammation what-
ever. The swelling in such cases subsided in the
course of a week. In none of 313 cases reported
as having had reactions was there anything which gave
rise to the slightest anxiety.
We did not find the Moloney test entirely helpful in
picking out children who would not be likely to
develop reactions with the prophylactic. .As stated
above all children over 7 were submitted to it and
670 such received the test. Of this number there were
286 Schick positives who yielded 153 Moloney
negatives and these were treated with A.P.T. The
results as regards reactions are shown in Table V.
In 28 per cent. reactions of varying degrees occurred.
ABSCESSES
In this series there has been a remarkable freedom
from abscess formation. Of the 2791 children who
received injections of A.P.T. only one case came
under our notice.
This was a child, aged 5, who was brought by her mother
three weeks after inoculation and then presented an
abscess over the site of injection. Arrangements were
made for treatment on the following day but it appears
that the abscess ‘‘ broke ” itself that evening and the mother
did not bother to take the child to hospital. The arm
then healed spontaneously and when seen recently the
child was perfectly well.
Apart from this case there has been a complete
freedom from abscess formation. This is important
as it seems to indicate that the makers have been
largely successful in their efforts to produce an A.P.T.
which would be free from this unpleasant side effect.
In our earlier series there were 4 abscesses among
579 cases (0:7 per cent.). The results of other
authorities are as follows :—
Cases. Abscesses. Per cent.
Kositza (1935) 2013 .... 19 0:9
Lai (1935) 489 .... 1 0-2
Murphy (1935) 363 3 0:8
Naughten (1935) 370. wees 1 . 03
Shafton (1936) TOL «2446. Zo = 25
Faragó experienced 0-01 to 0:3 per cent. in his series
and Baker and Gill refer to light abscesses in about
0-04 per cent. of a series of over 16,000 inoculations.
Shafton’s remarkable proportion is altogether excep-
tional and may be due to the presence of irritating
non-specific material in his toxoid.
INDURATION
It may be said that every case treated with A.P.T.
develops induration in some form. Every case
examined by us within five weeks presented it.
Varying degrees of size and hardness were experi-
enced. In the great majority of cases the condition
presented itself as a hard rounded mass, about
0-5 to 1 cm. in diameter, lying in the subcutaneous
tissues and freely movable. In some instances
the form assumed was that of a small plaque varying
in size from that of a shilling to sixpence. These
indurations were not so permanent as those experi-
enced in our earlier series and had disappeared in
the majority of the cases seen after twelve
weeks. In this respect, also, the antigen has been an
improvement on the earlier batches.
Summary
1. A report is given of 2791 children treated with
a single dose (1 c.cm.) of A.P.T.
MEDICINE AND THE LAW
[may 1, 1937
2. Of this number 2157 were Schick-tested at varying
periods after treatment and 98-7 per cent. yielded
negative reactions.
3. Of 849 children who were tested. in five weeks .
94-4 per cent. were negative.
4. Of 443 children tested at six weeks 99-3 per cent.
gave negative reactions.
5. At periods over six weeks in all cases the pro-
portions of negative reactions were over 99 per
cent.
6. A probable conversion rate of 98-6 per cent. is
assumed.
7. The proportion of cases who developed reactions
was small (14-5 per cent. of the total cases examined
after treatment). Of these only 2'8 per cent. were
classed as severe.
8. In only 1 case was there any question of abscess
formation.
9. Simultaneous with the administration of A.P.T.
there was a pronounced and apparently permanent -
decline in the incidence of diphtheria. It ‘is believed
that A.P.T. played a significant part in this decline.
10. An alteration in the Schick status of -the
community has been noted and allusion made to the .
possibility of a high natural immunity rate playing
some part in the good results obtained.
11. It is proposed to submit the cases to a further
Schick test after a lapse of three years with a view
to determining the permanency of the Schick-negative
state as induced by A.P.T.
REFERENCES
Ann. Rep. of M.O.H. waar City, 1935,
Baker, J. N., and Gill, D. G. (1934), bey. y publ. Hlth, 24, 22.
Bousfield, G. (1936) Med. Offr, 57, 15.
Brit. med. J. 1935, 2, 908.
Farago, F (1935a) Z. Poma a ae 191.
— (1 935b) Amer. J. Hyg.
D N and Halpern, K 4! (7935) Canad. publ. Hith J.
Glenny, A. T. (1930) Brit. med. J. 2, 244.
— and Barr, M. (1931) J. Path. Bact. 34, 131.
Haine, J. E. 1935) Brit. med. J. 896.
Isabolinski, , Judenitsch, W. Caden cow: I. (1935) Z. Immun-
Forsch. 85, 218.
Johan, B. (1937) 2nd Toena Congr. Microbiol. Rep. of
Proceedings, London, p. 481.
artes E” and Leathers, W. ‘S. (1934) J. Amer. med. Ass.
Kositza, L. (1935) J. Pediat. 7, 662.
Lai, D. T 935) Chin. med. J. 49, 340.
Leach, C. N. (1935) Ibid, p. 771
MeGinnes, G. F.,and Stebbins, E. L. (1934) Amer. J. publ. Hlth,
Murphy, W. A. (1935) Med. Offr, 53, 177.
Neveu. M., White, J. H., and Foley, A. (1935) Brit. med. J.
Pansing, H. H., and Shatter, E. R. (1936) Amer. J. publ. Hlth,
Parish, a. deat Brit. med. a 1, 209.
Saunders, C. (1932) Pa a , 1047.
— (19: T Tbid, i,
Schmidt- Bore A. (1936) Zbl. Bakt. 137, 122.
Shafton, A. sa (1936) J. Pediat. 8, oe
ndceacod. 1 (1935) Lancet, 1, 137.
Walker, A. a T Amer. Ce Ass. 103, 227.
MEDICINE AND THE LAW
Death after Ambulance Journey
THE St. Pancras coroner investigated last week
a case where a patient, unable to obtain treatment
at the hospital to which she was originally sent,
died after a 25-mile journey to a second hospital.
The deceased, a married woman aged 32, living at
Slough, was taken to the King Edward VII Hospital
at Windsor; she was due to have a child in
about six days. She proved to have a septic
infection, and at the inquest a medical witness
explained that the hospital regulations do not
permit cases of this nature to be retained in the
` tonitis ;
THE LANCET]
MEDICINE AND THE LAW
[may 1, 1937 1069
building, there being no isolation accommodation.
There was, he said, an isolation hospital for fever
diseases at Slough but it was understood not to
welcome cases of puerperal sepsis. The medical
officer for Berkshire had an arrangement with the
North-Western Hospital in London whereby the
latter would receive such cases from the Windsor
hospital. The patient was therefore removed to
the North-Western Hospital but died within 24
hours of her admission. There was some difference
of opinion among the medical witnesses over the
patient’s condition at the time of the journey. The
doctor who examined her at Windsor on that day
said she was not then suffering from general peri-
if she had been, he would not have sent
her away, in spite of the hospital regulations. The
pathologist who described the results of the post-
mortem-examination was of opinion that the infection
was present for about four days before death. Asked
by the coroner if the removal was desirable or not,
he described it as deplorable. The coroner thought
this adjective not too strong. He recorded a verdict
that the patient died as a result of general peritonitis
and that death was due to natural causes; this,
he said, was not to imply that he felt satisfied with
the removal. This unfortunate occurrence will
doubtless lead to a review of the accommodation
and arrangements in such emergencies.
Asleep at the Wheel ü
The Divisional Court has lately allowed an appeal
against a stipendiary magistrates decision that
a motorist who had suddenly fallen asleep at the
wheel of his car was not guilty of careless driving
under Section 12 of the Road Traffic Act. The
motorist was tired and, as can easily happen, dozed
off; his car swerved and struck two trees by the
side of the road. The magistrate took the view that
the driver who is overtaken by sleep is in the same
position as a person suddenly taken ill and is therefore
not responsible for the results. It may be true as
a general proposition of criminal law that an act
unconsciously committed is not an offence—for
instance, if one can imagine a sleepwalker rising
from bed and taking his car out on to the highway.
The Divisional Court, however, lent no countenance
to the view that a motorist who falls asleep at the
wheel cannot be convicted of careless driving. The
statutory offence under Section 12 is driving a motor
vehicle without due care and attention or without
reasonable consideration for other persons using
the road. A motorist has a duty to keep awake and
not to drive when so tired that there is a risk of his
falling asleep.
Manslaughter and Negligence
The broader aspects of homicide by dangerous
driving were considered by the House of Lords on
April 22nd (Andrews v. Director of Public Prosecu-
tions) upon a special appeal, by certificate of the
Attorney-General, from the Court of Criminal Appeal.
The judgment delivered by Lord Atkin analysed
the nature of manslaughter and made considerable
reference to cases where doctors are accused of
professional negligence. Andrews had killed a man
on a well-lighted road when overtaking another
car. He carried the injured man for a short distance
on the bonnet of his vehicle, then ran over him and
failed to stop or to report the accident. The offence
of murder contains, though not exclusively, the
element of intention to kill. The offence of man-
slaughter, on the other hand, is based mainly on the
absence of intention to kill but the presence of an
elusive element of ‘‘ unlawfulness.”” Where man-
slaughter is an unintentional killing caused by
negligence, what degree of carelessness must be
proved? Lord Atkin, tracing the development
‘of the law from the earliest times, observed that at
first there are judicial opinions which suggest that
death due to any lack of care will constitute man-
slaughter. ‘‘ As manners softened and the law became
more humane, a narrower criterion appeared.”
People shrank from attaching the penalty for a
felony (formerly a capital offence) to results produced
by mere inadvertence. The narrower view, continued
Lord Atkin, became apparent in prosecutions of
medical men, or men who professed medical or
surgical skill, for manslaughter by reason of negli-
gence. He referred in passing to R. v. Williamson
(1807), where a man who acted as a man-midwife
tore away a part of the prolapsed uterus, mistaking
it for the placenta. By a mistake in his observation
of the actual symptoms, the accused inflicted on the
patient terrible injuries from which she died. Yet
Lord Ellenborough held that, ‘to substantiate -
the charge of manslaughter, the prisoner must have
been guilty of criminal misconduct arising either
from the grossest negligence or the most criminal
inattention.” It was on this occasion that Lord
Ellenborough made an _ oft-quoted observation :
‘if the jury should find the accused guilty of man-
slaughter, it would tend to encompass a most
important and anxious profession with such dangers
as to deter reflecting men from entering into it.”
Lord Atkin then passed to the modern case of R. v.
Bateman. He cited Lord Hewart’s dicta as to the
distinction between negligence in a civil case and
negligence in a criminal case. Lord Hewart had said
that, ‘‘in order to establish criminal liability, the
facts must be such that in the opinion of the jury the
negligence of the accused went beyond a mere matter
of compensation between subjects and showed such
disregard for the life and safety of others as to amount
to a crime against the State and conduct deserving
punishment.” Lord Atkin was inclined ‘to think
that the ideas of crime and punishment do not in
themselves help a jury to decide whether in a particular
case the degree of negligence amounts to a crime and
deserves punishment. But he observed that the
substance of Lord Hewart’s judgment in R. v. Bateman
was most valuable and, he thought, correct. In
practice it had been adopted by judges in charging
juries in all cases of manslaughter by negligence,
whether in driving vehicles or otherwise.
The upshot of Lord Atkin’s judgment is that
recklessness can contain the element of negligence
which justifies a charge of manslaughter ; recklessness
is a specific element in the offence of “ dangerous
driving ” under Section 11 of the Road Traffic Act
of 1930; Parliament has since enacted that, on an
indictment for manslaughter, a man may be con-
victed of the lesser offence of “ dangerous driving ”’ ;
recklessness as an element of ‘‘ dangerous driving ”’
within Section 11 may amount, but by no means
necessarily amounts, to the degree of criminal
negligence requisite to establish the offence of man-
slaughter. The medical profession is only eae
concerned in the penalties for careless or dangerous
driving, or in the subtleties of the history of man-
slaughter. It will, however, appreciate that Lord
Atkin in the House of Lords has confirmed the
decision of the Court of Criminal Appeal in R. v.
Bateman, so that there has been no relaxation of
the high degree of negligence requisite to justify
a verdict of manslaughter.
THE LANCET]
1070
{may 1, 1937
GRAINS AND SCRUPLES
Under this heading appear week by week the unfettered thoughts of doctors in
various occupations.
Each contributor is responsible for the section for a month ;
his name can be seen later in the half-yearly index.
FROM A MEDICAL ECONOMIST
I
Some years ago the late Sir Walter Fletcher told
me that he had always wondered why it was so
impossible for a doctor to discuss medical matters
satisfactorily with a layman—“ even a very intelligent
layman.” He expressed the view that the difficulty
lay in outlook as well as in knowledge and training.
In fact the layman’s attitude to medicine is always
strictly utilitarian. He looks upon his doctor as
a man with a mission to cure disease and is apt to
become impatient when other considerations are
presented to him. Nor is he tolerant, as a rule, of a
practice which excludes personality or individual
predilection from its scope. He insists upon being
cured as a separate and distinct human being and
rejects vigorously the idea that any average therapy
can satisfy his needs.
His choice of a doctor is determined by this attitude.
He will assure you that he is fortunate in the respect
that his medical adviser knows his constitution
and has had experience of his family—knowledge
and experience to which he attaches quite as much
importance as to any professional attainment. Again,
he will avoid, if possible, a doctor possessed of a
reputation for giving the same drugs to all his patients
or advising many of his patients to submit to the
same surgical or specialist treatments. His doctor
must not prejudge him. Obstinately he refuses to
become a mere number in a ledger or upon a bed.
I have heard this attitude described as vanity
but, if so, then all men and all women are vain. A more
interesting consideration is its merit. Is there, in fact,
any substance in the contention of John Smith
that he must be treated and cured as John Smith
and not as an example of the average man ? - Again,
is John Smith entitled to his view that his doctor
must be, if not his friend, at least his father-
confessor and familiar? We all repeat the assertion
that the best treatment is to be obtained in great
hospitals ; but those of us who can afford to do so,
go, often enough, to private nursing-homes or private
wards. Nor do we choose, necessarily, the most
distinguished, academically, among our colleagues
to see us through our illnesses. We are certainly
not, in this action, casting any aspersions either
upon hospitals or upon learned professors. Rather
we are obeying an instinct which, in others, we are
apt to deprecate as irrational.
What is that instinct? The Duke of Wellington
stated on one occasion that the presence of Napoleon
on a battlefield was equivalent to a French reinforce-
ment of 50,000 men. The reference was not so much
to the Emperor’s genius as a commander as to the
effect of his personality upon his soldiers. Each
man became, in his presence, a being transformed.
Napoleon , was well aware of it; nor was he less
well aware of the importance, in war, of those
influences which he knew so well how to exert—
patriotism, the will to conquer, the sense of a crusade,
the. thirst for glory. These ‘‘imponderabilta,” as
he called them, represented in his view the most
important element of victory. His proclamations
to his soldiers remain as the eloquent witness of his
faith. Foch held the same opinion. His dispatch,
during the Battle of the Marne, remains a classic of
leadership: ‘‘My centre is broken, my right recoils.
All goes well. I attack.”
What has this to do with the choice of a doctor ?
Everything. I remember still, after nearly half a
century, the sense of ineffable relief and comfort
which I experienced at the sight of our family doctor
when any member of the family was ill. He was a -
very small man with an uncompromisingly bald
head. But there was a look in his eyes which was
worth the contents of a dozen chemists’ shops.
* x *
Not that he failed to prescribe medicines. I have
often observed that those men who, in any walk of
life, are able to inspire confidence are almost always
masters of the technique of their calling. Both
Napoleon and Foch were superlatively good soldiers
in the strictest professional sense; neither, had he
been a doctor, would have missed a ruptured appendix
or failed to make a diagnosis of diphtheria, and neither
would, have delayed to order the appropriate treat-
ment. But technique, in the view of both, cannot be
complete if the man himself is left out. Confidence
and inspiration they insisted are the mountain
peaks of technical efficiency. They would have
so achieved, consequently, that their patients. placed
in them implicit and comfortable trust.
It seems to stand to reason that an influence which
makes a man stronger and more confident than he
was before he had experience of it must, similarly,
exert effect upon every organ and every cell of every
organ. Few dispute to-day that healing, in the last
issue, is by that vis medicatriz nature upon which
the doctors of earlier days placed so much reliance.
The greatest doctor perhaps is he who can most
magnify, in his patient’s body, the healing power
of nature.
All this is commonplace, of course; but there is
much forgetfulness of the commonplace, The asser-
tion that, other things being equal, the doctor with
the biggest practice must necessarily be the best
doctor would scarcely go unchallenged among doctors
themselves. But most laymen would accept it as
obvious truth. And, in fact, Napoleon—to return to
him—put it forward as a rational basis for any
system of remuneration of doctors by the State.
He was hotly controverted by his medical advisers
but refused to change his mind. Indeed he pointed
to Corvisart, his personal physician, as proof of his
contention, saying that Corvisart was popular because
he could cure persons whom other doctors had failed
to cure.. Corvisart’s medical memoirs are ordinary
enough and do not suggest that he was possessed
of any special knowledge.
Medical achievement has been so great recently
in the field of physical science that.the science of
men has tended to be overlooked or even despised
as unworthy. So much so, indeed, that, as a clinical
teacher declared some years ago, “they are all
engaged in studying the molecular structure of
steel in order to find out what a bicycle looks like.”
That may perhaps be another way of saying that any
divorce of medical research from the bedside is
fraught with danger. For, in truth, there is no such
thing as disease ; there are only sick men and women.
THE LANCET]
And it is the sick men and women who must be
treated.
x- * *
It was suggested recently that the human organism
spends all its energies in reacting to stimuli every one
of which, in the absence of reaction, would be lethal
to it. On that showing, and there is a substantial
body of supporting evidence, the phenomena of
disease are signs not, as is often asserted, of reaction
but of failure to react completely. The sick man is
like the man in panic: he cannot bring himself
to face and overcome his trouble. That, it may be,
is where the doctor really comes in. His strength
and wisdom and skill are added to those of his patient
so that the impossible may be accomplished. The
doctor must necessarily fail where his knowledge
fails, and in this truth lies the abundant justification
of all research. But the fact remains that, knowledge
being equal, one man succeeds where another can
envisage nothing but calamity.
And this, certainly, is great mystery. I think,
sometimes, that our lively fear of falling into the
abyss of the magical has blinded our eyes to the
reality of the mysterious. Desperately we seek to
explain in terms of cells what belongs only to organs
and in terms of organs that which belongs to the
body as a whole. Worse still, we must force life into
the measure of the dead-house lest we confess to
commerce with spirit. The ‘endocrine complex ”
is all very well but it does not explain the influence
of man upon man or, more mysterious still, of man
upon himself through faith. Science it would seem
is no more free from the temptation to play “ Smart
Alec” than is any other branch of human activity.
— e ———
PANEL AND CONTRACT PRACTICE
i]
[may 1, 1937 1071
It must resist that temptation and the best tonic
of resistance is, without doubt, that sense of the
mysterious which so conspicuously informed the
minds of, for example, Pasteur and Lister. As was
said by the ‘“ Rusticating Pathologist” in these
columns, to hand out the present system of knowledge
as if it were a system of revealed truth is a travesty
of education of university standard.
* æ *
The doctor, indeed, ought to go to school with the
priest and the soldier, both of whom have much to
teach him. Lord Baden-Powell told me years ago
that his secret is the enlisting of a boy’s native
enthusiasm. Once that has been set to work, so
to speak, a real physical culture—as opposed to
“ physical jerks’’—-becomes possible. For enthu-
siasm compels the lad to submit to the hard discipline
of training which enthusiasm has recognised as
the prerequisite of efficiency. It is the same in the
arts and crafts. All these impose the fierce discipline
of the raw materials, the morality of things as opposed
to the morality of ideas; none lacking enthusiasm
will endure so stern a schooling. The doctor’s raw
material is humanity, not an incoherent mass but
a body of persons each sharply differentiated from
afi the others. The discipline imposed by them is
stern so that nothing but the love of them can make
it endurable. You may call this vocation or enthu-
siasm ; of its reality and its necessity you cannot,
beyond a very early age, remain in doubt. What
the patient asks for above skill and knowledge is
sympathy, dedication, sacrifice in the classic meaning
of that word. Nor will a wise man rest until he has
found it, for therein is the only true healing.
PANEL AND CONTRACT PRACTICE
The Capitation Fee
LAST year the Panel Conference asked the Insurance
Acts Committee to open negotiations with the Ministry
of Health for reconsideration of the capitation fee
of 9s. awarded by a court of inquiry in 1924. A
deputation waited on the Minister and pointed out
that the amount of work that insurance practitioners
are called upon to do has substantially increased
during the past twelve years. The Minister said
he thought that a flat rate below the present figure
could well be justified ; but since there was a difference
of opinion he was willing to arrange for arbitration.
| A similar difference of opinion, it will be recalled,
arose over the capitation fee to be paid for persons
under sixteen years of age when these are brought
under the National Health Insurance scheme, and
the council of the British Medical Association report
(Brit. med, J. April 24th, 1937, Suppl. p. 218) that
they have had no further communication from the
Ministry about this. They understand, however,
that the arbitrators to be appointed will be asked to
say what in their opinion should be the appropriate
fee for medical attendance on all sections of the
population. |
t Negligence ’’ and the Sequel
The London Medical Service Subcommittee has
not had to meet between December and April, which
we understand is a record “ vacation,” but they have
had now to consider three cases: one in which no
evidence of failure on the part of the practitioner was
adduced ; one in which an insurance practitioner was
led to issue two certificates without examining the
patient, who was actually in hospital (this was one of
those cases of importunity by a financially embar-
rassed wife and will probably cost the unfortunate
doctor £2); while the third has been the subject of
considerable attention by the lay press.
On Dec, 30th, 1936, an insured person became
ill and took his temperature which was 103° F.
He lived in a flat in a block of such dwellings and
his sister-in-law, who was looking after him while his
wife was in hospital, telephoned for the practitioner
at about midnight. She spoke to the caretaker of the
house in which the practitioner lives and being told
that the practitioner was out she again telephoned
about 1 A.M. with a like result. She told the sub-
committee that on each occasion she gave the name
of the patient, his address, and the exact location
of the flat close to a well-known hotel, indicating
also that the patient seemed to be seriously ill.
. According to the practitioner he returned home
between 1 and 2 a.m. and found a note that he was
wanted at “ X House,’ to which he proceeded, finding
the house in darkness and obtaining no reply to his
rings at the bell. He said he went again about 8.30 A.M.
and was then told by the manageress that no request |
for his services had been made from that address.
He telephoned home but was assured that the
messages indicated that he was wanted at ‘‘ X House.”
In point of fact the imsured person resided at
“Y House.” The subcommittee’s report says
that admittedly the names of the two establish-
ments are not dissimilar and might be confused over
the telephone; but they lie some distance apart,
and they had no hesitation in accepting the statement
of the relative that she was at pains when telephoning
-—
1072 THE LANCET]
IRELAND
[may 1, 1937
to explain the exact location of the house, and that
the directions were repeated to her. The practitioner
did not attend his morning surgery at all on Dec. 31st
but said he was visiting patients until 6 p.m. Further
telephonic applications for his services were made
at 8.45 A.M. and at two or three other times during
the morning, but although the caretaker asked another
practitioner to visit the patient he was unable to
de so. Eventually the practitioner saw the patient
at about 8.15 P.M., but by then another doctor had
been called and had ordered the patient’s removal
to hospital, where he died some eight hours later.
The practitioner told the medical service sub-
committee that it was the practice of his caretaker to
note the addresses from which the requests for visits
came, but not the names of the patients concerned.
- The comment of the medical service subcommittee
on these statements was as follows: ‘‘ The prac-
titioner’s explanation that he was unable after two
fruitless calls at ‘X House’ to refer to the record
card for the true address because the caretaker
was not in the habit of recording names, or, as it
appeared from the practitioner’s answers to us,
even the number of the tenement, in a block of
tenements, seems to us, if it is true, to point to a
lack of method in carrying on his practice, which
would be nothing less than appalling. His failure to
offer this explanation when he did visit ‘ Y House’
(where incidentally he enquired for the patient
by name) is a strong indication that the explanation
is not worthy of credence. We say this with much
regret, but we should frankly still more regret the
condition of things in this practice if the explanation
were true.” The committee decided to censure the
practitioner, to require him to assume responsibility
for the expense incurred in calling in another doctor,
and to ask the Minister of Health to withhold the
sum of £20 with a view to the deduction of a corre-
sponding amount from the remuneration of the
practitioner (who has, however, the right to appeal
to the Minister), The committee have also decided to
consider action under regulation 35 (2) (a). This
regulation provides that if the committee are satisfied
that owing to the number of persons included in his
list a practitioner is unable to give adequate treat-
ment to all of them, they may, after consultation with
the panel committee, impose a special limit on the
number of insured persons for whom the practitioner
may undertake to provide treatment. In that event
any number in excess of that limit shall be dealt
with as though the list of the practitioner was by that
number in excess of the general limit fixed for the list
of practitioners in the area. The insurance committee
decided to refer this case to the appropriate sub-
committee to consider whether the normal maximum
of 2500 insured persons should be reduced. Clearly
consultation with the panel committee will take a
little time and a question arises as to possible appeal.
This particular practitioner has a list which is
approaching the maximum and if a lower limit is
fixed for him, it will of course mean that his insurance
remuneration will be reduced. If, for instance, the
committee decide that a limit of, say, 2200 should be
applied to this practitioner, it will mean that his
potential yearly insurance income will be reduced by
about £135. The practitioner might feel that it was
undesirable to appeal against the withholding of
£20 in respect of the negligence found in the specific
case but the prospect of losing part of his annual
income might well lead him to appeal to the Minister.
If, in fact, the committee after consultation with the
panel committee, decides on a lower limit, as part
of the decision in the case, the period of one month
during which the practitioner may appeal will doubt-
less be regarded as beginning when notification
of the decision for or against a lower limit is sent
to him.
IRELAND
(FROM OUR OWN CORRESPONDENT)
A NATIONAL SERUM INSTITUTE
Dr. C. J. McSweeney has been speaking to the
Royal Academy of Medicine on the need for a
National Serum Institute in Ireland. At present, he
said, there are no manufactures of serums for diag-
nostic or therapeutic. purposes in Ireland, and in
the present state of Europe this position is not free
from danger, for national emergencies elsewhere
might lead to a shortage of supplies. Apart from
this, serums prepared from strains of micro-organisms
prevalent in other countries cannot be expected to be
as potent in Ireland as serums from the native |
strains. The fatality-rates for such diseases as
diphtheria and cerebro-spinal fever are consistently
higher in Dublin than in cities in Great Britain,
even when similar treatment and dosage were
employed. Dr. McSweeney suggested that this
difference of results may be due to a lesser efficacy of
the serums made from strange strains. An institute
such as he suggested would serve as a centre for
investigation and research into problems relating to
serum therapy and prophylaxis. If it were to be
established it could most fitly be associated with
the new Dublin Fever Hospital scheme, and, in such
circumstances it could undertake the task of preparing
an adequate supply of human immune serums for
the prophylaxis and treatment of such virus diseases
as measles and poliomyelitis. Convalescent donors
would be numerous enough to permit the issue of
serums so prepared to private practitioners. The
institute, if established, should be in close association
with the recently established Medical Research Council
and with the medical schools of the country. It
should not be given a monopoly in the manufacture
of serums for the Irish Free State, nor should it have
power to interfere with the business of the many
reputable firms which market their biological products
there. He thought it would be possible to find the
necessary finances from Hospital Sweepstakes funds.
Prof. J. W. Bigger, the next speaker, emphasised
the importance of such an institute from the points
of view of education and research. While approving
of the establishment of a serum institute, he would
oppose its being under State control. State activity
was seldom progressive and State control tended
toward parsimony even where expenditure might be
necessary. An institute would be expensive for the
services it could hope to render. In the discussion
which followed there was general agreement that the
establishment of. a serum institute deserved considera-
tion and investigation, and it was agreed to invite
the General Council of the Royal Academy of
Medicine to take appropriate steps. There was a
consensus of opinion that if established the institute
should be free of Government control, and that one
of its main objects should be the promotion of
research.
CHARING Cross HOspPITAL.—Mr. Philip Inman,
speaking at the annual general meeting of the court of
governors of this hospital, said that it was hoped to
rebuild in or near the present site. The income for 1936
was a record one, £85,729. The expenditure was £71,143.
THE LANCET]
[may 1, 1937 1073
PUBLIC HEALTH
THE INFLUENZA EPIDEMIC IN
RETROSPECT
As judged by the number of deaths attributed to
influenza in the 122 Great Towns of England and
Wales, the epidemic period of 1936-37 may be said
to have been, roughly, from the beginning of December,
1936, to the end of March, 1937. The secular trend
of the epidemic as judged by mortality in these
towns (the only general numerical data we possess)
is shown in the Table and diagrams below. In the
Deaths from Influenza in the Great Towns
Week Week
ending. Deaths. ending. Deaths. ending. Deaths.
1932 1935 1936
Dec. 3rd 3 | Dec. 7th 5 | Dec. 5th . 43
»» 10th 68 | ,, 14th 6 » 12th . 54
»» 17th 85 | ,, 21st 67 | ,, 19th. 57
»» 24th 120 | ,, 28th .. 80] ,, 26th. 97
+> 31st 303
3 6 1937
Jan. 7th 680 | Jan. 4th .. 110 | Jan. 2nd. 325
», 14th 1039 » llth .. 110 » 9th. 768
5» 2lst 1588 „ 18th .. 89 » 16th .. 1100
„ 28th 1933 25th .. 104 „ 23rd .. 1137
Feb. 4th 1909 | Feb. 1st 98 „ 30th .. 1155
»» llth 1306 » 8th .. 85 | Feb. 6th . 976
5» 18th 630 » 15th .. 97 » 13th . 697
, 25th 344 „ 22nd.. 119 » 20th 423
Mar. 4th 242 > 29th .. 107 > 27th 242
„ llth 157 | Mar. 7th .. 112 | Mar. 6th 181
», 18th 119 „ 14th 8 „ 13th 144
„ 25th 65 „ 21st 86 „ 20th 171
Total 10,621 1455 7570
seventeen weeks between the beginning of December,
1936, and the end of March, 1937, the number of
deaths registered as due to influenza reached the
total of 7570. This number may be compared with
the 1455 in the same period of 1935-36, a normal
non-epidemic year, and the 10,621 in 1932-33, the
last epidemic year.
Although on a lower scale than this last wide out-
2000
750
NUMBER OF DEATHS
500
250
|
JAN.
FIG. 1.—Graph showing weekly total deaths from influenza in
the Great Towns in three different years.
break, the recent epidemic, as judged both by
mortality and by the available evidence of widespread
incidence, must undoubtedly be added to the list
of major visitations to which the country has been
subject since the beginning of the century. In its
90
r —— Greater London
75 l ==— North >
+—+ Midlands
DEATHS PER MILLION PER WEEK
&i
30
IS
0
5 9 2 6 30 B 27 RB 27
DEC. JAN. ` FEB, MAR.
FIG. 2.—Weekly deaths from influenza in the Great Towns
per million of estimated population.
time of onset and of maximum mortality it closely
resembled the epidemic of 1932-33, but its rate
of decline has been relatively slower. The age-
distribution of mortality was of the type usually
described as normal, that is, the greater share was
borne by persons well on in years and relatively
little by young adults. With the exception of the
Welsh towns, which appear to have escaped rather
lightly, there is little evidence from the mortality
figures of the epidemic bearing more hardly on one
part of the country than another. The death-rates
from influenza between December and March vary
but little between the different regional areas. There
was, however, some considerable difference in the
time sequence of the epidemic trend. In London,
both the central area and the environs, the maximum
mortality fell in the week ending Jan. 16th, and in the
remaining towns of the south-east the peak came
only a week later. In the northern, midland, and
south-western towns it was not reached till the last
week of the month, and in the eastern and Welsh
towns the total continued to rise till the end of the
first week of February. In general the figures show
the epidemic progressing from the south to the north
and radiating at the same time to the east and west.
The Health Reports of the League of Nations
show that in Germany the epidemic occurred some
weeks earlier, between the middle of November and
the third week of December ; its incidence was falling
there at the same time as it rose in the southern
area of England. In the U.S.A. its course appears
to have been broadly parallel with that in this country.
Many other European countries show evidence of
epidemic prevalence and in the majority of them the
peak had been reached before the end of January.
There is little else to add. The work now in progress
at the National Institute for Medical Research and
elsewhere gives, we think, much hope of the final
production of an efficient vaccine, such as might tide
the population over these few weeks of sudden and
‘universal epidemicity. Such protection might well
reduce the ravages of outbreaks which we now seem
destined to endure every few years.
1074 THE LANCET]
[way 1, 1937
CORRESPONDENCE
AMBULANCES AND STRETCHERS
To the Editor of THE LANCET
Sir,—In his letter on this subject in your last issue
Surgeon Commander Ford advocates a standardisa-
tion which is obviously overdue. He suggests that
as the majority of stretchers are of the long type it
is desirable ‘‘ to encourage the production of long
ambulances only.”
The long ambulance may be all very well for
public authorities but there are large numbers of
firms using ambulances for industrial accidents and
the long ambulance is inconvenient and more costly.
Surely it would be much better to standardise the
stretchers with telescopic handles. After a few years
. of this standardisation the vast majority of stretchers
could easily have been converted to the telescopic
or short-handled type. °
Surgeon Commander Ford has omitted to mention
the other important factors in standardisation—
namely, the wheel base, wheel diameter, and gauge
of the stretcher wheels to enable them to run on a
standardised track on the ambulance racks. In
addition it is very necessary that hospital casualty
trolleys should be similarly standardised. A very
little investigation will show how standardisation of
one particular is quite useless unless all the factors
in stretcher construction are worked to a common
specification. I urged this in a letter to your columns
two years ago (Lancet, 1935, 1, 574). At the
moment however stretcher manufacturers and
ambulance makers are continuing to act with a sweet
individuality which may make it necessary to shift
a seriously injured patient as many as three times
between the location of the injury and his arrival in
the ward. This is entirely unnecessary and quite
absurd.
In advocating the retention of the long type
stretcher has Surgeon Commander Ford considered that
passenger lifts and railway carriages will not permit
the long-handled type, whereas the telescopic-
handled type of stretcher can be fitted in almost
anywhere? To my mind there is no possible alterna-
tive but that the long-handled type of stretcher
should be abolished.
I am, Sir, yours faithfully,
Beeston, Notts, April 23rd. L. P. LOCKHART.
ERADICATION OF BED-BUGS
* To the Editor of THE LANCET
Sır, —The article by Mr. Ashmore and Mr. McKenny
Hughes in your issue of Feb. 27th, on the use of coal-
tar naphtha distillates in bed-bug control, draws
attention once more to a serious problem. In spite
of improved standards of living Cimex lectularius
is still spreading, mainly through the introduction
of infested furniture into new premises.
An agent employed against bed-bugs should if
possible be (1) cheap, (2) toxic to the insect, (3) not
toxic to man and animals, (4) non-inflammable,
(5) easy to apply, (6) readily available, and (7) free
from residual odour and not injurious to the premises
disinfested. Further (8) its use should not involve
much preliminary preparation. How far do coal-
tar naphtha distillates fulfil these conditions ?
l. Cost.—Their present cost is only about 2s. 6d. per
gallon.
2. Toxicity to wnsects.—Since the naphtha fraction
forms a toxic vapour the liquid apparently need not
come into actual contact with the insects in order to kill,
though in the method described it appears to be applied
both as a contact insecticide and as a fumigant. Experi-
menting with a naphtha fraction of the same boiling range,
I found that the vapour has a rapid action on bed-bugs,
but that those receiving a sublethal dose rapidly recover.
“At the concentration specified (one gallon per 750 cubic
feet) in glass containers, an exposure of six hours at
73° F. did not produce a 100 per cent. kill using third and
fourth stage nymphs. After only two hours’ exposure all
the bugs recovered, and after,four hours, 75 per cent.
In each case all insects were apparently moribund after
removal from the containers. The same concentration
was found to be ineffective against the eggs in all stages
of incubation, there being a 100 per cent. hatch after six
hours’ exposure under the same conditions. Although
the exposure time was only six hours against 18-24 as
recommended, the greater resistance of eggs than nymphs
to naphtha is shown,
3. Toxicity to man and animals.—Although the saturated
atmosphere has been proved to be relatively non-toxic
to animals, gas-masks must be used during fumigation.
The possible occurrence of mesitylene, which has been
found to be toxic to man, must be considered. This
chemical, having a boiling- ‘point of 165° C., would, if
occurring in the crude naphtha, be present in the fraction
mentioned (distillation range 160°-190° C. approximately)
after distillation. Local government officials and others
might be led to imagine that any coal-tar naphtha fraction
coming within .the distillation range specified would
therefore be satisfactory. Gas-works and other sources
of supply, while endeavouring to keep down the cost of
the product, might fail to remove mesitylene from the
fraction.
4 and 5. Inflammability and ease of application.—The
fraction specified was stated to have a flash-point of not
less than 105° F. When applied by means of a sprayer,
the flash-point of the fraction would be even lower in
the atomised state. The fire hazard is, therefore, great,
and it is doubtful, even with premises carefully sealed
after fumigation, if it would be safe to have a naked light:
outside the room. There might also be a danger of
explosion due to static electricity, when the fraction
was applied by means of a pressure sprayer. Spontaneous
combustion of petrol vapour has been found to be caused
by static electricity, the risks being greatest under condi-
tions of low relative humidity. Such an explosion might
do much damage, and the attitude of fire insurance
companies must be considered.
The volatility of naphtha decreases rapidly with
decrease in temperature, but the resistance of the
bugs increases with decrease in temperature. It is
emphasised that fumigation should not be. attempted
at temperatures below 60° F., and pre-heating of the
premises by means of stoves should always be adopted,
except in hot weather when the room temperature is above
70° F. This is a serious drawback, especially as the
temperature cannot be maintained after the room is sealed,
because the stoves must be removed owing to the risk of
fire. The utmost caution must be observed when applying
naphtha, and the employment of well-trained men is
desirable. The vapour is heavier than air, and tends to
settle in the room, whereas the bugs are often located in
ceiling cracks. Thus measures must be taken to ensure
distribution; and concentrations far above those actually
needed to kill bugs in sealed containers are necessary.
In fact, the amount mentioned by Ashmore and McKenny
Hughes is ten times the lethal dose, although the
conditions were not stated.
6. Availability.—There would be no difficulty in obtain-
ing large supplies of naphtha from gas-works and other
places, but as I have said already, it is well to know the
nature and percentage of toxic constituents in the fraction.
7. Odour.—Naphtha has a very penetrating odour.
This is an objection, for it is undesirable for the sufferer
to have to broadcast the fact that his premises are infested,
and some vapour must escape before the rooms are sealed.
8. Preparation of premises.—As with HCN fumigation
removal of tenants and subsequent ventilation are required.
THE LANCET]
Though naphtha is not so poisonous as cyanide and the
vapour is stated to clear after a few minutes, the premises
must be thoroughly aired. |
With vacant houses the difficulty of finding temporary
accommodation does not arise, but the attitude of tenants
faced with teraporary removal while their rooms and
furniture are disinfested often prejudices local government
officials against fumigants. Apparently with naphtha it
is not thought necessary to remove all furniture, curtains,
&c., since the vapour is said to penetrate at least as far
as the bed-bugs secrete themselves. This is somewhat
surprising, because even when HCN is used the furnishings
are normally removed for van-fumigation, or steam-
disinfestation in special chambers.
It will therefore be appreciated that in the practical
application of an insecticide, whether against bed-
bugs, cockroaches, or other insects, the toxicity to the
insect is only one of many points to be considered.
HCN is known to be very toxic to bed-bugs (adults,
nymphs, and eggs) but it is so poisonous that it can
- be used only by experts. Naphtha, however, also
has limitations that make it far from ideal as an
insecticide. i
There appears to be a place for an insecticide which
the tenant, or other user, can apply himself. This
introduces contact insecticides proper. The past
few years have seen the development of certain contact
insecticides for use against household pests fulfilling
the desiderata stated at the beginning of this letter.
They are mainly vegetable extracts, which, although
non-toxic to man and warm-blooded animals, are
very toxic to insects. Their toxicity to insects has
lately been increased by the addition of certain
organic materials harmless to man,
These insecticides must come into actual contact
with the insect in order to kill. They are usually
in the form of liquids applied by pneumatic sprayers,
so as to produce a mist of finely divided droplets,
which under high pressure can be fórced to penetrate
behind loose wall-paper and behind cracks in skirting
boards. This type of disinfestation can be applied
at a fraction. of the cost, labour, and time of cyanide
fumigation, and withọut danger to the occupier or
operator.
When the extracts are dissolved in an odourless
kerosene base of high flash-point, the fire risk is
negligible. Too heavy an oil base is, however,
undesirable because there is danger of staining due
to its low volatility. Increased freight costs are
likely to be incurred on liquids below 150° F. flash-
point (see Railway Dangerous Goods Regulations)
and similar regulations applying to inflammable
liquids sent by road have now been introduced.
High transport costs are, therefore, another point
to be considered before adopting a new insecticide
for use on a large scale.
There is no doubt that with fumigation enormous
wastage occurs, not only in absorption but in
adsorption. Bed-bugs are rarely found crawling
on the walls in day-time, unless they are in very large
numbers. The great majority are hidden in cracks,
' behind loose wall-paper, behind skirtings, and in the
framework of bedsteads, and seams of mattresses and
furniture. Fumigation is impartial; the fumigant
cannot be concentrated on such hiding-places ; thus
there must be wastage. On the other hand, when
using a contact insecticide in the form of a finely
atomised spray from a good pneumatic hand sprayer,
or preferably an electric sprayer, most of the insecti-
cide can be directed on to the walls and into cracks,
rather than into the actual room space, and a smaller
volume of liquid suffices. Whatever method is
adopted—fumigation or contact insecticide spraying—
ERADICATION OF BED-BUGS
[may 1, 1937 1075
the room should be cleared beforehand, and the
furniture dealt with separately, either by steam or
cyanide fumigation. The best time to disinfest is
after the room is stripped and before redecoration.
I am, Sir, ‘yours faithfully,
J. M. HOLBORN.
Jeyes Sanitary Compounds Co. Ltd., Richmond-street, E.13.
KETOGENIC DIET AMONG ESKIMOS
To the Editor of THE LANCET
Sır, —I have recently returned from East Greenland,
where I lived for fifteen months as medical officer
to L. R. Wager’s British East Greenland Expedition,
1935-36. We were a party of seven Europeans and
fourteen Eskimos (increased by one by the end of
the year). During that time I was consulted by an
Eskimo woman of about 40 years of age who was
suffering from frequency of micturition and scalding
pain on passing her urine. I examined her urine
and found that she had a B. coli infection. She told
me that she had had several attacks in the past,
but that this attack did not seem very amenable
to treatment. On asking of what her treatment
consisted, I learnt that she had been eating very
large quantities of blubber, which is the fat: of the
seal. It appears that this treatment is traditional
among the Eskimo colony at Angmassalik, although
I do not know how frequently the condition occurs.
I should perhaps state that, contrary to normal
belief, the Eskimo does not live on a very high fat
diet, although he does live on a low carbohydrate
diet; he is not continually eating blubber, but
normally eats about as much fat with his meat as
we eat with a grilled chop; that is to say, that
although the total fat diet per day is higher than that
to which we are accustomed the protein-fat ratio is
about the same as ours.
In view of the modern treatment of cystitis by the
ketogenic diet and mandelic acid this traditional —
treatment of the Eskimo seems to deserve notice.
I am, Sir, yours faithfully,
E. C. FouNTAINE.
Royal Devon and Exeter Hospital, Exeter, April 22nd.
SHORT-WAVE THERAPY
To the Editor of TRE LANCET
Sık, —May I draw the attention of your readers
who are interested in short-wave therapy to the
following quotation from a report recently issued by
the American Council of Physical Therapy—a body
which should certainly have its counterpart in this
country.
s Much of the work of this Council in the past year
has been confined to the consideration of so-called
short-wave diathermy machines. In view of the
deliberations, the Council believed it was justifiable
to state, based on the present available evidence,
the following conclusions: (1) There is no specific
biologic action of high-frequency currents. (2) There
is no specific bactericidal action. (3) The therapeutic
effect is due to the heat produced. Elaborating
these three conclusions, the Council felt that the
general practitioner should understand that when he
buys a short-wave diathermy machine he is purchasing
an apparatus capable of producing heat. In the light
of available evidence it has absolutely no other
specific action.”
I am, Sir, yours faithfully,
London, S.W., April 23rd. H. J. TAYLOR.
1076 THE LANCET]
PRURITUS ANI
To the Editor of THE LANCET
Smr,—In the paper on pruritus ani which appeared
in your issue of April'17th Mr. Riddoch says:
“ I hope to show that idiopathic pruritus ani is caused
by oedema of the peri-anal skin, following on stasis
in the external hzemorrhoidal veins; in other words,
it is due to external piles.” He mentions that X rays
as a remedial agent appear to have some curative
value but does not refer to radium, although the
pathological condition described is one in which this
agent should prove beneficial to the extent of
producing a cure even in persistent cases.
The fact that X rays did not fulfil all the hopes
that were entertained for them in this condition
does not necessarily preclude the success of radium.
I am, Sir, yours faithfully,
RaLpH H. BROWNE-CARTHEW.
London, S.W., April 19th.
INFECTION THROUGH THE OLFACTORY
MUCOSA
To the Editor of THE LANCET
Smr,—The leading article in your issue of April 10th
is misleading as regards the passage of pigment
granules through the tissues. This follows an assump-
tion by Rake that a mixture of iron ammonium
citrate and potassium ferrocyanide solutions con-
stitutes a suspension of Prussian blue, which it does
not. Rake’s papers (J. exp. Med. 1937, 65, 303;
Proc. Soc. exp. Biol. 1936, 34, 716) contain several
references to pigment, granules, or particles. For
example, ‘‘ prussian blue particles pass rapidly from
the surface of the olfactory mucosa and within two
minutes are found in the perineural spaces of the
olfactory nerve-fibres and in the subarachnoid space.”
He misinterprets Le Gros Clark in saying that he “ con-
sidered that the granules had reached the olfactory
bulbs mainly by passage along the perineural spaces.”
Le Gros Clark tried various particulate dyes (trypan
blue and Indian ink) but in no case could he demon-
strate the passage of particles from the nose to the
brain. Both he and Rake used chemical solutions
which were precipitated by acid in the tissues only
after absorption. Rake uses his supposed passage of
particles through the olfactory mucosa to the sub-
arachnoid spaces in support of his studies of the
passage of organisms from the nose to the brain; but
as he used bacteriological methods only, such need
further confirmation.—I am, Sir, yours faithfully,
F. A. PICKWORTH.
Joint Board of Research for Mental Disease,
Birmingham, April 23rd.
PRISONERS AND CAPTIVES
To the Editor of TuE LANCET
Sir,—Whilst tully appreciating the kindliness and
human sympathy shown in the writings of your
contributor Taddygaddy, I feel that in your issue of
last week he allowed himself to be unnecessarily
provocative. Had he paused to re-weigh his ‘‘ Grains
and Scruples’’ I am sure that he would have avoided
what can only be taken as severe criticism of a
considerable section of his medical colleagues. His
“ unfettered thoughts ” have allowed him to wander
into the realms of fantasy. Surely it is unnecessary
and unhelpful to attempt to arouse from its grave
the voluntary hospitals’ claim to monopoly of human
feelings which died of inanition many years ago!
On behalf of those who have the responsibility of
INFECTION THROUGH THE OLFACTORY MUCOSA
[may 1, 1937
the care and treatment of the mentally deficient
and the mentally ill I wish to register a strong protest
against the attempt to build up prejudice against
mental hospitals and institutions. I feel sure that
your contributor would be persuaded to change his
antiquated opinions if he would accept the invitation
of any of my fellow medical superintendents or
myself to come and move freely among our patients.
He would run no risk of remaining ‘‘ cut off and
forgotten.” —I am, Sir, yours faithfully,
W. GORDON MASEFIELD.
Brentwood Mental Hospital, Brentwood,
Essex, April 27th.
POSTURAL DEFORMITIES OF THE
ANTEROPOSTERIOR CURVES OF THE SPINE
To the Editor of THE LANCET
Str,—Mr. Philip Wiles, in your issue of April 17th,
touches on the value of certain exercises used in
ballet training. | l
The system on which the ballet dancer is trained is
a highly technical arrangement of fundamental
exercises leading to the elaborations familiar to all.
They are taught always in the same order, the subject
holding a fixed bar with one hand, the other being
free to move. This training at “la barre” is in
accord with Mr. Wiles’s thesis in that, although to
the spectator it appears that the exercise is being
done by one leg whilst the subject stands on the
other, in reality the work being done on the sup-
porting side of the body is an apt illustration of
Mr. Wiles’s “ absence of movement.” To maintain
the upright position characteristic of the ballet
dancer whilst performing extremely taxing move-
ments with one leg requires strong adjustments
throughout the whole body. By the perpetual
repetition of these adjustments in successive exer-
cises, changes can be effected in posture not possible,
in my opinion, by other methods in use.at present.
The technique is powerful, and so has its dangers.
For this reason it is probably advisable that its
remedial application be confined to medical gymnasts
with ballet training, who are therefore able to make
necessary modifications according to individual needs.
I think that Mr. Wiles is too optimistic in main-
taining that it requires but little ingenuity to invent
a remedial system once the principles are understood.
Systems come and go. To live they must have an
inherent creative quality (the ballet technique has
survived some 300 years because it has this). Posture
exercises must have some primitive and/or esthetic
value: a potential, if not actual, emotional quality.
I am, Sir, yours faithfully,
| CELIA SPARGER, C.S.M.M.G.
London, W., April 23rd.
THE NEW WESTMINSTER HOSPITAL.—Part of the
new Westminster Hospital, now being built on the
St. John Gardens site in Westminster behind the
Abbey, will be known as the Coronation Wing, and by
gracious permission the first ward in this will be called
the King George the Sixth Ward. The total cost of
building the wing will be £30,000. It will contain two
wards of eleven beds each, and several rooms, ancillary
to the service of the wing, including a small patho-
logical laboratory for quick examination. Nearly £20,000
has already been contributed towards the cost of this
wing. Among recent contributions are two gifts of £1000
from ‘‘ Aged 77.” Mr. Bernard Docker, chairman of
the hospital, received the second £1000 from the same
generous donor this week. An alderman of Westminster
and governor of the hospital has also marked his apprecia-
tion of the project with a gift of £1000.
THE LANCET]
THE LANCET 100 YEARS AGO
[way 1, 1937 1077
THE SERVICES
ORGANISATION OF THE INDIAN
SERVICE
On April 3rd we gave an account of changes in
the organisation of the Indian Medical Service. The
London Gazette for April 20th contains a Royal
Warrant amending the current rules for the ‘‘ promo-
tion and precedence ” of the service. It is provided
that the director-general shall hold the substantive
rank of major-general, or, when approved by the
Secretary of State for India, of lieutenant-general.
The ranks of the other officers shall be: colonel,
lieutenant-colonel, major, captain, and lieutenant.
A captain with at least six years’ service, a major,
or a lieutenant-colonel, may be promoted to the
next higher rank by brevet. Officers will be placed
on the retired list when they attain the following
ages: major-general, 60; colonel and brevet
colonel, 57; lieutenant-colonel and major, 55; but
a lieutenant-colonel who entered the Service before
May 1st, 1911, and who has been specially selected
for increased pay may, if he attains the age of
55 years before he completes 27 years’ service for
pension, be retained until completion of such service.
An officer retiring on pension before completing
30 years’ service will be liable, till he attains the
age of 55, to be recalled to duty in case of emergency.
Six of the most meritorious officers on the active
list will be named honorary physicians to the King,
and six honorary surgeons. On such appointment
officers below the rank of colonel.may be promoted
to the brevet rank of colonel.
Major-General Ernest William Charles Bradfield, C.I.E.,
O.B.E., M.S. Lond., F.R.C.S. Edin., I.M.S., Hon. Surgeon
to H.M. The King, is now Director-General, Indian
Medical Service, vice Major-General C. A. Sprawson,
C.I. £., K.H.P., I.M.S. retired.
Lt.-Col. J. F. James, I.M.S., retires. r
The Commander-in-Chief in India has made the follow-
ing appointments :— ; |
Lt.-Col. J. J. D. Roche, R.A.M.C., as Assistant Director
of Hygiene and Pathology, Western Command Head-
quarters.
Major J. H. G. Hunter, R.A.M.C., as officiating Surgeon
to the Commander-in-Chief,
Major T. W. Davidson, R.A.M.C., as Specialist in Radio-
logy, Peshawar District.
ROYAL NAVAL MEDICAL SERVICE
ROYAL NAVAL VOLUNTEER RESERVE
Surg. Lt.-Comdr. H. M. Willoughby to Southampton.
Surg. Lt. M. P. Reddington to Pembroke for R.N. Hosp.,
Chatham.
Surg. Lt. (D) R. S. Daly promoted to Surg. Lt.-
Comdr. (D).
Mr. A. K. Kerr of St. Ives, Cornwall, has been appointed
Admiralty Surgeon and Agent for St. Ives.
ARMY MEDICAL SERVICES
MEDICAL
Col. C. M. Drew, D.S.O., late R.A.M.C., having attained
the age for retirement, is placed on retd. pay.
Lt.-Col. and Bt.-Col. J. A. Manifold, D.S.O., from
R.A.M.C., to be Col.
ROYAL ARMY MEDICAL CORPS
Maj. R. R. G. Atkins, M.C., to be Lt.-Col.
Lts. to be Capts. : R. J. G. Morrison, J. W. Orr, N. C.
Lendon, C. E. Watson, J. A. G. Carmichael, W. G. Bateson,
A. T. Marrable, H. R. Simon, A. C. Byles, J. A. Hamilton,
J. Shields, C. W. Maisey, W. T. M. Moar, K. H. Harper,
T. M. W. D'Arcy, M. F. Kelleher, E. J. Crowe, and C.
McGrath.
Lts. (on prob.) R. J. Niven and S. H. Gibbs are restored
to the estabt.
ARMY DENTAL CORPS
Short Service Commission : F. K. Johnson to be Lt.
(on prob.).
ROYAL AIR FORCE
Flight Lt. H. J. Melville is transferred to the Reserve,
Class D.
Flying Offr. H. C. de B. Milne is promoted to the rank
of Flight Lt.
‘DEATHS IN THE SERVICES
. The death occurred on April 24th, in London, of Major-
General Sir THomas Yarr, C.B., K.C.M.G. He joined
the Army as surgeon in January, 1886, became major,
R.A.M.C., in January, 1898, lieut.-colonel in 1906, colonel
in March, 1915, and major-general in 1917. He was
temporary surgeon-general (without pay and allowances of
the rank) while a D.M.S. in August, 1916. He served in the
European War from 1914 as an A.D.M.S. and D.D.MLS. of
the Mediterranean Expeditionary Force. He was men-
tioned in dispatches and created C.B. (Mil.) in 1915, and
K.C.M.G. in 1917. He was Inspector-General of Medical
Services at the War Office from 1919 to 1921. (See
p. 1080 for the Obituary Notice.)
THE LANCET 100 YEARS AGO
From a leading article, May 6th, 1837, p. 232.
In the two great endowed establishments of Southwark
it is even determined, by æ written rule, that no person
is eligible to be a surgeon to the hospital unless he have
served an apprenticeship with one of the surgical officers
of the establishment. This is what is called an attempt
to make the profession respectable, that is to say, by mak-
ing it expensive, and by restricting the selections of genius
and talent which are to be displayed in the “ upper ranks
of the profession,” from the ‘‘more respectable” and
“ wealthier ° persons in the “ upper classes of society.”
In pursuance of the same system, we find that the hospital
surgeons are permitted by the governors to charge each
student twenty or thirty guineas for the mere privilege
of walking through the wards of the hospital. Then,
again, the use of the patients having broken, dislocated,
and ulcerated limbs, is actually sold, for a time, to a
student who is yearning for the title of “ dresser,” for
the sum of fifty or sixty pounds.... we know not how
the provincial practitioners can be justly censured for the
course which they have thought it their duty to pursue
in obtaining their parochial offices, while not a word of
blame is to be thrown out against the monopolising and
hungry traffickers in disease and suffering in the great
endowed hospitals of the nation.
But the attempt has now been fully made to secure the
** respectability,” as well as the pecuniary interests, of the
profession, by rendering medical education expensive,
and never was there a more signal or self-evident failure
displayed than has been exhibited in the effort which
has been expended to carry into operation this fraudulent,
narrow-minded, irrational scheme. -——° '
* * *
From a news paragraph, p. 234.
The cerebral development of JAMES GREENACRE, who was
executed on Tuesday last, for the murder of HANNAH
Brown, was strictly confirmatory of the doctrine of
phrenology.
* * *
From a letter on The Ergot of Rye.
Operation, p. 239.
. . . I am of opinion, that contractions may, and I think
do, take place in less than 15 minutes after the use of
the secale (cornutum). On referring to my case-book,
I find notes of two cases wherein contractions came on in
12 minutes after the administration of the ergot; and I
also find a case published in THe Lancet of Sept. 20th,
1827-8, by Mr. J. C. Jerrard, where the pains increased
in 10 minutes after the exhibition of the ergot; but much
depends on the quality of the ergot, and the mode of
preparing the decoction; if it be ground in a coffee-
mill, with a little lump-sugar, and boiled in a tin sauce-
pan, I have found it more certain in its effects, than when
commonly produced in a mortar, and boiled in an tron
pan. I am, Sir, your obedient servant,
CHRISTOPHER BRADLEY, M.R.C.S.L., &c.
Church, near Blackburn, Lancashire, April 26th, 1837.
Speed of its
1078 THE LANCET]
[may 1, 1937
OBITUARY
ARCHIBALD DONALD, M.D. Edin., F.R.C.P. Lond.,
F.C.0.G.
EMERITUS PROFESSOR OF CLINICAL OBSTETRICS AND GYNAECOLOGY
IN MANCHESTER UNIVERSITY z
WE announced last week the death of the
distinguished gynæcologist, Prof. Archibald Donald,
which occurred on April 18th at his house in Alderley
Edge, Cheshire, in the 77th year of his age.
Archibald Donald, the son of Mr. John Donald
of Edinburgh, was born in 1860 and educated at
Craigmount House. School and the University of
Edinburgh. He graduated as M.B., Ch.B. with
honours in 1883, proceeding to the M.D. degree in
1886. He served
as house surgeon
at the Royal
Maternity Hospital,
Edinburgh, and
was then appointed
resident obstetric
surgeon at
St. Mary's Hos-
pitals, Manchester.
This was in 1885,
and from that time
forward to the end
of his long career
he worked in
Manchester. After
three years as a
senior resident of
St. Mary’s Hos-
pitals he was elected
to the honorary
staff and was recog-
nised at an early
age as a leader
in this branch of
medicine. By this
time he had pro-
duced a small but
valuable book on natural labour. In this introduction
to the science of midwifery he disclaimed any intention
of teaching the procedures needed in the presence of
complications, but he defined and described the abnor-
malities which rendered further assistance desirable.
The teaching was full and sound, and the book ran
through eight editions. In 1895 Donald was elected
gynecological surgeon to the Manchester Royal
Infirmary, and in 1912 professor of obstetrics and
gynecology in the University.
For those who have worked only under modern
conditions it is difficult’ to visualise the circum-
stances in which a surgeon worked in 1888, the year
Donald was appointed to the staff of St. Mary’s
Hospitals, Manchester. It is true that the work of
Lister was. gradually permeating surgical work, but
the methods were still, and for many years continued
to be, those of antisepsis and included the carbolic
spray and other methods, cumbersome, inefliicient,
and trying to operator and patient. There were no
steam sterilisers for instruments, gown, and dressings ;
no gloves; no masks or caps; no electric light ;
no radiators; no Trendelenburg position ; no reliable
sutures. In these crude surroundings had worked
the great pioneers of gynecological surgery—Clay,
Spencer Wells, Lawson Tait—and under these same
disabilities began the work of Donald and his con-
temporaries who were to develop this branch of
our profession into what we now know it.
PROF. DONALD
Donald began his work with one great advantage
over most of his contemporaries. St. Mary’s Hospitals
provided one of the largest maternity centres in the
country and being in the centre of a large industrial
population in which rickets abounded it ministered
to an enormous number of abnormal cases. Donald
was the senior resident in this hospital for three
years and was responsible each year for about 4000
births as well as acting as house surgeon to 40 gynæco-
logical beds. It was a wonderful preparation for
his lifes work and gave him a practical clinical
knowledge which few men of his age possessed.
Abdominal surgery was in its infancy and the
number of patients who could be submitted to a
major operation was necessarily restricted. This
fact turned Donald’s mind to the problem of pro-
lapsus uteri, a disabling condition which abounded
in a district employing so much female labour.
Up to this time attempts had been made to improve
the lot of these poor patients by the use of supports,
by anterior colporrhaphy, by amputation of the cervix,
or by repairing the perineum so that a pessary could be
retained, but no one had devised any operation which
could be considered a cure for this distressing state.
Donald decided that the only likely way was a
combination of these various procedures, and in
spite of universal discouragement he made the
attempt five times in 1888, in each case successfully.
In his first two cases silver wire was the suture
material; in both of these the wounds healed well
and the women were able subsequently to return
to their work as charwomen without any recurrence
of their trouble. For this purpose silver wire had
obvious disadvantages and Donald cast around for
something more suitable. About this time he heard
that some German surgeons were using catgut and he
decided to try it as, being absorbable, it would be ideal
for this type of operation if only it would hold
sufficiently long to allow healing to take place.
He used it in the remaining three cases in 1888 and
was delighted with the result, especially as he could
bury it and so build up the floor of the pelvis in
layers, upon the technique of which a good colpor-
rhaphy depends. The principle which he then
evolved, of combining an anterior and posterior
colporrhaphy with amputation of the cervix, making
a strong pelvic floor and perineum by building up
this tissue in layers with buried catgut, is still the
method employed in one of the most successful
operations in surgery—and from 1888 it has been
continuously employed in his old hospital. The
catgut first used by Donald in 1888 was imported
from Germany—each hank in a small bottle of
carbolic oil. This method of preparation was not
wholly satisfactory and Donald experimented with
many others and finally settled upon the one in which
the catgut is soaked in alcohol and iodine. For a
time he did try other suture materials but as his
confidence in the preparation and strength of catgut
increased he discarded these and during this century
rarely used anything else. He must have been
one of the first surgeons—if not the first—in this
country to use it and he was certainly the first to
rely entirely upon it. In the whole of his long career,
at first using catgut ill-prepared, he had only one
case of tetanus.
In the realm of abdominal surgery Donald played a
leading part, not so much in devising new operations
as by perfecting and making workable the suggestions
of others, his practical mind at once seizing upon the
THE LANCET]
essential and discarding the redundant. He was a
brilliant operator, with a long thin hand which could
reach places inaccessible to more brawny colleagues.
His hands were, however, always guided by his
brain: he thought out beforehand what should be
done and did it with delicacy, precision, and speed,
and with complete confidence in himself. His
inquiring and logical mind refused to accept views
merely because they were ancient or had met with
general acceptance. For long retroflexion of the
uterus had been regarded as one of the common
causes of female ills and if a uterus was found in this
position it must be rectified and held in position by
a pessary or operation. Donald could not accept
this and pointed out on every possible occasion that
the same symptoms occurred with anteflexed as
with retroflexed uteri and that many women with
retroflexed uteri were symptomless. For long his
was a voice crying in the wilderness, and now that a
more rational view is accepted his long fight may,
but should not, be forgotten. He was a strong
advocate of the curette; this he did not use indis-
criminately but only for specially selected cases and
when he curetted he scraped the uterus quite clean.
When a hysterectomy was necessary he believed in
the “clean sweep” and removed both ovaries with
the uterus. The conservation of an ovary on
sentimental grounds made no appeal to him.
One of his outstanding features was his clinical
memory which stood him in good stead in making
a diagnosis in a difficult case. Generally he could
recall a somewhat similar case and his skill in diagnosis
was sometimes uncanny. Although best known as
a gynecologist, he was keenly interested in obstetrics
and attended maternity cases up to the time of his
retirement as he was a firm believer in the indi-
visibility of these two subjects. His earliest papers
were on obstetrical subjects, and just before his
death he was writing about puerperal sepsis. He
served upon the departmental committee of the
Ministry of Health which reported upon the cause
and prevention of puerperal sepsis, and he held the
view very strongly that efficient cleansing of the
attendants’ hands would prevent most of these cases.
At an early age he became the acknowledged leader
in obstetrics and gynecology in Manchester and the
surrounding district and as time progressed his
circle ever widened, and he developed an enormous
practice, but even in his busiest years he found time
to read occasional papers before the obstetrical section
of the Royal Society of Medicine, and he rarely missed
a meeting of the North of England Obstetrical and
Gynecological Society where his ripe experience,
clinical memory, and humour made him one of the
most popular speakers.
But first and foremost Donald was a clinician.
A difficult diagnosis or a troublesome operation saw
him at his best and ever the patient came first. The
advances he made were in the clinical field and his
writings were invariably on clinical subjects. Not
that he despised the scientific side—far from it;
he knew more pathology than he was usually credited
with and was always interested in this branch and
ready to apply any scientific fact. What irritated
him was the pseudo-scientific mind and the paper
full of unproved theories based upon uncertain facts.
Thus as a teacher Donald shone on the clinical side.
For some years he was the professor of obstetrics
and gynecology at the Manchester University, but
systematic lectures full of theories and lists of names
never appealed to him and he finally persuaded the
University to bring his subject into line with medicine
and surgery and to create a new chair of clinical
OBITUARY
Infirmary also writes :
. [may 1, 1937 1079
obstetrics and gynecology. Here he was perfectly
happy and at home, teaching by the bedside, recalling
interesting cases from the vast storehouse of his
memory, noticing signs unrecognised by others, and
finally proving at operation that his diagnosis was
correct.
Prof. Fletcher Shaw, to whom we are indebted for
much of the above, gives the following personal
picture :
“Like all men of mark Donald had a strong
character and he always had himself in perfect
control, No matter how difficult or irritating the
position, he never betrayed what he felt by word or
action; always perfectly courteous he carried on
outwardly quite cool, and only those with intimate
knowledge of him knew by the set of his jaw what
he really felt. Slight in build and looking frail, it
was a wonder how he got through the vast amount of
work which he did, but he had a stronger constitution
than he showed and he had the faculty of working
without fuss or excitement. Upright, fearless, and
honest, and entirely unself-seeking, he expressed his
views openly though always with courtesy and with
care not to hurt his opponent’s feelings. He scorned
the man who worked subterraneously or crookedly
or pulled strings for his own glorification. What
honours came his way—and they were many—gave
him joy because they came unsought and generally
from his own profession. He was generous and genial,
radiating kindliness and with a fund of quiet humour ;
he loved his fellowmen and delighted to be with
them as they with him. And as a colleague he was
perfect. Kindly, courteous, without jealousy, and
ever ready to help, he retained the friendship and `
respect of those he outstripped, while in his juniors
he inspired pride and devotion.”
A surgical colleague at the Manchester Royal
“To those who recall the
extraordinary activities, physical and mental alike,
of Archie Donald throughout a long and extremely
distinguished professional career, it must have caused
considerable distress to witness the rapid decline of
the last few months during which he was confined
indoors, quite unable to enjoy his beautiful garden
which he loved so well and on which he had expended
so much thought, interest, and energy. Of the
details of such a career others, his colleagues in his
special sphere of work, are in a better position to
testify than the writer, but it is of Donald the man
himself that one would pen a few words in most
affectionate memory. Widely recognised from his
early days as the outstanding exponent of his chosen
specialty, Donald was throughout completely free
from any taint of professional jealousy, and his help
was always most willingly and cheerfully given to his
younger colleagues; indeed, most of the honorary
staffs of the M.R.I. and the St. Mary’s Hospitals
owe their position largely to his support, since his
influence with the governing bodies was greater than
that of any other individual medical man, and to
have Donald on one’s side practically connoted
success in such elections. His modesty so far as
concerned his own most valuable and original work
was carried almost to the point of absurdity. Endowed
with an almost uncanny power of sifting the wheat
from the chaff among the many suggestions in the
medical journals of his day, he was ever quick to
seize upon and to put into practice those he con-
sidered to make for real progress. A powerful and
fearless advocate of what he believed to be right,
he was absolutely intolerant of shams and frills of
every description, and although his advice when
1080 THE LANCET]
OBITUARY
{may 1, 1937
sought did not. always coincide with the seeker’s own
inclinations yet in the long run it invariably proved
correct. No one could be more loyal or generous
as a friend. At the outbreak of the war Donald,
then aged fifty-four, joined the à la suite staff of the
2nd General Western Hospital with the rank of
captain, becoming thereby junior to most of those
considerably junior to himself in civil practice; for
some months, in addition to his other military duties,
he took his turn to ‘live in’ and do what was, in
reality, merely the work of a house surgeon—an
admirable instance of his loyalty and devotion to
what he thought to be his duty.”
Prof. Donald was at different times president of
the obstetrical and -gynscological section of the
Royal Society of Medicine, of the North of England
Obstetrical and Gynecological Society, of the
Manchester Medical Society, and the Manchester
Pathological Society. He wasa LL.D. of the Univer-
sity of Edinburgh, and D.L. for the county of
Lancashire. He married Maude, daughter of Mr.
R. B. Wilkinson, who survives him with two daughters
and two sons. The home life was a very happy
one, but they had cruel blows in the loss of two sons.
The elder, an Oxford undergraduate, was killed early
in the war at Gallipoli, and the third son, a barrister,
died after a long illness, He is survived by a widow,
two sons and two daughters, one of the sons being in
medical practice in Manchester as a consulting
physician.
SIR THOMAS YARR, K.C.M.G., C.B., F.R.C.S.I1.
WE regret to record the death of Major-General
Sir (Michael) Thomas Yarr, a distinguished officer in
the R.A.M.C., and particularly well known for his
excellent work in ophthalmology in connexion with
military service. This occurred on April 24th in a
London nursing-home, —
Thomas Yarr was the son of Thomas Yarr, J.P.,
of Rathgar, and was born at Cloughjordan, Tipperary.
He was educated at the French College, Blackrock,
and Mesnières. He went for his medical training to
the school of the Royal College of Surgeons in Ireland,
took the diplomas of L.R.C.P.I. and L.M. in 1882, and
| almost immediately
joined the R.A.M.C.
. He distinguished him-
self at Netley, gaining
the Herbert prize, the
Parkes medal, and the
Martin and Montefiore
memorial medals. He
took the F.R.C.S.I.
diploma and was at
first attached to the
Ist Battalion of Cold-
stream Guards. From
ing four years he was
seconded to serve
under the Foreign
Office as physician to
the Crown Prince of
Siam, At the expira-
tion of this office
‘he was appointed to
the staff of the
Governor of Bombay,
a post which he held
for five years—i.e., until 1906, when he was promoted
lieutenant-colonel. Both in Siam and in Bombay
Yarr made his mark by his quiet efficiency and broad
SIR THOMAS YARR
(Photograph by Russ
1895 for the follow-'
grasp of affairs, and while in Bombay his interest in
ophthalmology developed, resulting in special work
in connexion with diseases of the eye peculiar to the
East. He now used his leave in attending con-
tinental clinics in Berlin, Paris, and Vienna, and
held also the post of chief clinical assistant at the
Royal London Ophthalmic Hospital. ;
Major Yarr saw service in the South African War
and was present at operations in the Orange Free
State, Transvaal, and Cape Colony, receiving the
Queen’s medal with four clasps. His experiences
there were drawn upon in his text-book, A Manual
of Military Ophthalmology, which appeared in 1902.
The book was directed particularly to the needs of
medical officers of the Home, Indian, and Colonial
Services, and in its plan it followed familiar lines,
but because of their common occurrence in soldiers,
particular stress was laid on the gonorrheal, syphi-
litic, and malarial infections in relation to diseases
of the eye. Also he laid stress on the regulation in
the Army Orders, which had just been issued, giving
permission to both officers and men to wear spectacles.
The regulation was due to the fact that in the South
African War the bad sight of many combatants was
held to have constituted a real drawback to certain
operations. Particular attention was also paid by
Yarr to injuries to the eye from gunshot wounds
and the entrance of foreign bodies into the eye, a
subject which he further dealt with in a paper com-
municated to the proceedings of the annual meeting
of the British Medical Association in the same year.
At the outbreak of the European War Yarr served
as ‘A.D.M.S. and D.D.M.S. of the Mediterranean
Expeditionary Force. He was present at the landing
at Gallipoli, and later did distinguished service in
Egypt and at Malta, where the hospital organisation
was put to a heavy strain by the large number of
eases brought to Valetta from every arm of the
fighting services. Yarr was. promoted temporary
surgeon-general in 1916, was mentioned in dispatches,
received the C.B., and, in 1917, was promoted major-
general and appointed a K.C.M.G. He was given
also the Legion of Honour and became a Knight of
Grace of the Order of St. John. At the conclusion
of hostilities he was selected to be Inspector-General
of Medical Services, a post which he held until 1921.
Major-General Yarr was 75 years of age at the time
of his death. He was unmarried.
THOMAS GUY MACAULAY HINE, O.B.E.,
M.D. Camb.
Dr. Macaulay Hine, who died on April 25th,
aged 66, was the son of the late Mr. George Hine,
F.R.I.B.A., consultitg architect to the Royal Com-
mission in Lunacy, who built some twenty of our -
largest asylums including Claybury. Dr. Hine was
educated at Charterhouse and King’s College,
Cambridge, and went for his medical training to
St. Bartholomew’s Hospital. He graduated as
M.B. Camb. in 1904 and became house physician to
Sir Norman Moore. :
Hine possessed a special flair for engineering, and
in his youth he spent a year in Germany making
a practical study of it. At Cambridge, however,
he decided to study medicine, and after he had
qualified and finished his house appointment settled
down to study the fermentative characters of organ-
isms of the diphtheria group. He wrote his M.D.
thesis on the results of this investigation, which showed
for the first time that certain carbohydrates, especially
saccharose and dextrine, can have a useful application
for the purpose of identifying the Klebs-Léffler
THE LANCET]
bacillus. When during the first winter of the war
cerebro-spinal fever broke out among recruits then
in training, and a large epidemic was threatened,
special measures became necessary for checking its
spread. The procedure adopted was under the
direction of Sir William Horrocks assisted by the late
Dr. R. J. Reece and by Dr. Mervyn Gordon. A
central laboratory was set up at Millbank with a
travelling laboratory attached to it. Dr. Gordon
gave practically the whole of his time to the research,
and as various points came to light they were applied
by Dr. Hine, who acted as O.C., Central C.S.F.
Laboratory. Thus when a special medium was
arrived at for detecting the meningococcus in the
nasopharynx, Dr. Hine manufactured and distributed
it on a large scale to military laboratories, some
fifty in number all over the country. Later on he
undertook in the same way the preparation and
distribution of monotypical agglutinating sera and
suspensions wherewith to check them and managed
to do a piece of research work as well on the optimum
procedure for the purpose of preparing this serum.
Later he undertook in the same way the distribution
of special monotypical therapeutic serum and assessed
its potency in a careful report. The special reports
Nos. 3 and 50 om cerebro-spinal fever of the Medical
Research Council series contains several valuable
contributions by him,
PARLIAMENTARY
THE FACTORIES BILL IN COMMITTEE
THE Factories Bill was further considered by a
Standing Committee of the House of Commons on
April 20th. Major LLOYD GEORGE was in the chair.
The discussion was resumed on Clause 68, which
provides among other things that, subject to certain
exceptions, the total number of hours worked by
women and young persons in factories, exclusive of
intervals for meals and rest, shall not exceed 9 in
any day, nor exceed 48 in any week; that the period
of employment shall not exceed 11 hours in any day,
and shall not begin earlier than six o’clock in the
morning nor end later than eight o’clock in the
evening, or, on Saturday, one o’clock in the afternoon ;
provided that where women or young persons are not
employed on more than five days in the week the
total hours worked may extend to 10 and the period
of employment may extend to 12 hours, in any
one day.
Mr. A. SHORT moved an amendment to limit the
hours of work of women in factories to 40 per week.
At the suggestion of the chairman the Committee
agreed to discuss at the same time two other amend-
ments on the Order Paper proposing that the hours
of work of young persons in factories should be
limited to 7 per day and 40 per week. Mr. Short
said that up-to now the Committee in the con-
sideration of this clause had, acting on the advice
of the Home Secretary, taken a most reactionary
course. None of the amendments put forward by the
Labour Party which were calculated to improve the
position of employees which would come under this
‘clause had been accepted. He would like to know
whether the Home Secretary and the Home Office
were in the pocket of the employers as to the provisions
of this Bill. Women were more prone to accidents
than men, and now that workshops were being
included under this Bill he had no doubt that there
would be an increased number of accidents. They
must make this Bill worthy of the occasion. Forty-
eight hours’ work per week was too long for women.
On the question of hours the employers of this country
had been most reactionary and retrograde, and it was
for Parliament, by legislation, to force them to
introduce a 40-hour week.
PARLIAMENTARY INTELLIGENCE
[may 1, 1937 1081
Towards the end of the war ‘when some form of
mass disinfection became ‘desirable for diminishing
the abundance of the meningococcus in the naso-
pharynx of carriers, experiments at the Central
Laboratory madé on actual carriers showed that
the comparatively delicate meningococcus can be
temporarily got rid of by causing carriers to inhale
steam-laden air charged with droplets of zinc sulphate
(1 : 50). Hine’s previous training as an engineer now
enabled him to devise a special jet for the purpose of
keeping the air of an inhaling room charged with
zinc sulphate droplets of the required strength, and
later the Navy adopted this device, employing air
compression instead of steam for the purpose of
spraying. For his services during the war Hine
received the O.B.E. and ‘was given the honorary
rank of Major. After the war he assisted the admini-
strative staff of the Medical Research Council for a
time, but for several years past he lived in retirement
in Devonshire. 7
In 1918 he married Miss Margaret Lillywhite, who
survives him with two children, a son, aged 16 and
a daughter. Dr. Hine’s sister, Mrs. Coxon, is the
well-known novelist, Muriel Hine. Dr. Hine had been a
past master of the Worshipful Company of Fruiterers,
was an enthusiastic fisherman, and very popular
in lay as well as medical circles where his genial
presence will be much missed.
INTELLIGENCE
Mr. GRAHAM WHITE said it was absolutely necessary
for the well-being of the country that young people
should be fit, both mentally and physically. The
hours of work permitted under the Bill did not
allow that degree of fitness to which the individual
was entitled and which the nation required. 7
Mr. McCorRQUODALE said he was particularly
interested in young persons, but he thought that
having decided to reject the 40-hour week for men
they must necessarily reject it for adult women.
He thought that this country would be well advised
to hold its hand in regard to the question of the
40-hour week until it had seen what would happen
in France. According to his information at the
present time the net result of the 40-hour week
being put into practice in France had been to increase
prices by nearly 30 per cent., which meant that the
working men and women in France were 30 per cent.
worse off than they were before as they got the same
money wages. But the question of young persons—
especially those under 16—was entirely different,
- and he strongly urged the Government to meet them
in that matter. He did not believe that young
persons—especially those under 16—could work
48 hours a week and maintain the best of health.
Mr. ELLIS SMITH said that he was concerned about
the young people who went into industry fresh from
school, particularly those between the ages of 14
and 16. More and more in modern industry they
found that young persons were being put on repetition
work. Work was being speeded up in this way until
the increase in production in Great Britain since
1929 was greater than in any other capitalist country
in the world. In big factories employing repetition
methods a new process was being carried out known
as ‘‘ micromotion,’’ introduced from America. Persons
were specially trained to watch people at work in the
factories. Films were taken of the people at work
and afterwards discussed by managers and assistants
in order to decide what unnecessary use of human
energy there had been and what unnecessary opera-
tions could be cut out. That was a good thing. It
was important in these times to increase production
and obtain the maximum output in the least number
of hours possible ; but instead of being looked upon
as a blessing methods of increased production were
1082 THE LANCET]
regarded as a menace by the workpeople because
they were not getting the benefits from this increased
Se OR which they ought to do.
DENMAN said that he did not think they
could confine the working hours to seven a day.
He thought that the Committee ought to agree to
limit the hours of young persons to 40 per week.
Since the passing of the Education Act the Govern-
ment had launched a great programme of physical
development and a 40-hour week was the maximum
which was consistent with the declared policy of the
Government in those respects. The refusal of a
40-hour week for young persons would cause severe
disappointment and cause a drift away from the
support of the National Government.—Viscountess
ASTOR said that Mr. Denman had made it almost
impossible for the Government to reject the proposal
for a 40-hour week for children. -
Wing Commander WRIGHT said that as an employer
with a factory, in which a good deal of repetition
work was done, he was in entire agreement with
almost everything that Mr. Ellis Smith had said.
There was no question that they could get the same
sort of production in very much shorter hours and
if they saw that their workpeople got a just reward
for the extra effort they must make. He believed
that a 40-hour week was in sight. In his own factory
the workpeople always worked only 45 hours a week
and they found that the workers were better,
healthier, and happier, that they earned the same
money, and that production had not decreased.
He would like to see the hours of work of young
children up to 16 reduced so far as to make it
uneconomical to employ them for production in a
factory while making the hours sufficient for them to
be employed for instruction.
Sir J. Sm™moNn, Home Secretary, said that there
were at present about 3,000,000 men employed as
workpeople in manufacturing industries; about
1,500,000 women over 18; and something like
1,000,000 young persons under 18, and of that
number over 500,000 were under 16. The supply of
juvenile labour in this country. would fall off in a very
few years, and it was much better to deal with the
matter deliberately now before trouble had been
stored up. But it would be a very great mistake to
regard the proposals of this Bill as though they did
not represent a very great improvement in this
respect. As far as the present law was concerned,
from the point of view of permitted hours, juveniles
_ between 14 and 16 and between 16 and 18 and
women of any age were all treated, and were, on a
level. The hours at present permitted for women
and young persons classed together were 554 in
textile factories and 60 hours in other factories. He
was glad to think that in most cases these very long
hours were never touched. But at present there
was an agreed working week—say, of 48 hours—
and on top of that there was a very large quantity
of overtime which might extend over the whole year.
In that respect women and young persons up to now
had not been treated separately.
The first thing-to notice about the present Bill
was that it contained a gradation as regards hours.
The question to decide was whether the gradation
was steep enough. Under the Bill as at present
drawn up adult men, as before, were left to collective
bargaining, and so on. There was a statutory limit
of 48 hours a week for women with permissive over-
time, which was limited both in number of hours
and in number of weeks. As regards young persons
between 16 and 18 there was a 48-hours week, but
a more limited provision concerning overtime, and as
regards young persons between 14 and 16 there
could not be any overtime. The gradation was an
entirely new .and important principle. There came
the question as to whether they could do better than
was done in the Bill as regards juveniles between
14 and 16. He had for some time taken the view
that they could. He would like to see the permitted
hours of juveniles between 14 and 16 reduced. On
inquiry the medical advisers to the Home Office
PARLIAMENTARY INTELLIGENCE
[may 1, 1937 ~
had advised him that the existing 48 hours could
not be said, on present information, to be injurious
to health, but, naturally, they would be very glad to
see more time for leisure and recreation. He would
put the case rather on the ground that whether they
considered educational policy or physical recreation, or
the future conditions under which young citizens
were going to grow up, it was high time that they
had a more limited number of working hours than
48 a week. : l
Mr. GIBBINS: Do the Minister’s medical advisers,
in suggesting that it is not injurious to work 48 hours
a week between 14 and 16 years of age, have regard
to any consequences later for young persons who
work those hours ?>—Sir E. GRAHAM-LITTLE: Is the
right hon. gentleman aware of the unanimous opinion
expressed in the medical press on this subject ?
Sir J. Suwon said he had stated the opinion of his
skilled advisers, but on general grounds he took it
that it would be better if they could get the hours
reduced. But first of all more information must be
obtained as to what the hours ought to be, and
therefore he suggested that the alteration should be
made when the Bill reached the Report stage. He
did not believe that it would be possible to introduce
such a provision as early as other provisions in the
Bill. There must be sufficient time for the important
industries to consider the question of reorganisation,
but they could possibly bring the ifmprovement into
force within two years. They must leave to a par-
ticular industry the opportunity of proving, if it
could, that in each case a figure different from the
statutory figure—it might not be as much as 48;
it might be something between the two—was justified.
His view was that before that could be done three
things would have to be proved: first, that the
hours in that branch of industry could not reasonably
be regarded asinjurious to the health of young people ;
secondly, it would be right to stipulate that the
industry must prove that the hours were not only
consistent with the health of the children, but that
the organisation and proper carrying out of that
industry made it desirable that the young people
should work these longer hours side by side with their
elders; and thirdly, the industry would have to prove
that the juveniles would be engaged in work of such
a character as ‘would familiarise them with and
help them to train for processes in which the older
people were employed and would be likely to lead up
to their employment in those processes. He was not
saying that these exceptions would be taken advantage
of; he did not know to what extent they might be
necessary, but it seemed that they constituted a fair
proposal to make to industry. ;
Mr. SALT: Would the suggestion regarding health
cut out all repetition work ?—Viscountess ASTOR :
And would the exception with regard to children
learning a trade be dependent on proof that they were
really learning it ?
`- Sir J. SmoN said that that was his idea. He had
not the least doubt that as a result of his statement
the Home Office would receive a great deal of
information before the Report stage of the Bill. He
would be happy indeed if that information proved
to be in support of an improvement of this sort.
Mr. VIANT said that the Labour Opposition were
grievously disappointed with the Home Secretary’s
statement.—Mr. McCoRQUODALE said he thought
that the Home Secretary had met the Committee in
a very frank and fair manner. The Committee
adjourned.
The consideration of the Bill was resumed on
April 22nd. The discussion on Clause 68 was
continued.
Sir J. Suwon, referring to his statement at the
Pee sitting, said that the modifications which
e had sketched out and which he had suggested
should come into force after an interval of two
years would have to be expressed in a clause which
pe that after that interval the figure 48 would
e altered to a smaller figure with the other provisions
that he indicated. That could properly be done in a
. there.
THE LANCET]
PARLIAMENTARY INTELLIGENCE
[may 1, 1937 1083
new clause ahh would be Clause 69. Clause 68
would be a provision as to what would happen when
the Bill passed, and the new Clause 69 would be a
provision as to how that would be altered after an
interval. After further reflection he had come to the
conclusion that the proposed change could better be
made in Committee than on the Report stage, and
he would undertake that that should be the procedure
followed. |
i Mr. WAKEFIELD urged that the Home Secretary
should reconsider the position of the hours of work
of young persons between the ages of 16 and 18
with a view to applying similar conditions to those
which he had foreshadowed for young people between
14 and 16. It would be impossible to carry out the
provisions of the Bill for physical trajning and
recreation unless young persons worked shorter hours.
The health of our young people was the greatest
asset we possessed and it was important, especially
es the birth-rate was now declining, that we should
make every effort to preserve it.
Viscountess ASTOR said it was just as important
that hours should be reduced for children from
16 to 18 as for those between 14 and 16. This was a
wonderful opportunity and if the Government did
not take it, it would make their grant for physical
fitness absurd.—Mr. BroapD said he questioned the
medical advice given to the Home Secretary to the
effect that factory work had no effect on the health
of children. Such work stunted them in mind and
body. He hoped that they would be able to restrict
the hours of employment of young people until the
age of 21. | |
Sir E. GRAHAM-LITTLE said that there were certain
medical and educational arguments which had not
been brought out quite explicitly and which made a
very special class of the children from 14 to 16 years
of age. It was for that class-that he wanted very
particularly to plead. Medical opinion was unani-
mous in wishing to restrict the hours of labour of
children from 14 to 16 years of age. There was no
division of opinion on that matter in any informal
circle. He hoped that the Home Secretary would go
beyond his official advisers in that respect. In the
period from 14 to 16 years of age the whole structure
of the child, physical and psychological, changed.
A very great deal of work had been done—he was
glad to say chiefly in this country—in investigating
the psychology of that period. It was a very
important consideration. The mental and physical
stability of the child in those years was in a state of
turmoil. The child from 14 to 16 years of age ought
not to be in a factory atall. It was a most distressing
thing that he should ever have been allowed to be
Our descendants would think as harshly of
us for having permitted it as we thought harshly of
those persons who allowed children of tender years to
work in a factory for 20 hours a day. The medical
point of view was important, but they pleaded also
for the educational point of view. The spirit of
enthusiasm, training, discipline, and forward-looking
was what the children lost if they went into a factory.
‘They did not want the children to lose it. Children
who go on from 14 to 16 should be allowed to com-
plete that part of their education, adding to the
structure of theory and science and fitting themselves
to become really skilled workers in trades and occu-
pations. The work which they did in factories from
14 to 16 was in no way a preparation for a trade.
‘They lost all the incentive which they learned at
school and they had a great period of indolence as
regarded mental activity because of the absence of any
incentive. At 18 they were lifeless persons and were
thrown again on to the labour market. That process
was utterly uneconomic and foolish. They would be
contributing to the making of a C3 nation if they
did not make a great effort, the opportunity for which
now presented itself, for physical reconstitution.
After further discussion the Committee divided on
a Labour amendment limiting the working week for
women and young persons to 40 hours. This was
negatived by 24 votes to 15.
“withdrawn.
Mr. LLOYD, Under-Secretary, Home Office, moved
an amendment substituting 7 o’clock for 6 o’clock as
the hour for beginning work in factories. He said
that the Government were prepared to agree that
work should not begin before 7 o’clock, except in
special cases where authorised by the Secretary of
State. Under a new duse which would be moved
` later the Secretary of State would be empowered to
allow the period of employment to begin earlier than
7 o’clock, but not earlier than 6 o’clock in the case
of a particular class of factory where the exigencies
of the trade or the convenience of the persons
employed so required.
The amendment was agreed to.
Mr. SILKIN moved an amendment providing that
the period of employment should end not later than
6 o’clock instead of 8 o’clock. .
Mr. Luoyp said that in certain circumstances it
was for the convenience of the workers that they
should start late. It would be impracticable as a
matter of administration to fix an earlier period and
then to give a large number of exemptions.
After further discussion Mr. Lloyd said that he
had been impressed with the arguments put forward
and he asked the Committee to allow the Home
Office to reconsider this matter from the point of
view of young persons. The amendment was
Subsection (c) of Clause 68 provides that a woman
or young person shall not be employed continuously
for a spell of more than 4} hours without an interval
of at least half an hour for a meal or rest, so, however,
that where an interval of not less than 10 minutes
is allowed in the course of a spell, the spell may be
increased to 5 hours.
‘Mr. WHITE moved to leave out the words ‘or
young person ” from the subsection. He said that
it was not the intention of the amendment merely to
take young people out of the protection of the clause.
The amendment had to be read in conjunction with
another providing for the limitation of spells of
work of young people to 34 hours. -
Mr. LLOYD said that the provisions in the Bill had
been put in as a result of the experience of the
Factory Department of the Home Office in order to
provide the intervals and rest pauses that were
necessary, but also to avoid making unnecessary long
rest pauses which were inconvenient and much
resented by the workers concerned. He thought
they ought to have heard some stronger reasons for
the insertion of the amendment. These proposals
had been incorporated in the Bill as a result of
work subsidised by the Medical Research Council.
Mr. WHITE said that 34 hours’ work at a time was a
sufficiently long period for any young person who
came straight from school. The amendment was
negatived. |
Sir E. GRAHAM-LITTLE moved to leave out the
words ‘‘four and a half” and to insert the word
‘‘three ” in the subsection. He said that it was well
established that spells of work of more than three
hours, especially in the case of young people, caused
attention to flag and the incidence of accidents was
very largely due to, and increased by, inattention.
Practical proof of that was to hand in statistics.
Mr. Luoyp said that the hon. Member had put
forward medical opinion that the proposal in the Bill
was too long and that three hours was the maximum
that ought to prevail. That was not the conclusion
to which the Industrial Health Research Board came
when they made a special investigation into these
subjects. Their general conclusion after an examina-
tion of sickness records and so on was that it was
impossible to obtain reliable evidence as to the
change in the duration of work spells affecting sickness
rates. Therefore in this matter medical opinion was
divided.
Sir E. GRAHAM-LITTLE: Does ‘sickness rates ”
include accidents ?—Mr. LLOYD: No, but from the
accidents point of view the reports of the factory
inspectors tend to show that it is not at the end of
the period of work, even in regard to young persons,
1084 THE LANCET]
that accidents mostly occur. They tend much more
to occur somewhere about the beginning of work or
during periods of maximum production when there is
a tendency to work too fast.
The amendment was negatived.
The further consideration of the Bill was adjourned.
GOVERNMENT AND MILK POLICY
NEW BILL PROMISED
In the House of Lords on April 27th, on the motion
of Lord Marks, the Poole Corporation Bill was read
a second time.
Lord CRANWORTH moved an instruction to the
Committee which will consider the Bill to delete
Clause 21, which relates to by-laws ‘‘ as to pasteurisa-
tion, &c., of milk.” He said that the Poole Cor-
poration admitted that this clause was included in
the Bill because of the recent outbreak of typhoid at
. Bournemouth. This was panic legislation. .
Viscount HALIFAX, Lord Privy Seal, said that the
health of the people must be the first and last con-
sideration, and the question of vested interests did
not arise. The Bill was not opposed on petitions,
but he understood it was the intention of the Chairman
of Committees to refer the Bill to a Select Committee
of the House in order that the proposals as to
pasteurisation might be examined. In the view of
the Government such an inquiry would be unsatis-
factory and probably inconclusive. An inquiry of
that kind ought not to be held in connexion with
any particular locality ; the question could only be
considered as a general one affecting the country as
a whole. The Government had reviewed the whole
matter, and he was authorised to announce that it
was their intention to bring forward long-term legis-
lation dealing with milk policy generally in the near
future. In this connexion the Government would
examine the question of pasteurisation in the light
of all the evidence that was available with a view to
deciding whether or not it would be in the public
interest, with due regard to the interests of the milk
industry, to include provisions with regard to it
in the legislative proposals. He supported Lord
Cranworth’s motion. ©
Viscount Dawson OF PENN said that the Poole
experiment would have been a very valuable one,
but they were obliged to be influenced by the question
of cost. If it was to be such a costly matter he could
see the force of the argument for waiting for a general
measure. ‘But no indication had been given how
long it would be before that general measure came
into operation. There was an overwhelming body of
evidence in every civilised country that pasteurisation
was an efficient means of preventing the continuance
of certain infectious diseases. The mortality from
tuberculosis had declined, but there had not been so
much improvement in regard to the bovine type of
infection as in regard to the human form of infection.
Lord Cranworth’s motion was carried.
NOTES ON CURRENT TOPICS
In the House of Lords on April 22nd the Hydrogen
Cyanide (Fumigation) Bill passed through Committee.
The Lords amendments to the Education (Deaf
Children) Bill were agreed to in the House of
Commons on April 21st. On April 22nd, in the House
of Commons, the Special Areas (Amendment) Bill
passed through Committee.
In the House of Lords on April 27th the Special
Areas Bill, which was read the third time in the
House of Commons on April 26th, was read a first
time. .
In the House of Lords on April 27th Lord
STRATHCONA AND MounT ROYAL moved the second
reading of the Maternity Services (Scotland) Bill.
The Bill was read a second time.
The Edinburgh Royal Maternity and Simpson
Memorial Hospital Order Confirmation Bill was read
the third time in the House of Commons on April 26th.
PARLIAMENTARY INTELLIGENCE
` coming into operation of the scheme.
[may 1, 1937
Consideration of the Widows’, Orphans’, and Old
Age Contributory Pensions (Voluntary Contributors)
Bill was concluded by the Standing Committee of the
House of Commons on April 27th. Sir KINGSLEY
Woop, Minister of Health, announced that on the
third reading in the House of Commons he would
make a statement with regard to the date of the
The Bill was
ordered to be reported, with amendments, to the
House of Commons.
QUESTION TIME
WEDNESDAY, APRIL 21st
Medical Reports on Gaol Conditions in Kenya-
Mr. Day: asked the Secretary of State for the Colonies
whether he would give particulars of any recent reports
on gaol conditions that he had received from the local
medical authorities in Nairobi, Kenya, and the number
of deaths from tuberculosis that had been recorded at ther
Nairobi prison for each of the last three years; and what
steps it was proposed to take to further improve existing
conditions.—Mr. ORMSBY-GORE replied: I have received
no reports from the medical authorities in Kenya relating
specifically to gaol conditions in the Colony. The annual
reports of the Prisons Department for the years 1933,
1934, and 1935 indicate that the total deaths in the
Nairobi prison during those years were 12, 31, and 22
respectively, of which more than half were due to pneu-
monia. No deaths were due to tuberculosis. A separate
ward for the hospital treatment of patients with this
disease was constructed in 1933.
Mr. Day: Does the report show that the conditions in
this gaol are considerably worse than they are in other
Colonial prisons ?—Mr. ORMsBY-GoRE: No, Sir.
Hillingdon Hospital and Omnibus Services
Mr. Day asked the Minister of Transport whether he
was aware that there was no omnibus service from the
terminus at Hillingdon Church to the Hillingdon County
Hospital, Middlesex, which necessitated out-patients
attending this hospital daily walking long distances,
and caused many of them to rest by the wayside or collapse
on arrival at the hospital ; and if he would make representa-
tions to the omnibus authorities serving this district, asking
them to continue the omnibus service to this hospital
during certain hours.—Mr. HoRrE-BELISHA replied: The
Board have informed the councils concerned that they are
prepared to make application for a route between Uxbridge
and West Drayton passing the hospital as soon as the
roads are suitable for omnibus operation.
THURSDAY, APRIL 22ND
Irish Casual Labour and Insurance Payments
Captain MoEWEN asked the Minister of Labour whether
he was aware that in the case of casual labour from the
Irish Free State contributions to the national health and
unemployment insurance funds were demanded from
employers; and, seeing that in most cases the labourer
did not remain in this country for as long as the statutory
six months which would enable him to qualify for benefit,
would he take steps to alter this position.—Mr. ERNEST
Brown replied: Under the general scheme of unemploy-
ment insurance joint contributions are payable in respect
of all persons employed in insurable employment in Great
Britain. Under the agricultural scheme persons not
domiciled in and ordinarily resident outside the United
Kingdom are excluded from unemployment insurance.
Their employers are, however, required to pay employers’
contributions in order to avoid a special inducement to
employ such persons. In the case of health and pensions
insurance, there is an arrangement whereby contributions
paid in respect of employment in Great Britain count for
benefit in the Irish Free State.
Coroners and Post-mortem Examinations
Mr. Wixson asked the Home Secretary whether he could
state for the last available year and for other than county
boroughs the number of post-mortem examinations
directed or requested by coroners; and in how many of
these cases the examination took place in hospitals, in
4
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PARLIAMENTARY INTELLIGENCE
[may 1, 1937 1085 l
mortuary premises, and in other places, respectively, —
Sir Jonn Smon replied: Excluding the City of London,
. the County of London, and county boroughs forming com-
plete coroners’ districts, the figure for 1936 was 10,274.
I have no information which would enable me to answer
the second part of the question.
Mr. Wuson : Is the right hon. gentleman aware that
on a recent occasion there was no fit place for a post-
mortem examination and that it was held on the village
green.—Sir J. Smon: I do not know that,
Magistrates and the Birching of Boys
Mr. SHort asked the Home Secretary if he was aware
that nine boys were ordered to be birched by justices
in the West Riding juvenile court, Doncaster, on April 7th ;
whether the sentences had been carried out; and whether,
seeing that a committee was being appointed to consider
the question of birching, he proposed to advise magistrates
and others not to order birching between now and the
committee reporting.—Sir JoHN Srmon replied: Yes,
Sir, nine boys were ordered on April 7th to receive three
strokes of the birch. Eight were birched on that day ;
a medical officer certified that the ninth was unfit for the
punishment. As it must be widely known that I have
decided to appoint a committee to consider the question,
I do not think that further action on my part is required.
Mr. SHort: Will the right hon. gentleman go a little
further than that and advise magistrates not to order
_ such sentences having regard to the fact that a committee
of inquiry is being appointed ?—Sir J. Smmon: I do not
think I can do that. The duty of the committee will be
to ascertain and to advise, and I am hurrying up the
appointment of the committee in every possible way. In
the meantime I am sure that benches of magistrates will
realise that I regard this subject as one which needs
investigation.
Deaths in Armley Gaol, Leeds
Mr. Lunw asked the Home Secretary whether he would
make a statement concerning the death of one man two
days after admission to Armley Gaol, Leeds, as a debtor,
and another, 19 years of age, who had committed suicide
in the gaol during this month; and if he would institute
-an inquiry into the circumstances.—Sir Jonn SIMON
replied: I have already made careful inquiry into both
these cases. The first prisoner was a man of 43 who was
received into Leeds prison on April 2nd. He was examined
on admission by the medical officer and found to be
suffering from valvular disease of the heart. In view
of this it was arranged that he should be given no work
requiring physical exertion. On the night of April 3rd
he died—apparently in his sleep. The law requires that
there shall be an inquest on every death in prison, and the
jury found that death was due to natural causes. There
is no suggestion that anything in his treatment in prison
contributed to his death, and there is nothing the prison
staff could have.done to prevent or to render less likely
this sudden heart failure. The second case was that of
a young man serving a sentence of three months in the
second division. He was examined on his admission
on April 2nd, and there was nothing wrong with him
physically or mentally. His conduct while in prison
was good; he gave no trouble and there was no question
of any disciplinary treatment. On April 12th he was
at work in the morning in association with other prisoners
and there was nothing abnormal in his behaviour. At
about 12.45 he was in his cel] and was seen by the medical
officer in the course of a routine round of the cells. He
was then quite cheerful. At 1.15 the librarian officer
who distributes books to prisoners visited his cell and the
prisoner was then sitting reading. At 1.40 he was found
dead, having hanged himself from the window bars of
his cell, In this case also there was an inquest. There
was nothing the prison staff could have done to prevent
this tragic occurrence and there is no suggestion that
there was anything in the nature of harsh treatment which
might have contributed to this impulsive suicide.
Mr. Lunn: Is the right hon. gentleman aware that
there is some uneasiness in Leeds about these two tragic
events and will the Home Office not call for some further
inquiry into this.matter, as well as other matters in
connexion with our prisons, s0.as to remove the possibility
of such happenings as these'?—Sir J. Smmon: I am not
at all surprised that people in Leeds or elsewhere should
feel anxious about these incidents, and they are deeply
distressing, I need not say that to ‘the Home Office, but I
have given information quite impartially and I hope
very much that with the hon. Member’s help that will
allay public anxiety about these two cases.
Provision of School Canteens
Viscountess Astor asked the President of the Board of
Education whether, in view of the growing realisation
of the importance of nutrition, and particularly of the
fact that children who underwent physical exercises
should be properly fed, he would take measures to ensure
that no new school, whether for juniors or seniors, was
built without provision being made for a canteen.—
Mr. OLIVER STANLEY replied: I have already drawn the
attention of local authorities to the desirability of providing
school canteens at schools where children come from a.
distance, and in the consideration of plans for new senior
schools this point is always borne in mind. I am also
prepared to consider any proposals by local authorities
to make arrangements for school dinners in schools where
children do not come from a distance, but I am not
prepared to require the provision of canteens in all new
senior and junior schools.
Anthropometric Surveys of School-children
Mr. Epe asked the President of the Board of Education
if he would publish the results of the anthropometric
survey made by his officers of the children attending the
Alderman Wraith Secondary School, Spennymoor, County
Durham, the Surbiton County School for Boys, Surrey,
„and the Woking County , School for Girls, Surrey.—
Mr. OLIVER STANLEY replied : I do not think that the
subject is one of sufficient general interest to justify
separate publication of the particulars, but I am having
a copy placed in the Library of the House for hon. Members
who may be interested. Moreover, I understand that the
Board’s chief medical officer proposes to refer to the
matter in his next annual report.
Mortuaries
Mr. WIitson asked the Minister of Health how many
local authorities, other than those of county boroughs,
had provided mortuaries as empowered by Section 143
of the Public Health Act of 1875; and how many had not
made any such provision.—Sir KinastEy Woop replied :
I have no complete information on this subject, but since
April Ist, 1920, loans have been sanctioned by my depart-
ment for the provision of mortuaries by 63 local authorities
other than county boroughs.
Maternal Mortality Reports
Mrs. TATE asked the Minister of Health when the report
on the ‘special investigations into maternal mortality
made by his officers in various parts of the country would
be available.—Sir KinastEy Woop replied: I hope
to lay this report before the House in the course of the
next few days.
Infantile Mortality
Mr. THORNE: Has the Minister any reasons why there
is such a very low infantile mortality in Letchworth ?—
Sir K. Woop: Letchworth is a very small unit, the total
births being about 200 or less each year. During the
past few years the infantile mortality-rate has been
17-62 per 1000 live births.
Mr. THORNE asked the Minister of Health the rate of
infant mortality in the city of Letchworth ; and if he can
say what is the average infantile mortality for England
Wales, and Scotland.—Sir Kinastey Woop replied :
For 1935, the last year for which separate figures are as
yet available, the mortality-rates of infants under one
year of age per thousand live births were: Letchworth
U.D., 17; England, 56; Wales (including Monmouth),
63. With regard to Scotland, the hon. Member should
address an inquiry to my right hon. friend, the rary
of State.
1086 THE Lincar
PARLIAMENTARY INTELLIGENCE
[may 1, 1937
‘Hospital Facilities in Newfoundland
Mr. BROOKE asked the Secretary of State for Dominion
Affairs whether any steps were being taken to remedy
the lack of hospital facilities in Newfoundland which was
shown in the report of the Department of Health and
Welfare; and whether any measures are contemplated
to combat the high rate of infant mortality and the
prevalence of tuberculosis.—Lord Harrineton, Parlia-
mentary Secretary for Dominion Office, replied: The
measures now in progress for the improvement of the
hospital facilities in Newfoundland, including the enlarge-
ment of certain hospitals at St. John’s and the completion
of a chain of Cottage Hospitals outside the capital, were
summarised in chapter iv of the annual report of the
Commission of Government for 1936, Cmd. 5425. My
right hon. friend has recently received from the Governor
detailed proposals for the extension of the Tuberculosis
Sanatorium, and a special survey of tuberculosis conditions
is in progress. Consideration is also being given to the
establishment in outpost districts of prenatal clinics
and child welfare services corresponding to those in
operation at St. John’s, I may add that special attention
will be given to the improvement of medical and health
facilities in the formulation of the long-term programme
of economic reconstruction which is now under
consideration.
Mr. PETHERICK : Is it not the case that a considerable
number of additional medical officers have been appointed ?
—No further answer was given.
MONDAY, APRIL 26TH
Medical Practitioners and Health Insurance
Mr. Rays Daves asked the Minister of Health whether
he was now able to state the terms of reference and the
personnel of the tribunal to inquire into the fees paid to
panel doctors under the national health insurance scheme.—
Mr. Hopson, Parliamentary Secretary to the Ministry
of Health, replied: No, Sir. The arrangements for the
inquiry are not quite complete, but I will inform the hon.
Member as soon as they are settled.
TUESDAY, APRIL 27TH
The Army and Blood Transfusions
Mr. WAKEFIELD asked the Secretary of State for War
what supplies, if any, were available of human blood
suitable for transfusion, grouped and _ bacteriologically
tested, for large-scale emergency treatment.—Mr. DUFF
COOPER replied: The Army policy is not to store blood
for large-scale transfusion, as the period for which this
can be done is very limited. Each military formation has
a number of donors grouped and tested who are available
for this service.
Mr. WAKEFIELD asked if the right hon. gentleman was
aware that in Russia large stores of human blood were
available and had been used very successfully in cases of
emergency.—Mr. Durr Coorer said that there were
reports to that effect, but it was more satisfactory to store
our blood in our people.—Mr. Murr: May I ask if it is
blue blood ?
The Causes of Silicosis
Mr. Tom SmitH asked the Secretary for Mines if he had
any information concerning discussions relative to silicosis
and its causes mentioned recently by the President of the
Institute of Mining and Metallurgy.—Captain CROOK-
SHANK replied: I have not yet seen a full report of the
President’s speech last Thursday, but I understand that
it referred particularly to the progress of research into
methods of collecting samples of dust from the air breathed
by mineworkers, and of examining and analysing such
samples. My Department is closely in touch with this
work through its technical officers.
Family Incomes and the Means Test
Mr. OLIVER asked the Minister of Labour whether his
attention had been drawn to the hardships caused by the
inclusion, for the purpose of calculating family incomes in
respect of the means test, of lump sums paid to injured
workmen by way of compensation under the Workmen's
Compensation Act; and whether, in view of the fact
that these commutated sums represented the loss of
earning capacity, both present and future, of injured
workmen, and were not savings or interest on invest-
ments, he would consider discontinuing assessing these
settlements for the purposes of relief `of unemployment
existing in the households of these workmen.—-Lieut.-
Colonel MurrHeaDd replied: I would remind the hon.
Member that the special nature of these lump sum pay-
ments has already been recognised by the Board so that
one-half is treated as required for the special needs or
personal requirements of the holder. If the holder is
other than the applicant or the applicant’s husband, wife,
father, or mother, the balance is taken into account only
in so far as the actual income derived from it, together
with any other available resources, exceeds the amount of
the scale rates of the holder and his dependants. In other
cases the balance of one-half is regarded as producing an
income of ls. per week for each £25 in excess of the
first £25,
Day and Night Nursery at Bristol
Mrs. TATE asked the Minister of Health (1) whether
the Bristol Council proposed that one member of the staff
of the Bristol day and night nursery in Ashley-road,
Bristol, should be a trained nurse; (2) what steps the
Bristol Council were taking to ensure that fuller medical
records should be kept at the Bristol day and night
nursery ; and (3) whether arrangements had now been
made by the Bristol Council for systematic medical inspec-
tion of children in the Bristol day and night nursery.—
Sir J. BLUNDELL, Lord of the Treasury, replied: My
right hon. friend is in communication with the Bristol
City Council regarding the three matters referred to and
will inform my hon. friend of the result.
School-children and Tuberculosis
Mr. Groves asked the Minister of Health how many
cases of tuberculosis had been notified among school-
children during the last year for which the figures were
available, in Chesterfield and in Sheffield, respectively.—
Sir KinasLEy Woop replied: 394 fresh cases of tubercu-
losis were notified among children between the ages of
5 and 15 in Sheffield in 1936, and 7 were notified among
children between the same ages in Chesterfield in 1935, the
last year for which figures are at present available for
that borough.
INFECTIOUS DISEASE
IN ENGLAND AND WALES DURING THE WEEK ENDED
APRIL 17TH, 1937
_Notifications—The following cases of infectious
disease were notified during the week: Small-pox, 0;
scarlet fever, 1678; diphtheria, 1019; enteric fever,
25 3 pneumonia (primary or influenzal), 1159;
puerperal fever, 33 ; puerperal pyrexia, 137 ;'` cerebro-
spinal fever, 24; acute poliomyelitis, 8; acute polio-
encephalitis, 0 ; encephalitis lethargica, 6 ; dysentery,
18 ; ophthalmia neonatorum, 106. 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 April 23rd was 3196 which included: Scarlet
fever, 853; diphtheria, 904; measles, 39; whooping-cough,
512; puerperal fever, 18 mothers (plus 14 babies); encephalitis
lethargica, 284; poliomyelitis, 1. At St. Margaret’s Hospital
there were 19 babies (plus 5 mothers) with ophthalmia
neonatorum.
Deaths.—In 123 great towns, including London,
there was no death from small-pox or from enteric
fever, 13 (0) from measles, 3 (0) from scarlet fever,
24 (5) from whooping-cough, 26 (3) from diphtheria,
53 (14) from diarrhoea and enteritis under two years, `
and 73 (10) from influenza. The figures in parentheses
are those for London itself. :
Greater London had one death from enteric fever.
deaths from measles were reported from B i
4 deaths from whooping-cough from Manchester.
also 3 deaths from diphtheria at Birmingham.
The number of stillbirths notified during the week
was 299 (corresponding to a rate of 42 per 1000
total births), including 46 in London.
Eight
ham and
There were
THE LANCET] |
[may l, 1937 1087
MEDICAL NEWS
University of Oxford
The electors to the Nuffield professorship of obstetrics
and gynecology at Oxford announce the appointment of
John Chassar Moir to the post, duties to start on Oct. lst.
Dr. Moir is 37 years of age and was educated at Montrose
Academy and Edinburgh University. He graduated in 1922,
and in 1930 gained the M.D. degree, his thesis on an obstetrical
subject being awarded a gold medal. He is a fellow of the
Royal College of Surgeons of Edinburgh and a fellow of the
British College of Obstetricians and Gynecologists. After
some years’ experience of general practice and of general
surgery Dr. Moir devoted himself to gyneecology and obstetrics.
He studied in Vienna and Berlin and later (having been awarded
a Rockefeller travelling fellowship) in Johns Hopkins Hospital
and other American clinics. In 1930, he became full-time
assistant to the obstetrical unit at University College Hospital,
London, and, in 1935, was appointed reader in obstetrics and
gynæcology in the University of London, holding office at the
new British Postgraduate Medical School. Dr. Moir is known for
his clinical research, especially for his studies of the muscular
activity of the human pregnant and non-pregnant uterus.
This work led to the discovery of a new active principle in ergot,
and in a later combined investigation with the late H. W.
Dudley, F.R.S., the substance responsible for the traditional
clinical activity of this drug was isolated and identified as a
new alkaloiu, now known as ergometrine.
University of Cambridge
On Monday, May 10th, at 5 p.m., Prof. A. V. Hill, F.R.S.,
will deliver the Linacre lecture. His subject will be the
heat-production of muscle and nerve.
University of Glasgow
On April 24th the following degrees were conferred :—
M.D.—Annie R. Chalmers, D.-K. M. Chalmers, *Edgar
Cochrane, J. A. M. Hall, D. W. Hendry, and William Telfer
(with commendation); S. M. Laird, *J. S. McNair.
*In absentia.
M.B., Ch.B.—R. B. Wright (with honours); I. C. Wilson
(with commendation); M. O. Alakija, I. A. M. Beaton, William
Begg, S. A. Bond, J. M. Brown, Robert Browning, Bernard
Camber, Annie Cameron, D. A. Cannon, Harold Carnovsky,
John Cassells, W. J. Christie, Isabel S. Craig, William Cross,
J. M. Cuthbert, A. L. Dick, Alexander Donald, Muriel F. Frew,
C. R. George, W. E. Gifford, A. M. Gilchrist, D. R. Gorrie,
J. D. P. Graham, R. F. Hand, Calman Hecht, Violet M. M.
Howat, Mary M. C. V. Howie, J. B. Hurll, Alexander Jack,
M. I. Krischer, O. P. D. Lawson, J. C. Liddle, B. D. Ling, John
Loudon, J. M. McBride, A. H. McDougall, J. C. MacIntosh,
W. W. W. McNeish, A. M. Maiden, W. W. Millen, W. N. Miller,
D. N. B. Morrison, Kenneth Murray, W. G. Oman, J. R. Preston,
P. A. Rodger, D. G. Russell, Joseph Shapiro, Reynard Smith,
A. N. Stirling, Isidor Stoll, Irma M. A. Thomson, J. D. Uytman,
J. Y. Walker, Alexandra C. Watson, and D. C. Wiseman.
Royal Faculty of Physicians and Surgeons of
Glasgow.
At a meeting of the Faculty held on April 5th, with
Prof. Archibald Young, the president, in the chair, the
following were admitted to the fellowship :—
Andrew Girdwood Fergusson and Thomas Landles Gordon
Glasgow), Donald Valsler Marshall (Hull), and Arthur Maclennan
utherland (Glasgow). °
British College of Obstetricians and Gynecologists
A meeting of the council of the College was held on
April 24th, with Sir Ewen Maclean, the president, in
the chair. The following were formally admitted to the
fellowship :—
O’Donel Thornley Dodwell Browne (Dublin), James Robertson
Campbell Canney (Cambridge), Robert He Joseph Mulhall
Corbet (Dublin), *Thomas_ frederick Corkill (Wellington,
New Zealand), *Herculano Diogo De Sa (Bombay), Charlotte
Anne tn tas (Edinburgh), Henry Harvey Evers (Newcastle-
upon I e), Arthur Oliver Gray (London), Sidney Blashill
erd (Liverpool), *Charlotte Leighton Houlton (Delhi), Andrew
Carey Mc ter and William McKim Herbert McCullagh
London), *George Henry Mahony (Patna), Percy Malpas
Liverpool), *Mangaldas Mehta (Bombay), Douglas Miller
Edinburgh), *Cyril MacDonald Plumptre (Madras), Frederick
Roques (London), Harold Harley Seymour (Hove), Harry
Leslie Shepherd (Bristol), John Eric Stacey (Sheffield), and
*Brian Herbert Swift (Adelaide).
The following were admitted to the membership :—
G. S. Adam, *R. F. W. K. Allen, Doris C. Bates, *F. A.
Bellingham, Margaret G. Bott, *Edith M. Brown, H. H. Caple,
William Clement, D. I. Finlayson, W. F. Flint, U. P. Gupta,
Wiliam Hunter, C. W. A. Kimbell, W. A. Liston, Barbara M.
Macewen, Margaret M. McDowall, K. A. McGarrity, Gerald
Maizels, *Gladys H. Marchant, C. F. Marks, H. S. Morton,
B. C. Murless, Louis Ricb, C. E. B. Rickards, G. W. Robson,
J. M. Sanson, J.W. Schabort, C. P. Scott, *Lydia 1. H. Torrance,
and William Waddell.
* In absentia.
At the annual general meeting which followed Dr. J. P.
Hedley, Prof. E. F. Murray, Prof. Gilbert Strachan, Prof.
annually at the school.
Wiliam Gough, and Dr. D. G. Madill were elected to the
, council as representatives of the fellows, and Dr. J. W. G. H.
Riddell, Mr. John Sturrock, and Dr. A. W. Spain as
representatives of the members. l
King’s College Hospital
The Listerian Society -of this hospital will meet there
on Wednesday, May 5th, at 8.15 P.M., when Prof. Charles
Singer will speak on medicine in early England.
London School of Hygiene and Tropical Medicine
One Fishmongers’ Company studentship is awarded
It carries remission of fees for
the D.P.H. course. Applications to compete for the-
studentship must be sent to the secretary of the school,
Keppel-street, W.C.1, by June 14th. The examination
will be held on June 22nd and 23rd.
Glasgow University Club, London
This club will dine at the Trocadero Restaurant, London,
W., on Friday, 28th May, at 7.30 Pp.m., when the principal
_of the University, Sir Hector Hetherington, will be in the
chair. The Earl of Derby will be the guest of the chair-
man. The hon. secretaries may be addressed at 62, Harley-
house, London, N.W.1.
College of Physicians and Surgeons of Bombay
At a meeting held in January the council of the college —
decided to institute an examination for a diploma in
ophthalmic medicine and surgery and appointed a com-
mittee to draw up regulations and a syllabus. On
March 12th the report of this committee was adopted,
and the first examination for the diploma will be held
in July. Copies of the regulations may be had from the
secretary of the college.
The Factories Bill
The council of the Save the, Children Fund, while
welcoming the Factories Bill now before Parliament, has
passed a resolution urging its amendment so as to ensure
that no child shall be employed in a factory before the age
of 15; that no child or young person shall be permitted
to work more than 40 hours a week; that no overtime be
permitted for workers under 18 years of age ; that holidays
with pay be assured to all children and young persons ;
that the hour of leaving work may be sufficiently early
to enable children and young persons to take advantage
of available opportunities for education and recreation ;
and that the clause providing that the Home Secretary
may suspend Part II of the Bill (dealing with safety)
until 1940 be eliminated.
London County Council
A meeting of the Council on April 27th received
proposals for a new antitoxin establishment at a
site which is available at Queen Mary’s Hospital,
Carshalton. The accommodation at the existing anti-
toxin establishment, at Belmont, Sutton, is still inadequate
despite the alterations and additions which have been
carried out from time to time, and twice the existing
space is required. The proposed new establishment,
which will cost about £116,000, will ensure a constant
and ample supply for the Council’s hospitals of products
which are made at Belmont and also of others which are
now being purchased. There will also be extra facilities
for research work. The laboratories at Belmont will
be retained for work which can conveniently be carried
out there,
Other improvements which are to be carried out at
the Council’s hospitals include the construction of two
new isolation blocks, each containing 60 single-bed wards,
at the Southern Hospital. A new nurses’ home will also
be provided and the existing accommodation for the
nursing staff will be altered. The total estimated cost of
these extensions is about £91,300. A new sanitary annexe
is to be provided at St. George-in-the-East Hospital, and
the sanitary annexes at Archway Hospital are to be
remodelled and extended. A new operating theatre is to
be added at St. Charles’ Hospital at a cost of about £9000.
Dame Janet Campbell has been appointed a member of
the hospitals and medical services committee of the
Council.
1088 THE LANCET]
Soran Research Fellowship in Medical Science,
The Board of the Faculty of Medicine at Oxford will
make an election to the above Fellowship in June, 1937,
if a candidate of sufficient merit presents himself. The
fellowship, which will be of the value of £300, will be
tenable for one year from Oct. lst, 1937, in any medical
department or institute at Oxford, under such regula-
tions as the Board may approve. Candidates must be
graduate members of the University, holding a registrable
medical qualification, and must be under thirty-five years
of age on Oct. lst, 1937. Candidates must submit their
applications to the dean of the medical school, University
Museum, not later than Monday, May 3rd, 1937. Each
candidate must submit: (1) evidence of age; (2) testi-
monials (three copies) or names of referees ; (3) a statement
of his career ; (4) a statement of the department of medical
science in which he proposes to research.
The British Social Hygiene Council
There is a real need for further subscriptions to the
British Social Hygiene Council if its valuable work is to
be continued in its present practical way. The B.B.C.
will consequently afford the Council an opportunity of
making a public appeal. This will be done on Sunday,
May 2nd at 8.45 P.M., Prof. John Hilton making the
appeal. In a second direction the Council is seeking
public support by holding an Empire Ball on July 6th.
The Ball will take place at Grosvenor House and an
important number of patrons have already been secured.
There will be a cabaret and various competitions for
prizes; the tickets for the Ball are £2 2s. each, or £10 10s.
for six, and it is hoped that visitors from overseas will
support the entertainment. The tickets are obtainable
from Grosvenor House, Park lane, The Ball Committee,
Carteret House, Carteret-street, Westminster, S.W.1,
and the Over-Seas League, Park-place, St. James’s, 8S.W.1,
| Incorporated Society of Chiropodists
The annual dinner was held at the Trocadero, London,
on April 24th. The toast of the medical profession was
proposed by Mr. Charles Doughty, K.C. Sir Frederick
Menzies, F.R.C.P., in response, said that medical science
was developing more and more in the direction of team
work, one of the remarkable developments was the forma-
tion of groups of non-medical workers, without whom the
efficient work of a hospital could not be done; radio-
graphers, dieticians, electric therapists, masseurs, and
so on. One of these days the work in which chiropodists
were engaged must also become an essential unit of any
hospital service. Thousands of people were going about
the country suffering acutely from conditions of the feet
which could be remedied by chiropodists who had an
enormous sphere of work. So long as the members of the
Incorporated Society of Chiropodists rigidly adhered to
the high standards they had set themselves, they were
bound to succeed in their aims. He looked to the greatest
possible coöperation between them and the medical
profession in the interests of the community. Mr. A.
Simpson-Smith, F.R.C.S., proposed the toast of ‘“‘ this
“most progressive society.” Chiropody, he said, was
assuming greater importance year by year and had long
eclipsed the mere cure of the corn. Chiropody was rapidly
becoming of national importance, particularly as every
week something like 135 people were killed and 5000
injured on the road largely through not being quick enough
on their feet. He foresaw that in the national scheme
of physical fitness, that is about to be launched, there would
be proper provision for the many C3 feet which were the
increasing outcome of arduous occupations in industry.
One could not have an Al nation with C3 feet. Mr. John H.
Hanby, F.I.S.Ch., responded from the chair. They had,
he said, recently secured the coöperation of the Royal
College of Surgeons with regard to their examinations,
and had every hope that the Royal College of Physicians
would codperate in a similar manner by confirming a
recommendation made by a joint committee of both
colleges, thus strengthening the confidence which had been
placed in them both collectively and individually by
various public bodies such as general hospitals and
infirmaries, where so large a number of their members held
appointments. Certain authorities, hospitals and other
MEDICAL NEWS
[may l, 1937
institutions throughout the country had realised the
importance of chiropodial treatment, and last year 120,000.
treatments were given in the five foot hospitals with
which the society was associated. But all these were
merely touching the fringe of this vital problem. The
only way of dealing adequately with this important
question was to make chiropody available as a panel
benefit under the National Health Insurance, thus giving
15,000,000 people the opportunity to improve their
general physical condition. |
' Royal Society of Medicine
This society’s house and library will be closed from
Wednesday, May 12th, to Tuesday, May 18th, both days
inclusive.
International Congress on Occupational Diseases
and Industrial Welfare
The Journées Internationales de Pathologie et d’Organisa-
tion du Travail will be held in Paris from June Ist to 6th
under the presidency of V. Balthazard, professor of
forensic medicine in the University of Paris. Further
information may be had from the secretary-general of the
congress, Dr. G. Hausser, Institute Médico-Légal, Place
Mazas, Paris XII.
Travelling Fellowships in Medicine
The Medical Research Council invite applications for
six Rockefeller medical fellowships for the academic year
1937-38. These are provided from a fund with which the
council have been entrusted by the Rockefeller Founda-
tion of New York. They are intended for British graduates
who have had some training in research work in clinical
medicine or surgery, or in some other branch of medical
science, and who are likely to profit by a period of work
at a centre in the United States or elsewhere abroad,
before taking up positions for higher teaching or research
in the United Kingdom. The stipend will ordinarily be
at the rate of £400 per annum for a single fellow, and of
£450 per annum for a married fellow.. Travelling expenses
and some other allowances will be paid in addition.
The Council also invite applications for four Dorothy
Temple Cross research fellowships in tuberculosis. The
_ object of these fellowships is to give special opportunities
for study or research to suitably qualified British subjects
of either sex ‘‘intending to devote .themselves to the
advancement by teaching or research of curative or
preventive treatment of tuberculosis in all or any of its
forms.” The stipend will ordinarily be fixed at the rate
of £400 per annum, with travelling expenses in addition.
Applications for these fellowships must be sent to the
Council not later than June Ist. Further particulars may
be had from the secretary of the Council, 38, Old Queen
street, London, S.W.1.
Fellowship of Medicine and Post-Graduate Medical
Association |
The following courses will be given during May and early
June: dermatology at St. John’s Hospital (afternoons,
May 3rd to 29th); thoracic surgery at the Brompton
Hospital (all-day, May 24th to 29th); urology at
St. Peter’s Hospital (all-day, May 3lst to June 12th);
gynecology at the Chelsea Hospital for Women (June 14th
to 26th). Week-end courses will be held in chest diseases
at the Brompton Hospital (May 8th and 9th); in physical
medicine at the St. John Clinic and Institute of Physical
Medicine (May 22nd and 23rd); in children’s diseases
at the Princess Elizabeth of York Hospital (May 29th and
30th) ; in general medicine at the Prince of Wales Hospital
(June 5th and 6th); in obstetrics at the City of London
Maternity Hospital (June 12th and 13th). During June, for
M.R.C.P. candidates, there will be a clinical and patho-
logical course at the National Temperance Hospital (8 P.m.,
Tuesdays and Thursdays, June Ist to 17th); a course in
chest diseases at the Brompton Hospital (twice weekly,
5 P.M., June 7th to July 3rd); a course in heart and lung
diseases at the Victoria Park Hospital (Wednesdays and
Fridays, 6 P.m., June 9th to July 3rd); and an afternoon
course in neurology at the West End Hospital for Nervous
Diseases (June 21st to July 3rd). The annual dinner-dance
of the fellowship will take place at Claridge’s Hotel on
Friday, May 28th; tickets can be obtained from the
secretary of the fellowship at 1, Wimpole-street, London,
W.1, by any member of the medical profession,
THE LANCET]
3 Medi cal Diary
Information to be included in this column should reach us
én 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.
TUESDAY, May 4th.
Orthopaedics. 5.30 P.M. (Cases at 4.30 P.M.) Annual
General Meeting. Mr. L. H. F. Walton: 1. Congenital
Deformity of the Hip. 2. Lumbar Scoliosis; case
for diagnosis.
WEDNESDAY.
Surgery. 5.30 P.M. Annual General Meeting.
THURSDAY.
History of Medicine. 5 P.M. Annual General Meeting.
Prof. Bernard Ashmole: The Monster in Greek Art.
(Illustrated by lantern slides.)
FRIDAY.
Otology. 10.30 A.M. (Cases at 9.30 A.M.) Annual General
Meeting. Dr. Le Mée (Paris), Dr. Ritchie Rodger,
Mr. Stirk Adams, Dr. J. H. Ebbs, Mr. C. E. Scott,
and Mr. R. B. Lumsden: Otitis Media in Early
Childhood. :
Laryngology. 5 P.M. (Cases at 4.30 P.M.) Annual General
Meeting. Prof. Hugh Cairns: Injuries of the Frontal
and Ethmoidal Sinuses, producing Cerebro-spinal
Rhinorrhea. Mr. V. E. Negus: Short Paper and
Demonstration of Anatomical Specimens. 4 P.M.
Dr. Le Mée: Fulminating Laryngo-tracheo-bronchitis.
(Film.) Ten Minutes in the Bronchoscopic Clinic at
Philadelphia. (Colour film.)
PADDINGTON MEDICAL SOCIETY.
TUESDAY, May 4th.—9 p.m. (Town Hall, Paddington-
green, W.), Dr. G. F. McCleary: The Threatened
Depopulation of the British Commonwealth.
LONDON JEWISH HOSPITAL MEDICAL SOCIETY,
Stepney-green, E.
THURSDAY, May 6th.—3.15 P.M., Dr. D. T. Davies, Prof.
G. Grey Turner, and Dr. H. Graham Hodgson : Modern
ee on the Diagnosis and Treatment of Gastric
cer.
LECTURES, ADDRESSES, DEMONSTRATIONS, &c.
UNIVERSITY OF LONDON. :
MONDAY, May 3rd, TUESDAY, and THURSDAY.—5 P.M.
(University College, Gower-street, W.C.), Prof. H.
Rein: Some HKconomising Mechanisms as a Condition
of the Body’s Adaptation to Increased Activity.
UNIVERSITY OF BIRMINGHAM.
THURSDAY, May 6th.—4 P.M., Prof. J. C. Drummond,
D.Sc.: The D Vitamins and other Members of the
Fat-soluble Group. (William Withering lecture.)
EMPIRE CONFERENCE ON CARE AND AFTER-CARE
OF THE TUBERCULOUS. .
MONDAY, May 3rd.—10.30 A.M. (Overseas House,
St. James’s), Sir Kingsley Wood. Sir Arthur MacNalty :
The Modern Outlook on Tuberculosis. Major-General
Sir Cuthbert Sprawson: Peculiarities of the Tuber-
culosis Problem in India. Dr. R. E. Wodehouse
(Ottawa), and Dr. B. A. Dormer (S. Africa) will
also speak. 2.30 P.M., Dr. A. D. Pringle: The Care
and After-care of the Tuberculous among (a) the
European Mining Population of the Rand, (bò) the
European Non-mining Population of the Transvaal
and Natal. Dr. S. Vere Pearson and Dr. F. R. G.
Heaf : Tuberculosis and City Environment.
Sir Pendrill Varrier-Jones: Environmental Factors
in Care and After-care.
TUESDAY.—10.30 A.M., Dr. D. A. Powell: The Fight
against Tuberculosis throughout the Empire: Wales.
Sir Henry Gauvain; Some Problems of Surgical
Tuberculosis. Dr. L. S. T. Burrell: The Function of
the Hospital in the Tuberculosis Problem. Dr. A. J.
Collins (Australia) and Dr. R. J. Collins enata)
will also speak. 2.30 P.M., Dr. Ernest Watt, Ishbe
Marchioness of Aberdeen and Temair, and Miss Gloria
Langmaid (Canada) will speak. Dr. j. B. McDougall:
The Re-Settlement of the Tuberculous ex-Soldier.
Mr. Douglas M. Deane (Angorichina) and Dr. G.
Lissant Cox will also speak.
WEDNESDAY.— 10.30 A.M., Dr. Charles Wilcocks
(Tanganyika): Tuberculosis in East Africa. Dr.
P. V. Benjamin (South India) and Mr. Norman M.
Maclennan (Palestine) will also speak. 2.30 P.M.,
Dr. Pringle: Tuberculosis in the Natives of
respect to Care and After-care.
Dr. J. Cauchi (Nigeria): Tuberculosis in West Africa.
Dr. G. M. C. Powell (Northern Rhodesia) and Dr.
R. B. MacGregor (Straits Settlements) will also speak.
ST. MARY’S HOSPITAL, W.
South Africa with
TUESDAY, May 4th.—5 P.M. (Institute of Pathology),
Dr. F. M. R. Walshe: Some General Principles in
Neurological Diagnosis.
Bae POSTGRADUATE MEDICAL SCHOOL, Ducane-
road, ° z
MONDAY, May 3rd.—2.30 P.M., Dr. C. W. Buckley : Arthritis.
WEDNESDAY —Noon, clinical and pathological conference
(medical). 2 P.M., Mr. E. J. King, Ph.D.: Acid-base
Metabolism. 3 P.M., clinical and pathological con-
ference (surgical). 4 P.M., Mr. J. E. H. Roberts:
MEDICAL DIABRY.—VACANCIES
1089
Surgery of the Chest. 4.30 P.M., Dr. W. E. Gye:
Experimental Cancer Research.
THURSDAY.—2.15 P.M., Dr. Duncan White: Radiological
Demonstration. 3.30 P.M., Mr. A. K. Henry: Demon-
strations of the Cadaver of Surgical Exposures.
3.30 P.M., Mr. Aleck Bourne: Salpingitis.
FRIDAY.—2 P.M., operative, obstetrics. 3 P.M., clinical
and pathological conference (obstetrics and secology).
Daily, 10 a.M. to 4 P.M., medical clinics, surgical clinics,
and operations, obstetrical and gynecological clinics
rere operations. Refresher course for general prac-
oners.
WEST LONDON HOSPITAL POST-GRADUATE COLLEGE,
Hammersmith, W.
MONDAY, May 3rd.—10 a.m., Dr. Post: X Ray Film
Demonstration, skin clinic. 11 A.M., surgical wards.
2 P.M., operations, surgical and gynecological wards,
medical, surgical, and gynecological clinics. 4.15 P.M.,
Dr. Archer: Biochemical Demonstration. ,
TUESDAY.—10 A.M., medical wards. 11 a.M., surgical
wards. 2 P.M., operations, medical, surgical, and
throat clinics.
WEDNESDAY.—10 a.M., children’s ward and clinic. 11 A.M.,
medical wards. 2 P.M., a rmupeclouteet operations,
medical, surgical, and eye clinics. l
THURSDAY.—10 A.M., neurological and gynæcological
clinics. Noon, fracture clinic. 2 P.M., operations,
medical, surgical, genito-urinary, and eye clinics.
FRIDAY.—10 a.M., medical wards, skin clinic. Noon,
lecture on treatment. 2 P.M., operations, medical,
surgical, and throat clinics. 4.15 P.M., Dr. Archer :
Biochemical Demonstration.
SATURDAY.—10 A.M., children’s and surgical clinics. 11 A.M.,
medical wards. ,
The lectures at 4.15 P.M. are open to all medical prac-
titioners without fee.
FELLOWSHIP OF MEDICINE AND POST-GRADUATE
MEDICAL ASSOCIATION, 1, Wimpole-street, W. '
MONDAY, May 3rd, to SUNDAY, May 9th.—MAUDSLEY
HOSPITAL, Denmark-hill, S.E., afternoon course in
sychological medicine—ST. JOHN’S HOSPITAL, 5,
isle-street, W.C., afternoon course in dermatology
(open to non-members).—BROMPTON HOSPITAL, S.W.,
Sat. and Sun., course in chest diseases.—Unless
otherwise stated, courses arranged by the fellowship
are open only to members.
HO TTAR FOR SICK CHILDREN, Great Ormond-street,
THURSDAY, May 6th.—2 P.M., Dr. Wilfred Pearson :
Nephritis. 3 P.M., Mr. Denis Browne: Treatment of
Empyema.
Outpatient clinics daily at 10 a.M. and ward visits at
P.M.
ay a SCHOOL OF DERMATOLOGY, 5, Lisle-street,
MONDAY, May 3rd.—5 P.M, Dr. M. Sydney Thomson:
Animal Diseases Communicable. to Man.
Diseases of the Nails.
Ringworm
[may 1, 1987
TUESDAY.—5 P.M., Dr. H. Corsi:
THURSDAY.—5 P.M., Dr. J. M. H. MacLeod:
Infections.
FRIDAY.—5 P.M., Dr. W. K. Sibley: Alopecia.
MANCHESTER ROYAL INFIRMARY.
TUESDAY, May 4th.—4.15 P.M., Dr. A. Hillyard Holmes:
Heematemesis.
Frmoay.—4.15 P.M., Dr. William Brockbank: Demonstra-
tion of Medical Cases.
GLASGOW POST-GRADUATE MEDICAL ASSOCIATION.
WEDNESDAY, May 5dth.—4.15 P.M. (Royal Hospital for
Sick Children), Dr. Stanley Graham: Deficiency
Diseases in Childhood.
V acancies
_For further information refer to the advertisement columns
Aberdeen Royal Infirmary.—Second Hon. Ophth. Surgeon. Also
Surg. Reg., £200.
Barking Borough.—Res. M.O., £350.
Barnsley, Beckett Hosp. and Dispensary.—Cas. O., £250.
Barnsley, St. Helen Municipal General Hosp.—M.0O., £650.
Bath and Wessex Children’s Orthopedic Hosp., Combe Park.—
H.S., at rate of £120.
Bedford County Hosp.—Second H.S., at rate of £150.
Benenden, Kent National Sanatorium.—Med. Supt., £600.
Birmingham City.—Res. Asst. M.O., £400. °
i i Great Barr Park Colony.—Jun. Asst. Res. M.O.,
Birmingham, Queen’s Hosp.—Res. Surg. O., £150.
Bolingbroke Hosp., Wandsworth Common,''S.W.—Cas. O. and
H.S., each at rate of £120. aa
Botleys Park Colony, near Chertsey, Surrey.—Med. Supt., £1000.
Bournemouthi, Royal National Sanatorium.—Res. Asst. M.O.,
Brighton, Royal Alexandra Hosp. for Sick Children.—-H.S., £120.
Brighton, Royal Sussex County Hosp.—H.8., £150.
Bristol Royal Infirmary and Bristol General Hosp.—Two Hon.
Radiologists. Also Radio-Diagnostician, £500.
Cardiff, Welsh National School of Medicitne.—Jun. Asst. for
Medical Unit, £250. : $
Central London Throat, Nose, and Ear Hosp., Gray’s Inn-road,
W.C.—Hon. Assts. to Out-patient’s Dept. Also Third Res. .
H.S., at rate of £75. l
Children’s Hosp., Hampstead, N.W.—Res. M.O., at rate of £150.
>.
1090 THE LANCET]
VACANCIES.—APPOINTMENTS
[may 1, 1937
Colchester, Essex County Hosp.—H.P., £150.
Connaught Hosp., Walthamstow, E —Cas. O., at rate of £100.
Coventry and Warwickshire Hosp.—Res. Cas. O., £125.
Croydon County Borough.—Asst. M.O.H. and Asst. School M. O.,
£500. ‘Also Deputy M.O.H. and Deputy School M.O., £720.
Dorchester, Dorset County Hosp.—H. ry at rate of £150.
Dudley, Guest Hosp.—Second H.S.,
East Ham Memorial f7 OSD. i Sheenam E. —H.S. to
Spec. Depts., and Cas. O., at rate of £120.
Hampstead General and N nie Tost London Hosp., Haverstock-
l hill, N.W.—Cas. M.O. and Cas. Surg. O. for Out- patient
Dept., each at rate of £100.
Hosp. for Tropical Diseases, 25, COON Iree; W.C.—Hon. Asst.
Physician. Also Pathologist, £750
Hove General Hosp.—Sen. and Jun. Res. M.O.’ s, £150 and £120
respectively.
Hull Royal Infirmary.—Second Cas. O., at rate of £150.
Ilford, King George Hosp.—Hon., Chiof Asst. to Orthopedic
- and Fracture Dept. Res. Surg. O. and Med. Reg., £250
and £150 respectively. Also two H.S.’s, each at rate of £100.
Kettering and District General Hosp. — Res. O. and Second
- Res. M.O., £160 and £140 respectively.
Larbert, Stirling District Mental Hosp. —Third Asati M.O., £250.
Leeds General 1 Infirmary.—Hon. Physician.
Leicester City Mental Hosp.,
Asst. M.O., 10 guineas per week.
Lincoln County’ Hosp.—Jun. H.S., at rate of £150.
London County Council—Asst. M.O., £470. neo M.O.’s
Grade II., £250. Also Temp. District M.O.,
London Jewish H osp., Stepney Green, E —Res. M. }. ‘and H. P.,
at Tate or £1 50. Also Res. H.S. and Res. Cas. O., each at rate
` i Oo `
Maidstone, West Kent General Hosp.—H.S., £17 5.
Manchester City Education Committee. — Psychiatrist, £500.
Marice aa ie here Joint Sanatorium.—Resident Locum,
gns. per wee
Middlesbrough, N orii Riding Infirmary.—Cas. O., at rate of £150.
Middlesex Hosp. .. W.—Jun. M.O. for Radio- -therapy Dept. and
Asst. for Dept. of Physical Medicine, each £300.
NOE ENTS DIT County Council.—Temp. Asst. County M.O.H.,
Northwood, Mount Vernon Hosp.—Clin. Pathologist, £500.
Norwich, Norfolk and Norwich Hosp.—Res. Surg. O., £250.
Nottingham General Hosp.—H.S. for Ear, Nose, and Throat Dept.
. and Res. Cas. O., each at rate of £150.
Oldham Municipal Hosp. --—Res. Asst. M.O., at rate of £200.
. Saona e Hosp., Walton-street.—H.S. to Ophthalmic Dept.,
Plymouth, Prince of Wales’s Hosp.—H.S., at rate of £120.
TRE County Mental Hosp., Whittingham. —Res. Jun. Asst.
Preston, harot. Green Hosp.—Med. Supt., £850.
Princess Louise Kensington Hosp. for Children, St. Quintin-
avenue, W.—Hon. Ophth. Surgeon. Also H.S., at rate of
£120-£150.
eee ee: for Children, Hackney-road, E.—H.S., at rate of
KARNIN ANERUS; Riding House-street, W —Res. M.O., at rate
Reading, Royal Berkshire Hosp.—Cas. O. and H.S. to Spec.
Depts., each at rate of £150.
Royal Cancer Hosp., Fulham-road, S.W .—H.S., at rate of £100.
Also H.S. to Radium Dept., at rate of £200
Royal Free Hosp., Gray’s Inn-road, W.C. —Asst. Physician.
Royal London Ophthalmic Hosp., City- road, E.C.—Out-patient
Officer, £100.
Royal Naval Medical Service.—M.0.’s
Royal Northern Hosp., Holloway, N. —H.P. and H.S., each at
rate of £70.
Royal Waterloo Hosp. for Children and Women, Waterloo-road,
S.E.—Res. Cas. O. for Out-patient Dept., at rate of £150.
Si. Bartholomew’s Hosp., E.C.—Asst. Aural Surgeon.
St. Helens County Borough.—Asst. M.O.H., £500.
na Metropolitan Borough. —Asst. Welfare M. O.,
guineas per session.
Safo City. —Asst. Maternity and Child Welfare M.O., £250.
Salisbury General Infirmary.—H.P., at rate of £125. Also Res.
Salvation Ano Mothers’ Hosp., Lower Clapton-road, E.—T wo
Jun. Res. M.O.’s, each £80.
Shrewsbury, Royal Salop Infirmary.—Res. H.S., at rate of £160.
Simla, Medical Council of India.—Secretary, Rs. 1200-75-1500.
Southampton, Royal South Hants and Southampton Hosp.—
Sen. H.S., £200. H.P., H.S., Res. Anesthetist and H.S., &c.,
and Cas. O., each at rate of £150.
Stockton- on- Tees, Durham County Mental Hosp., Winterton.—
Locum Tenens Asst. M. O., 1 guinea per day
PORON Trent, Burslem, Haywood, and Tunstall “War Memorial
sp.—Res. H.S., at rate of £175.
Sibonaea ( General and Eye Hosp.—Cas. O., at rate of £150-£175.
Tunbridge Wells, Kent and Sussex Hosp. —H. S., £150.
University of London. — University Chair of Bacteriology, £1000.
Uxbridge, Hillingdon County Hosp.—Jun. Res. Asst. M.O., at
rate of £250.
Wallasey, Victoria Central Hosp.—Jun. H.S., £150.
West Ham County Borough —M.O.H. and School M. O., £1500.
West Suffolk County Council.—Asst. County M.O. and Asst.
School M.O., £500
Wickford, Runwell Hosp. for Nervous and Mental Disorders.—
H.P., at rate of £150.
Wolverhampton, New Cross Hosp Res. Asst. M.O., £200.
Wolverhampton Royal Hosp.—H.S.’s, at rate of £100.
Woolwich and District War Memorial Hosp., Shooters-hill, S.E —
Three Hon. Anesthetists.
Worthing Hosp.—H.S8., at rate of £130.
The Chief Inspector of Factories announces vacancies for
Certifying Factory Surgeons at Pewsey (Wilts) and Redcar
(Yorks, N.R.).
ROBINSON, G. L.,
Humberstone.—Locum Tenens Z
`
Åppointments
BLAIR, BRYCE, M.B. Lond., Resident Assistant Medical Officer
at the Epsom County Hospit tal.
CHISHOLM, W. N., R.C.S. Edin., D.C.0.G., Resident
Medical Superintendent at Park Hospital, Davyhulme,
near Manchester.
GORROD, C. E., M.B. Aberd., Assistant Medical Officer at King
George’ s Sanatorium for Sailors, Bramshott.
ODLUM, DORIS, M.R.C.S. Eng., D.P.M., Hon. Psychiatrist to the
Psychiatric Department of the Elizabeth Garrett Anderson
Hospital; and Hon. Senior Psychiatrist to the Department
for Nervous Disorders of the Royal Victoria and West
Hants Hospital, Bournemouth.
M.B. Camb., Research Worker in Rheumatic
Diseases at the Devonshire Royal Hospital, Buxton.
TIERNEY, J. A., M.B. Glasg., Assistant Medical Officer at the
Royal Eastern Counties Institution, Colchester.
London County Council Hospital Staff—The following appoint-
ments, promotions, and transfers are announced. A.M.O. (I.)
and (Il.) = Assistant Medical Officer, Grades I. or II.,
Temp.=temporary, Med. Sup.=Medical Superintendent.
MARTIN, R., M.D. Glasg., D.P.M., Temp. Visiting M.O.
(part- -time), Sutton roe Centre
OSBORNE, J. W., M. » M.R.C.P.. Lond., A.M.O. (1.),
St. Mary Abbots ; :
LS, GERALD, M.B. Manch., M.C.O.G., A.M.O. (L),
Dulwich ; ,
LEONARD, F. R., M.B. N.Z., F.R.C.S. Eng., A.M.O. (1.),
St. Alfege’s ;
HoTSON, CHRISTOPHER, M.B., F.R.C.S. Edin., A.M.O. (I.),
Lambeth ;
BRADLEY, J., M.B. Dubl, A.M.O. (I.), Queen Mary’s,
Ce alias
Kay, ELIZABETH B., M.B. Glasg., A.M.O. (1.), Queen Mary’s,
Carshalton ;
NEVIN, Mary E., M.B. Belf., A.M.O. (II.), ois Oak;
SMELLIE, ELSPETH W., B .M. Oxon. .„ A.M.O. (Il.), Queen
Mar. y’s, Carshalton : i
VICKERS, KATHLEEN M. N., L.R.C.S. Irel., L.M., A.M.O. (II.),
N orwood Children’s ;
M.B. Camb., D.A., A.M.O. (II.),
PALMER, E. A. B,
St. ’ Andrew’ 83
MITCHELL, EVELYN E., M.B. Edin., A.M.O. (II.), St. Giles ;
ROGERS, KATHARINE C., .R.C.S. Eng., AN O. (II.), St. Giles ;
Bee
MAYEUR, Mary H. F M. . Lond., A.M.O .(II.), St. James’ ;
BAKER, HARRY, M.B. Manch., A M.O. (II.), Bethnal Green :
SMITE, T. M., M.B. Na
A.M.O. No i Bethnal-Green ;__ .
eib. O. (II.), Lambeth ;
ACN. O. (II.), Queen Mary’s,
BLAIR, E. Ý, M.D. Durh., .O. (II.), St. Mary, Islington ;
ROGERS, GEOFFREY, M.R.C. ng., A. M.O. (II.), St. Peter’s ;
GUNN, * WILLIAM, "M.B. Aberd., M.R.C.P. Lond., D.P.H.,
Med. Sup., North-Western ; :
Muroy, J. MCN., M.B. Glasg., F.R.C.S. Eng., Med. Sup.,
Ar chway ; ;
West, H. O0., M.D., F.R.C.P. Lond., D.P.H., Med. Sup.,
Queen Mary’ S, Carshalton :
HENDERSON, R. G, M.D. Aberd., D.P.H., Divisional Medical
Officer, ‘Central Administrative Staff ;
AIKEN, J. P., M.B., N.U.I., Deputy Med. Sup, I., Dulwich ;
EVANS, J. C., M. R.C.P. Lond., Deputy Med. Sup., II., Bethnal
reen ;
WILKIE, DAVID, M.D. Edin., F.R.C.S. Eng., Senior A.M.O.(I.),
St. Pancras ; :
LEWYS-LLOoYD, R. A. V., M.B. Lond., D.P.H., Senior
A.M.O. (I.), St. Nicholas ;
WILKIE, TAON M.B. Aberd., Senior A.M.O. (II.), Heather-
woo
HAL, R. À., M.B. Lond., F.R.C.S. Edin., Senior A.M.O. (II.),
St. Charles’;
THomas, R. G., M.B. Lond., F.R.C.S. Edin., A.M.O. (II.),
St. George- -in-the- East ;
DEWAR, A. F. » M.D. Glasg., A ar: O. (II.), St. Stephen’s ;
ARTHUR, J. B., M. B. Edin., O. (I.), Bethnal Green ;
BOYLE, A. K., M.B. Glasg., ETRA (I. ), St. Peter’s ;
FRASER, T. A., M.D. Aberd., A.M.O. (I.), Mile Booi
MELTON, GEORGE, M.D., ’M.R.C.P. Lond.,
Lewisham ;
SAVAGE, O. aa M.R.C.S. Eng., A.M.O. (I.), Grove ;
. HOGARTH, J. C., M.B. Glasg., “A. M.O. (I.), Eastern ;
CLARE, D. C., Gi., B. Lond., A. M.O. (II.), St. Mary, Islington ;
M.B. Lon F.R.C.S. Eng., Deputy Med.
~ PRICE, ISAAC,
M.B. Belf., Senior A.M.O. (II.),
Sup. (II.), St. ‘Andrew's «
MOOR ELIZABETH M.,
l e :
GRIFFIN, T. F. R., M.B. Lond., F.R.C.S. Eng., A.M.O. (1.),
Bethnal Green ; .
NICHOL, R. W., B.A., M.R.C.S. Eng., A.M.O. (1.), St. T
BYRNE, P. A., M.B., N.U.I., A.M.O. (II.), Lambeth ;
COVENEY, MARGARET F., M.B. Sheff., D.P.H., A.M. O. (L. );
White Oak.
Cae Surgeons under the Factory and Workshop Acts:
JAMES (Calne, yee Dr. ©. J. FAIRLIE
(Blyth, Northumberland) ; ; Dr. J. B. VAILE (Chertsey
Surrey) ; Dr. C. S. LEWIS (Staveley, Derbyshire); an
Dr. G. W. ScoTT (Malvern, Worcester).
O. (I.),
WORCESTER ROYAL INFIRMARY.— Lady Atkins,
mayor of Worcester, was on April 19th elected
chairman of this hospital.
THE LANCET]
(may 1, 1987 1091
NOTES, COMMENTS, AND ABSTRACTS
THE MATERNAL MORTALITY REPORT
For two years medical officers of the Ministry of
Health have been making a special investigation of
maternal mortality and morbidity. Their long-
awaited report is published as we go to press.
The task before them was to discover why the
puerperal mortality-rate has not fallen, despite
increased interest taken in maternal welfare, extension
of maternity services, and improvement in the
general health.
FACTORS IN CAUSATION
Dealing with the regional distribution they point
out that for. set years puerperal mortality has
been higher in Wales and the north-west of England
than in the country as a whole. This regional
inequality is, however, not confined to maternal
mortality-rates ; with certain exceptions the distribu-
tion of the general death-rates, infant mortality-
rates, tuberculosis and other rates show some
correspondence with the rates from puerperal causes.
Various factors possibly responsible were considered.
The available evidence shows, it is reported, that
districts in which there are areas with bad housing
and overcrowding are just as likely to have low rates
of puerperal mortality as those in which the housing
is good and the overcrowding less. In the districts
visited it was not generally found that the puerperal
mortality-rates were higher in the areas with most
overcrowding. Nor did these show any consistent’
association with corresponding variations in economic
conditions. The influence of the nature of the
dietary and of nutrition on maternal mortality cannot,
it is observed, be accurately assessed in the present
state of knowledge. The tendency for the mortality-
rates to be higher in the north and west and lower in
the south and east of the country suggested that
climatic conditions might in part exert an influence,
but the data required to demonstrate the association
are not complete. Again, it was found that deaths
from puerperal sepsis tended to occur most frequently
in the coldest quarter of the year, that being the
quarter which immediately succeeds the wettest and
most sunless quarter, while deaths from toxemia
tend to occur in the warmest quarter. But the
significance of this association cannot yet be assessed.
The information obtained by the investigators
. suggests that the practice of artificially induced
abortion is frequent, appears to be increasing, is
more prevalent in some districts than in others, and
is not restricted to any one social class. Approxi-
mately 14 per cent. of all puerperal deaths are due
to this cause (excluding deaths from abortion classed
as criminal). The risk attending artificially induced
abortion does not appear to be sufficiently realised,
and there ig urgent need for the education of women
respecting the damage to health and the danger
to . life from attempts to terminate pregnancy
artificially. The facilities available in some areas
for the in-patient treatment of cases of abortion under
expert supervision are inadequate.
THE MATERNITY SERVICE AND THE PRACTITIONER
Local investigation of maternal deaths indicates
that ignorance or lack of coöperation on the part of
the patient or her relatives often prejudiced her
chance of recovery, and illustrated the need for more
systematic and careful medical supervision during
the antenatal period, more skilful management of
some confinements, more frequent reference of cases
of doubt or difficulty for the advice and treatment of
an expert obstetrician, and earlier admission to
hospital of many patients. The primary conclusions
of the investigators are that (1) those general
practitioners who undertake obstetric work should
be interested, experienced, and actively engaged in
the practice of midwifery, have sufficient time for
unhurried work, and be prepared to codperate with
the appropriate members of the local public health
department and with the other agents concerned
with the promotion of maternal welfare in the
district. (2) The services of obstetric experts should
be readily accessible in every area. (3) Everything
possible should be done not only to induce expectant
mothers to avail themselves of the facilities provided
for them, but also to impress upon them the
importance of accepting and acting upon the advice
proffered. ’
The report contains an outline of an efficient
maternity service of a local authority and includes
subjects recommended for consideration in order
to render the services more fully effective. It is
pointed out that the underlying principles of ante-
natal care are sound, but that optimal results cannot
be expected until antenatal supervision attains a
high general standard and expectant mothers make
full and intelligent use of it. The development of
consultative antenatal clinic sessions, under the
clinical supervision of an expert obstetrician, to
serve every area is of importance in order to render
antenatal services more efficient.
The report refers to the decrease in domiciliary
confinements conducted by general practitioners,
the increase in those for which midwives are responsible,
and the rapid and increasing development of institu-
tional midwifery in many districts. The investiga-
tion showed that many medical practitioners under-
take a considerable amount of obstetric work with
competence and skill. The midwifery practice of
some doctors has, however, decreased, and the
position in some towns is that, unless a general
practitioner has a special interest in midwifery, or
is of repute for his obstetric skill, his maternity
practice may be largely restricted to a few medical
aid calls from midwives in the course of a year. The
general practitioner is often called to an emergency
in the patient’s home and may have to cope, without
adequate assistance and in unfavourable surround-
ings, with critical situations which would challenge
the skill of an obstetric specialist. Other calls upon
his time may be pressing. Moreover, the condition
of the patient may be such as to compel him to take
immediate action however disadvantageous the
circumstances may be. The histories of many of the
maternal deaths investigated indicated that, not- -
withstanding these handicaps, careful obstetric
procedures were adopted, but others showed that the
woman’s chance of recovery would often have been
enhanced had a practitioner experienced in midwifery
been in attendance, had the doctor been assisted by
an obstetric expert, or had the patient been admitted
to hospital sufficiently early.
The investigators consider that a docto¥ whose
practice of midwifery is restricted to only a few
cases each year cannot be expected to assist the
midwife in difficulties which may urgently call for
judgment and experience which, in the circumstances,
he cannot be expected to possess. They suggest
that the local supervising authority, in consultation
with the local medical profession, should in future
be empowered to take steps to ensure that the best
local obstetric skill is made available in all cases
1092 THB LANCET]
BIRTHS, MARRIAGES, AND DEATHS
[may 1, 1937
in which midwives are required under the rules of
the Central Midwives Board to call in a doctor.
Reference is also made to the need for specialist
advice, and facilities for in-patient treatment, after
confinement.
Much. stress is laid on the value of a service
of obstetric consultants, and attention is drawn to
the infrequency with which the consultant facilities
were utilised in some areas where they had been
provided. ‘The provision of so-called emergency
units or ‘flying squads” in connexion with a
maternity department, under the direction of an
expert obstetrician, should help to reduce maternal
mortality.
In the opinion of the investigators it is essential
to the success of a maternity scheme that there should
be coöperation between all those concerned; and,
although this was a satisfactory feature in a few of
the areas visited; in others its importance had not
been recognised. The time for independent individual
effort, they believe, is past. All persons engaged in
any branch of a maternity service should consider
. themselves to be members of a team working towards
the goal of safer motherhood. It is in this way and
this way alone that effective continuity of super-
vision and treatment can be secured.
While there are many factors which influence
maternal mortality, it is clear at least, says the report,
that it is capable of reduction; and of the factors
known to influence it the most important from the
point of view of remedial action is the standard of
midwifery practice.
THE ‘‘ BONOCHORD ” HEARING-AID
A NEW valve amplifier hearing-aid has been sub-
mitted to us by Messrs. Allen and Hanburys. The
model examined; M.V.36, is assembled in a neat
case measuring 6x3}x3 inches, and employs two
stages of amplification, a small 36-volt dry battery
and a 2-volt chargeable accumulator. The micro-
phone is of the immersed electrode type, and a
volume control is incorporated in the switch; in
addition an automatic volume control is provided,
which ensures that the ear will not be damaged by
accidental loud noises. Tone control is obtained by
the use of earpieces of various impedance, or by the
employment of electrical filters.. The price is
16 guineas, which includes a spare accumulator.
The dry battery is said to have a life of about three
months, and the accumulator to give 25 hours’ use
before recharging. A larger and more powerful
model, M.V.52, is obtainable, with three valves, at a
cost of 18 guineas. A piezo-electric crystal micro-
phone can.be fitted to either model at an additional
cost of 2 guineas; this is practically free from back-
ground noise and is particularly suitable for sufferers
from tinnitus and for cases of. senile deafness. We
‘think that this microphone will be advisable in most
cases, as background noise is considerable in valve
aids which are capable of a very high degree of
amplification.
THE WHOLESOMENESS OF CANNED Foops.—A cir-
cular written by Mr. H. B. Cronshaw, Ph.D., entitled
‘‘The Wholesomeness of Canned Foods,” has been
issued under the auspices of the International Tin
Research and Development Council. The pamphlet
contains a brief account of the history of canning and
describes the premises and processes used for the
purpose. The safety of ‘cahmed foods as regards
both chemical and bacterial contamination is empha-
sised and a brief review is given of recent work on
the effect of heat, as applied in canning processes, -
and on the nutritive value of foods (including
vitamins). The statements are moderate and
accurate so far as the best British factories are
concerned. Te
2
Births, Marriages, and Deaths
BIRTHS
Craia.—On April 22nd, at Fulbourn-street, E., the wife of
Dr. Norman S. Crai , of a son.
DUNLoP.—On April 18th, at Tetbury, Glos, the wife of Dr. J.
Leeper Dunlop, of a daughter.
JENKINS.—On April 20th, the wife of Dr. R. D. Jenkins, of
spe eg ioe of a son.
Dia oe April 16th, the wife of Dr. Eric Lyle, Bromley, .
son
PRICE.—On April 21st, the wife of Roy Kemball Price, M.D.,
of Brighton, of a daughter.
D.—On April 10th, at Batu Gajab, F.M.S., the wife of
Dr. J. G. Reed, of a son.
SMALLSHAW.—On April 20th, at Epsom Downs, the wife of
Dr. D. B. Smallishaw, of a son.
STEWART.—On April 17th, at Edinburgh, the wife of Dr. James
Stewart, 33, Hatton-place, Edinburgh, of a daughter.
h, at Caterham, the wife of Dr. P.
THWAITES.—On April 20
Thwaites, of yteleafe, of a daughter.
MARRIAGES
LANOASHIRE—GOODFELLOW.—On April 17th, at Bermuda.
Roger Wiliam George Lancashire, Surg.-Lt to
Christina Sophia, daughter of Dr. and Mrs. T. A. ‘Goodfellow,
West Didsbury, Manchester.
MacLEAN—LOVE.—On April 15th, at Burton-on-Trent, Neil
Peck, M.B. Camb.
to Norah Eugenie, daughter of the Rev. M. Johnson, of
HITEHEAD—CHAPMAN.—On April 8th, 1937, at St. Paul’s
Church, Mill Hill, James Edward, son of the late John
Kay Whitehead, of Royton, Lancs, and Mrs. Whitehead,
to Marjorie Beatrix, younger daughter of Charles W.
Chapman, M.D., M.R.C.P.,and Mrs. Chapman, of Highwood
Coombe, Mill Hill, N.W.7. ©
DEATHS
ANDERSON.—On April 19th, at Erdington, Birmingham,
Kober, Anderson, B.Chir. Camb., Captain R.A.M.O. (T.),
age f .
Harg -On Apri 22nd, at Woking, Francis Murray Haig,
Hinz.—On April 25th, at a eae Devon, Thomas Guy
.E., M.A., M.
D.Camb., Hon. Major,
HuNTER.—On aoe 18th, at Haughley, Suffolk, G. H. Hunter,
M.R.O.S., D.P.H., aged 79.
Mupp.—On April 21st, at Illovo, Johannesburg, Frank Burnand.
Mudd, M.R.C.S., younger son of the late Dr. Barrington R.
Mudd, of Storrington, Sussex.
PHILIP.—On the 23rd April, at 45, Charlotte-square, Edinburgh,
Elizabeth, wife of Sir Robert Philip, M.D., F.R.O.P. (Please
no flowers.
WaLpy.—On April 25th, at Darlington, C. Durham, John
Waldy, F.R.C.S. Eng., aged 76.
Wippup.—On April 23rd, at Southsea, the home of his daughter
(Mrs. Nora Blackwood), John Charles Ponsonby Widdup,
late Colonial Medical Service.
YARR.—On April 24th, in London, Major-General Sir (Michael)
Thomas Yarr, K.O.M.G., O.B., late R.A.M.C., of Queen
Anne’s Mansions, St. James’s. ;
N.B.—A fee of 13. 6d. is charged for the insertion of Notices of
ths Deaths.
irlhs, Marriages, and
UNWANTED INDICES to “THE LANCET.”’—Any
reader who has an unbound copy not in use of the
index for 1935 (Vol. I) and 1936 (Vol. I) would
greatly oblige by posting the same to the Editor
of THE LANCET, 7, Adam-street, Adelphi, London,
W.C.2. i
ST. BARTHOLOMEW’S HoOsSPITAL.—Overseas visitors
are to be given the opportunity of “‘ viewing” the
old Priory Church and ancient hospital of St. Bartholo-
mew’s. Conducted tours have been arranged from
May 7th to 14th (excluding Sunday and Coronation
Day) at 11 a.m. and 2.30 p.m. each day. There will
also be an exhibition in the great hall of the treasures
of the hospital, of drugs obtained from the Empire, a
collection of historical pathological specimens and many
first editions of well-known medical works. The exhibi-
tion will be open from 11 a.m. to 5.30 P.m. daily. There
will be short talks on the Hogarth painting at 4.30 each
afternoon, Further information may be had from the
hospital. |
THE LANCET]
ADDRESSES AND ORIGINAL ARTICLES
[may 8, 1937
THE PREVENTION OF
PULMONARY TUBERCULOSIS AMONG
ADULTS IN ENGLAND
IN THE PAST AND IN THE FUTURE *
By P. M. D’Arcy Hart, M.D. Camb., F.R.C.P. Lond.
ASSISTANT PHYSICIAN TO UNIVERSITY COLLEGE
HOSPITAL, LONDON
(Concluded from p. 1035)
At the beginning of these lectures I adopted a
wide use of the term “ prevention ” as applied to
pulmonary tuberculosis, and included within it
the prevention of further advance of progressive
lesions after their presence has been recognised.
The likelihood of this being achieved in a particular
instance is intimately connected with the prognosis
of the “case.” One of the objects of the anti-
tuberculosis measures embodied in the national
tuberculosis scheme has been to improve this
prognosis.
The ratios of new cases to deaths, published annually
by the Ministry of Health (e.g., 1935a), give a rough
indication of changes in the average prognosis of
diagnosed cases of pulmonary tuberculosis over the
past two decades, and so enable us to judge approxi-
mately the success of this endeavour. Unfortunately
these ratios actually decreased between 1913 and 1922,
and changed but little between 1923 and 1935, these
being comparable years. While a number of minor
factors affect their significance, it would be difficult,
in view of their failure to increase, to assert that
average prognosis has improved materially. In
other words a decline in incidence of new cases rather
than an improvement in their prognosis appears to
have been mainly responsible for the decline in
mortality. This view is supported by the conclusions
of Hartley, Wingfield, and Burrows (1935), based
on the records of the Brompton Hospital Sanatorium,
Frimley, that the prognosis of an average case of
pulmonary tuberculosis has not materially changed
during the past thirty years, though that of a small
selected class, treated by collapse therapy, has
considerably improved.
It follows that unless we are to rely upon general
social improvements, and protection from contacts,
to continue the reduction in incidence of pulmonary
tuberculosis, we shall be faced with the serious
problem of how to improve the prognosis. Such
improvement might be achieved by earlier diagnosis,
better treatment, and better after-care—the last of
these having already been discussed.
EARLIER DIAGNOSIS AS A MEANS OF IMPROVING
PROGNOSIS
That there is room for earlier diagnosis is generally
agreed.
Of 32,000 patients discharged from, or dying in, approved
residential institutions in England and Wales during the
year 1935, 63 per cent. were classified at the time of
admission as belonging to Class T.B. plus, Groups 2 or 3
(intermediate or advanced); this figure, if anything,
understates the position since Class T.B. minus is not also
subdivided into groups. The total number of Class
T.B. plus cases was 23,000, all of which must have been
infective and diagnosable for an unknown period, and of
these only 12 per.cent. were classified in Group 1 (early or
* The Milroy lectures for 1937 delivered before the Royal
Conn of Physicians of London on Feb. 18th and 23rd.
slight), the remaining 88. per cent. being already in an
intermediate or advanced stage (Ministry of Health
1930, 1935d).
Itis also believed that an increase in the proportion
of persons diagnosed in the slight or early stages would
be of great benefit. This view is founded upon two
pieces of evidence. One is that recognition and treat-
ment is an actual advantage. This may appear
obvious from clinical experience, but its statistical
demonstration is not easy (see MacNalty . 1932c),
and has only lately been achieved with any degree
of certainty (Hartley, Wingfield, and Burrows 1935).
The other piete of evidence is that, whatever the
particular form of treatment, the prognosis is closely
related to the extent of lung involvement at the
time of diagnosis. , |
Thus Trail and Stockman (1931), in their follow-up of
patients of Midhurst sanatorium, found that the survival-
rate of early sputum-positive cases five years after admis-
sion was twice that of advanced cases. In his analysis of
the ultimate results of sanatorium treatment MacNalty
(1932b) concludes that “ a patient’s chance of survival is
enormously increased in proportion as he is admitted to
sanatorium treatment in the early stage of his disease.”
The London County Council (e.g:, 1935b) consistently
reports similar findings as to survival and fitness for work
among its patients five years after residential treatment.
Bentley (1936b), in his analysis of the pneumothorax
cases of the L.C.C. since 1922, stresses the greater likelihood
of finding unilateral disease and obtaining complete
collapse (on which two factors prognosis largely depends)
where the disease has not progressed for long. And
Hartley, Wingfield, and Burrows (1935), in their study of
the after-histories of Frimley patients, conclude that the
mortality in their series depended almost entirely upon
the classified stage of the disease at the time of entry, and
was relatively unaffected by sex or age; while the finding
of a strong relationship between radiographic extent of
the disease and the prognosis provided similar evidence
from a different angle. |
The apparent lack of improvement in average
prognosis in the past twenty or thirty years, together
with the fact that prognosis is related to the stage
at which the disease is recognised, suggests that the
proportion of cases diagnosed in the slighter or earlier
stages has not materially increased during this period.
Direct comparison is difficult because of changes in
personnel and point of view, but the following figures
are of interest.
They are obtained from a county whose local tuberculosis
scheme is unsurpassed in efficiency, and for better com-
parison the analysis is confined to sputum-positive cases.
In the triennium 1926-28 there were 2394 new sputum-
positive cases, and in the triennium 1933-35 this total was
2234. The percentage of these cases classified as belonging
to Group 1 and Group 3, respectively, was 13:5 and 27
in the earlier triennium, and 12 and 21 in the later
triennium (Lancashire 1926, 1927, 1928, 1933, 1934,
1935a).
While the interval is short, these figures, taken at
their face-value, show little sign of earlier diagnosis
under the best conditions of present practice. ft
It is clear, therefore, that diagnosis remains
unsatisfactorily late, and that every effort should
be made to advance it so as to improve prognosis.
BETTER TREATMENT AS A MEANS OF IMPROVING
PROGNOSIS
The extent to which modern methods of treatment '
improve prognosis may be gauged from recent
_ A similar lack of increase in the proportion diagnosed as
minimal tuberculosis (American classification) has been noted
for the clinics operated by the health department of New York
City during 1930-36 (Edwards 1937).
T
1094 THE LANCET]
reports from institutions, including Midhurst sana-
torium (Trail and Stockman 1932, Trail 1934),
Frimley sanatorium (Hartley, Wingfield, and Burrows
1935), and the L.C.C. sanatoria (Bentley 1936b).
It appears that the proportion of cases found suitable
for pneumothorax treatment is relatively small
(10 per cent. in the L.C.C. service). The chance of
survival in all cases undertaken, considered together,
is materially improved (by 20 per cent. at five years,
in the L.C.C. series) by such treatment, the best
results being obtained in those whose lesions are
strictly. unilateral and in which complete collapse
is secured (accounting only for a quarter of the
L.C.C. cases undertaken), This suggests that
pneumothorax treatment has improved prognosis in a
small selected category of cases, though it has not
yet made a significant impression on the prognosis
of the average tuberculous case. In the future the
technique of other methods of collapse will probably
improve and their range will widen, but this is less
obviously likely with pneumothorax treatment.
Its effect on’ average prognosis is likely to remain
small and limited (4 per cent. increased chance |
of survival at five years, according to Bentley’s esti-
mate), unless the proportion of suitable cases increases.
Since suitable cases and slight or early cases are
in the main synonymous, the future usefulness of
pneumothorax treatment on tuberculous patients
as a whole appears to turn on more frequent diagnosis
in the early stages. Such earlier diagnosis would be
doubly useful since it should also help to -eliminate
pone or actual sources of infection for others.
Methods of Obtaining. Early Diagnosis
in the Past
What methods have been used to obtain early
diagnosis? Why have they been a comparative
failure ? Is extension of these older’ methods, or the
introduction of fresh ones, desirable to ensure better
success ?
CONSULTANT SERVICE
Until recently it was usual to date the onset of
tuberculous disease in adults from the appearance
‘of symptoms or physical signs. The consultant
service of the dispensary system of the national
tuberculosis scheme was based on this conception.
To the patient has been left the initiative of obtaining
the first medical interview. A “ case” of pulmonary
tuberculosis has therefore meant a case with symptoms
or physical signs as well as radiographic abnormalities,
and attempts at earlier diagnosis have been directed
to shortening the interval between the development
of symptoms that attracts the attention of the
patient, and the recognition of progressive lesions.
Delay in diagnosis after the appearance of symptoms.—
For purposes of discussion the interval between
symptoms and diagnosis can be divided into two
parts: (1) the patient has symptoms but has not
yet sought medical advice; (2) he is under medical
observation but his condition has not yet been
diagnosed as pulmonary tuberculosis.
A common reason for delay in seeking medical
advice is the hope of recovery without recourse to
the doctor. Self-deception may be another reason ;
or personal courage, or the stigma attaching to the
label of tuberculosis, may prevent him giving in.
' Other important causes for delay are economic:
chief among these are the knowledge that a long
period of sickness probably means a reduced family
income, and possibly unemployment afterwards—
factors that may prevent the patient consulting his
doctor until he is incapacitated for work.
DR. D’AROY HART: PULMONARY TUBERCULOSIS IN ADULTS
[way 8, 1987
If the duration of’ symptoms before first medical
interview is variable, so also is the period between
the interview and the diagnosis, Burton-Fanning
(1934) states that in one series of tuberculous patients
there was undue delay by the patient in 20 per cent.
of cases, and by the doctor in a—not coextensive—
25 per cent. In another series (different investigator
and criteria), the corresponding percentages were
20 and 35. These figures may give a crude indica-
tion of responsibility, but they are of more interest
perhaps in suggesting that in the majority of cases
there is no, undue delay in diagnosis from the onset
of really defintte symptoms. The difficulty is that
the first symptoms are often quite indefinite.
Efforts to reduce this delayWhile patients are
left to decide whether they require treatment it is
by no means easy to shorten the interval between
symptoms and diagnosis. One method used for the
purpose is publicity. “ A larger number of persons
who may be suffering from tuberculosis must be
persuaded to submit themselves for examination ”
(Ministry of Health 1933). “‘ The initiative to seek
treatment when ill rests with the patient himself, and
the only feasible remedy (for delay) lies in the educa-
tion of the public as to symptoms and common
dangers of tuberculosis and the need for securing
prompt treatment” (Lancashire 1935c). Informa-
tive pamphlets have been issued by local health
authorities and by the National Association for Pre-
vention of Tuberculosis. For the family doctor, closer
coöperation between the dispensary physician and
himself has been secured, while he has been given the
right to free sputum examination without intermediary.
Since, in the country as a whole, there is little evidence
_ on whether the interval between symptoms and diag-
nosis has been reduced in the past fifteen years, it is
difficult to judge the effect of these specifically
planned efforts. However, from the figures already
given, it seems clear that even if diagnosis is now
somewhat earlier in time it is not yet sufficiently
early in stage. Two explanations of this comparative
failure may be suggested.
One is that the planned efforts have not been
adequately exploited—that enough has not been
done to counter the economic factors that deter the
patient from seeking advice, and that attempts
to educate the public have not been sufficiently bold.
Perhaps caution in the use of public instruction is
partly due to anxiety lest ‘“‘ disease consciousness ”’
or hypochondriasis be created in the nation (see
Hutchison 1934), Again, while the family doctor
has been given direct access to sputum examination,
the even more important privilege of direct free radio-
graphic chest examination and report has not yet
been granted; and in the absence of this privilege
intensive propaganda might burden hospitals with
a large influx of unwanted out-patients.
The other possible explanation for the failure is
that the attempt to secure sufficiently early diagnosis
solely by efforts to shorten the interval between
symptoms and diagnosis is unsound, being based
upon an out-moded conception of the evolution of
pulmonary tuberculosis. It is nowadays supposed
that the first stage of the process is pulmonary first-
infection, discoverable by the tuberculin test and
sometimes also radiographically. After a short.
or long interval progressive pulmonary lesions develop,
which are often detectable with X rays for some
considerable time before they give rise to significant
symptoms or physical signs, though indefinite or
insidious symptoms may be present at this stage.
During this asymptomatic (latent, preclinical) stage
progressive lesions ‘are, therefore, recognisable as such
THE LANCET]
by radiography but in no other way. They may be
slight in extent; on the other hand they may
develop beyond the size that corresponds to the
Ministry of Health’s Group 1 classification before
they lead to definite symptoms. When significant
symptoms do develop, they may be toxæmic or local
or both. In this, the so-called clinical or manifest
stage, the. presence of progressive lesions is discover-
able clinically, radiographically, and possibly bacterio-
logically. However, while tubercle bacilli in the
sputum, with their implication of infectiousness,
may be found early in this stage, they must be
regarded as heralding a comparatively late and
dangerous phase when the whole course of the
disease is taken into consideration.
This view differs from the older conception, which
has dominated the methods of tuberculosis dis-
pensary consultant practice, chiefly in emphasising
the asymptomatic stage of progressive lesions and
by dating the onset of disease from the first appearance
of these lesions and not from development of the
symptoms. The deduction is that efforts, such as
those already undertaken under the national tuber-
culosis scheme, to shorten the interval between the
onset of significant symptoms and the making of the
diagnosis cannot be expected by themselves to secure
diagnosis at a time when the lesions are slight, non-
infectious, and usually susceptible to treatment.
In expanded form, and in conjunction with different
methods, however, they should be of considerable
use. On the other hand, attempts to recognise
progressive tuberculosis from early but indefinite
symptoms, such as slight general unfitness, are more
likely to confuse than to assist.
Methods of Obtaining Early Diagnosis
in the Future
PERIODIC MEDICAL EXAMINATION
: What is required, therefore, is a procedure whereby
progressive lesions may be discovered in the asympto-
matic or preclinical stage and as early as possible
in their development. This must involve the periodic
X ray examination of persons supposed to be in good
health. The length of the intervals between such
examinations will be determined by the person’s
history, by the risk likely to be run, and by the
presence of any suspicious X ray shadows or
symptoms.
Such a method is essentially dynamic, for its aim
is to detect changes—of progression and regression—
and not merely to ascertain statically the extent and
character of a lesion at a particular time. For this
purpose it is well to secure if possible at least one
negative examination to serve as the individual’s
base-line: hence the first examination should be
carried out when he is likely to be in actual as
well as in supposed health.
For economy of effort the unit for investigation
would best be a group of persons who are normally
associated together and therefore easily accessible—
e.g., students of a college, or workers in a factory
—rather than isolated and independent individuals.
Since it affords a reasonable chance of detecting the
pulmonary lesions before symptoms arise, and of
forming a precise opinion as to the progressive
nature of these lesions when detected, routine periodic
examination should secure improved results from
treatment and greater safety for the local community.
If lesions develop between the periodic examinations
the initiative will of course rest, as at present, with
the patient; but with the established routine of
medical examination, the provision of the medical
DR. D’ARCY HART: PULMONARY TUBERCULOSIS IN ADULTS
[may 8, 1987 1095
service on the spot, and the warning to report par-
ticular complaints, he might be expected to take this
initiative sooner than in ordinary practice. In any
event, a limit is set to the delay; and whether the
disease is detected before or at the next routine
examination, the advantage of serial radiograms in
helping to form an opinion will still apply.
Since it involves regular examination while in
health, and since it takes the main initiative of medical
interview away from the patient and gives it to the
doctor, this method of obtaining early diagnosis rests
upon a principle that differs profoundly from that
underlying the patient-family-doctor-specialist rela-
tionship of the greater part of medical practice. But
it is, of course, no new principle, for it has been adopted
by many departments of the voluntary and municipal
hospital and public health services—e.g., in child
welfare and antenatal clinics, in school medical and
dental inspection—as well as by many dental surgeons
in private practice.
THE PRESENT CONTACT EXAMINATION SERVICE OF ©
THE TUBERCULOSIS DISPENSARY SYSTEM
At the time of its introduction the national tuber-
culosis scheme could not have included routine
periodic examination as a part of the functions of its
consultant dispensary service, but an important step
was taken in establishing the service for examination
of contacts. This is, of course, no more than a step
in the right direction. Since the first examination of
a contact cannot be made until at least one case has
been discovered in the household—and in nearly
10 per cent. this discovery is not made until there
has been a death—it is often made too late to prevent
the disease from spreading. And since, for the same
reason, first examination of a contact takes place at
a time when already he has a more than average
chance of having a progressive lesion, the scheme
may well fail in its intention to detect disease in its
early stages.
Other limitations of the present contacts scheme lie in
its execution. The proportion of home contacts examined
as such is increasing: thus in London in 1935 the ratio of
new contacts (adults and children) examined to new
cases of tuberculosis taken on the dispensary registers
was 1-8 to 1 (Bentley 1936c). But for the country as a whole
in that year the ratio was only 1-2 to 1 (Ministry of Health
1935e), and, taking the 1931 census figure of 3-72 as the
average number of persons per family in England and
Wales, this represents slightly less than half the possible
home contacts.
Again, while in some dispensaries all adult contacts are
radiographed on first examination, in others this is only
done if suspicious symptoms or signs be present; and
while in some dispensaries the adult contact, more par-
ticularly the young adult contact, who is found normal on
first examination is invited to return at regular intervals
for re-examination so long as exposure continues and for
some years afterwards, in others he is only instructed to
return should he feel ill or alarmed. Even where close
observation of apparently healthy young adult home
contacts is being maintained, many local authorities
would consider themselves unable to carry the expense of
including serial radiograms in such periodic examination.
If all new contacts (adult and child) of all new cases of
tuberculosis in the London dispensary area were to be
radiographed once a year for five years, and if the inci-
dence of new cases were to remain at their present figure,
then, according to a rough estimate made by Bentley
(1936c), over 60,000 radiograms of home contacts (25,000
if limited to contacts of sputum-positive cases) would have
to be taken and read annually in this area. :
Finally, it should be noted that the examination of
contacts (child and adult) accounted for 8 per cent. of the
total number of cases of tuberculosis diagnosed by the
dispensary service in 1935 ens of Health 1935b).
T
1096 THE LANCET]
In assessing this result, however, this figure of 8 per cent.
may be compared with Lloyd and MacPherson’s (1936)
finding that 30 per cent. of their series of young adult cases
of pulmonary tuberculosis gave a history of contact in
the home, and therefore could presumably themselves
have been located by a follow-up of the family of the
earlier case. The comparison is crude, since the material
has a different age-constitution, but it is nevertheless of
some interest.
Although in its present form the examination of
contacts under the tuberculosis scheme cannot be
regarded as more than a partially developed example
of periodic examination of adults in supposed health,
the experience gained would be of immense value
should any further step be contemplated. Whether,
the present service is likely to be expanded and
modified, or to be eventually superseded, is a question
that will be discussed later.
EXAMPLES OF SCHEMES OF PERIODIC EXAMINATION
During the past few years a number of group-
schemes of periodic examination of supposedly
healthy persons for tuberculosis have been introduced,
especially in the United States. So far the majority
of them have been applied to groups of young adults,
more particularly those who run a greater than
average risk of exposure to open tuberculosis. For
this category of persons, such schemes probably
constitute the best means of observation, especially
if combined with Mantoux testing, which—whatever
its other implications—should exclude the presence
of tuberculous infection in some of them (see Hart
1932, 1937). The selected groups. have included
medical students (Hetherington, McPhedran, Landis,
and Opie 1931, 1935), medical and other university
students (Soper and Wilson 1935, Diehl and Myers
1936), and hospital nurses. In most of the schemes
the standard interval between routine examinations
has been a year, but the prescribed interval is of
course reduced in individual cases when indicated.
At the first examination after the introduction of a
scheme, a number of persons in presumed health have
usually been discovered to have serious and open lesions.
In one large university hospital in America these included
the sister in charge of the labour ward, and also a nurse
working in the operating theatre. On the other hand
(Downes 1934, Barnard 1934), the number of cases with
severe lesions (Stage 2 or 3), expressed as a percentage
of total active cases found, tends, as would be expected,
to be smaller than in a series of tuberculous cases diagnosed
in the ordinary way. While the immediate discoveries
usually provide immediate justification for the scheme
as a method of case-finding, it is only after it has been in
operation for some little time that its full benefits are
experienced, with a further fall in the incidence of severe
lesions among the active cases discovered.
Periodic examination of employees——The scheme
: that has attracted most attention is one that does not
come into the category of examination of young
adults exposed to exceptional risks of contact, but
applies to adults of various ages under ordinary
conditions of work. It has been in operation since
1928, under the direction of Dr. H. H. Fellows and
his associates, among the 13,000 employee population
of the New York office of the Metropolitan Life
Insurance Co., a mutual company with no stock-
holders.
Before the introduction of this scheme all employees
had a complete physical examination once a year, but a
chest radiogram was taken only if suspicious symptoms
or signs were elicited. Now, however, in addition to their
physical overhaul, they have an annual screening, followed
by a film if thought desirable. For those with doubtful
lesions the interval is deliberately shortened, and all
employees are asked to report during intermediate periods
DR. D'ARCY HART: PULMONARY TUBERCULOSIS IN ADULTS
[may 8, 1937
if symptoms should appear. Persons discovered to have
significant active lesions are kept under close supervision
or are advised, though not compelled, to have sanatorium
treatment; the latter can, if desired, be given at the
company’s own sanatorium, so that the scheme is self-
contained. These persons return to work after treatment
as soon as they are considered fit.
The success of this scheme can be judged from
the following details. (The difference between the
American and English classifications must be borne
in mind, in particular the American subdivision of
T.B. minus as well as of T.B. plus cases into three
groups.)
A total of 201 new cases with significant active lesions
requiring treatment occurred between 1929 and 1935
among employees, the incidence per 10,000 employee
population being 28 in 1929, 23 in 1930, thereafter remain-
ing between 19 and 24 (except for 1933 when it was 14). .
The incidence, per 10,000 employee population, of new
active cases found in Stage 2 or 3 (moderately or far
advanced) fell from 21 in 1929 (already a year after the
scheme had commenced) and 15 in 1930 to 12 in 1931,
7 in 1932 and 1933, 6 in 1934, and 9 in 1935 ;, while the
number of new active cases found in Stage 1 (minimal),
expressed as a percentage of the total new active cases,
rose from 31 in 1929-30 to 62 in 1932-33 and 1934-35.
A series of 141 active cases admitted to the company’s
sanatorium was analysed in especial detail. In the
majority the disease had been detected before they were ill
in the ordinary sense, and before physical signs were present.
One-third had no symptoms at the time of diagnosis ;
over half had not lost weight during the previous year ;
and only 13 per cent. admitted to having a cough. Half
were discovered at a routine examination, and the other
half as a result of seeking advice for symptoms in an
interval period. Thirty-one per cent. of the cases were
T.B. plus at some time during treatment. The percentage
of the whole group detected in Stage 1 (minimal) was 65,
which was stated to be five times the average admission-
rate for minimal cases among United States sanatoria
in general. Of those discovered as a result of symptoms,
60 per cent. were in Stage 1; for those discovered at
routine examination the percentage was 69; while for
those with no symptoms at the time of diagnosis it was as
high as 79. Of the sputum-positive cases however—
one-third of which were cases that had been diagnosed
at a routine examination—only 27 per cent. were in Stage 1
and 12 per cent. were actually in Stage 3 (Fellows 1934a,
1934b, 1935; Reid 1933, 1934, 1935; Barnard 1934).
While it is too early to know the ultimate results
of treatment of the active cases discovered by this
scheme, it seems to have justified the hope of recognis-
ing lesions at an earlier stage than before. One would
expect even better results if a film as well as, or instead
of, screening were made at each routine examination,
so as to give a permanent record for comparison.
SCHEME FOR STUDENTS OF UNIVERSITY COLLEGE
HOSPITAL MEDICAL SCHOOL
In 1935, having regard to the gathering movement
in favour of student health services in this country, to
the predominance of pulmonary tuberculosis among
the incapacitating diseases of young adults, and to the
retardation in decline of mortality from this disease at
this age in recent years, the medical school committee
of University College Hospital instituted a scheme of
periodic medical examination of students occupied
in clinical training or in qualified house appoint-
ments. (The examination, at present limited to
the detection of pulmonary tuberculosis, may form
part of a more comprehensive health service to be
introduced later.) The scheme was placed under the
charge of Mrs. Gwen Hilton as radiologist, and of
myself as physician, and has now been in operation
for a year. Since it is apparently the first of its
kind in this country, I will describe the administrative
THE LANCET]
routine in some detail (with permission of the dean),
in the hope that it may assist others contemplating
+ œ similar service,
All but 4 of 300 eligible and accessible students have
- entered the scheme, which is essentially voluntary. The
` information is treated as confidential, and any student
found to have doubtful or definite progressive lesions is
referred to the doctor of his choice for further opinion or
advice. While he is not required to take the advice
given, it is not anticipated that the problem of a serious
or sputum -positive case refusing treatment is likely to
arise. The service is free, but no provision is made for
the cost of treatment.
An explanatory leaflet is issued to each student before
his first examination. The latter consists of screening
and film of the chest, and the student answers a question-
naire concerning his family and past and present medical
- history as regards repiratory disease. Discussion between
radiologist and physician is followed, a few days later, .
by an interview between the physician and the student,
at which the weight is recorded, the history completed,
and physical or sputum examination made if the history
or radiogram indicates it. At this interview the result
of the whole examination is given to the student, any
special action to be taken is decided upon, and the date
for the next routine examination fixed.
The standard interval between routine examinations
is at present one year, but this interval is shortened either
at the will of the doctors, if the history or radiogram of the
previous examination suggests the advisability of closer
observation, or at the will of the student, if suspicious
symptoms develop. The student is particularly asked
to seek advice during the period between routine examina-
tions sheuld he become worried about his chest; and it
is hoped that the items on the questionnaire, ' together
with his medical training, will enable him to recognise
ptoms requiring an intermediate re-examination, and
that the established routine and convenient situation of the
medical service will encourage him to take the initiative
to obtain it.
Re-examinations are similar to the first examination,
though screening is usually omitted. The chest film is
taken under conditions so far as possible comparable with
those used on the first occasion. At the clinical interview
the weight record and medical history are brought up to
date.
Already this scheme has revealed several persons
with undoubtedly progressive, though comparatively
slight and favourable, lesions requiring treatment.
These lesions were discovered at routine examina-
tion, were, unaccompanied by definitely significant
symptoms, and would not have been detected until
later without such a scheme, The number of such
cases, however, was considered no more than would
be expected in a medical student population.
_ It is hoped that within a few years the University
College Hospital and any similar schemes will have
demonstrated the practical possibilities and value
of this type of health service for young adults, and
may justify their introduction on a large scale.
By that time some of the results of the Prophit scheme
of the Royal College of Physicians, concerning the
evolution of the types of pulmonary lesion likely
to be met and their relationship to Mantoux
sensitivity, should be available. Besides serving as
one possible model, the present scheme should throw
light on the significance of the common respiratory
symptoms in a student population.
. OBJECTIONS AND DIFFICULTIES
Since the adaptation of the tuberculosis services
so as to allow of periodic examination is envisaged as a
possibility of the near future, both in the United
States (Kiernan 1936) and in England (Trail 1936,
Wingfield and MacPherson 1936), it is worth consider-
ing some of.the objections likely to be raised, and
difficulties likely to be encountered.
DR. D’ARCY HART: PULMONARY. TUBERCULOSIS IN ADULTS
[may 8, 1937 1097
The first is unnecessary radiological examinations.
To avoid these, in a group of adults where there is a
relatively low incidence of tuberculous infection
negative Mantoux tests may be used to reduce the
number of persons undergoing : radiography as a
part of their periodic examination. (Among medical
students and hospital nurses, judged by continental
and American figures and by. one set of English
data—Edwards 1936—the incidence of negative
reactors at the commencement of clinical traming
may be up to 20 per cent. or more.) In persons giving
a negative response the test must of course be
repeated at intervals so long as it remains
negative.
Apart from the small economy obtained by Mantoux.
tests in such groups, it is usual for every individual
to be radiographed at each routine examination,
even in the absence of symptoms, since serial radio-
grams form the basis of the method. The presence
or absence of symptoms is carefully noted, but, in
the University College Hospital scheme at any rate,
physical examination is only made if symptoms or
radiography suggests its advisability. This relegation;
of physical examination of the chest to an inferior
position as a method of case-finding in tuberculosis
may be objected to by some. It is, however,
justified by results of clinical and radiological mass-
studies (see Reid 1934, Wingfield and MacPherson
1936, Trail 1936), while the impracticability, in the
present state of knowledge, of sorting out adolescents
for radiological examination by means of differences
in general physical condition has also been pointed
out (McKinlay and Watt 1934).
Anxiety state among examinees.—An objection
usually raised to the principle in schemes of the type
contemplated is that more harm will be done by
producing nosophobia than good by detecting early
disease (see, for example, Hutchison 1934). At
present this danger does not appear to have affected
any established scheme to any serious extent, the
routine being accepted as of little mental consequence
once the novelty has worn off. Since, however,
every young adult population will contain many
persons liable to develop anxiety about various
diseases, every effort should be made to implant
health-consciousness rather than disease-consciousness.
The eventual inclusion of periodic examination for
early tuberculosis as part of larger schemes of
health inspection should help towards this end.
But the best argument against allowing the danger
of creating tuberculophobia to hold up establishment
of such schemes is that young adults, more often
than not, already have an outstanding dread of
tuberculosis—a dread founded on a sound knowledge
of public health statistics, And the best weapon
for removing this dread is to provide them with
experience that the majority of their fellow-workers
who are found to have lesions return to their jobs
after treatment. In any case the only alternative to
schemes of this type—namely, to emphasise early
but vague symptoms—seems itself just as likely
to produce nosophobia and with less return for the
effort expended.
Stigma attached to tuberculosis.—Somewhat allied
to the fear at present attached to. tuberculosis is the
associated social stigma.
This difficulty has to be faced in persuading
members of schemes to undergo treatment when
they do not feel particularly ill. If, however, the
hopes placed in this method are fulfilled, the
gradual preponderance of mild sputum-negative
cases undergoing relatively short periods of treat-
ment should alter the popular, and at present
1098 THE LANCET]
DR. D’ARCY HART: PULMONARY TUBERCULOSIS IN ADULTS
[way 8, 1937
substantially correct, picture of phthisis with its usual
consequences.. :
Moreover, the treatment of these slight cases may
come to be simplified. Thus home supervision, with
some degree of restricted life but without loss of work,
has been. used for some types. ‘‘ Ambulant” chryso-
therapy has been suggested for certain early cases by
Sayé (1934), while Diehl and Myers (1936) mention 16
students who have recently commenced pneumothorax
treatment without loss of work. When sanatorium
treatment is used, it may eventually be found practicable
to arrange that sputum-positive and asymptomatic
cases are not sent to the same institution.
In association with these developments public
instruction pointing out the importance of treatment
of slight asymptomatic cases in preventing tuberculosis
as it is usually known would be of value, while the sana-
torium for such patients might appropriately be termed
a@preventorium. It is of interest that the present Sheffield
tuberculosis service appears to be concentrating upon the
hospitalisation and after-care of the preclinical and
minimal sputum-negative case, regarding a sputum-
positive case as a comparatively late one, and claims
by these measures to be reducing tne stigma usually
attached to the disease.
Classification.—It may become advisable to classify
the asymptomatic or preclinical case separately, as
suggested by Opie (1935). In England this would
necessitate subdivision of the T.B. minus class of
Ministry of Health form 17/T (revised), the sub-
groups possibly to include such headings as slight
or minimal, and asymptomatic-progressive or pre-
clinical. On the other hand, official recognition of
insignificant or healing lesions not requiring treat-
ment would be of little value. It should be
emphasised that the gradual introduction of schemes
of periodic examination in the country at large would
have a marked effect upon the statistics of new
cases, causing a gradual unnatural increase,
Difficulties in X ray interpretation—With a
standard interval of a year one must expect to meet
some cases that show extensive lesions and yet have
had a negative previous examination (see Reid
1934), if only because some individuals will delay
to report symptoms occurring during an intermediate
period. Nevertheless, in a certain number of such
cases the previous radiogram, on reinspection, may be
found to show smalt shadows that had been regarded
as insignificant, or had been missed altogether. A
good quality of film, so far as possible comparable
conditions, and a high degree of competence in
interpretation are therefore essential ; while even the
smallest visible shadows could advantageously be
recorded—for information only—at least until
experience has been gained in the method.
When a particular shadow, ascribable to early
tuberculosis, has been detected, difficulty may still
arise as to its prognostic significance and as to any
action required. It may be argued that many of
the slight progressive lesions would have healed by
themselves if left undiscovered; that others would
do as well—even though by that time more extensive
— if detected later on in the ordinary way ; and that
others will still progress unfa¥ourably no matter
what is done.
It may be stated, in reply, that the rationale of
this method of diagnosis depends, so far as the
individual patient is concerned, upon the hypothesis
that, on the average, a slight and early case does better
with than without treatment, and that with treatment
it does better than does a later and more extensive
case. The difficulty in interpreting a particular
lesion, and of deciding any action required, can
often be resolved after keeping the person under
close observation. Intensive research, such as the
Prophit scheme, should add greatly to knowledge
of the prognostic significance of these various early
X ray lesions, but the results will not be available ~
for some years, and delay in proceeding with trial
routine schemes of periodic medical examination
until then appears to be unjustifiable. In any case,
even if they were assumed to be useless to the
individual patient, such routine schemes would benefit
the community by earlier removal of otherwise
undetected sources of infection. Nevertheless, until
further experience in interpretation has accumulated,
we must face the occasional risk of unnecessary treat-
ment as an altermative to postponing interference
until too late. At the same time, this element of
uncertainty makes it all the more necessary to see
that treatment does not mean avoidable economic
suffering.
Economic security of the examimee.—lIf schemes of
periodic examination are to be introduced on a large
scale into industry, economic factors are likely to
play a decisive part. I have already spoken of
the temptation for a man to resume his occupation
too soon and of the tendency to remain too long
at work without seeking medical advice. But the
financial difficulty is far greater when a man is
advised to discontinue work and to undergo treat-
ment at a time when he does not feel particularly ill.
The assurance of economic security to the examinee
. would make this advice more acceptable, and would.
make him more likely to report suspicious symptoms
arising in the interval between routine examinations
—an integral part of the scheme.
Since the safety of the group of workers, as well as of the
individual sufferer, must be considered, and at the same
time the information obtained must be treated as confi-
dential, the acceptability and success of a scheme would
be best assured by providing economic security in some
such way as the following. At the beginning information
explaining its purpose might be circulated, with the
assurance that under no circumstances will any worker
suffer dismissal as a result of any discovery made under
the scheme, and that where treatment is considered
necessary he shall have the right to another opinion of
his choice and shall receive, say, full wages (up to a
maximum) for a limited period. The period might be
chosen to cover the ordinary course of treatment and
- convalescence found after trial to be effective in favourable
cases. The payments might be derived from a special
sickness insurance fund.
Expenditure on schemes.—The economic E
of these schemes affect not only the individual
but also the community, which ultimately bears
the cost.. Hence some estimate of expenditure must
be attempted.
Probably the cheapest and most rapid radiographic
method is that of the Powers X-ray Tuberculosis Travelling
Survey Service, a triumph of American mass-production,
which takes paper films at the rate of 150 an hour at an
over-all charge of about three shillings a head (Barnard
1934). The interpretation and clinical part of the
examination are, of course, not included in these figures.
Presumably celluloid films, which are preferable, could
be cheapened to satisfy a mass demand, but an apparatus
for taking at high speed might be difficult to devise.
The University College Hospital scheme absorbs 1 man-
hour per student per examination from the whole (medical,
technical, and clerical) personnel and 4 to ł hour from each
student; but these times would undoubtedly be reduced
as procedure became standardised.
In considering the return to be obtained for the expendi-
ture in time and money, the number of cases likely to
be found, and the possible gain in the saving of life and
man-power, must be borne in mind. According to recent
reports, the incidence of clinical tuberculosis likely to be
found in a survey of a young adult population in a large
city of England or the United States is about 0-5 to 1 per
. Ua
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DR. D’ARCY HART: PULMONARY TUBERCULOSIS IN ADULTS
[may 8, 1937 1099
cent., while another 0-5 to 1 per cent. may be found to have
asymptomatic significant lesions, potentially or actually
progressive ; the figures being considerably higher where
groups of contacts or persons in unusually poor environ-
ment are being examined (Barnard 1934, Downes 1934,
Reid 1934, Fellows 1934, Opie ‘1935, Wingfield and
MacPherson 1936). These figures must- be taken as rough
indications and the incidence of lesions would be expected
to be somewhat smaller in subsequent examinations
than in a first survey.’ Thus the incidence of (mainly
young adult) applicants for employment at the Metro-
politan Life Insurance Co. from 1927 to 1932 with
significant active lesions requiring treatment was 0-4 per
cent., while the annual incidence of new such cases among
the actual employee population from 1930 to 1935 was
about 0-2 per cent.
The average annual expenditure per head of the com-
munity on tuberculosis services is more than 2s. at the
present time, and the immediate increase in expenditure
-~ under this head due to schemes of periodic examinations,
were the whole population included, would probably be
at least double this amount annually for diagnosis alone.
The expenditure on treatment, per head of the com-
munity, would also increase at first, since more cases of
tuberculosis would be diagnosed and sent for treatment.
But against this increase must be set the fact that much
of the present expenditure goes to prolonged and unprofit-
able treatment and to the after-care of chronic cases with
little prospect of resuming any useful occupation. . If the
proportion of cases diagnosed in a slight and favourable
stage increases, the expenditure per case should decline,
‘and this decline, together with the hoped-for reduction
in new cases as the result of eradication of infective
sources, will tend to offset the immediate increase in
expenditure on treatment per head of the community.
The value to the community of the lives and health
that might be saved by schemes of the type described,
even if only assessed in terms of fecundity or of the
monetary value of their potential work is, however, the
most important consideration in estimating whether
the increased expenditure entailed is justified. For the
younger adult age-groups this value is enhanced by the
notorious rapidly changing age-composition of the popula-
tion towards a preponderance of older persons, and by
the recent decline in the birth-rate. (For calculation,
on an actuarial basis, of the prospective money value of
& man as a wage-earner at different ages, and according
to the amount of his earnings, see Dublin and Lotka 1930.)
PERIODIC MEDICAL EXAMINATION ON A LARGE SCALE
I have purposely emphasised the possible objections
and difficulties. But since it is to be hoped that
the method will in spite of them find increasing
favour in this country, it is well to conclude by
indicating how such schemes might be introduced
in the community at large.
It seems desirable, at first, to limit them to young
adults, aged 15-24, and to select groups that are
easily accessible—more particularly those with a
greater than average chance of developing progressive
lesions. These categories will include university
students and nurses, and persons attending diabetic
and antenatal clinics. The next step might be to
introduce schemes for young adults in State-controlled
employment, such as the civil service or Navy,
after which schemes might be developed among
industrial groups, presumably under the control of the
industrial medical or public health service.
At some point in their development these schemes
would come into conflict with the diagnostic side,
both of the consultant and of the contacts service
of the present tuberculosis dispensary system. It
would be difficult, even if it were desirable, to avoid
taking over the function of the former, but the future
of the contact examination service is a more complex
matter, though obviously of great importance since
the yield of cases is higher than in any other set of
persons. The points in which the present contact
examination service differs from a fully developed
scheme of periodic examination have already been
described. There appear to be two alternatives for
the future.
The first is that the present contacts service be
expanded and modified so as to work, so far as possible,
on the model of the other, fully developed, schemes.
The main object of expansion would be to render
practicable the examination of a greater number of
new adult contacts and to make their follow-up
more complete. This expansion, even if limited to
young adults, would have to be very considerable,
from the estimates given previously. A compromise
might, however, be reached whereby adult contacts
of all ages are radiographed once (to discover the
primary infective source and any other cases), while
further observation by periodic examination and
serial radiography is limited to young adults in those
families where the original case, or any other discovered
at first examination, is sputum-positive. The main
point in favour of retaining a contacts service in some
form or other is the advantage of having one doctor
in charge of a tuberculous person and his entire family,
for purposes of observation and social care.
The second alternative is to permit the functions
of the present contact examination service to be
taken over by the fully developed schemes of periodic
examination (which of course include non-contacts
as well as home-contacts). Certainly the dual
purpose of the latter—to help prevent disabling
pulmonary tuberculosis and to help prevent spread of
infection to others—seems to cover the diagnostic
functions of any special contacts service. And it is
possible that selection of a group of young adults
on an industrial or study basis rather than on a
family basis might do more to achieve this dual
purpose, because of the greater accessibility of the
examinees ; while the determination of an individual’s
first examination under a scheme by his age, rather
than by the discovery of a clinical case of tuberculosis
in his proximity, might also be an advantage. The
industrial or other fully developed schemes would
allow the close observation of persons who have had
pleurisy, the full importance of which as a precursor
of progressive pulmonary lesions is becoming increas-
ingly realised (see Trail 1937). Finally, the industrial
or other schemes could form part of a comprehensive
health service that would include the detection of
pulmonary tuberculosis as merely one of its important
functions.
Conclusions Regarding Early Diagnosis
Earlier diagnosis and treatment of progressive
pulmonary tuberculosis among adults should benefit
the community by helping to prevent the more serious
forms of the disease, to restore more persons to health
and work, and to eradicate sources of infection.
For achieving early diagnosis in the past we have
tended to concentrate upon the early clinical case—
i.e., the patient who already has symptoms or physical
signs. In the future we must concentrate upon the
preclinical case. In the past we have for the most
part attempted to recognise the presence of progressive
lesions, soon after symptoms have developed, by a
single examination at the request of the individual
when he feels ill, In the future we must try as far
as possible to discover these lesions before the onset
of definite symptoms by the routine periodic examina-
tion of selected groups of individuals, particularly
young adults, supposedly in health. Serial radio-
grams and (especially where a low tuberculous
1100 THE LANCET]
infection incidence prevails) Mantoux tests would be
the basis of such examinations.
* * x
With its sensitivity to social conditions, its chronic
course, its infectiousness, and its possible detection
'before signs and symptoms develop, and with the
benefits attainable from early treatment, pulmonary
tuberculosis has offered and still offers remarkable
opportunities for the practice of preventive medicine.
And the four measures particularly emphasised in
these lectures—social measures applicable to the
community at large, social measures applicable to
the individual sufferer and his family, protection of
members of the community from infectious disease,
and the detection of the first signs of deviation from
health—treflect the varied aspects of preventive
medical practice in general. Furthermore, the
changes envisaged in applying these four measures
to the particular disease tuberculosis coincide with
a general movement of the profession towards regard-
ing maintenance of health as its primary goal, and
towards a greater interest in those social conditions
‘often forming the background of illness. The
measures used in the fight against tuberculosis can
form the spearhead of this movement.
I wish to record my deep gratitude to Prof. G, Payling
Wright for the advice given throughout the preparation
of these lectures. I wish.also to thank Dr, G. W. Pickering
for suggestions towards improvement of thetext; Dr. A. J.
Morland and Miss H. M. Matheson, of Holborn Tuber-
culosis Dispensary, and Dr. C. H.C. Toussaint and
Miss O, J. Pike,of Bermondsey Dispensary, for supplying
certain data ; and Dr. J. E. Chapman, Dr. T. O. Garland,
and Dr. D. H. Mills for help on special points,
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and Burrows, V. A.
. DR. D'ARCY HART: PULMONARY TUBERCULOSIS IN ADULTS
‘Leighton, G.,
[may 8, 1937
ee (1926-28, 1933-34, 1935a) Reps. of central Tuberc.
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. 17, 132.
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Stocks, P. tay D Statist. Soc. 99, 283.
Trail, R. R. (1934) B rit. med. J. 1, 373.
— d 936) Trans. PAR Ass. Tuberc., Lond. 22, 67.
— (1937) Lancet, Jan. ET p. 247.
— and Stockman, G. D (1931) Mortality after Sanatorium
_ Treátment anurat Sanatorium).
— Nett: ) Quart. J ed. n.8. 1, 415.
Walleren, A 1934) J. Amer. med. Ass. 103, 1341.
Webb, S. Webb, B. Cas Soviet Communism: a New
Civilisation ?, London
= an
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Wingfield, R.C.,and MacPherson A. M.C. (1936) Brit. med. J. 1,
LANCASHIRE MENTAL HosPITALs.—The Minister
of Health has sanctioned the borrowing of £488,666
by the Lancashire Mental Hospitals Board for works
in connexion with the extension of the Brockhall
Certified Institution for mental defectives to provide
accommodation for 1326 additional patients. This will
bring the total accommodation of the institution up to
2098. The additional accommodation to be provided
includes a hospital, school, work-rooms, recreation hall,
staff cottages, and administrative buildings.
SEAMEN’S HOSPITAL SOcCIETY.—The Earl of Athlone,
presiding at the annual meeting of the court of
governors of this society on April 21st, said that at
the new Albert Dock Hospital a model fracture clinic
is being built through Lord Nuffield’s generosity,
where after discharge from the wards, patients will be
retained under observation and treatment in the rehabili-
tation centre. There will also be a dining-room where
men who only receive a maximum of 30s. a week as
compensation pay will receive proper nourishment.
Only £9500 is now required to complete the appeal made
by the Albert Dock Hospital rebuilding fund for £50,000.
THE LANCET]
INSULIN SHOCK TREATMENT OF
SCHIZOPHRENIA
By G. W. B. James, M.C., M.D. Lond.’
PHYSICIAN FOR MENTAL DISEASES TO ST. MARY’S HOSPITAL,
LONDON, AND MOORCROFT HOUSE, HILLINGDON ; LECTURER
IN MENTAL DISEASES, ST. MARY’S HOSPITAL
MEDICAL SCHOOL
RUDOLF FREUDENBERG, M.D. Freiburg
ADVISORY PHYSICIAN TO MOOROROFT HOUSE, HILLINGDON ; AND
A. Tanpy Cannon, L.R.C.P. Irel.
ASSISTANT PHYSICIAN, MOORCROFT HOUSE, HILLINGDON
GROWING interest is being shown in the insulin
shock treatment of schizophrenia introduced by
M. Sakel in 1933 at the Pötzl Clinic, Vienna. By
the courtesy of Prof. O. Pétzl we were enabled
to study the method in Vienna, and formed the
opinion that it may prove to be an important thera-
peutic contribution to the attack on a disease which
has hitherto defeated most curative efforts by its
chronic and progressive course. As a result we have
used the insulin shock therapy at Moorcroft House,
Hillingdon, since the beginning of the present year.
To discuss results would be premature in view of
our brief experience ; it may be said in general that
they are encouraging. |
References in British journals to this form of treat-
ment are at present limited. Apart from the well-
known study by I. G. H. Wilson (1936) there has
been a brief note by D. K. Henderson (1936) in the
report of the Edinburgh Royal Hospital on the
cases treated there by P. Strecker, and recent articles
by L. W. Russell (1937) and E. H. Larkin (1337).
The latter are of special interest in that they report
the use of the treatment in two English hospitals
and set out the results obtained in a small series of
cases,
Some definition of terms commonly confused may
be useful at the outset. It is essential to distinguish
between ‘shock’? and “coma,” sometimes used
synonymously. -The term ‘“shock’’ should be
confined to the period of time between the initial
symptoms of hypoglycæmia and their interruption
by the administration of glucose. The term “ coma,”
on the other hand, should be limited. to the stage of
hypoglycemia during which consciousness is lost,
the patient: being insensible to stimuli such as shouting
his name or touching his body. We speak.of “ deep
coma’’ when hypotonus appears, the corneal and
plantar reflexes being absent. “Deep coma” should
never be permitted to last longer than 14 hours.
We attach great importance to certain details in
which our technique differs from that outlined by
Russell and by Larkin. For example, Russell
states that he leaves the patient in coma for 2-23
hours daily, but fails to say by what standards the
depth of coma is measured. If the patient is left
more than 1} hours in “‘ deep coma ” there is serious
risk that restoration may be difficult. Larkin avoids
the occurrence of epileptiform fits by premedication
with Prominal. Our experience confirms the generally
accepted view that fits are useful therapeutic accidents.
In selected catatonic cases we have therefore induced
occasional epileptiform seizures by the intravenous
use of Cardiazol, insulin being omitted on these days,
thus combining the methods of L. Meduna (1937)
and Sakel. These cardiazol seizures lasting a few
seconds require no remedial interference, but fits
occurring during hypoglycemia must be interrupted
DR. JAMES & OTHERS: INSULIN SHOCK TREATMENT OF SCHIZOPHRENIA [may 8, 1937
1101
forthwith on account of the danger that status
epilepticus may develop.
More importance should be attached to constant
medical attendance on patients in hypoglycemia.
Alarming emergencies may arise, sudden in onset
and serious in their results. Hypoglycemic coma
may be compared with anzsthesia, and the anæs-
thetist never leaves his patient. A doctor should
remain in the insulin department from the time of
the injection until the last patient is awake. When
six or more patients are undergoing treatment a
second doctor should be quickly available during
the critical period of hypoglycemia (in our case
10 A.M. to noon) as it has happened that we had to
deal with two or more emergencies simultaneously.
Care must be exercised to ensure that the nursing
staff can obtain a doctor at short notice for the rest
of the day and following night.
If wide departures are made from the established
principles of the treatment as evolved by its originator,
serious risk to life will ensue, and the method may
thereby be brought into disrepute. These considera-
tions must serve as our excuse for recapitulating
in detail the technique used in Vienna, Munsingen, and
Otwock, carefully summarised by E. P. Frostig
in a lecture given to the Arbeitsgemeinschaft für
Psychiatrie und Pathophysiologie, Vienna, in 1936,
and as far as we know unpublished. We include a
description of the major manifestations to be expected
during the shock period and their management with
the object of obtaining maximum therapeutic results
with a minimum of risk.
“THE SELECTION OF MATERIAL
The criteria of the diagnosis of schizophrenia is
one of the first difficulties. The standards are
subject to slight variations in different countries and
even in different schools in the same country. All
workers should follow a definite plan for arriving
at the diagnosis and report the data on which that
diagnosis rests. Further, the different classes into
which workers divide schizophrenia should be clearly
defined and described, as it would seem that insulin
therapy produces different results in the separate
clinical types of the disease, Our own diagnostic
requirements roughly follow the classical description
of dementia precox and paraphrenia by Kraepelin,
and therefore include patients that some writers would
distinguish from schizophrenia. In recording histories
it is of the utmost importance to differentiate between
the more chronic and progressive cases and those
with acute onset and a tendency to show remissions ;
this differentiation will be found essential when
a final assessment of the worth of the method comes
to be made. We would stress the importance of
classifying the cases according to the duration of
schizophrenic symptoms; they are usually grouped
under headings which distinguish the length of the
illness as up to six months, up to one year, up to
eighteen months, and over eighteen months.
PHYSICAL EXAMINATION OF THE PATIENT
A detailed and orderly physical examination is
essential. This is especially necessary if advanced
cases are to be treated. Contra-indications to insulin
therapy are not yet clearly defined, and further
accurate information on this subject is needed.
The rule at Moorcroft House is that when routine
examination reveals any suspicion of organic disease,
especially cardiovascular or hepatic disease, the
treatment is postponed or abandoned. We have
learned to pay particular attention to the lean
asthenic type of individual with cold extremities
1102
and low blood pressure. Our experience teaches
that such types are highly sensitive to insulin, often
produce severe hypoglycemic manifestations, and
prove difficult to arouse from coma after the
administration of glucose. Such difficulties appear to
us less common in the athletic and pyknic physical
types. In asthenic types insulin may more often
produce toxic hypoglycemic reactions and after effects,
which include vomiting, diarrhea, tachycardia, and
pyrexia. When such manifestations occur, treat-
ment (after a short rest) is carried on with much
reduced doses. The patient may then acquire
a higher level of resistance, described by E. Küppers
(1937) as “ adaptation.” In the experience of one
of us (Freudenberg 1936), this adaptation is assisted
by giving intramuscular injections of vitamin B,
together with an extract of suprarenal cortex every
evening until adaptation is established. In a few
patients very resistant to insulin premedication with
alkalis—e.g., sod. bicarb.—orally or intravenously
has been found to increase sensitivity (R. F.).
BRAND OF INSULIN
All the experience gained of insulin shock therapy
has been obtained by the use of pancreatic extracts.
These extracts are standardised experimentally
by their effects on the blood-sugar of rabbits. The
mechanism of the effects of high doses of insulin
continued over a long period, as in insulin shock
therapy, has not yet received sufficient experimental
investigation, these effects having been studied
chiefly by clinical observations recently summarised
by K. Th. Dussik and R. Freudenberg in a lecture
given to the Arbeitsgemeinschaft fiir Psychiatrie und
Pathophysiologie, printed by Ars medici Verlag,
Vienna, 1937.
There seem to be small differences in the effects
produced by different trade preparations of insulin.
For this reason the commercial preparations used
should always be mentioned in records of cases. We
have used the Wellcome brand of pure crystalline
insulin. Our experience confirms the view of Miiller
(1936) who lays stress on the apparent increase in
sensitivity to insulin which occurs in many patients
during treatment. We believe this change in sensi-
tivity to be of the utmost importance, and it is our
rule to attempt to diminish the amount of insulin
once the coma dose has been reached. Other patients
develop increased resistance to insulin in the course
of treatment. It is of interest that increased sensitivity
may change to a high resistance to insulin in the same
patient. These facts have not yet been satisfactorily
explained. During our fifteen weeks’ experience
crystalline insulin has not produced an urticarial
rash in any of our cases. The ‘‘ Wellcome” brand
has the great advantage of being prepared in three
strengths, 80, 40, and 20 units per c.cm., thus saving
patients on large doses much discomfort.
PHASES OF THE TREATMENT
Phase I.—The usual practice is to begin the treat-
ment with a subcutaneous injection of 20 units of
insulin (or less in the case of debilitated patients)
given at 7 A.M., the patient fasting from 7.30 P.M.
the night before. This dose is increased daily by
5 to 10 units until the initial coma dose (15-300 units)
has been reached. In two of our cases 30 units produced
severe epileptiform convulsions less than one hour
after injection ; in one of these coma is now obtained
with 15 units. This patient was of the asthenic type.
The duration of phase I depends on the sensitivity
of the patient, the amount by which the dose ‘is
increased, and probably also on factors which are
THE LANCET] DR. JAMES & OTHERS: INSULIN SHOCK TREATMENT OF SCHIZOPHRENIA
[may 8, 1937
at present unknown. The physical and mental
signs and symptoms in phase I are here briefly
described as far as possible in the order in which they
appear. No hard and fast rule can be laid down
either as to the time or order in which they arise.
Indeed, some patients seem to present very few signs
and symptoms in phase I, and the manifestations
may vary from day to day in the same patient. |
During the first hour signs and symptoms are mostly
absent. Flushing of the face is usually the first noticeable
change, and may be followed by a mild euphoria, accom-
panied by giggling and often a feeling of well-being and
strength. Commonly associated with the euphoria is a
period of lucidity and insight which will be referred to
below. The patient often complains of hunger. Sweating
may occur with the flushing, but is more marked later
when the flush has given way to pallor. Somnolence
follows, often after a short spell of restless tossing in the
bed. The euphoric period may develop into almost any
type of excitement from singing, whistling, and obscene
remarks, to a wild psycho-motor restlessness, with constant
incoérdinated movements, from which injury may result
unless padding of the bedstead is adequate. There is
usually a prelimi rise in the pulse-rate, and slowing
in the later stages. Myoclonic twitchings may appear
in the third or fourth hour, when the patient is gradually
losing consciousness, and may develop into an epileptiform
attack.
Interruption in this phase is carried out by making
the patient drink sugared tea (7 oz. of sugar in
500 c.cm.).
Phase II.—This is the phase which is ushered in
by the establishment of the initial coma, afterwards
repeated daily during this phase of the treatment.
In coma the patient is unconscious and incapable of
being roused; as it progresses salivation becomes
profuse, and extensor plantar responses, often
bilateral and spontaneous, appear. Next hyper-
tonus, usually in flexion, is seen but this should
disappear and give place to hypotonus.
-= From the clinical point of view the coma now enters
on a stage requiring careful observation. With hypotonus
and flaccidity of the muscular system generally, the
reflexes disappear. There is no response to the plantar
reflex, the corneal reflex is absent, the deep and superficial
reflexes cannot be obtained. Eventually, if the coma
is allowed to proceed, hypertonus may reappear. The
upper linibs are rigidly extended in pronation, the lower
limbs become rigid in extension, opisthotonos may occur
and the patient resembles the decerebrate animal. With
the early hypertonus and myoclonic twitchings the pupils
tend to be dilated. When hypotonus and flaccidity occur
and the corneal and other reflexes fail, the pupils are
contracted. Finally, in the stage at which hypertonus
reappears, the pupils again dilate and may fail to react
to light. In this condition, referred to above as resembling
the decerebrate animal, interruption becomes an immediate
necessity.
Dosage should be arranged so that coma does not
begin until the third hour following the insulin
injection. If coma commences prematurely it is a
sign that the dose is too big.
A word of caution as to the management of all
cases during the hypoglycemic period may be added
here. Patients should be left as quiet as possible.
Movements or struggling will produce compensatory
secretion of adrenaline, resulting in a lessening of the
depth of coma.
Phase III.—This term was used by Sakel to denote
periods of rest. It is still used in this sense and now
means the weekly day of freedom (Sundays), and the
compulsory rests after the patient has suffered from
“ emergencies ’’ (see below), or after effects of treat-
ment. A day or more of rest should also follow
diarrhcea and pyrexia.
THE LANCET |
: Phase IV.—This phase (withdrawal of the therapy)
begins when no further clinical improvement can be
obtained, and in any case after about three months
of treatment. The dose of insulin is reduced to
roughly one-third or less of the coma dose and
interruption is carried out about 2 hours after the
injection. This process occupies from 4 to 8 days.
INTERRUPTION
In phase II interruption is normally carried out
by the nasal tube. We believe the tube should be
passed only when the patient is in coma, Gastric
secretion, usually increased in quantity, is withdrawn
and tested by litmus paper so that there can be no
question that the tube has arrived at its proper
destination. A precautionary passing of the tube
at an. early stage of coma is justified when signs
such as severe myoclonic twitchings suggest that a
state of emergency is imminent. If such pre-
cautionary insertion of the tube has been carried out
and a period of time has elapsed before actual interrup-
tion the gastric juice is again tested. A funnel and
tube with a glass connexion enables dilute sugared
tea (7 oz. in 500 c.cm.) to be run into the stomach.
When a patient is known to have a tendency to
vomit, 2 minims of 1 : 1000 solution of atropine
sulphate are introduced through the tube before the
feed. During the whole of this operation the tube is
held in position by doctor or nurse. For patients
refusing meals this opportunity is used to administer
a good feed containing the same amount of sugar,
with milk, cream, and three eggs. After the intro-
duction of the feed the nasal tube is removed
immediately. Our experience supports the view that
patients are adversely affected by waking to find the
nasal tube in position, and we consider that to leave
the tube in situ until the patient awakes as advised
by Larkin is undesirable. Waking should take
place within 20 to 30 minutes and the patient is then
given cake or biscuits and milk to drink. During
coma the body temperature falls to a very low level,
often under 95° F. After interruption. patients
appear cold, with shivering and “ goose flesh,”
and it is our practice to have hot-water bottles ready
to apply in every case. mer
The daily length of the coma must be extended
gradually and never continued beyond a period (dis-
covered by trial) that allows the patient to awake easily
and without after effects. There is an “ optimum ”
duration of coma for each patient which is often less
than 14 hours.
After interruption patients rest in bed for about
half an hour, care being taken to change the clothing
which is generally soaked in perspiration. Patients
take an ordinary lunch and someone must see that
sufficient food is taken at all subsequent meals, or
late hypoglycæmic symptoms may occur. It is our
practice to record the food consumed during the day,
a task entrusted to one of the nurses.
AFTER EFFECTS
Reference must be made to after effects, rare if-
proper precautions are observed. Among them is
vomiting, with loss of the glucose feed and resulting
repetition of any of the hypoglycæmia signs, including
coma and fits. Intravenous glucose may be required
when this happens but if the patient is sufficiently
awake and the manifestations of hypoglycæmia
are slight, carbohydrate food may be given by the
mouth. A less frequent after effect is the progressive
deepening of the coma subsequent to the administra-
tion of glucose. When this phenomenon is observed
intravenous interruption is required.
7
DR. JAMES & OTHERS: INSULIN SHOCK TREATMENT OF SCHIZOPHRENIA [may 8, 1937 1103
General Indications for Interruption
Hypoglycemia must always be interrupted :—
1. By the end of the fifth hour from the time of the
injection—e.g., by noon if beginning at 7 A.M.
2. Whenever gross disturbances or variations of the
pulse occur—e.g., irregularities, or rates of over 120 or
less than 40. |
3. If hyperextension of the limbs with pronation of the
upper limbs is persistent.
4. In the presence of stridor with cyanosis and movement
of the accessory muscles of respiration.
5. en hunger excitement occurs (Sakel 1935).
This is to be distinguished from the customary requests for
food, and consists of wild excitement and a fierce shouted
insistence on an immediate meal.
Interruption should take place at whatever stage
of the hypoglyczmia these general indications appear.
Sometimes the patient is able to drink his sugared
tea, but usually the nasal tube is required.
INDICATIONS FOR INTRAVENOUS INTERRUPTION :
“ EMERGENCIES ”
The following “‘ emergencies >° are indications for
intravenous interruption :—
1. Respiratory embarrassments which include the
sudden cessation of respiration and laryngeal spasm.
2. The premature incidence of coma. Premature coma
tends to deepen with alarming rapidity. This phenomenon
results from an unwise increase in the initial coma dose,
or in a specially sensitive patient.
3. Obvious cyanosis of the mucous membranes with a
weak and rapid pulse.
4. Epileptiform fits. These attacks may occur at any
time in the hypoglycemic period or after interruption.
Fits after interruption usually develop within 40 to 50 .
minutes. They may occur rarely at a much later period
should hypoglycemia for any reason return. In addition
to the intravenous glucose the nasal tube should be passed
and a feed inserted into the stomach, thus providing a
carbohydrate depôt on which the patient can draw. In
the epileptiform attack, the usual precautions against
tongue biting are taken. i
5. Cardiovascular collapse. In this sudden emergency
subcutaneous injection of adrenaline (l c.cm. of 1 : 1000
solution) is the best initial step. Intravenous therapy
may be rendered impossible by the collapsed condition
of the veins, in which case the physician should proceed
to give an intraventricular injection of 2 to 4 c.cm. of
33 per cent. glucose solution. If adrenaline has not already
been given subcutaneously or intramuscularly, it may be
added to the intraventricular injection.
6. Vomiting.
7. A state of wild psycho-motor excitement, with
flushed face, and dilated pupils. This condition is some-
times seen after interruption by nasal tube, and in such
cases intravenous glucose must be given. If the excite-
ment continues lumbar puncture will sometimes be
necessary. Paraldehyde or amylene hydrate by the
rectum are useful.
CERTAIN POINTS IN TECHNIQUE
Lumbar puncture is advisable when the patient
fails to awake after intravenous interruption. In
this condition bleeding is also advisable, and up to
300 c.cm. of blood should be withdrawn.
A 33 per cent. sterile solution of glucose is always
used for intravenous interruption, the injection of
from 60 to 120 c.cm. being sufficient to awake most
cases. We use 20 c.cm. syringes, which are easily
refilled while the needle remains in position.
There is one restorative measure which we have
found very useful in certain emergencies. A cylinder
of mixed oxygen and CO, (5 per cent.) is kept ready
on a wheeled stand. Administration of this mixture
is especially useful in cases of cyanosis, and in patients
who fail to awake after intravenous interruption.
In our experience it has also relieved laryngeal spasm.
T3
1104 THE LANCET] DR. E. SCHNOHR: CALCIUM MANDELATE IN URINARY INFECTIONS
We have applied the suggestion of Sakel (1936)
that paranoid cases be treated with deep coma.
He advocates that in treating catatonic stupor
interruption should be effected while the patient
is in a euphoric or excited condition. This often
puts an end to the stupor, exposing a loose system of
paranoid ideas. Subsequent treatment should then
-be directed towards obtaining deep coma. On
the other hand, catatonic excitement should be
interrupted during the period of quiet somnolence
before the onset of coma, carefully avoiding interrup-
tion during excitement. When the patient has
become sufficiently quiet the treatment is continued
with daily coma. l
We never use adrenaline to secure interruption,
its use for this purpose having been abandoned
in Vienna. We reserve it for cardiovascular collapse
and laryngeal spasm.
SYMPTOMS AND THERAPEUTIC
MEASURES
We have already stated that before coma appears
euphoria is common, with some degree of lucidity
and insight. This is an opportunity for the physician
to re-establish contact with inaccessible patients.
A word of warning is here necessary. Throughout
the treatment until comatose, patients are extremely
sensitive and exhibit a pronounced hyperacusis.
Caution must be exercised as to what is said in the
neighbourhood of the patient, even in a whisper.
An unwise chance remark may act as a serious psychic
trauma. It is best to leave the patient alone while
he is waking from coma and, in the early days of the
treatment, to avoid any discussion with him concerning
his illness. Such discussion has in our experience
resulted in relapse in an otherwise improved patient.
For this reason the visits of relatives are a potential
source of danger.
The phenomenon of “reactivated psychosis” is
described by Sakel (1935) as a reproduction of
psychotic symptoms during the hypoglyczmic period,
the patient being normal during the rest of the day.
This phenomenon has frequently been observed
by us, and seems to be explained as a combination
of the ‘insulin psychosis” observed in mentally
normal diabetics, and the actual schizophrenic
condition for which the patient is being treated.
Sakel advises that phase II should be continued until
the “ reactivated psychosis ” disappears. There does
not seem to be general agreement on this point, and
our experience is still too limited to enable us to form
an opinion. All agree that the daily hypoglycemia
should never be interrupted during “ reactivation.”
The care of the patient after interruption is
important. So far as is feasible we try to ensure
that some definite occupation is provided for the
afternoon and evening. Patients leaving the grounds
should be accompanied by a nurse or responsible
relative, and chocolate should be carried as a con-
venient form of sugar in case of any return of hypo-
glycemic symptoms. This has actually occurred
PSYCHOLOGICAL
to one of our patients during a walk. Night nurses -
must be familiar with the signs indicating hypo-
glycemia, and must be instructed to pay frequent
visits during the night to patients undergoing
treatment.
CLASSIFICATION OF RESULTS
We are often asked as to the mortality to be expected
among patients treated with insulin shock therapy.
The most recent figure from a series of 400 cases
(Küppers 1937) is 1:5 per cent. It must not be
forgotten that the 400 cases collected by Küppers
contain those treated in the early days when mortality
[may 8, 1937
was higher from inexperience and faulty technique.
We believe that the death-rate will always prove
to be in inverse relationship to the care with which |.
a proved method of technique is adopted and applied.
We would strongly recommend the adoption of
some standard method recording results. We suggest
the four categories established by Miller (1936).
1. Complete remission.—This category represents com-
plete disappearance of schizophrenic symptoms, with
normal affective relationship, full insight, and ability to
return to the normal sphere of work.
2. Incomplete remission.—This category includes patients
who are able to work but with persistence of any one of the
psychic symptoms described under 1.
3. Partial remission.—Patients in this category are
able to resume work; symptoms remain without inter-
fering with their daily life. |
4. Unimproved, and requiring hospital care.
CONCLUSION
It seems likely that this method will be given an
extensive trial in this country, and it is clearly of the
utmost importance that fresh workers, or those
already engaged on this work, should make a serious
attempt to codrdinate and standardise not only the
technical side of a difficult and laborious procedure
but also the criteria of diagnosis by which cases are
selected, and the classification of results. It is hardly
necessary to enlarge on the advantages gained from
such standardisation. First, the undoubted dangers
of the procedure will be minimised by the adoption
of the proved technique. This is not meant to
imply that no modifications are possible; they are
bound to be tried. But in applying a method of
treatment that is not without danger to life, it seems
to us wise to follow closely a technical procedure
already fully tested in Vienna, Munsingen, and
elsewhere. Secondly, if it is possible to arrive at
agreement on the criteria of diagnosis, the cases
selected for treatment will command a general
acceptance as properly belonging to the schizo-
phrenic group of mental disorders. Thirdly, agree-
ment on classification of results will enable a quicker
judgment to be made of the real value of the new
method.
REFERENCES
Küppers, E. (1937) Dtsch. med. W schr. 10, 377.
Larkin, E. H. (1937) Brit. med. J. 1, 745.
Meduna, L. $ 1937) Die Konvulsionstherapie der Schizophrenie,
Halle a/S.
Müller; M. (1936) Schweiz. mel. Wschr. 39, 929.
Russell, L. W. (1937) Lancet, March 21h, p: 747.
pakel M (1935) Neue Behandlungsmethode der Schizophrenie,
ienna.
— (1936) Wien. klin. Wschr. 42, 1.
Wilson, I. G. H. (1936) Study of Hypoglycemic Shock
Treatment in Schizophrenia, London.
TREATMENT OF URINARY INFECTIONS
WITH CALCIUM MANDELATE
By EDGAR ScHnour, M.D.
(From the Surgical Department at the Sundby Hospital,
Copenhagen)
MANDELICc acid has been widely used in the treat-
ment of urinary infections since Rosenheim introduced
it in 1935, and the results published have all been
excellent.
I have treated 30 patients with sodium mandelate
and ammonium chloride as originally advised by
Rosenheim, and found that in 23 the urine was
sterile after 4-30 days, although several were severely
ill, some with stones and urinary stasis. The only
disadvantage of the treatment is that mandelic acid
THE LANCET] .
has a very disagreeable taste and not infrequently
causes nausea and vomiting. For some patients
the dyspeptic discomfort was enhanced by the
ammonium chloride, and occasionally the treatment
had to be given up. This led me to try the calcium
salt of mandelic acid which, unlike the sodium and
ammonium salts, is quite tasteless. The preparation
used * has the following constituents :—
Calcium mandelate 72-25
Cocoa powder .. : 7-50
Saccharum purificatum 20-00
Saccharinum solubile . 0-02
It is in granular form and one level dessertspoonful
contains 2 grammes of mandelic acid. In the
stomach calcium mandelate is broken down to
mandelic acid and calcium chloride, most of which
is converted into non-absorbable calcium salts in the
intestines. This gives a surplus of mandelic acid.
Since a part of the administered calcium is absorbed,
together with the mandelic acid, the calcium mandelate
will have a less pronounced acidifying effect than
ammonium mandelate, the all ammonia of which is
converted into urea. I have found, however, that
with calcium mandelate it is possible to obtain
a sufficiently acid urine. The values of pH obtained
have corresponded exactly with those following
administration of sodium mandelate with ammonium
chloride or of ammonium mandelate.
The results of treatment in 8 cases are summarised.
in the accompanying Table.
Result of Treatment with Calcium Mandelate
4s
©
Z REE
œ | Sex | Duration Days before | 2728
' a | and| of infec- Diagnosis. urine became | p53
© |age.| tion sterile. STS
‘ A ww
i B. coli, Pyelitis. 4 4°9 ,
41 | 5 yrs.
2 | F. | B. colt, re 4 4°8
29 | 2 yrs.
3 | F. | B. coli, Pyelitis; polypus |: 9 4°8
62 ? vesicee ; cholelithiasis ; g
cholecystitis.
4 B. coli, Pyelitis ; uretero- 6 5'1
57 | 4 yrs lithiasis.
6 Hem Cystitis ; pregnancy. 2 5°5
21 strep
1 mth
6 | F. | B. colt, Pyelitis ; broma 5 5'0
35 ? uteri; chron.
salpingitis ; cystic
degen. ovaries.
7 B. coli, Pyelitis ; nephro- Crystal clear 5°3
33 | 8 days. | lithiasis; dilatation within 10
both pelves. days.
8 | M. | B. colt Pyelitis ; nephro- After 10 days; 55
51 and lithiasis, dilated no growth of
proteus, | calyces. and ureter ; ; | B. coli. Con-
3 yrs. stone in bladder ; tinued growth
urethral stricture. of proleus.
Case 5 was given 6 grammes of mandelic acid daily, the
others 12 g.
With all the reservation necessary when comparing
groups of 30 and 8 patients, I must nevertheless
express my opinion that the infection of the urinary
passages was if anything more serious in the 8 patients
who received calcium mandelate than it was in
those who received sodium or ammonium mandelate.
And the therapeutic result was at least equally
* It was placed at my disposal by the Ferrosan Co., Copen-
hagen, and is sold by them under t e name of Camygdal aad ig
obtainable in Great Britain from H. R. Napp Ltd., London.
DR. E. SCHNOHR: CALCIUM MANDELATE IN URINARY INFECTIONS [may 8, 1937
1105
satisfactory. It is especially worth noticing that
the urine became sterile in Case 4, in which pyelitis
was complicated by the presence of an ureterolith
and dilatation of the urinary passage. The same
thing happened in Case 7, where there was nephrop-
tosis, dilatation of the pelvis, and a kink in the
ureter. In Case 3, where pyelitis was complicated
by polypi in the bladder, a month’s treatment with
sodium mandelate plus ammonium chloride had
no effect on the infection; yet after giving calcium
mandelate for nine days the urine was sterile. It is
hard to see how the calcium salt could be more
effective than sodium mandelate plus ammonium
chloride, when—as in this patient—the acidity
of the urine is identical, and it is easiest to assume
that continued treatment with sodium mandelate
would have given the same result, though sterility
of the urine is seldom so long delayed. If there is
a therapeutic difference, it is presumably attributable
to some action by the calcium ion itself on the
infection.
Regarding the question whether it is justifiable
to give mandelic acid in cases of renal insufficiency,
I would point out that three weeks previously this
patient had had serious renal insufficiency with
temporary anuria and greatly increased blood-
urea—a condition, I suppose, of ‘‘azotémie par
manque de sel.” The mandelic acid did not in any
respect impair the function of the kidney.
Of the two patients whose urine did not become
sterile, the first (No. 7) had bilateral nephroptosis,
dilatation of the pelvis and a kink in the ureter.
On the tenth day (when this report was brought
to a close) the urine was as clear as crystal, but still
gave a scanty growth of B. coli. In Case 8 there was
associated infection by coli and proteus; also there
was a stricture of the urethra, retention of urine,
dilatation of the calyces and the pelvis on one side,
and a concretion in the pelvis—conditions which
make it unlikely that care will be attained by medical
means. The proteus infection did not respond to the
treatment, but, on the other hand, the coli disappeared
within ten days.
All 8 patients who were given calcium mandelate
- agreed that it had no taste, and i in 5 of them it caused
no dyspeptic symptoms whatsoever. Among these
patients was No. 3, who had previously had sodium
mandelate and ammonium chloride which made
her vomit.
Of the 3 patients who had nausea after calcium
mandelate, No. 6 had no dyspepsia when she took the
medicine between meals and washed it down with
water. No. 7 was only nauseated for the first two
days, and No. 8 not until six days had passed. In
no case was it necessary to stop the treatment
because of dyspepsia. Thus there can scarcely be
any doubt that calcium mandelate has a great
advantage over treatment with sodium mandelate
and ammonium chloride.
SUMMARY
A new preparation in which mandelic acid is
presented as the calcium salt has been tried in the
treatment of urinary infections. It is tasteless,
seldom causes dyspeptic symptoms and gives a
sufficiently acid urine.
Treatment of 8 patients with this preparation gave
the same good results as treatment with other
preparations of mandelic acid.
I am indebted to Prof. Svend Hansen, chief of the
surgical department of the Sundby Hospital, for permission
to report these cases.
1106 ‘THE LANCET] |
CORNEAL GRAFTING (KERATOPLASTY)
REPORT OF A CASE
By T. H. SPENCER T1zzarpD, M.B. Glasg., D.O.M.S.,
HON. SURGEON TO THE EYE INFIRMARY, BATH
CORNEAL grafting was first successfully practised
as long ago as 1888 by von Hippel. His method was
to use a mechanical trephine, which is, however,
a difficult instrument to control, and liable to inflict
severe damage. The same method has been used by
Elschnig. Castroviejo (1934) employs a twin-bladed
knife which cuts a rectangular graft ; this he retains
in position by means of a conjunctival flap. Tudor
Thomas (1930, 1931) obtains his graft by using a
circular trephine of just over 4 mm. in diameter.
In his method the cornea is cut with the trephine
as far as the deeper layers, and he then uses a pair
of finely curved bevelled scissors to cut the remaining
portion. This shelving process prevents the cornea
from becoming dislodged and slipping into the
anterior chamber. The recipient’s eye is trephined
in the same way, but the instrument is of a slightly
larger diameter. Thus the graft can be more easily
slipped into the bed. It is retained in position by
an ingenious method of cross-stitching.
To retain the graft in position Castroviejo draws
the conjunctival flaps together over the graft by
undermining the conjunctiva from the limbus back-
wards above and below. Rycroft (1935, 1936)
employs a complete conjunctival flap, which is
drawn like a tent over the entire cornea and the graft,
and retained in position by a purse-string suture.
INDICATIONS
Cases of grafting are done in which opacification
of the cornea is due to interstitial keratitis, healed
ulcers, and chemical burns. In interstitial keratitis
the eye should have been quiet for at least twelve
inonths. .
Cultures should be taken from the conjunctival
sac of the donor and the recipient. The operation is
contra-indicated if any pathogenic micro-organisms
are grown during forty-eight hours’ incubation.
Tension should be within normal limits. There should
be accurate projection of light and there must be
no active inflammation.
CASE REPORT
The following case is that of a young man of 21
who two years previously had very severe interstitial
keratitis involving both eyes.
The patient first attended the Eye Infirmary, Bath,
in the summer of 1935. Both cornee were opaque.
In the right eye there was perception of light, in the left,
of hand movements. The pupils were fully active, but
it was not possible, owing to the diffuse corneal opacities,
to view even a portion of the fundi through the dilated
pupil. It was noted that there was an anterior capsular
cataract in the left eye, but owing to the density of
the corneal opacities in the right eye I was unable to
see whether there was a similar cataract in this eye.
He had had 18 months previously a full course of
Novarsenobillon, extending over six months, at another
eye hospital. As interstitial keratitis can recur, a very
small peripheral iridectomy was performed on the right
eye, the object being to see how it reacted. The eye
remained perfectly quiet after the operation. Since
vision in the right eye was less than in the left, vision being
so poor that it was useless as an organ of sight, I decided
to do the corneal graft if possible on this eye. During
the time he was in the infirmary in 1935 he was given
mercury and iodide.
MR. T. H. S. TIZZARD: CORNEAL GRAFTING
[uray 8, 1937
It was not until the summer of 1936 that a suitable
eye was found from which to take a graft. The cornea
for grafting purposes should be quite transparent and
clear and of normal thickness. I considered that a
cornea taken from a glaucomatous blind eye would be
unsuitable, as it would have been subject at some time
to abnormal stresses. The eye that became available was
taken from a man who was hit with a piece of steel, dis-
organising the interior of the eye, but leaving the cornea
in part uninjured.
OPERATION
The evening before operation the palpebral conjunctiva
was painted with 2 per cent. silver nitrate, and afterwards
irrigated with an alkaline lotion. Gut. eserin 4 per cent.
was instilled into the right eye. The morning of the
operation gut. eserin } per cent. was again instilled into the
right eye.
The recipient’s eye was anzsthetised with Pantocain,
a derivative of novocain that has no deleterious effect
Tho vae" k E T
A CORR ce a T a a T DLU a
Right eye before, and three months after, operation.
upon the corneal epithelium and no effect on the pupil
or intraocular pressure. The 7th cranial nerve was
blocked with Novutox at the site where its branch
crossed the neck of the condyle: of the mandible.
Complete paralysis of the orbicularis oculi was secured
with an injection of 2 c.cm. ' :
Preparation of the site in the recipient’s eye was firs
begun. The conjunctiva was dissected from the limbus
in its whole circumference, and the conjunctiva was
undermined and freed from the underlying tissue, so that
it could be drawn over the corne&’s by a purse-string suture.
Bleeding points were few and were easily controlled by
adrenaline, and there was no need to use a cautery.. The
site of the graft was delineated by placing a trephine
(4-63 mm.) over the centre of the cornea and cutting
through the epithelium. The trephine was removed and
a drop of sterile fluorescein was placed on the cornea. This
outlined the graft. When the section had involved half
the thickness the trephine was slightly tilted to one side
so that the cutting edge was directed obliquely through
the deeper layers of the cornea. The anterior chamber was
thus entered. The trephine was removed and the section
was completed by dividing the remainder of the cornea
with a pair of scissors whose cutting edges were bevelled.
The corneal graft from the donor’s eye was removed in
the same way, but with a trephine of 4-5 mm. so that the
piece of cornea could easily fit into the bed prepared.
The corneal graft was removed by sliding a repositor
beneath it and placing it in a watch glass filled with sterile
normal saline and little above body temperature.
The bed for the graft having been prepared, very
little time was lost between removing the graft from the
donor and placing it in its new bed. The conjunctiva
was now drawn completely over the graft and the cornea,
the former being kept in position by an oiled repositor
which was placed through a small hole underneath the
“tent ” so to speak, and held gently on the surface of
the cornea, while the purse strings were drawn tightlv
over it. One now felt that the graft was really in position
and had not been dislodged when drawing the conjunctiva
over it. Atropine oil was instilled and both eyes bandaged
firmly.
PROGRESS
On the fourth day the bandages were removed and one
drop of atropine oil was instilled into the operated eye.
The graft at this time could not be seen as it was still
completely covered with conjunctiva. The patient
complained of no pain or discomfort. The eyes were
again firmly bandaged. On the sixth day the bandages
THE LANCET]
were again removed and the graft was seen in position
and it was quite clear and transparent. Through it could
be seen the white opaque lens capsule resting on the
deep surface of the graft. By the tenth day the graft
had taken, but it did not appear as clear and transparent
as before around its periphery. The graft appeared to
be going opaque, but there was a clear area in the centre.
The patient complained of pain. Atropine oil was instilled
and the eye firmly bandaged. As the tension remained
+1, atropine was discontinued three weeks after the
operation. Now the graft began gradually to clear. The
tension however remained high for a further two weeks,
when it slowly returned to normal. The whole of the time
during which the tension was raised the eye was firmly
bandaged. Three weeks after the operation the patient
was able to count fingers two feet away. At the present
time vision remains the same, and the graft is transparent.
COMMENTS
The method employed in this case has, to my mind,
one great advantage. The conjunctiva when drawn
over the graft brings nourishment through the
lymph channels to the graft in the first few days when
CLINICAL AND LABORATORY NOTES
[may 8, 1937 1107
the graft is taking. At the same time the conjunctiva
protects the corneal epithelium from damage. The
one great disadvantage is that when one has drawn
the conjunctiva completely over the cornea and graft,
one is not sure that the graft has not been entirely
dislodged from its bed, or that it has not been even
slightly tilted.
In a case of interstitial keratitis, or in fact in most
eye operations, iritis is likely to be produced. Atropine,
by dilating the pupil, prevented anterior synechia.
The graft having remained clear, I propose, at
some future date, to extract the right lens.
This case was shown at the South Western
Ophthalmological Society’s meeting in December last.
REFERENCES
aoe ah Amer. J. Ophthal.
Ischnig, a (1923) Ibid, 6, 998.
Rycroft’ B (1986) Lancet, 1, 239.
— and Handelsman, G . (1935) Brit. med. J. 1; 919.
Thomas, J. W.T. Fh 30) Trans. ophthal. Soc. aK 50, 127.
— (1931) Ibid, 5
— 11233) Proc. HA Sa Med, 2
— (1935) Trans. ophthal. Soc. ad "55, 373.
Castroviejo, R. 17, 932.
CLINICAL AND LABORATORY NOTES
AN ABNORMAL LARGE INTESTINE
ENCOUNTERED DURING APPENDICECTOMY
By JOHN ALEXANDER MACKENZIE, Ch.M. Aberd.
BURGEON TO THE VICTORIA HOSPITAL, BURNLEY, AND
TO THE HARTLEY HOSPITAL, COLNE
On Sept. 3rd, 1936, I was called to the Victoria
Hospital, Burnley, by my house surgeon to see an
“ acute abdomen.”
The patient was a labourer, aged 29, married with two
healthy children. His mother had died of “cancer ”
at 35; his father was alive and well, and his brothers and
sisters healthy. Up to the age of 14 he had “ incontinence”
of fæces; from 14 to 16 he was troubled with diarrhea,
but from 16 to the present date he had been quite
healthy. He was well built and healthy looking. He
had a mitral murmur due to valvular incompetence,
but he was unaware of it and the condition had never
given him any trouble. The urine was normal.
The tempera-
ture was 101° F., ; 1
the pulse-rate
120, and the
pationt had
every classical
symptom and
sign of acute
appendicitis. I
operated at once
and on opening
the abdomen by
a right para-
median incision
was confronted
with a much
dilated large
intestine, which
on tracing up-
wards went up
below the liver
and on tracing
downwards went
over the right
side of the brim
of the pelvis to
form the rectum.
I discovered the
cecum behind
this and partly
covered by it,
(FIG. 1.— Radiogram after barium meal.
FIG. 2.— Barium enema filling the colon.
reaching down to within an inch of the brim of the
pelvis, while the peritoneum covering this large intes-
tine shaded off from its mesentery over the cecum,
covering it and fixing it down. At that point I could
find no trace of the appendix, although the bowel
showed inflammation. No small intestine was visible;
but passing my hand in front of this dilated part of large
intestine over to the left side I found all the small intestine
congregated there and by tracing it found where it entered
the cecum behind this dilated large intestine. On splitting
the peritoneum where the small intestine joined the
cecum in the acute angle pointing towards the umbilicus
I found a small and acutely inflamed appendix which
I removed. I resutured the peritoneum where I had
split it and closed the abdomen as quickly as I could,
because the man was desperately ill.
The patient made an uninterrupted recovery and
was later examined by barium meal. Fig.1 shows
the barium leaving the stomach and making for the
left side of the abdomen where the whole of the small
intestine is collected. A second radiogram showed
the' meal
2 entering the
cæcum behind
and at the
upper angle
where the
entrance was,
the diseased
appendix was
situated. It
could also be
seen passing
up the ascend-
ing colon and
into the trans-
verse colon. A
third radiogram
showed the
meal coming
down the-
descending
colon to the
normal sigmoid
flexure, but
S EREE A when it
eee reached the
Small intestine seen on right of abdomen. brim of the
pelvis it
1108 THE LANCET]
CLINICAL AND LABORATORY NOTES
[may 8, 1937
tinuous epigastric bruit in which post-mortem
suddenly changed its mind and ascended transversely i i i i
across the abdomen to the hepatic flexure, lying in front
and covering the original hepatic flexure and descend-
ing in front and a little to the left of the cecum where
it entered the pelvis on the right side to become the.
rectum. Fig. 2 was taken after a barium enema
and shows the splenic flexure and transverse colon
also. In all the radiograms a large gland could be
seen to the left of the vertebral column.
=- I have often found the sigmoid and rectum on the
right side of the pelvis, especially in women; and
in all these cases there has been a well-marked
mesentery. But I have never seen or read of any
case like this, nor have J seen any developmental
theory to explain it. Possibly the condition was
the cause of the incontinence of fæces in early life.
I am indebted to Dr. James Grieve, radiologist to the
Victoria Hospital, for preparing radiograms for me.
CONTINUOUS VENOUS HUM IN CIRRHOSIS
OF THE LIVER
By J. L. Bates, M.B. Lond.
RESIDENT PHYSICIAN, RUTHIN CASTLE, NORTH WALES
THE comparative rarity of a venous hum in
cirrhosis of the liver and the question of its causation
gives interest to the following case.
A man, aged 53, was admitted on March llth, 1936,
to Newcastle General Hospital under Prof. Thomas
Beattie for swelling of the abdomen, noticed ten days
previously, and dyspncea on exertion. His increasing
pallor and occasional attacks of giddiness had begun four
months previously when he was obliged to give up his work
as a turner and fitter. He had recently suffered from
flatulence and intermittent diarrhea. There was no
history of hrematemesis. The left leg had been amputated
in 1926 at Newcastle Royal Infirmary for chronic osteo-
myelitis following a war injury. At the same time a blood
test was performed and he was thereafter given a course of
injections. He used to be a heavy beer-drinker.
The patient was well built but appeared to have lost
weight recently. The abdomen contained much free
fluid and dilated veins were visible in both loins but not
around the umbilicus. The distension made palpation
difficult. Liver dullness not increased. Spleen not palpable.
No cardiovascular abnormality. The pupils were equal but
did not react to light. On auscultation of the abdomen,
there was a continuous, loud, high pitched bruit with
systolic and inspiratory exacerbation. This was heard
only over an area the size of half a crown just below
the xiphoid process.
Investigation.—A blood count showed:
2,340,000 ; white cells, 3200; hemoglobin, 20 per cent. ;
colour-index, 0:4; reticulocytes, 3 per cent. Blood-urea
35 mg. per 100 c.cm. Urine contained a trace of albumin
and occasional pus cells. Blood Wassermann, weak
positive. Radiography of stomach and duodenum gave no
evidence of ulcer or neoplasm. Occult-blood test negative.
Treatment.—The patient was tapped on seven occasions
between March 12th and June 5th. Small quantities
were obtained at first but later up to 18 pints were with-
drawn at a time and the ascites still increased. Shortly
after admission he was given a blood transfusion which
raised the hemoglobin to 50 per cent. He was given iron
without visible improvement and later mercury and
potassium iodide.
red cells,
Various explanations have been offered to account
for the bruit. Rolleston and McNee (1929) cite
examples ascribed to dilatation of the coronary
vein or a dilated communication between the internal
mammary and radicles of the portal vein. Other
authors have postulated an arteriovenous anasto-
mosis which has not been substantiated post mortem.
Rolleston and McNee also describe a case of con-
examination showed cirrhosis of the liver and a thin-
walled vein in the falciform ligament as big as one’s
little finger. In a case described by Lutembacher
(1936) the bruit was strictly localised in the xiphoid
region and occurred in a syphilitic subject. In
Florand’s case it was of more widespread distribution
and was audible posteriorly. Autopsy revealed a
varicose plexus between the internal mammary
veins and a persistent umbilical vein. Martini
(1893) described a soft murmur over the liver near
the right axilla which he ascribed to compression
of the inferior vena cava.
Venous hum has been found in Hanot’s cirrhosis
and Banti’s disease and has occasionally been heard
only below the umbilicus or above the costal angle.
The bruit may be compared with that heard in the
left anterior axillary line in some cases of splenic
enlargement. In the case outlined above I have
tried to find the most probable explanation, taking _
into account the rarity and the strict localisation
of the bruit. One factor may be the associated
anæmia, but the transfusion had no effect on the
murmur. If it were due to hyperplasia of the para-
umbilical veins one would expect to hear it best over
the “ caput medusæ,” but the bruit was not heard
at all over the umbilicus. It was not influenced
by abdominal paracentesis. This suggested that the
cause might be intrahepatic rather than lying in the
anterior abdominal wall. Its rarity suggests its
dependence on extreme hepatic fibrosis, which
would be made more likely by the coincident specific
infection.
A consideration of the “ bruit de diable” heard
where the jugular veins pass through the deep
cervical fascia makes it seem probable that a venous
bruit is caused by the passage of blood through
a constricted lumen into a relatively dilated channel.
The murmur in this case was heard at about the
level at which the vena cava pierces the diaphragm.
The vena cava is adherent to the margin of this
opening and just below this the vessel receives the
hepatic veins. I believe that the bruit is caused by
stenosis of the vena cava by the perivenous hepatic
fibrosis. The blood has to pass through this con-
stricted part of the vena cava before entering the
wider diaphragmatic hiatus. —
I am indebted to Prof. Beattie for permission to publish
this case.
REFERENCES
Florand, quoted by Rolleston
Lutembacher, R. (1936) Pr. méd. 44, 847.
Martini, quoted by Rolleston.
Rolleston, D., and McNee, J. W. (1929) Diseases of the
Liver, London, p. 267.
PROGRESS AT THE MIDDLESEX HOSPITAL.—Prince
Arthur of Connaught, speaking at a court of governors
of this hospital, said that the work was increasing
in every direction, including that of cost. It was not
possible, owing to lack of funds, to open to the full extent
of the institution’s 700 beds but 592 were at the public
service and in-patients numbered 9821 in 1936. The
cost of the hospital and cancer wing was approximately
£186,000 as against £106,000 a dozen years ago.
BEQUESTS TO HospiITaLts.— The late Mr. Caleb
Diplock of Polegate, Sussex, has left many charitable
bequests. Those to hospitals include £20,000 to Guy’s
Hospital, £8000 to St. George’s Hospital, £5000 to
the Royal National Orthopedic Hospital, £4000 each
to the Westminster Hospital, to the London Hospital,
and to the Middlesex Hospital. St. Bartholomew’s
Hospital and Charing Cross Hospital each receive
£3000, and the Princess Alice Hospital, Eastbourne,
£5000.
THE LANCET]
[may 8, 1937 1109
MEDICAL SOCIETIES
OPHTHALMOLOGICAL SOCIETY OF
THE UNITED KINGDOM
THE annual congress of this society was held on
April 29th to May lst, under the presidency of
Dr. GoRDON Hormes, F.R.S., who delivered an
address on the
Prognosis in Papilleedema
He said that papilledema was one of the common
conditions which were a meeting ground of the
ophthalmologist and the neurologist, and for academic
and practical reasons concerned the practice of
both. No aspect of the condition demanded more
attention than its prognosis in regard to preservation
of vision. Noteworthy contributions on the matter
had been made to the society’s Transactions, particu-
larly by Dr. James Taylor and Mr. Leslie Paton.
The presence of papilledema was often regarded
as an immediate danger to vision, and in different
branches of the profession there was a good deal of
misapprehension on the point. In this address
the president proposed to discuss only that form of
papilledema which was associated with increased
intracranial pressure, leaving aside its diagnosis.
The condition was now recognised to be essentially
an odema of the nerve head, in which—for a time
at least—there was little structural damage or
functional disturbance of the nerve elements, though
these might be strangled and destroyed: by over-
growth of interstitial tissue when the edema subsided
into atrophy. In the latter stage recovery of vision ©
could not be expected. The essential etiological
factor in papilledema was increased intracranial
pressure, therefore relief of that pressure would lead
to a disappearance of the condition and so remove the
risk of blindness or serious visual deterioration if the
relief could be given before the development of
secondary changes in the disc. Often there were
cogent reasons against immediate operation. If the
cause of the condition was a tumour, its removal was
frequently impossible, especially if it were an extensive
infiltrating one of the glioma type; in that kind of
case, operation quite often reduced the length and
utility of life. Moreover, operation, even in the
most skilled hands, entailed considerable risk to
life. To the question of how long measures for
relieving pressure could be delayed without endanger-
ing vision no general answer could be given. Even
intense œdema might not cause any disturbance of
vision, aS was emphasised by Hughlings Jackson
48 years ago ; vision, indeed, might remain unimpaired
for long periods. In rare cases the papilledema
subsided without surgical intervention or other
specific treatment, and vision remained unaffected.
In most of those cases it was impossible to ascertain
the exact nature of the condition to which the
papilledema was due; in some there might be a
tuberculous or gummatous tumour which became
quiescent or a gliomatous growth which degenerated ;
but internal hydrocephalus was probably responsible
in many of them for the raising of intracranial pressure.
In others there might be an external hydrocephalus
or a serous meningitis.
In most cases of papilledema relief of intracranial
pressure was necessary, or soon became so, in order to
save sight, and the important question arose of recog-
nising the time when further delay was dangerous. The
more rapidly the congestion and swelling of the optic
disc developed, the more intense did the papilledema
. become and the greater the danger to sight if no relief
were undertaken. A swelling of 4 or 5 diopters was
a warning against undue delay. Equally serious
was great engorgement of retinal veins and early
and extensive hemorrhages on the surface of the
swollen disc. An even more important danger was
a narrowing of the arteries in the swollen disc and
its vicinity. Frequent examination should be made
in order to evaluate the fundal changes and detect
the earliest signs of secondary atrophy. A further
serious sign was the transient loss of sight complained
of by many patients; this might follow sudden
changes of posture. If the tumour or other cause
of the increased pressure could not be removed by
extirpation, a decompression craniectomy usually
caused subsidence of the congestion in from two to
_four weeks, and if secondary changes had not appeared
by then, there was no further risk of impairment
of vision.
Papers were read by Mr. R. FostER MOORE and
Mr. J. COLE MARSHALL on the
Treatment of Retinal Detachment |
Mr. Foster Moore’s communication summarised
some observations on the technique of katholysis
in the treatment of retinal detachment and on the
early results obtained in 31 cases. The object of the
procedure was to produce coagulation in the choroid
as the result of the liberation of sodium ions at the
negative terminal inserted through the sclerotic ;
at the same time, hydroxyl ions were set free. The
apparatus he used was made by Messrs. Hamblin ;
the needles were either straight, or bent at a right
angle. The length of the active part of the needle
varied from 1 mm, upwards; they were made of
platinum iridium. The best strength of current
he had found to be 5 milliampéres ; usually he passed
it for six seconds. An almost unlimited number of
punctures could be made, even though the eye might
be rather soft. The flaccidity might make subsequent
trephining difficult. Bubbles of gas were seen at the
site of the puncture from which there was always
some escape of fluid; when the escape was free no
additional exit was required for the subretinal
fluid. But it was better to make a definite hole by
trephining or with the galvanocautery. Of the
31 cases, 14 were myopic. In 12 of them the retina
was replaced and remained in position when last
the patient was seen; 2 were discharged slightly
improved, 4 much improved, 9 not improved. But
the longest period since the treatment was not more
than twelve months, and in many of them only a
few weeks. The advantages of the method were
that the apparatus was light, portable, and easy
to use; its effects were sharply localised, and less
damage was done to intra-ocular tissues than with
diathermy. It was unnecessary to divide the muscles
unless exposure was needed of the sclerotic far back.
The crucial test, however, was not in how many
cases the retina went back, but in what proportion
the replacement was permanent. To that question
he had at present no answer.
Mr. Cole Marshall said that in katholysis the
whole length of the needle was active, not only its
base; a keratitis was formed and a retinitis round the
region where the bubbles had been liberated which
might subsequently cause changes in the choroid.
Mr. Foster Moore appeared to retain the needle in
the eye longer than did most continental operators,
and to use a slightly stronger current. Katholysis
1110
was not only a good localising agent but a good
adjunct to diathermy scarring. Mr. Marshall had
found katholysis very beneficial in conjunction with
diathermy, using very fine needles for the latter.
transilumination method described by Weve he
regarded as very important, as also was the continuous
use of saline during the operation, this being applied
every minute.
On April 29th a discussion on
Exophthalmic Ophthalmoplegia
was opened by Dr. W. RUSSELL Brain. He said that
in this condition exophthalmos and ophthalmoplegia
might be either unilateral or bilateral. General
symptoms of thyrotoxicosis, usually slight, might
be present if the condition arose spontaneously ;
if it followed thyroidectomy for hyperthyroidism
such symptoms were often absent, the basal metabolic
rate being normal, or even subnormal.
= The separation of exophthalmic ophthalmoplegia
as a syndrome from exophthalmic goitre depended
on a number of features, the most important of these
being that it might occur after operation not only
in the absence of thyrotoxicosis but in the presence
of actual hypothyroidism. It also differed from
Graves’s disease in its age-incidence and its sex-
incidence, in the usually slight degree of the thyro-
toxic symptoms when present, in the usual lack of
response to thyroidectomy, and in the somewhat
atypical histological picture in the thyroid. Exoph-
thalmic ophthalmoplegia was a disorder of middle
age. The mode of onset was usually subacute; one
eye became increasingly prominent over a period of
three to four months, the ophthalmoplegia and the
double vision developing concurrently. Generally
the other eye lagged behind in the matter of proptosis,
and might not exhibit ophthalmoplegia at all. Both
exophthalmos and ophthalmoplegia might develop
simultaneously in both eyes in three or four months.
Exophthalmos was present in all Dr. Russell Brain’s
cases: unilateral in 5, bilateral in 24. Among the
latter the degree of exophthalmos was equal in 8,
unequal in 16. An asymmetry of the eye protrusion
was present in 21 out of 29 cases. The ophthalmo-
plegia was a paresis or paralysis not of individual
extra-ocular muscles but of movements of the eye
in a particular plane. In the 12 unilateral cases,
elevation was the movement most often affected ;
in the 17 bilateral cases abduction was affected
31 times, elevation 23 times, depression 18 times,
adduction 17 times. In 6 patients all movements of
both eyes were affected. Widening of the palpebral
fissures with retraction of the upper lid was the usual
finding in both unilateral and bilateral cases, but
ptosis was present on both sides in 5 cases, and on
one side in 3 cases with bilateral ophthalmoplegia.
With regard to the pathology of the ocular muscles
the changes consisted of marked cedema, with foci
of lymphocytic infiltration, and, in later stages,
fibrosis. In one portion of levator palpebræ superioris
removed at operation Prof. H. M. Turnbull found
general odema and great enlargement of muscle-
fibres. In 4 out of 5 cases sections of the thyroid
gland examined by Prof. Turnbull showed that the
gland was atypical, and in the other case the gland
was the same as in Graves’s disease.
The usual treatment given for exophthalmic
goitre had been, in his experience, disappointing when
applied to exophthalmic ophthalmoplegia. Thyroid-
ectomy was done in 4 cases. In one of them there
was distinct general improvement and considerable
improvement in the condition of the eyes, though
some ophthalmoplegia remained. Following orbital
THE ‘LANCET ]
OPHTHALMOLOGICAL SOCIETY OF THE UNITED KINGDOM
The.
[may 8, 1937
decompression there occurred an immediate recession
of the eye, but the ophthalmoplegia remained
unchanged in one case and was only moderately
benefited in the other two. Dr. Brain looked
forward to the day when the condition could be
dealt with in a more physiological manner than by
surgery.
Prof. F. R. FRASER gave a general survey of the
similarities between toxic goitre and myasthenia
gravis and said that he had been able to test the
effect of prostigmin on two patients with toxic
goitre. The first was a woman aged 41, who
had begun to show signs of toxic goitre—tremors,
palpitation, and marked sweating—at the age
of 26. A year later she developed exophthalmos,
more marked on the right side, diplopia, and a
pronounced ptosis of the left upper eyelid. The
ophthalmoplegia progressed rapidly and interfered
with her work as a teacher. The drooping of the
eyelid became more marked towards the end of the
day, and at the end of the school term the diplopia
was much more severe. In 1925 ophthalmoplegia
definitely improved after partial thyroidectomy,
and the ptosis improved so much that she could
resume teaching. The tachycardia and tremors,
however, never disappeared, She was accordingly
treated with prostigmin (2-5 mg.), a large dose whose
possible upsetting effects were countered by atropine
administered some 20 minutes beforehand. Four
minutes after giving the prostigmin there was improve-
ment in the upward vertical movement of the right
eye; in a few minutes the axes of the eyeballs became
parallel on looking straightforward, there was a
twitching of the orbicularis, and diplopia was only
present when the patient looked above the horizontal.
Seventeen minutes after the injection diplopia was
only to be found on extreme upward elevation of the
eyes. At that stage the patient began to go back
a little, as diplopia could be elicited more easily,
and after half an hour the axes were again deviated.
She said that during the rest of the evening her
eyes were stronger. A week later a similar dramatic
result was achieved. The second patient was also
a woman aged 41, whose toxic goitre had developed
9 years previously, beginning with a feeling of weari-
ness. A year later exophthalmos was noticeable,
without severe toxicity. Then diplopia appeared.
Thyroidectomy was carried out in 1930, and since
then the ophthalmoplegia had remained stationary.
During the last few years the patient had been
treated with thyroid because of lassitude and general
depression, and in the last year the exophthalmos
had become more pronounced than ever before.
Prostigmin had no effect. The difference in results
in these two cases suggested, Prof. Fraser said, a
different pathology, or that the disease process in
the second patient had so progressed that it could not
respond.
Mr. H. B. STALLARD also described a case of
exophthalmic ophthalmoplegia in a man aged 31
in whom the thyrotropic hormone of the anterior
lobe of the pituitary stimulated the thyroid gland,
increasing the exophthalmos, and causing typical
thyrotoxic manifestations.
The PRESIDENT said that in a certain proportion
of cases of proptosis of the eyes there were very few
other symptoms of thyrotoxicosis; notably the
pulse-rate was not increased. Possibly there were
three types of case. Prof. Fraser had shown that
different reactions might follow the use of prostigmin,
thus indicating two classes ; and he had seen instances
of a rarer condition characterised by definite weakness
THE LANCET]
of some of the ocular muscles with rapidly develop-
ing exophthalmos; some subluxation of the globe
had been described in cases of thyrotoxicosis. He
considered that the transient palsies were due to
a sudden stretching of the muscles, due to mechanical
causes, in the orbit itself. As to pathology, Sir
William Gowers had referred many years ago to the
possibility of a primary degeneration of the cells
occurring in these cases. Vigor demonstrated leuco-
cytic infiltrations in myasthenia gravis; but Mr.
Stallard had said the muscle-fibres in his case did
not show pathological change. The question whether
there was a change in the nervous supply of the
muscles had not been answered. In ophthalmic
ophthalmoplegias there was some variability of the
symptoms; several patients said their ocular move-
ments were fuller in the morning than when they were
tired at the end of the day. This exhaustibility of
ocular movements brought these cases more into
line with myasthenia gravis,'as Prof. Fraser had said.
The Nettleship Medal
During the congress the President presented the
Nettleship Medal to Mr. H. B. Stallard, particularly
for his work on the treatment of glioma of the retina
by radium emanations.
GASTRO-ENTEROLOGY WEEK IN FRANCE
THE International Society of Gastro-enterology has
organised its second congress which will take place in
Paris during the Universal Exhibition on Sept. 13th,
14th, and 15th under the presidency of Prof. Pierre Duval
(Paris). The subjects for discussion will be early diagnosis
of cancer of the stomach, and it will be dealt with by
French and German speakers. The collected reports of
the French contributors will be presented by Prof. Duval
and Prof. Gosset with the collaboration of Prof. Carnot
(clinical and serological diagnosis), Dr. Gutman (radiology),
Dr. Moutier (gastroscopy), Dr. Garin (photographic
gastroscopy), Prof. Labbé (chemical diagnosis), Dr. Yvan
Bertrand (pathological histology), and Dr. Gatellier and
Dr. Charrier (operative diagnosis). Prof. Konjetzny will
present the collected reports of the German contributors
with the collaboration of Prof. Sauerbruch (surgery),
Prof. Buerger (chemical diagnosis), Prof. Berg (radiology),
Prof. Henning (gastroscopy and gastrophotography),
and Prof. Staemmler (pathological anatomy). The
second subject for discussion will be intestinal obstruction,
and Dr. Mogena, (Spain) will deal with it from the medical
side, Dr. Bottin (Belgium) from the physiopathological,
Dr. Kryuski (Poland) from the radiological, Sir David
Wilkie (Great Britain) from the surgical, and Prof. Bindo
de Vecchio (Italy) from the psthological-anatomical.
At the end of the Paris congress the International
Congress on Liver Insufficiency will meet at Vichy on
Sept. 16th, 17th, and 18th under the presidency of Prof.
Loeper. It will have a medical and a therapeutic section,
and. the subjects for discussion will be hepatic cedema, the
malarial liver, enlarged liver in children, sulphur
metabolism, the liver from the point of view of surgical
intervention, and hepatic drugs.
Dr. A. F. Hurst is president of the British committee
of the society, and Dr. T. C. Hunt, 49, Wimpole-street,
London, W.1, is the hon. secretary.
JOURNEES MEDICALES INTERNATIONALES DE PARIS.
A conference organised by the Révue Médicale Française
will take place in Paris on June 26th to 30th, and will
discuss the biological, clinical, and therapeutic action
of hormones. The itinerary includes sessions at which
papers will be read and visits made to appropriate centres.
Communications from those requiring detailed information
should be directed to Dr. Louis Lamy, treasurer of the
Journées Médicales, 18, Rue de Verneuil, Paris, accom-
NEW INVENTIONS
[may 8, 1937 1111
~NEW INVENTIONS
T-TUBE FOR GALL-BLADDER OPERATIONS
THERE are several types of T-tube for draining the
common bile-duct, most of these being modifications
of Kehr’s pattern. During the last few years the
indications for exploration and drainage of the
biliary ducts have been greatly extended, and this
is now rarely omitted in operations for cholelithiasis,
as soft pigment stones, collections of biliary sand,
inspissated pus, and inflammatory debris cannot
always be palpated, even when present in large
amounts.
The T-tube I use is the thickness of No. 7 English
catheter gauge, and it is 25 in. in length. The
transverse trough-shaped piece is 2 in. long, and
is fitted obliquely to the tube. The soft rubber
trough is easily inserted into the incision in the
common duct, being securely fixed into position by
stitching over it the edges of the incision in the duct
by means of a few interrupted catgut sutures. The
long limb of the tube is led through the abdominal
‘wound or through a special stab wound, and is
anchored to the skin margin to prevent it from being
inadvertently withdrawn. By means of a glass
connexion, which is attached to another length of
rubber tubing, the bile is made to drain through into
a small medicine bottle which is fixed to the patient’s
side or to the bed. Some of the bile thus collected
is returned per rectum two or three times a day.
I find this tube very easy to insert into the common
duct; and, what is more, it is easy to remove after
it has done its work. Provided there is no obstruc-
tion in the lower reaches of the duct, there is no
discharge of bile through the wound after the tube
has been withdrawn.
The tube is made to my specification by Messrs,
John Bell and Croyden, Wigmore-street, London, W.1.
RODNEY Marxcor, F.R.C.S. Eng.
Senior Surgeon to the Royal] Waterloo Hospital and
to the Southend General Hospital.
panied with the necessary fee by cheque or postal order.
The fee for admission to the Congress for doctors is 100 Frs. ;
the subscription for medical students, and for the wives
and children of doctors, is 50 Frs. Adherence will secure
for the applicants admission to all the sessions and to
various pleasure reunions, which include a performance
at the Théâtre des Champs-Elysées, a reception by the
Municipal Council of Paris, and an evening visit to the.
Louvre,
1112 THE LANCET]
[may 8, 1937
REVIEWS AND NOTICES OF BOOKS
1. Cushny’s Text-Book of Pharmacology and
Therapeutics
Or the Action of Drugs in Health and Disease.
Eleventh edition. By C. W. EpmMunpbs, A.B., M.D.,
Professor of Materia Medica and Therapeutics and
Director of the Pharmacological Laboratories in
the University of Michigan; and J. A. GUNN,
M.A., M.D., D.Se., F.R.C.P., Professor of Pharma-
cology and Director of the Nuffield Institute for
Medical Research, University of Oxford. London:
J. and A. Churchill. 1936. Pp. 808. 25s.
2. An Introduction to Pharmacology and
Therapeutics
Fifth edition. By J. A. Gunn. London: Humphrey
Milford, Oxford University Press. 1936. Pp. 240. 5s.
1. A thoroughly revised edition of this standard
work was published in 1932 when it was also brought
into conformity with the new British Pharmacopoeia.
The eleventh decennial revision of the Pharmacopoeia
of the United States has made another edition
desirable. The most striking change is a rearrange-
ment in the order of the book. It is not yet possible
to arrange substances used as drugs in any strictly
scientific way and in whatever order they are arranged
some repetition is inevitable. In this edition the
simpler substances—e.g., salts and inorganic com-
pounds—are dealt with first and the more complex
substances later. On the whole, this rearrangement
is an improvement on the plan of previous editions.
The book has been brought up to date in several
important respects. For example, a fuller account of
acetylcholine and its derivatives is given than in
previous editions, and the use of derivatives of
physostigmine in myasthenia gravis is dealt with.
New ameobicides such as Carbasone, Chiniofon, and
Vioform receive full discussion, and protamine
insulinate is mentioned. There is in fact hardly a
section which does not show signs of revision.
Excellent accounts of the vitamins and hormones
are given. It is curious to find no mention of the
sex hormones, especially as the gonadotropic factors
of the anterior lobe of the pituitary are described.
A commendable change is the introduction of struc-
tural formulæ for the alkaloids and other substances
where these are known. The bibliography which
follows each main section has mostly been inherited
from Cushny’s original book although several more
recent references have been added. Its value is
doubtful, since few medical students are likely to
refer to original. papers for information and the
number of references given are too few for the research
worker, who is more likely to consult a larger work.
The authors, however, recognise this defect and have
tried to remedy it to some extent by giving as many
references as possible to reviews which themselves
contain a good bibliography. The book thoroughly
deserves the high esteem in which it is held by
teacher, student, and practitioner alike, .
2. This little book is well known to examiners in
pharmacology since too often it seems to be the sole
source of information to which the candidates have
had recourse. This fact cannot be laid to the author’s
charge, for he indicates clearly in his preface that
the book is intended only to supplement the student’s
lectures or reading. It is, in fact, quite unlike the
usual “ cram book,” for brevity has been achieved
by judicious selection and not by mere compression.
It affords an excellent introduction to pharmacology,
and when properly used for purposes of revision can
hardly fail to help the student. It can be heartily
commended, too, to the practitioner who wishes to
survey rapidly the changes which have taken place
in recent years in our knowledge of drugs. The
exhaustion of the previous edition in only two years has
provided the opportunity of making minor revisions
and of bringing the book into accord with the revised
United States Pharmacopeia. The changes are few
and the author is to be congratulated on resisting any
temptation to expand the book.
Occupational Diseases
By Donatp Hunter, F.R.C.P. London:
Lewis. 1937. Pp. 122. 9s.
THIs book consists of a reprint from the London
Hospital Gazette of a series of, lectures delivered to
the Derby Medical Society during 1935. A surprising
amount of useful information on a very wide variety
of industrial medical subjects is presented in a read-
able form. The illustrations (of which there are
many) are good in themselves and excellently
reproduced. The lectures were not designed for
specialists in industrial medicine, although few
even among experts could fail to glean valuable
knowledge from them. In the first lecture Dr.
H. K.
-Hunter discusses lead, arsenic, and (very briefly)
phosphoretted hydrogen; in the second metal
poisonings, industrial infections, and deficiency
diseases are rapidly surveyed. The third lecture
deals with a wide variety of subjects, including some
of the “dust diseases,” the toxic gases, benzene,
aniline, and the chlorinated hydrocarbons; and in
the last a number of topics including cancer, derma-
titis, nystagmus, Workmen’s Compensation, and the
prevention of industrial disease are reviewed. It
is obviously impossible to deal profoundly in a little
over 100 pages with so wide a field. -E
The book will prove especially valuable, we think,
to practitioners in industrial areas or works, and
certifying or examining surgeons. We must join
issue with the author upon one major and a number
of minor issues. The major issue concerns the
diagnosis of industrial lead poisoning. To suggest
that a diagnosis of lead poisoning cannot be established
unless one of the toxic episodes has occurred. (see
p. 11) is, we believe, contrary to modern industrial
medical opinion. The work of R. E. Lane and others
enables a diagnosis of lead poisoning to be made
before the occurrence of a toxic crisis. A falling
Hb per cent., with or without a rising “ punctate
count,” in a worker exposed to lead raises a suspicion
that “ absorption ” is passing over into “ poisoning.”
This suspicion becomes a certainty when these changes
are well marked or can be shown to be progressive.
This is a point of considerable medico-legal importance.
The minor points are the following: metal fume
fever is now known to be caused by other metals
besides zinc (e.g., cadmium and magnesium); the
“ sericite ” theory of the causation of silicosis rests
upon a less solid basis of fact than Dr. Hunter appears
to suggest; the Kolar Gold miners suffer from
pneumonoconiosis ; the clinical dictum that occupa-
tional cramps “‘ are always associated with anxiety ...
to get the work done in time and up to standard ”
would be seriously questioned in many quarters.
Dr. Hunter’s “ 15-point summary ” of the prevention
of disease in industry must not be taken as an
adequate summary of the potential contributions
of industrial medicine to industry.
THE LANCET]
As we have said this book provides a useful clinical
summary of that part of industrial medicine which
is concerned with the diagnosis of the recognised
diseases and toxæmias of occupation.
that it will have a wide circulation amongst industrial
practitioners concerned with the prevention and
treatment of these conditions.
Christian R. Holmes, Man and Physician
By MARTIN FISCHER, Springfield, Ill.: Charles C.
Thomas; London: Bailliére, Tindall and Cox.
1937. Pp. 233. $4.
THIs is a sumptuous memorial volume in format,
printing, and binding. It is fortunate that the subject
of the biography led a life of single-minded absorption
in a great ideal or the terms of eulogy would seem
unduly high. Dr. Christian Holmes was the centre
of medical progress in Cincinnatti. The son of a
Danish immigrant, he was 15 years old when he landed
with his father in New York. He had been well
taught and having considerable skill as a draughtsman
he secured work at once in the designing rooms of a
civil engineer. As a young man work as a self-taught
engineer brought him to Cincinnatti, and in 1879
he began to read medicine at what was then a rather
primitive centre. On qualification he became resident
in the Cincinnatti Hospital and for the rest of his
life he was connected with the institution and devoted
to its development. In practice he was energetic and
versatile and quick professional success enabled him to
pay regular visits to the chief medical centres in
Europe, with the result that he took the lead in a
movement forthe construction in Cincinnatti of a new
central hospital. The details of this work—how
public support was obtained and how Holmes
organised a financial backing—make an interesting
story and show him to have been a man of initiative,
drive, and perseverance. Soon a medical college
arose in connexion with the hospital and in 1916
Holmes was able to claim for the students of medicine
in Cincinnatti that they had facilities for clinical
study of a high standard, laboratories available for
teaching and research, and a fine corps of instructors.
Christian Holmes died in 1920, having devoted
40 years to the object which he set before him almost `
at the outset of his career—to establish in Cincinnati
a first-class medical centre.
Cytologie du liquide
normal chez l’homme
By H. JESSEN (Aarhus, Denmark).
et Cie. 1936. Pp. 168. Fr.40.
IF the scope of this monograph is limited the
work it describes is nevertheless important. Dr.
Jessen deserves thanks for carrying through a
lakorious task which many would find uncongenial.
The book has three sections, dealing respectively
with the morphology, enumeration, and probable
function (or lack of function) of the cellular con-
stituents of normal cerebro- spinal fluid. An exhaustive
account and criticism of the various technical methods
for dealing with the fluid justifies the author's
contention that the subject is in a state of great
confusion, attributable to the tendency of the cells
to rapid degeneration, and the consequent medley of
different classifications and results according to the
methods used by various observers. He himself
has worked on about 500 individuals, after having
selected what he believed to be the best techniques
and modified them for his purpose. His reasons
for his choice are convincing, and since he indicates
céphalo-rachidien
Paris: Masson
REVIEWS AND NOTICES OF BOOKS
We hope
[may 8, 1937 1113
wherein they are unsatisfactory subsequent investi-
gators are not likely to accuse him of making
exaggerated claims for them. The same moderation
characterises his general conclusions. He finds
that there are three types of cells : (1) those resembling
and possibly identical with lymphocytes; (2)
larger cells resembling the large lymphocytes of the
blood, but probably of epithelial origin; and (3)
irregularly shaped cells, characteristic of the cerebro-
spinal fluid, whose nature and origin can only be
surmised. All three are very variable in number,
both in different individuals and in the same individual
at different times, and all tend to degenerate very
rapidly, in vivo and in vitro. Other types of cell,
such as granulocytes, are always the result of con-
` tamination. A count of more than 10 cells per c.mm.,
is pathological, and between 5 and 10 per c.mm.
suspicious, but extensive variations below these
concentrations are common and not significant.
In view of the ample opportunities of the cerebro-
spinal fluid to pick up cellular elements from the.
meninges during its circulation, their occurrence
and number must be regarded as fortuitous in the
absence of definite evidence to the contrary, and
no function can be ascribed to them.
Although the outcome of this study seems meagre
in comparison with the amount of labour involved,
the monograph gives an excellent review of the
subject, contains much sound and critical discussion
of technical matters, and has an exhaustive biblio-
graphy. It will be of distinct value to those
interested specially in the cerebro-spmal fluid, and
furnishes a much better basis than has hitherto
existed from which to start pathological and diagnostic
studies.
A Dissertation on the Sensible and Irritable
Parts of Animals
By ALBRECHT VON HALLER. Baltimore:
Hopkins Press. 1936. Pp. 49. $1.
THIS is a pleasing reprint of a minor neurological
classic and its interest is much increased’ by an
excellent introduction by O. Temkin. Originally
published by von Haller in 1752 when he was professor
of physiology at Gottingen, it was translated into
French and thence into the English version of 1755
which is here reproduced. Haller’s thesis was that
only those parts of the body which have nerves
possess ‘“‘sensibility”’’ -while “irritability” is a
property of muscle. It was a clarifying conception
if only because it at once aroused serious and
substantial criticism: surgeons challenged his facts—
e.g., about the insensibility of periosteum—while
experimentalists rightly objected to the narrow
interpretation of irritability. His work was indeed
a stepping-stone so wobbly that it led others to build
a bridge, and it is now of little more than archeological
moment. The reprint has some English interest
for the title page is reproduced in facsimile and
shows the stamp of the “ Warrington Dispensary
Library,” reminding us of the pioneers in medicine
and education who brought fame to that grim town
150 years ago.
Johns
Dr. Argyll Campbell and Dr. E. P. Poulton have
written an addendum to their book ‘‘ Oxygen and
Carbon Dioxide Therapy,” reviewed in our issue of
March 2nd, 1935. It is entitled ‘‘The Oxygen
Tent and Nasal Catheter” and will be supplied
gratis to purchasers of the book who apply to the
Oxford University Press, Amen House, Warwick-
square, London, E.C.4,
1114
THE LANCET].
MEDICINE AND THE LAW
Epilepsy and Criminal Responsibility .
In R. v. Edwards the accused was found guilty at
Leeds assizes last March of having murdered his
fiancée, The defence did not dispute that the dead
woman met her death at the hands of the accused
man. The evidence, however, showed that he and
she had been on the best of terms and no motive could
be assigned for his violence. It was suggested at the
trial that there was a long history, from the time
the accused was three years old, of entirely unpro-
voked attacks ending in some kind of fit or hysterical
seizure involving unconsciousness. It was proved
that a relative of Edwards had died of fits. The
defence called two doctors who came to the con-
clusion that Edwards was an epileptic subject.
All the medical witnesses agreed that, if the attack
had been committed during an epileptic seizure, it
was committed at a time when he was incapable of
forming an intent. These considerations were put
forward on his behalf in the Court of Criminal Appeal,
with the argument that the jury should have been
directed at the trial upon the question of the proof
of intent; it was contended that the trial judge
should have told the jurors that, if they were left
in doubt whether the attack was committed during
an epileptic seizure, they could not return a verdict
of murder because the requisite intention would not
have been proved.
Lord Hewart dismissed this argument. He regarded
the defence of epilepsy as a defence of insanity, and he
repeated what he has so often said before—namely,
that the burden of establishing the defence of insanity
is always on the defence, It is now suggested, he said,
that although an inchoate defence of insanity fails
and the proof of it is not made clear, it may never-
theless leave the minds of the jury in a state of
flux or uncertainty, so that they can find a verdict
of either “‘ not guilty ”? or “ guilty of manslaughter.”
That proposition is not the law; nor can it be
permitted to undermine the well-known rules in
McNaghten’s case.
Psychology in Prisons
While the criminal law thus continues to recognise
at assizes and in the Court of Criminal Appeal only
one species of insanity and to require strict proof of
the existence of this insanity from the accused, the
annual report of the Commissioners of Prisons, just
issued for the year 1935 (Cmd. 5430, 2s.), con-
tains a corrective. ‘‘ It would be helpful,” writes the
Medical Commissioner, Dr. W. Norwood East, in
his important contribution to the report, “if justices
and police authorities remembered that the diagnosis
of the mental condition of an accused person does not
rest merely between sanity, insanity and mental
deficiency.” He then proceeds to set out the classifica-
tion of psychoses encountered and identified by the
medical officers of English prisons. Dr. East, as his
previous reports have shown, approaches with caution
the psychiatric treatment of crime. Necessary and
useful as it may be, he regards it as a dangerous
weapon when it leads people to believe that benefits
will follow although failures outnumber successes. ~
He reasserts his view that psychiatric treatment
of criminals must follow the method of science and
that it has as yet produced no impressive series of
carefully tested results. In the first half of the
nineteenth century the phrenologists claimed that their
MEDICINE AND THE LAW
[may 8, 1937
doctrines could be applied to analyse the nature of
certain crimes and to provide a sound judgment
of the appropriate punishment. After the phreno-
logists came the anthropologists with fresh specula-
tions on the cause and prevention of anti-social
conduct. Dr. East would have us test the application
of psychological medicine to criminal mentality by
the same scientific method as might have exposed
the inadequacy of conceptions formerly fashionable.
He commits himself to the definite statement that
psychological treatment is unnecessary and undesir-
able in the majority of criminal cases. All will not
agree with him even after considering his elaboration
of the following points which affect the medical
profession. Sometimes a court postpones sentence
in order that an opinion on the prisoner’s suitability
for psychological treatment may first be obtained.
Then, having been furnished with medical evidence
and advice which favours such treatment, the court
occasionally imposes a sentence of imprisonment
nevertheless. The result is that the prisoner thinks
that he might have escaped prison but for the medical .
evidence; hostility follows, instead of codperation.
Again it sometimes happens that a defending advocate
urges that an accused man requires medical treat-
ment rather than imprisonment; medical witnesses
are exploited in support of such a plea in cases which
are unsuitable. Here, too, hostility is the natural
sequel if imprisonment is imposed. The prisoner
tries to obtain preferential treatment on the strength
of the medical opinions; when this is refused, he is
inclined to attribute his future conduct to medical
ineptitude. Alternatively, if the court does not send
him to prison, no useful purpose is served by non-
effective treatment at a clinic or elsewhere. The
Medical Commissioner closes his feport with further
significant reminders. Abnormal behaviour may be
due to group conduct as well as to individual conduct.
It is common experience that persons will, as
members of a gang, commit offences which they would
hesitate to undertake of their own motion. Such
cases may more properly be dealt with by change of
environment than by prolonged psychological investi-
gation. Secondly the comfortable doctrine of self-
expression gives anxiety if it discounts the value of
self-control. Criminals are all too ready to avoid
reality and to refuse to acknowledge their own fault.
The psychologists examination, after all, may
explain criminal conduct but is not meant to excuse
it. Lastly he observes that present-day psycho-
therapy is practised by some who have no medical
or psychiatric training. Only medical experts, he
reasonably contends, should assess and give evidence
on the mental condition of accused persons in relation
to their suitability for psychiatric treatment.
WEST CORNWALL MINERS’ AND WOMEN’S HOSPITAL,
REDRUTH.—Commander Sir Edward Nicholl has cut
the first sod of the extension to be built at this
hospital, He has contributed £15,000 towards the
cost. The number of beds will be increased from
57 to 91.
FUND FOR SPA TREATMENT.—Miss Sophia Gifford
“Edmonds, London, has given the sum of £500 a year
to enable poor persons living outside a radius of fifty
miles from the town to obtain treatment at Droit-
wich Spa. The fund will be known as The Droitwich
Brine Fund for the Treatment of Rheumatism. As
only a limited number of patients can be accepted
under the scheme, participation in it is being offered to
certain general hospitals in England and Wales. The
founder hopes however that in time other charitably
disposed persons will be led to enlarge its scope.
THE LANCET]
_ THE LANCET
LONDON: SATURDAY, MAY 8, 1937
ON CROWNING THE KING
THE Kine, “the fountain of honour,” has
honour bestowed on him by his people only
once—at coronation. At other times he receives
their gifts of honour as a tribute to the Crown.
The ceremony of the Coronation serves two
purposes: it brings the person of the king
within range, as it were, by doing something
to him, and its traditional elaboration makes
the act of more than local or topical significance.
By following custom we bridge the generations
and lift the immediate occasion out of the
present, making it—and ourselves—a part of
a timeless, age-long, and therefore solid relation
between the Ruler, the Head of the Family,
and his people. The ceremony itself satisfies
the desire to express something of the mystical
reverence which lies deep—often deep hidden—
in the human heart. However modern our
outlook, however little ceremony may mean
to us as individuals, its value in public life
cannot be denied. It helps the separate
individuals in the community to identify
themselves with one another by adopting the
same attitude to the Ruler. The sense of
relationship to other members of the com-
munity gained by making the Ruler a common
ideal, is one of the factors: which stabilise an
empire, however distant are its constituent
parts. The maintenance of this common ideal
cannot be achieved without effort on the part
of both ruler and peoples. The ruler on his
side must not be merely a remote figure-
head, nor may he fall below the ideal standard
the people have set for themselves. The
model must be both worthy and capable of
being copied—i.e., it must be “human.”
The people for their part must resist a tendency,
which may at first seem harmless, to over-
idealise or to exalt to deistic proportions those
who hold positions of authority. This tendency
is a legacy from childhood and is accompanied
by another relic of our primitive nursery
impulses—a wish to control the behaviour
of the being thus exalted. Doctors have a
special opportunity for observation of this
in daily life: when a person holds this or that
parent too high above criticism he regards
ON CROWNING THE KING
[may 8, 1937 1115
himself as specially fitted to manage the
affairs of the person he adores. So it is in the
constitutional relationship—groups which claim
to possess a superior kind of loyalty or a more
mystical understanding of the true nature of
the Royal heart and mind also claim as of
right to interpret the Royal will. Such an
attitude is dangerous to constitutional develop-
ment because its arrogance is concealed behind
a mask of apparently generous intentions.
We have to go back to the nursery in order to
understand the basis of the monarchical form
of government, which draws its strength from
a displacement of the ties of the family—
the group in which we begin our social
experience—to the central government of our
national life. In the much used phrase, “the
King is the Father of his People,” there is
a profound psychological truth. The wish to
reanimate in the: national life the intense
experience of veneration, once felt in nursery
life towards the father, exerts a powerful
influence on our social institutions. |
The smooth flow of corporate life, which
has for the most part characterised British
history in recent centuries, obscures’the strong
forces which lie beneath the surface. Priding
ourselves, rightly perhaps, on bringing to
public life a sturdy common sense, we tend to
take institutions for granted, unless either they
begin to fail in their purpose or an external
event calls them to our notice. We have
moreover found a means of preserving an
equilibrium in our relations to the governing
authority which other nations do not so fully
employ. The political part of our’ emotional
life is split into two: one portion is reserved
for the Crown and all that it implies, the other
for the Cabinet. Thus even acute discontent,
when it arises, does not destroy the whole of the
sovereign power but only a replaceable portion
of it—we only turn out a party government.
The parliamentary system is safe so long as it
does not absorb the whole of the political
sentiment of the people or receive the full force
of popular opposition; the throne is safe so
long as the cabinet is strong enough to be
worth attacking. This view may help to
resolve some of the difficulties of the jurists
and philosophers of the past and bring them
into a new alignment. Blackstone examined
the royal prerogative which invests “our
Sovereign Lord, thus all-perfect and immortal,
in his Kingly capacity,” Paley remarked
that these formidable prerogatives dwindle
into mere ceremonies, while Bagehot, coming
nearer to our modern views, described the
limits of royal power and explained its function
in terms of loyalty. |
1116 THE LANCET]
In our Empire the Krna is above politics,
and we have in the last century been favoured
with a Royal House which has understood
its responsibility as that of exacting only
loyalty as tribute and giving life-long service
in return. A constitutional monarch is like
the father of a grown-up family; his power
‘depends on his behaviour. So long as that is
determined by consideration of the common
good he receives the devotion of his children |
based on their respect for one who gives them
all an equal share of his good regard. The
British preserve a human relationship and a
family feeling for their Ruler, neither debasing
him into a puppet nor turning him into a
god. King GrorGcE VI is the head of our
family and in crowning him we honour him,
our constitution, and ourselves.
OBSTETRICS IN GENERAL PRACTICE
THe Ministry of Health’s report on maternal
mortality is more revolutionary than may appear
at first sight. It says that many women die
unnecessarily through childbirth, and that if they
are to be saved the first need is better midwifery.
It makes a recommendation that in blunt words
means this—that public authorities shall no longer
pay a doctor to attend a confinement unless he is
known to have special ability for the task. At
present when a midwife wants
she has to call in whatever doctor the patient
chooses; and the local authority pays. The
Ministry is evidently going to propose that in
future the midwife shall only be able to call a doctor
whose skill in midwifery is recognised in the
neighbourhood. If local authorities are to pay for
pipers they will henceforth have a say in choosing
them, and will ask that their tune shall harmonise
with what is being played by the rest of their
orchestra, consisting of midwives, consultants,
and hospital officers. |
the new training rules of the C.M.B. will secure
greater efficiency from midwives by providing
better trained, better organised, and fully employed
women. The local authorities under whom they
work will want to strengthen the vital link between
midwife and consultant by selecting from the
available local talent a limited number of the best
qualified practitioners to come to their aid when
required. In other words, they will no longer
accept a registrable medical qualification as
sufficient evidence that a man is competent to
practise difficult midwifery. The significance
of this proposal needs no underlining. It
must be recognised as a big step towards the
removal of midwifery from ordinary general
practice.
What has led the Ministry’s investigators to
favour such a step ? From the summary appearing
on p. 1125 it will be seen that they made a laborious
inquiry into all the maternal deaths in certain
areas during 1934 and found much to criticise in
the conduct of pregnancy, labour, and the puer-
OBSTETRICS IN GENERAL PRAOCTICE
medical help `
The new Midwives Act and
[may 8, 1937
perium. Their observations are consistent with
the results of the analysis of nearly 6000 maternal
deaths made by the Departmental Committee in
1932, when it was estimated that in nearly half the
cases there was a “primary avoidable factor.”
But the study of failures does not reveal the whole
truth, as the Ministry’s medical officers would be
the first to admit. An examination of 700 fatal
cases of appendicitis would probably suggest that
everyone with a pain in the stomach should at
once see a surgeon; yet this would be nonsense.
The evidence of failure provided by these surveys
is supporting evidence, but is not in itself enough.
The true argument in favour of taking midwifery
out of ordinary general practice is this. The
birth-rate is falling ; more and more women are
being delivered in hospital or by midwives alone ;
the number of general practitioners is increasing,
and so is the volume of their work. The result is
that many practitioners deliver very few women
in the year, and some are called only to abnormal
confinements. Many of the younger men, although
they feel obliged to undertake such work, have had
too little experience of midwifery to be com-
petent in emergenciés that may tax the most skilful
—and these emergencies are often encountered in
the very difficult circumstances of poor homes.
The medical student’s instruction—however much
is squeezed into it—does not turn out an obstet-
rician but only a man capable of becoming one.
Unless he has special post-graduate training or a
long experience of unselected cases, he cannot be
regarded as the proper person to go to the rescue
of a midwife. Occasional obstetrics is even more
dangerous than occasional motoring, and the
conduct of labour should be undertaken only by
those who are genuinely interested in it and willing
to give it time and thought.
These arguments are familiar enough, and there
are good answers to them. The British Medical
Association’s scheme for a maternity service is
based on every woman having her own doctor to
attend her before, during, and after confinement,
and its exponents emphasise the value of this
continuity of care. Where, as often happens, a
practitioner takes a pride “in his midwifery, and
does not allow other duties to deflect him from it,
he can certainly offer his patient a service of the
very best. But it has clearly become impossible for
every general practitioner to take this attitude or.
give this service, and many would be thankful if
they were no longer expected to practise what
they regard as a specialty. Moreover, those who
do in fact want to do such work might welcome
the withdrawal of unenthusiastic competitors. Be
this as it may, what is immediately to be expected
is that the Ministry will instruct each local
authority to consult with the medical profession
in its district and prepare a panel of those prac-
titioners who are best qualified to assist midwives
in case of need. From this no great flight of
imagination is required to foresee a day when post-
graduate diplomas will be demanded as a condition
of obstetric practice ; and the Ministry’s present
report marks a turning-point which it is well at
least to recognise.
-THB LANCET]
THE VOLUNTARY HOSPITALS: GOODWILL
AND FINANCE
THE recommendations of the commission on the
voluntary hospitals summarised on p. 1123 deserve
careful study. The commissioners show a full
understanding of the spirit that inspires the
traditional system of hospital administration in
this country, and the value of the freedom
associated with voluntary service. But they have
reached the deliberate conclusion that a limitation
of independence is essential to the continued
existence and expansion of voluntary hospitals,
and that methods must be devised whereby
coöperation among the voluntary hospitals them-
selves and between voluntary and municipal
hospitals can be promoted. An important recom-
mendation designed to this end is the division of
the whole country into separate regions based on
the present regional organisation of the British
Hospitals Association. The regional councils
appointed to codrdinate the services rendered
would have no coercive or compulsory powers,
but would receive day-to-day, information about
empty beds, and so facilitate the admission of
patients. The functions of regional councils would
include also the maintenance and direction of an
‘‘ambulance service; the arrangement for the
transfer of patients no longer acutely ill to
“ auxiliary hospitals” ; and, perhaps most import-
antly, the strengthening of the hospitals’ finances.
Following logically enough the general conclusion
that if the total annual income of the voluntary
hospitals could be distributed in accordance with
their individual needs their financial position would
not be unsatisfactory, it is suggested that in
course of time regional funds should be created
on lines similar to that of King Edward’s Hospital
Fund for London.. The idea is that such funds
would create new sources of support, and that the
education of donors to-contribute to hospitals as a
whole would ensure a better allocation of their
contributions than results at present from gifts to
the particular institution of their choice. If the
regional councils acquired enough influence they
would be able to improve or close down inadequate
and inefficient institutions; new hospitals would
not be built nor would old ones be extended
without their approval. And the anomalies whereby
there is overlapping of effort in one district while
others have a defective hospital service would be
gradually eliminated. ——
The question arises whether the voluntary
hospital income can be spread over the voluntary
hospital system without substantial diminution of
the total sum available. It may be that some of
those hospitals which are in a better financial
position than others are earning it by the value of
their work; and it may be that some at least of
those in financial stress could gain more support
if the value of the service they offer to their public
were greater. It is curious that in a report which
touches on almost every aspect of hospital activity,
and in remarkable detail, there is little reference to
variation in the quality of the service given in
different voluntary hospitals. The fact that for
THE VOLUNTARY HOSPITALS: GOODWILL AND FINANCE
[may 8, 1937 1117
the most part this service is of a very high order
should not blind us to a second fact that almost
everywhere it is capable of improvement, and in
some places of considerable improvement. The
word service is used in its broadest connotation, to
include not only medicines and surgery and
nursing, food and lodging, light and air, it includes
also contact of patients with resident staff and
honorary staff; contact of relations with both
and with sisters of wards, and contact of hospital
doctors with general practitioners ; conditions of
admission and discharge of patients, and of con-
sultations for out-patients; and finally the pro-
portions in which zeal and discretion are mingled
in the almoner’s and secretary’s departments. It
must be obvious to everyone that quality of service
is not the only factor in determining support, if
only because it is so difficult for the laity to dis-
criminate between its grades. Other factors
include location, prosperity of the district, and the
luck which sometimes brings rich ‘patrons to
charities irrespective of their special needs. The
commissioners themselves point out that the public
are not yet educated to give as readily to a hospital
service as to a particular hospital. Will they
ever be? Certainly now, and perhaps always,
there are many who would sooner give one pound
to a poor person who is ill than a pound or some-
thing less to “ the sick poor.” Local patriotism is
a strong incentive to personal service. Anythi
which weakens interest in the local hospital for
its own sake will go far to undermine the present
strength of the voluntary hospital system; and a
so-called parochial interest may well bring stronger
financial support to the voluntary system than a
regional or cosmopolitan attitude.
If we remain less hopeful than the commissioners
that their solutions are necessarily the best ones
we must commend their laborious study of the
problem. Though the conclusions they have
reached are simply and even dogmatically stated,
it is obvious that the considerations on which
these conclusions are based have been carefully
weighed, and that this report will take a worthy
place in the series of documents issued during the
last 20 years on different aspects of the services
and responsibilities of voluntary hospitals. The
peculiar merit, to which attention is drawn in its
pages, is that it is a drive towards reform not
from without but from within, and that for this
reason if for no other, it is the more likely to be
implemented.
THE FUTURE OF TUBERCULOSIS
Dr. D’Arcy Harrt’s Milroy lectures, concluded
in our present issue, illustrate the change in
attitude that is coming over younger physicians.
The facts on which he builds his argument are
for the most part widely known. We are most of
us aware that there has been an ominous lag in
the decline of tuberculosis mortality among young
adults, especially females and especially in depressed
areas. Despite the distribution of diagnostic
centres throughout the country in the form of
tuberculosis dispensaries, the proportion of cases
1118 THE LANCET]
. diagnosed early has shown little increase in the
last twenty or thirty years. The prognosis per
group has also been little affected ; the one great
therapeutic advance, collapse therapy, is applicable
only to a small proportion of cases (10 per cent.
in the recent London County Council series)
although many advanced cases must have passed
through a stage, before diagnosis, when it might
have altered the course of their lives.
Hence it is evident that, however gratifying
the drop in the general incidence of tuberculosis,
there is still a long way to go. Delay by the
patient in seeking advice is obviously the cause of
much late diagnosis, and social factors such as
fear of unemployment play a part in causing this
delay. Progressive public health authorities
are encouraging patients to present themselves for
dispensary examination as soon as suggestive
symptoms appear, and by facilitating the use of
X rays they are ensuring that the examination
will be as effective as possible in detecting disease
even in its earliest clinical stages. But it is here
that Dr. Hart steps in with arguments which cut
at the roots of the present organisation, however
efficiently run. He points out that radiological
signs appear considerably in advance of symptoms
and that this being so it is illogical, in attempting
to ensure early diagnosis, to wait for the patient
to take the initiative after the appearance of
symptoms. The alternative, he suggests, is the
periodic health examination of selected groups of
people, especially young adults. This examination
would be based primarily on radiography, although
in groups with low tuberculosis incidence, expense
might be saved by preliminary Mantoux testing.
This scheme is theoretically no more revolutionary
than the periodical inspection of the teeth of school-
children, but progress along the lines suggested
would lead eventually to “a comprehensive
health service that would include the detection
of pulmonary tuberculosis as merely one of its
important functions.” Objections would no doubt
be many and varied. At Dr. HARTS estimate the
cost of the tuberculosis scheme, which is at present
rather over two shillings per head, would increase
and require the expenditure of at least double
this amount on diagnosis alone. Other objections
include the danger of inducing a tuberculosis
phobia and also the difficulty of persuading a
symptomless patient to accept the stigma of
sanatorium treatment. Although presumably
this stigma would diminish if really early diagnosis
and treatment were to make complete recovery
the rule, the physicians administering such a
scheme would have difficulty in inducing a symp-
tomless patient to undergo a course of treatment
if it involved the risk of losing his job. Their
task would be made still more onerous by their
knowledge that many such cases recover without
ever knowing they have been ill. |
Nevertheless the conclusion to be drawn from
Dr. Harts lectures is that although it has many
excellent features our present tuberculosis scheme
does not strike sufficiently near the root of the
problem to satisfy the demands of the future.
The radical attitude he represents is associated,
THE FUTURE OF TUBERCULOSIS
[may 8, 1937
moreover, with a growing realisation that pre-
ventive medicine cannot make much headway
in face of bad social conditions. At present it
is all too clear that barely adequate nutrition is
often the lot both of the tuberculous patient
and of other members of his family just at a time
when abundant food is essential to their well-
being. And those who follow Dr. Hart’s close
reasoning must conclude that, if common sense is
to be applied to tuberculosis, society must do more
to tip the balance in favour of the patient rather
than in favour of the tubercle bacillus.
THE SITUATION IN SPAIN
Muc# is said nowadays about the way in which
rapid communications have diminished distances.
Yet the civil war in Spain is still so far away as to be
barely credible. The feeling that these events are
only newspaper stories must be the chief explanation
of our comparative failure to respond to the desperate
needs of people living only a few days’ sail to south-
ward of us. In the past week or two something has
been done to bring home the realities of the situation
in the Basque provinces. Serious attempts are being
made to remove from Bilbao women and children
whose danger is evident from the fate of Guernica,
and we understand that money for this purpose will
be gratefully received by the National Joint Com-
mittee for Spanish Relief, 35, Marsham-street, London,
S.W.1. Associated with the committee in its general
work in Spain are the Save the Children Fund
(20, Gordon-square, W.C.1) and the Friends’ Service
Council (Friends House, Euston-road, N.W.1), both
of which, despite deficient funds, are doing much to
dispel the idea that the English have ceased to care.
An illustrated pamphlet called ‘‘ Children in Spain
To-day °” reaches us from the Committee Against
Malnutrition, with a foreword signed, among others,
by Dame Janet Campbell, Miss Harriette Chick, and
Miss Edith Pye. It shows that already in January
the number of refugees in the Government area
exceeded a million, or 10 per cent. of the population,
and it adds that ‘‘the public conscience in western
countries may have to prepare itself for a great
relief effort in the near future, if the misery of a
famine upon our European continent—however short
its duration and restricted its scope—is not to be
repeated in our time.” There is no collapse of health
and welfare services, however, on the Government
side of the lines ; indeed they have expanded remark-
ably. Hence whatever help is given for the prevention
or relief of distress is likely to be used effectively.
Finally—which directly concerns the medical
profession and its allies—there is a constant demand
for medical and surgical equipment and supplies.
The goodwill of manufacturers is now being asked
for a scheme by which workpeople engaged in making
such things may work overtime and thus earn credit
with their employers for organisations sending aid to
Spain. It is believed that a large proportion of
employees would gladly give a few hours a week to
such voluntary work, and since the firms concerned
would secure the orders for equipment they would
gain rather than lose by according the facilities
asked for. We hope that many firms may be
willing to give the scheme sympathetic considera-
tion. It is planned by Voluntary Industrial Aid for
Spain (32, Great Ormond-street, W.C.1), which is
already applying the principle to the manufacture of
motor-cycle sidecar ambulances. These have proved
their worth in mountainous regions where other
vehicles cannot reach the wounded.
THE LANCET]
a a
\
[may 8, 1937 1119
ANNOTATIONS
ARTHROGRAPHY IN CONGENITAL DISLOCATION
OF THE HIP
DIFFICULTIES in treatment of congenital dislocation
of the hip-joint are due as much to peculiarities in
the shape and attachments of the capsule as to
mis-shape of the femoral head. Jacques Leveuf and
Pierre Bertrand ! claim that arthrography provides a
valuable aid in assessing the chances of success of
closed reduction. The shadow picture obtained in
congenital hip disease defines the capsular cavity as
consisting of two parts: a cephalic, in relation to the
femoral head and the dorsum ilii, and an acetabular.
The communication between the two parts may
(1) be free, (2) a narrow isthmus, and (3) obliterated by
adhesions. In the first group reduction is likely to
be easy, and retention of the hip in the reduced
position may present little difficulty. When com-
munication between the two parts of the capsular
cavity is evidently much narrowed, Leveuf and
Bertrand regard reduction by manipulation as a very
traumatic procedure liable to cause damage and not
worth attempting ; open reduction is then indicated.
Arthrography also explains the unsatisfactory clinical
results sometimes obtained in cases where the radio-
graphic report on the reduction has been encouraging.
Adhesions to the dorsum ilii prevent the capsule
from slipping down with the femoral head. The
arthrograph may show a fold of capsule intervening
between the joint surfaces, and such a joint wil
necessarily be unstable.
A variety of substances have been suggested as
suitable for injection into joints. Of these Leveuf
and Bertrand prefer two—Diagnorénol, in a 35 per
cent. solution, and Ténébryl, in a 30 per cent.
`- solution, Some authors have suggested preliminary
injection of a small quantity of air, but Leveuf and
Bertrand have found this unnecessary. The procedure
is, however, distinctly painful, and general anæs-
thesia is usually advisable in young children. In
others, 2 c.cm. of novocain are injected before the
contrast solution by means of a 10 c.cm. syringe
and a lumbar puncture needle. The hip to be injected
is raised on a cushion and the limb held by an
assistant who rotates it as necessary. The needle is
entered flush with the anterior surface of the great
trochanter just below its summit. It is pushed along
the neck of the femur till stopped by the projection
of the head. When the head is obviously anteverted
it may be simpler to aim directly at the head of the
bone, and not to use the trochanter and the neck as |
a guide to it. The contrast solution is injected
five minutes after the novocain. About 10 c.cm. is
usually necessary for a luxated hip, although in a
normal joint 2 c.cm. is sufficient. The radiogram is
taken as soon as possible, for absorption of the
solution is very rapid, and after 15 minutes no
shadow may be obtained. A slight circumduction
of the joint aids spread of the solution. Where a
complete block occurs between the capitular and
acetabular parts of the capsular cavity the solution
will remain localised around the head. Constriction
of the capsule between the acetabular rim and the
psoas muscle, its contraction by adhesions, or its
obstruction by the round ligament produce the
narrowing of the isthmus mentioned above. The
longer the condition has existed, the more definite
_ the capsular deformities are likely to be; this corre-
sponds with the recognised difficulties in reduction in
oN Se es ee
1 Pr. méd. March 20th, 1937, p. 437.
children seen after the first two or three years of age.
A complete and stable reduction will show a crescentic
shadow out-lining the head of the bone and without
extension on to the dorsum ilii. |
THE ERADICATION OF OPHTHALMIA
Tue Elizabethan poor-law broke down badly with
the poverty that prevailed in England after the
Napoleonic wars. Pauperisation of large masses of
people threatened to become the established principle
in the running of industry and particularly of agri-
culture, for such monetary grants as were received
in outdoor relief tended to be taken by employers
as part of the wages of their employees; indeed,
some farmers made it their practice only to employ
those who were on relief. In an attempt to break this
vicious circle the Poor Law Act of 1834 was intro-
duced, with its radical change of emphasis from out-
door to indoor relief. Under the new dispensation
whole families were transferred to the workhouses
and care was taken not to make these comfortable.
The inmates were herded together—the old and the
young, the sick and the healthy, the desperate and
the merely simple. What it all meant in terms of
human misery may be guessed from the columns of
this journal at the middle of last century: the
example reproduced on p. 1145 is sufficiently shocking.
And readers may remember “ Oliver Twist, or the
Parish Boy’s Progress,” which appeared in 1837,
Not the least of the problems that emerged was
the wholesale infection of children at workhouses
with trachoma and gonorrheal ophthalmia. The
difficulties did not lessen to any extent when poor-
law schools came to be built to replace the private
contractors’ schools, which the guardians used at
first because they were cheapest. When the poor-law
schools ultimately did come in the ’fifties no provision
was made for more than the most elementary treat-
ment of the sick child. These institutions, which
later came to be known as barrack schools, were
almost ideally planned for the propagation of infective
conditions among the very large number of children
herded in them, and the spread of ophthalmia was
but part of the larger problem of the spread of infec-
tious diseases in general. The guardians were not
altogether oblivious to their duties ; when an epidemic
broke out costly steps were taken to check it. But
a feature of these epidemics was the advice given with
monotonous frequency by every ophthalmologist
called in, and declined with equally monotonous
persistence by the guardians—the establishment of
sufficient facilities to isolate every infected child
within the schools or, better still, in some central
outside institution where they could be kept under
school conditions until every sign of infection had
disappeared. A tentative experiment by N ettleship
in 1873 fully justified such a procedure, but the cost
of erecting such a central hospital school was con-
sidered a final objection, just as the cost of erecting
schools under the authority of the guardians instead
of sending children to the contractors’ establishment
had been held as an equally final objection a generation
earlier. In the meantime the toll of complete or
partial blindness kept on mounting steadily in the
“good years,” hectically in the “bad years.” No
poor-law school was ever completely free from
ophthalmia, and in some almost all the children were
affected. Persistent agitation against this state of
affairs ultimately led to the setting up in 1894 of a
departmental committee to investigate .the whole
1120 THE LANCET]
working of the Poor Law Act as it affected children.
The labours of that committee led to a complete
change in poor-law education and a central ophthalmic
isolation hospital school came at last to be built
when the Metropolitan Asylums Board was charged
with the responsibility of looking after the physically
defective children in poor-law schools. The central
hospital school, White Oak Hospital, Swanley, was
opened in 1903, and a year later the sister institution,
Highwood Hospital at Brentwood. Trachoma quickly
ceased to be a problem of importance: as against
292 cases admitted in 1903, 10 were admitted last
year, despite the fact that the hospital draws nowadays
not only on what is left of the poor-law school services,
but also on the whole of the elementary schools
under the London County Council. Indeed, trachoma
was stamped out with surprising ease once the proper
machinery was established, and White Oak Hospital
is no longer a school devoted exclusively or mainly to
trachoma, but has become a highly specialised institute
for dealing with chronic eye diseases in children.
The lesson that Mr. Arnold Sorsby emphasises in
his review of the origin and development of White
Oak Hospital,! which he serves as visiting ophthalmo-
logist, is the one to which the Board of Education
drew attention in 1929—namely, that there is still a
dead weight of external eye conditions in children
all over the country. It must be admitted that
London, with its rate of 4-9 per 1000 as against 14-7
for the country as a whole, has reason to be satisfied
with the achievement of its hospital school institution,
and it is regrettable that there is only one such
institution in the whole of the country. The change
in the character of White Oak Hospital leaves one
wondering not so much that the problem which the
hospital has solved was ever allowed to arise, but
that the road to its eradication should have been so
full of difficulties and obstruction. Like most suc-
cessful public health measures, the history of the
hospital illustrates not so much the “ inevitability of
gradualness”’ as the desperate gradualness of the
inevitable.
ABNORMALITIES OF SWEATING
ABNORMALITIES of sweating may be the result
of interference in the nervous supply, of alteration
in the sweat glands themselves, or, as in the case
recently quoted by Berkman and Horton, at a
staff meeting of the Mayo Clinic,? of hysteria. Several
cases have been quoted by Wilson and another
by Uprus, Gaylor, and Carmichael,‘ in which excessive
sweating has occurred on certain parts of the face in
association with salivation, when the normal sympa-
thetic nervous supply has been interfered with as a
result of previous trauma. Cases of auriculo-temporal
syndrome and “crocodile tears °” show phenomena
of a similar type. Wilson suggests that the condition
is caused by a hyperactive state of the sweat glands,
as the result of removal of inhibition resulting from ,
the degeneration of their sympathetic nerve-supply.
In the case presented by Mogens Fog ë the lesion
was one of the glands. His patient, following a
prolonged attack of paratyphoid fever, was unable
to sweat when exposed to great heat, or after pro-
longed muscular exercise, such as would produce
profuse sweating in a normal, individual. He com-
plained of intense discomfort, palpitation, and burn-
1 Ann. Rep. London County Council for 1935.
1937. Vol. IV. Part III.
2 Berkman, J. M., and Horton, B. T. (1937) Proc. Mayo Ce
12, 161. 3 Wilson, W. O. (1936) Clinical Science, 2,
‘ Uprus, V., Gaylor, J. B., ana Carmichael, E. A. Bisa)
Brain. 57, 443°
5 Fog, M. (1936) Amer. J. med. Ass, 107, 2040.
London,
ABNORMALITIES OF SWEATING
[may 8, 1937
ing and flushing of his skin, particularly of his face.
Microscopic examination of his skin showed consider-
able destruction of his sweat glands. Mogens Fog
suggests that these phenomena are the result of the
body’s attempt to promote heat loss by radiation —
by extreme dilatation of the skin vessels, in the
absence of the usual elimination by sweat formation
and evaporation. The most interesting feature
of Berkman and Horton’s case of hysteria associated
with absence of sweating is the unconscious
resistance on the part of the patient to any muscular
effort which might cause a rise in body temperature
and so promote sweating; when the nature of her
disorder was explained to the patient and this
resistance was overcome normal sweating resulted.
Uprus, Gaylor, and Carmichael were of the opinion
that the immersion method of warming the subject
was a more certain and satisfactory method of
raising the blood temperature and promoting sweating
than the dry air-bath method used by Berkman and
Horton. The latter point out that their patient,
although showing, in their opinion, signs of sympa-
thetic dysfunction, did not present the usual features
of heat allergy, such as the urticaria usually complained
of, and they do not mention any history of intense
flushing or of dry scaly skin, which were both such
marked features in Mogens Fog’s case. It is unfor-
tunate that they were not able to test any of the
other systems under sympathetic nervous control.
PSITTACOSIS
IN 1929 the Minister of Health issued a memorandum
calling attention to the existence of psittacosis in
England both in birds and in man, and asking that
material from suspected cases should be sent to the
laboratory of the Ministry for investigation. A new
report has now been issued! in which the methods
for the laboratory diagnosis of the disease are
described in such detail that with its aid it ought to
be possible to investigate cases of psittacosis in any
properly equipped bacteriological department. The
Ministry obviously now consider that diagnostic
methods have reached a state when they can be
relied on for routine use. The new report describes
the precautions necessary in handling infectious
material and stresses the risks of infection from
experimental material. The morbid anatomy of the
disease in infected birds is described. Findings
suggestive of psittacosis are: (1) fibrinous pericardial
effusion ; (2) greatly enlarged spleen, sometimes with
necrotic nodules; and (3) a pale or yellow liver with
necrotic or hemorrhagic spots. It is recommended
that direct smears should be made from obviously
affected organs and from the lungs and heart blood.
The smears are stained with Giemsa or by Bedson
and Bland’s or Lépine’s modification of Castefiada’s
method. If the smears are clearly positive for virus
bodies no further procedures are necessary in routine
diagnosis. If they are negative or doubtful the
ground-up tissues are injected intraperitoneally into
mice. Mice injected with virulent material usually
die in 5 to 30 days. The post-mortem appearances
vary somewhat according to the time taken by the
mice to die. If death takes place three or more
days after injection the peritoneal exudate is thick
and fibrinous and virus bodies can generally be
demonstrated in the macrophage cells of the exudate.
In man the sputum, blood, and pleural exudate
from the living patient, particularly during the early
stages of the disease, or such post-mortem material
1 Laboratory Diagnosis of Psittacosis. Rep. publ. Huth med.
P Hoes No. 80. London: H.M. Stationery Office. 1937.
p. 11. .
THE LANCET]
as the spleen, affected lung, &c., should be examined
both directly and after passage through mice. In
all psittacosis infection, whether of birds, rodents, or
man, the essential change is the invasion and destruc-
tion of the reticulo-endothelial cells, and special
attention should therefore be given to these cells in
the search for virus bodies. A good coloured plate
shows the characteristic appearances of these bodies.
The concluding paragraphs of the report discuss
the special problem of psittacosis in budgerigars
(love-birds), The disease in these birds is less severe
than in ordinary parrots and parakeets, and instead
of dying they may survive to become carriers of the
virus. Further investigation is required as to the
extent of infection among the budgerigar flocks of
this country and the Ministry asks pathologists to
endeavour to obtain more information on the matter,
SERUM TREATMENT OF PNEUMONIA
THE treatment of lobar pneumonia with specific
antibacterial sera began in America soon after the
discovery of the serological types of the pneumococcus
in 1913, and later it received a decided filliip from
Felton’s discovery of a practical process for the
refinement and concentration of antisera to Types
I and II pneumococci. Following the good reports of
Cole, Park, Bullowa, Cecil, Finland, and others,
several of the United States, notably Massachusetts
and New York, have begun a “ pneumonia service ”’
to encourage the serum treatment of lobar pneumonia
in smaller urban and rural districts—a plan which
may be recommended especially to the industrial
areas in the midlands and north of England and to
Scotland where pneumonia is more common than it
is in the south. Meanwhile the pioneers forge ahead.
The division of the heterogeneous Group IV pneumo-
cocci into some 29 specific types by Cooper and her
co-workers has enabled the clinician to find out the
relative incidences of these types as causal organisms
of lobar pneumonia and the serologist to prepare
antisera to the more common of them. In par-
ticular, the treatment of lobar pneumonia due to
Types V, VII, VIII, and XIV pneumococci has been
under investigation. For example, Bullowa and
Wilcox! have collected 249 cases of Type V lobar
pneumonia (or 7-5 per cent. of the total pneumonias)
at the Harlem Hospital, New York, in the past
seven years: in comparison with a mortality-rate of
20-8 per cent. in an untreated series of 163, there
were only 5 deaths (7-5 per cent.) among 67 treated
with serum. Similarly Finland and co-workers,? at
the City Hospital, Boston, isolated Type VII pneumo-
coccus from 195 patients in seven years, representing
5-5 per cent. of all the cases from which specifically
typed pneumococci were obtained during this period.
Of these, 160 were suffering from pneumonia and it is
significant that whereas Type I and II infections are
almost constantly lobar in type, about one-fifth of
the Type VII cases were classified as broncho-
pneumonia. In a series of 30 cases of Type VII
lobar pneumonia, rapid and permanent clinical
improvement followed treatment with concentrated
type-specific antiserum. Finland and Tilghman 4
have reported similar results in a small series of
Type V lobar pneumonia. Nor, in the pursuit of new
types, has Type I been forgotten, as may be seen from
the paper * Cecil read to the International Micro-
and, M., ee J. M., Dowling, H. F., and
Tilghman, É. C. (1937) Amer. J. med. Sci. 193, 48, 59.
a15 oan, » M., and Tilghman, R. C. (1936) New Engl. J. med.
4 Cecil, R. L. (1937) J. Amer. med. Ass. 108, 689.
SERUM TREATMENT OF PNEUMONIA
[may 8, 1937 1121
biological Congress last summer. The illness, he says,
from being a serious exhausting infection of 7-8 days’
duration can be reduced by early serum treatment
almost to the status of an influenzal attack ; in other
words, it is dramatically aborted. Spread of infection
is prevented, bacterizmia is checked, complications `
are inhibited, and the death-rate is cut to approxi-
mately one-sixth of the standard mortality for
Type I pneumonia. Meanwhile, despite the truth of
Cecil’s remark that reports on serotherapy of lobar
pneumonia have been without exception favourable,
little enthusiasm for this new line of treatment is
being shown in this country. We were glad, therefore,
to be able to publish a few weeks ago the observations
made by Drs. Langley, Mackay, and Stent® on
Types I and II pneumococcal pneumonias treated
with specific sera at the Hope Hospital, Salford.
Though some of their conclusions are open to argu-
ment, it is clear that the work they are doing is of
real value.
THE SEX HORMONES IN ECLAMPSIA
THe work of O. W. Smith and G. Van S. Smith
on the secretion of sex hormones in eclampsia and
pre-eclampsia has already been annotated in these
columns. These authors reported that the blood,
urine, and placentas of eclamptic subjects contained
excessive amounts of a gonadotropic hormone, and,
less constantly, a paucity of cestrogenic hormones.
Their experimental results indicated that the extra
gonadotropic hormone was the same luteinising
type (prolan B) that is found in normal pregnancy ;
and that it was derived from the placenta. The
methods at present available for the assay of sex
hormones are far from satisfactory, but if the above
observations are correct it becomes important to
find out whether over-secretion of prolan B is
responsible, partly or wholly, for eclampsia, or
whether it is merely a secondary response to some
other dislocation of endocrine balance—analogous,
for instance, to the excessive output of prolan A
which is seen at the menopause.
With an equation involving so many inter-related
variables as the reproductive cycle it is no easy
task to distinguish between cause and effect. The
fact that toxæmia is especially common in multiple
pregnancy and in cases of hydatidiform mole suggests
that increased secretion of prolan B may ‘be
of primary rather than secondary import. But
the inference is not conclusive and it is more to the
point to ask whether, when eclampsia complicates
an otherwise normal pregnancy, hypersecretion of
prolan precedes or merely accompanies the clinical
symptoms. Preliminary observations by Smith and
Smith suggested that over-secretion may antedate
symptoms by several weeks, and they now’ bring
forward further evidence that bears out this suggestion.
They have collected serial samples of blood and urine
throughout pregnancy in a series of 27 pregnant
women, and estimated the prolan and cestrin content
of the samples. Their series includes 11 diabetic
subjects, who were selected because the incidence
of toxemia is high in diabetes. Of their 27 patients,
6 developed pre-eclampsia, 4 of these being diabetics ;
17, including 5 diabetics, remained free from
symptoms ; while the remaining 4 pregnancies were
neither normal nor frankly toxemic. In the toxæmic
patients high prolan and low cestrin figures were
observed, and it seems clear that the rise in serum
Romer ts G. F., Mackay, W., and Stent, L., Lancet, April 3rd,
1937, p
€ Lancet, 1935, 2, 564.
Amer. J. Obstet. Gynec. 1937, 33, 365.
1122 THE LANCET]
DIVINYL ETHER
[may 8, 1937
prolan occurs about six weeks before the appearance
of clinical symptoms. —
This strengthens the opinion that over-production of
prolan plays some part in causing eclampsia. How it
does so is uncertain. There appears to be a reciprocal
relationship between the prolan-B and cstrin content
of the plasma, and cestrin deficiency may be the
important factor. It does not seem likely that over-
secretion of prolan is the only cause of toxemia,
for eclamptic symptoms may be wholly lacking in
cases of chorion carcinoma, where the output of
prolan is enormous. The work of Smith and Smith
has not, therefore, solved the problem of eclampsia,
but one may hope that further research along these
lines may eventually disclose the secret, and lead
to rational, instead of empirical, treatment of these
tragic illnesses.
LONDON STARLINGS
Ir has been shown that the genitalia of many
birds, mammals, reptiles, amphibia, and fish may be
induced to anticipate their normal time of develop-
ment by extending the daylight available in winter
and early spring by artificial ilumination ; lengthen-
ing daylight seems certainly to be an important factor
in spring breeding, and it is possible that man had a
more definite reproductive reason than he has now
before he learned to equalise his days with artificial
light. There is also some evidence, not altogether
consistent, that maturation may be hurried by
disturbance and curtailing the usual hours of sleep.
Prof. William Rowan now finds 1 that the testes and
ovaries of starlings from the huge flocks which come
into London every night to roost are more forward
in development than those of country birds, and
suggests that this is due to their being kept on the
fidget by the noise of traffic; the light at the roosting
places he finds to be well below the effective threshold.
The night noises of London are indeed dreadful,
but we doubt whether he has made out his case,
Birds often choose to put their nests in noisy places
by railway lines and busy high roads, so that it is
unlikely that they find such conditions disturbing.
Prof. Rowan also does not state the origin of his
country controls, whether they came from a big
country roost or from sporadic birds. The former
is obviously necessary since the dormitories in woods
and plantations far from towns are by no means
altogether quiet at night. Perhaps it 1s not the noise
of the vehicles but the aggregation of so many birds
together that stimulates sex.
DIVINYL ETHER
WHATEVER may be its merits or demerits as an
anesthetic for long operations divinyl ether is cer-
tainly a most valuable agent when a short but
profound narcosis is required. It is not uncomfortable
or irritating to inhale, and the patient recovers
quickly and generally without distress from its
effects. Moreover, it has the great practical advan-
tage that it can be administered by very simple
means. These and other points are well brought out
in a recent review of a series of 2675 administrations.’
The authors recommend that when more than half
an hour’s anesthesia is wanted the ether should be
volatilised with oxygen; otherwise they use a simple
drop method on a few layers of loosely fluffed gauze.
Divinyl ether is of course a potent anzsthetic, the
1 Nature, April 17th, 1937, p. 668.
2 Ravdin, I. S., Eliason, E. L., Coates, G. I., Holloway, T. B.,
Ferguson, L. K., Gill, A. B., and Cook, T. J., J. Amer. med.
Ass. April 3rd, 1937, p. 1163.
concentration necessary in the blood for production
of anæsthesia being even less than that of chloroform.
Consequently the drug must be given with due care,
and danger is easily introduced if a closed apparatus
is employed by means of which too high a percentage
of vapour would be rapidly acquired. The wide
applicability of divinyl ether is illustrated by the
fact that in this series the youngest patient was
fifteen months old and the eldest seventy-five years.
The authors remark on the freedom from post-
anesthetic pulmonary complications. This, however,
would surely be expected from any anzsthetic used
for such short periods of time as was divinyl ether
on most of the recorded occasions. It is three years
since Wesley Bourne of Montreal’ recorded his
satisfaction with divinyl ether in obstetrics, and we
would be interested to learn whether it has been
tried for that purpose in this country. So simple a
method if it proved equally safe might well come to
rival gas-and-oxygen in popularity.
THE MARCH OF TIME
Many of our readers may not. know, but their
children will tell them, that this is the title of an
instructional—or, as it is called technically, a docu-
mentary—film which is shown in many picture
theatres as a serial, In this film, which consists of
several short episodes, the moving picture is used as
. a newspaper or rather as a magazine. Accompanied
by a running commentary it depicts matters of
current interest, grave and gay, and it is changed
every few weeks. One cannot see some of the episodes
dealing with a serious subject without being impressed
by the extraordinary, even alarming, power of this
‘new technique in educating and moulding public
opinion. The latest edition of this series—No. 11—
contains an episode entitled The Conquest of Cancer.
The greater part of the film has been made in the
United States. Several of the leading American
medical authorities on cancer appear, without their
names being mentioned, and make brief statements
emphasising the fact that cancer is curable, and that
many thousands of persons have been cured of cancer
because they have sought medical advice sufficiently
early. They warn the public against the use of
quack cures on which in the United States a large
amount of money is being wasted. The scene then
shifts to England where Sir Kingsley Wood appears
on the film to teach the same lesson. The film has
evidently been editorially supervised by responsible
medical authorities in America, and it proves that
the admittedly difficult task of educating public
opinion with regard to cancer can be accomplished
effectively and at the same time with tact and
restraint. The English portion is not as strictly
anonymous as the American ; and though no exception
can be taken to the discreet reference to distinguished
workers made by Sir Kingsley Wood, danger lies in
this use of the cinema to advertise individual insti-
tutions. It must not be allowed to weaken the self-
denying code of anonymity that the medical profession
has for very good reasons imposed upon itself.
WE regret to learn of the death at an advanced
age of Prof. Bennett May, emeritus professor of
surgery at the University of Birmingham.
Queen Mary has appointed Mr. C. B. Goulden
surgeon oculist, and Mr. Francis Donovan surgeon
dentist, to her household. ,
3 Lance, 1934, 1, 566..
THE LANCET]
{may 8, 1937 1123
BRITISH HOSPITALS ASSOCIATION
REPORT OF A COMMISSION ON VOLUNTARY
HOSPITALS
THE annual conference of the British Hospitals
Association appointed on June Ist, 1935, a com-
mission to take into consideration the present position
of the voluntary hospitals of the country ; to inquire
whether in view of recent legislative and social
developments it is desirable that any steps should
be taken to promote their interests, develop their
policy and safeguard their future, and to frame such
recommendations as may be thought expedient and
acceptable. The members of the Commission were
Viscount Sankey (chairman), Alderman Miss Bartleet,
Sir Henry Brackenbury, M.D., Alderman Alan Davies,
Prof. L. S. Dudgeon, F.R.C.P., Mr. H. L. H. Hill,
Col. D. J. Mackintosh, M.B., Miss E. M. Musson,
S.R.N., Sir Reginald Poole, Provost A. W. Sheen,
M.S., with Mr. R. H. P. Orde as honorary secretary.
After taking a large body of oral and written
evidence from representatives of all the associations
which could give valuable information, the Com-
mission have issued their report.:
The Commission recall the action of the Minister
-~ of Health in 1921 in setting up the Cave Committee
to ‘‘consider the present financial position of the
voluntary hospitals and to make recommendations
as to any action which should-be taken to assist them.’
The Cave Committee reported that the lack of
organisation and codperation among the voluntary
hospitals detracted from their efficiency and caused
much avoidable expenditure. These institutions,
which should be parts of a connected system, were
for the most part units working in isolation or in
competition with one another and learning little
or nothing from one another’s successes or failures.
Subject to qualifications concerning the teaching
hospitals and special hospitals, the committee saw
no reason why arrangements should not be made
both for defining the functions of hospitals and for
promoting coöperation among them. They accord-
ingly recommended the setting up of a Voluntary
Hospitals Commission consisting of up to twelve
members nominated by the Minister of Health, the
Secretary of State for Scotland, the Joint Committee
of the British Red Cross and the Order of St. John
of Jerusalem, King Edward’s Hospital Fund for
London, the British Hospitals Association, the
Royal College of Physicians, the Royal College of
Surgeons, the British Medical Association, and the
Scottish Committee of the British Medical Association ;
also the formation of local voluntary hospital com-
mittees nominated by the Lord-Lieutenants. They
hoped that although these bodies were to be
established primarily for the purpose of distributing
definite sums of money, they would continue to per-
form their functions after these sums had been
exhausted : to collect information, advise on accounts,
marshal appeals for funds, act as clearing-houses
for patients, and promote the grading and coöperation
of hospitals in their areas. ‘They were to have no
compulsory powers but would derive authority from
their personnel and from their control over the
distribution of money grants. Both the commission
and the local committees were set up and distributed
1 Published by the British Hospital
s Association, 12,
Grosvenor-crescent, London, S.W.1. Pp. 85. ls.
~ SPECIAL ARTICLES
£500,000 which had been granted them by Parliament.
They survived for some time after this money had
been spent, but failed to bring about the reforms
which the Cave Committeé had urged as necessary
for the efficiency of the voluntary system. They
gradually disappeared—according to the present
Commission—because, possibly owing to their method
of appointment, they never secured the whole-
hearted support of the hospitals; also because in
1921 the efficiency of the voluntary hospitals as a
system, and not their individual existence, was at
stake, because opinions as to reform differed and
because there was no external menace to drive them
together. The stimulus of immediate danger to
their existence which was absent in 1921 has now,
the Commission say, been supplied by the passing
of the Local Government Act, 1929, and the advent
of the council hospital. To-day the voluntary
hospitals are themselves demanding those very
reforms which the Cave Committee urged upon
them and which they neglected to carry out.
THE COMMISSION’S RECOMMENDATIONS
This is the thesis on which the present Commission
base their recommendations, of which the principal
ones are as follows :—
1. The division of the country into hospital regions.
2. The formation in each region of a Voluntary Hospitals
Regional Council to correlate hospital work and needs
in the region.
3. The formation of a Voluntary Hospitals Central
Council to coérdinate the work of the regional councils.
4. The establishment of central and regional offices.
5. The initiation of the above scheme by the British
Hospitals Association with the subsequent incorporation
of the scheme in the:work of the association.
6. The grouping of hospitals in a region round a central
hospital.
7. The grading of hospitals into central, district and
cottage hospitals. |
8. The creation of a regional fund for the benefit of all
the hospitals in a region.
9.°"The payment of the expenses of the. new organisa-
tions proposed from hospital and regional funds and from
government grants.
10. The adoption by all hospitals of a uniform system of
accounts.
11. The securing of financial aid for hospitals from the
State and from the local authorities.
12. The adoption of improved methods for the collection
of funds for hospitals.
13. The setting-up, or development to the full, in all
regions of contributory schemes.
14. The making of arrangements by which all the
hospital beds in a region can be utilised in the best interests
of patients and to the fullest extent.
15. The full provision of auxiliary hospitals to relieve
the main hospitals.
16. The undesirability of the establishment of special
hospitals and the affiliation—as far as possible—of those
at present existing with general hospitals. i
17. The establishment of machinery to obviate
congestion in some hospitals and empty beds in others.
18. The provision by all hospitals of accommodation
for paying patients.
19. The restriction of attendance at out-patient depart-
ments of hospitals by adopting certain limitations and the
taking of steps to remedy the present inconveniences of
departments.
20. The making of appointments to the visiting medical
staff of a hospital under the guidance of appropriate
experts. i
21. The appointment of a member of the visiting
medical staff of a hospital to be governed by a formal
agreement between such member and the hospital.
1124 THE LANCET]
22. The- payment—with certain qualifications—of the
visiting medical staff.
25. In regard to the nursing service: (i) the improve-
ment of the conditions, including higher pay for trained
nurses ; (ii) the adoption of a higher educational standard
for entrants; (ili) the commencement of training in all
cases by attendance at Preliminary Training Schools ;
(iv) the recognition of the position of the matron as an
administrative officer and her direct access to committees
when matters affecting her department are under considera-
tion ; (v) the universal adoption of a pensions scheme.
24. The recognition of the special qualifications required
for the chief administrative officer of a hospital.
25. The furtherance of a definite scheme of education
in hospital administration.
26. The universal adoption of a pensions scheme for
the administrative staff.
27. The provision of the services of a qualified
accountant for hospital accounting when required.
28. The consideration of the advisability of separating
the collection of funds from administration.
29. The securing of those holding statutory qualifica-
tions for some auxiliary services in hospitals and of those
specially qualified through a recognised test for certain
others.
30. The organisation of the ambulance service in a
region by the local authorities and the adoption—with
certain exceptions—of a moderate charge to the patient
for the service.
31. The recognition of the special requirements of
teaching hospitals.
32. The keeping by all hospitals of patients’ records
on a uniform system of classification ; a record depart-
ment at each regional office.
33. The furtherance by hospitals of research and of
“follow-up °? methods.
34. The publication by hospitals of annual clinical
reports.
35. The adoption of suitable publicity methods for
hospitals with formation of a press bureau and the publica-
tion of a periodical.
36. The special organisation of the voluntary hospitals
in Scotland. !
37. The practical recognition by all hospitals of the
powers conferred by Section 13 of the Local Government
Act, 1929, with full coöperation as regards provision for
the public health between voluntary hospitals and local
authorities.
FINANCE
The Commission conclude that if the thousand
British voluntary hospitals could distribute their
total annual income according to their individual
needs, their financial position would not be unsatis-
factory. They suggest as an ideal plan the pooling
of a percentage of the revenue of each hospital, but
doubt, however, whether the supporters of voluntary
hospitals are yet prepared for so fundamental a
change. They therefore recommend as a first step
the creation of regional funds on a basis similar to
that of King Edward’s Hospital Fund for London.
Such funds would, they think, possess the double
advantage of creating new sources of support and
of educating donors to help the hospitals as a whole.
A uniform system of accounts would be necessary,
but the Commission do not recommend the adoption
of the “ Revised Uniform System” of the King
Edward’s Fund, believing that a modification of
this system could be devised that would strike a
balance between the advantage of having good
statistical records and that of simplicity. The
Commission find no reason why the State should not
contribute grants in aid of the voluntary hospitals.
They lay down governing principles for contributory
schemes, the establishment and growth of which they
welcome. They also favour the establishment of
provident schemes for paying patients of moderate
means. They consider it to be the duty of voluntary
hospitals to provide beds for paying patients of all
BRITISH HOSPITALS ASSOCIATION
[may 8, 1937
classes of the community and to give them a free
choice of medical attendants, who should receive
a separate fee.
VISITING MEDICAL STAFFS
The Commission accept the payment of medical
staffs as a general principle, but the suggestion was
made to them that there exist three classes of medical
staff to which this principle does not apply with the
same force—viz., the staffs of teachmg hospitals,
the staffs of hospitals with a considerable number of
pay-beds, and the senior staffs of other large general
hospitals. They found some point in this contention
when applied to the first two classes. A position
on the staff of a hospital with a medical school is,
they recognise, undoubtedly a valuable asset; but
since there must be a lag of a number of years before
the teacher can reap the reward of the time and work
which he has given, the general argument for some
form of payment therefore still applies to the junior
members of the staff. If the State ever makes a
special grant to teaching hospitals (as was recom-
mended in the Report of the Scottish Departmental
Committee on Health Services last year) some portion
should, they think, be assigned to those members of
the staff who actually give the clinical instruction. |
Moreover, in hospitals with a considerable number of
pay-beds, the patients in which are liable for the
fee of their medical attendants by private arrange-
ment, the medical staff stand to gain a material
advantage. This, however, only applies when the
staff have a monopoly of attendance on patients
in the pay-beds. The Commission do not see that
the senior staffs of other large general hospitals derive
advantages which would lessen their claim to payment.
Prolonged service on the staff of a hospital sometimes
has material value, but by no means always, and it is
not always the senior members of the staff who are
preferred by their fellow practitioners or by the
general public in the district.
While, therefore, the Commission agree with the
general principle that the medical and surgical
staffs should be paid, they think that there might
well be exceptions or modifications in these stated
directions. They. would not expect a universal
application of the principle immediately, because
the circumstances of individual hospitals and the
attitude of many members of their stafis vary so
widely. If the principle is right, however, they
think that the formidable difficulties in the way should
in time be overcome, They suggest that the most
satisfactory method may ultimately be found to be
a definite part-time honorarium or salary. This
must involve a statement of the duties undertaken
and an obligation to fulfil them more exactly than
is sometimes considered necessary to-day.
THE NURSING SERVICE
Broadly speaking, the recommendations of the
Commission for the improvement of the nursing
service appear to follow tbose of THE LANCET
Commission on Nursing. The problem of attracting
a larger number of good candidates can, the Com-
mission say, only be met by making the conditions
of service more attractive. The _ school-leaving
certificate may be a suitable standard of education,
though it may not be required of some otherwise
suitable applicants. All nurses should begin in a
preliminary training school, and central schools
should be established in regions. From these schools
candidates would pass to recognised hospitals. All
possible opportunities should be taken for higher
training and qualification. The Commission welcome
THE LANCET]
the diploma in nursing of certain universities and
hope that this development will be extended. Special
courses—e.g., in housekeeping and dietetics—should
be facilitated. Remuneration should, they say, be
higher and all nurses should be enabled to become
members of the Federated Superannuation Scheme
for nurses and hospital officers. Present hours of
duty are considered to be too long, the ideal being a
48-hour week. Until this ideal is attainable, more
nurses should be appointed to the relief staff. The
ratio of nurses to beds should be at least one member
of the nursing staff employed during every 24 hours
to every two available beds, excluding nurses in
special departments. Every large hospital should
have a suitable nurses’ home with full amenities ;
in smaller hospitals separate accommodation should
be provided. The ratio of trained nurses to nurses
in training should be increased. Small hospitals not
recognised as training schools should be staffed by
trained nurses with adequate domestic help.
The report contains many other matters of interest,
notably discussions of the relationship between
voluntary and council hospitals and of the out-
patient problem.
MATERNAL MORTALITY.
THE TWO REPORTS
Last week we gave a preliminary account of the
Ministry of Health’s report! on maternal mortality.
The investigation was made, it will be remembered,
to discover why the maternal mortality-rate of this
country has tended to rise while the conditions of
living, the health services, and expectation of life
have improved. In particular the maternal mor-
tality has been persistently greater in some districts
than in others; the investigation has therefore been
directed to the conditions in those and in a few
control districts. It was made by study of the
figures in the Registrar-General’s Review and of
others relating to those districts extracted by the
General Register Office for the investigation; by
inquiry into the circumstances of all maternal deaths
and abortions in those districts in 1934; and by
survey of the maternity services. The local inquiries
were made by six medical officers of health, three of
whom had special knowledge of maternity services
and three of health services in general. They were
assisted by Sir Comyns Berkeley in a consultant
capacity and by the local medical officers.
The districts visited were mainly those which in
the decade 1924-33 had experienced an average
puerperal mortality-rate in excess of the arbitrary
figure of 5 per 1000 live births. They included
the administrative counties of Lancashire, the West
Riding, Cumberland and Westmorland, the 22 county
districts autonomous for maternity and child welfare
work in the West Riding and 14 in Lancashire, the
18 county boroughs of Blackburn, Blackpool, Bolton,
Preston, Rochdale, Wigan, Barnsley, Bradford,
Dewsbury, Halifax, Huddersfield, Sheffield, Wake-
field, Canterbury, Carlisle, Darlington, Lincoln, and
Plymouth. In addition, for comparison, visits were
paid to seven districts where the average mortality-
rate for the decade had been low. These were the
administrative county of Lincoln (Kesteven), and the
county boroughs of Barrow, Bootle, Liverpool,
Portsmouth, West Ham, and Hartlepool.
2? Report on an Investigation into Maternal Mortality.
Ministry of Health. Cmd. 5422. London: H.M. Stationery
Office. 1937. Pp. 353. 5s. 6d.
MATERNAL MORTALITY : THE TWO REPORTS
since about 1923 has bee
[may 8, 1937 1125
THE STATISTICS OF MATERNAL MORTALITY
The trend of the puerperal mortality in England
and Wales has been slightly upward during the past .
ten years (Fig. 1), and the report points out that the
changes in classification of deaths have not been
such as to affect this conclusion. It is possible that.
increased accuracy of certification may have con-
tributed but this factor cannot be assessed. A
stationary or upward trend is also shown by the
mortality-rates in other countries, and although
differences in certification and classification make
comparison of little value the international position
of England and Wales is probably neither so com-
pletely unsatisfactory nor so “‘ near the bottom of the
list” as some allege. Studying the individual causes
of death, it appears that the rise in the total rate
due to a definite increase
in the rate from sepsis, while that from other causes
has remained about the same. The mortality from
toxemia shows an upward trend, while that from
hemorrhage a decline. The increase over eight
years in the rate for total abortions is about 18 per
cent. as compared with about 9 per cent. for all
puerperal causes.
Taking the whole of the 79 county boroughs of
England, no association between overcrowding and
puerperal mortality was found; in the West Riding,
however, the towns with most “overcrowding tend to
have the highest rate of puerperal mortality, the
three boroughs with the largest proportion of over-
crowding having also the highest mortality from
toxemia. In Lancashire, on the other hand, the
towns with most overcrowding had a lower mortality
than the others and similar results were obtained
for the districts of London.
On the whole, the proportion of women employed
in any “‘ gainful ” occupation and the rates of puer-
peral mortality are found to rise and fall together ;
when the occupation is industrial the tendency is
more conspicuous. In the county boroughs of
England the proportion of women employed in
personal service tended to be inversely related to
mortality-rate ; this, the report points out, does not
mean that personal service per se is conducive to a
low rate, and the -association is reversed in London.
The extent of unemployment seemed to be the best
index of prevailing economic conditions available for
general use, and using that index no consistent
association is found between puerperal mortality-
rates and economic conditions either in the same year
or the succeeding year. The distribution of rainfall
and of the incidence of puerperal mortality are similar
(Figs. 2 and 3), but unfortunately the meteorological
observations have not necessarily been made in the
administrative areas to which the mortality returns
relate. The statistically significant degree of correla-
tion which exists does not mean that there is any
causal relation between rainfall and puerperal mor-
tality ; the association may be merely that high rates
and high rainfall occur in certain geographical areas
of the country. The report says that there may also
be an association between other climatic factors—
sunshine, temperature, and humidity for instance—
but the data to demonstrate this association are not
available. In the areas visited deaths from puerperal
sepsis tend to occur most frequently in the coldest
quarter of the year, the time succeeding the wettest
and most sunless quarter; deaths from toxemia, in
contrast, tend to occur most in the warmest quarter,
which succeeds the driest and sunniest.
The relation of parity to risks of maternal mor-
tality was studied from a sample of births. Between
1126 THE LANCET]
MATERNAL MORTALITY : THE TWO REPORTS
[may 8, 1937
Wa
i=]
>
Qr
4:37 | 433
4-17 | 4.18
at
eS
e
_ PUERPERAL MORTALITY RATE
ta
An
i91} 1912 [913 1914 3195 1916 19I7 19I8 19I9 1920 192I
YEAR
3 4340
18_|_ 4-12 / N 4-08 s e- F742
-3:38 | 596 `~ 7 N < é a Ie 40
a: "3 A 3-97
387 389 $99
; 3-5
30 30
1922
5'0
T ec)
42 r N
4°51 4°60
442
r
1923 1924 1925 1926 1927 1928 1929 1930 193) 1932 1933 1934
. FIG. 1 (reproduced from the Ministry of Health Report).—Trend of puerperal mortality in England and Wales during 1911-34
as indicated by a line representing the five-year moving averages of the rates.
35 and 40 per cent. of legitimate and from 60 to 70 per
cent. of illegitimate live births were the outcome of first
pregnancies, and after excluding deaths from abortion
about 45 per cent. of the deaths of married women
are found to occur in first pregnancies. The average
risk to married women who have already reached the
seventh month of pregnancy is lowest in the third
pregnancy and then increases progressively with
birth order. The average risk of confinement at the
first pregnancy is about 25 per cent. in excess of the
general risk for all confinements and exceeds the
risk for subsequent confinements up to about the
eighth, after which the risks become greater than
that of a first confinement. Twin confinements are
subject to a considerably higher mortality risk than
those resulting in a single child. The falling birth-
rate has resulted during the last ten years in an
increase in the proportion of first confinements and
at the same time in a fall in the proportion of con-
finements of women who have had many children.
FIG. 2 (from the Report).—Puerperal mortality by counties
during 1924-33. Group A = rates higher than that of England
and Wales (i.e., 4°21 per 1000 live births) by 20 per cent. or
more. Group B= rates higher by less than 20 per cent.
Group C= rates lower by less than 20 per cent. Group D =
rates lower by 20 per cent. or more.
The opposing effects of these changes on the total
mortality risk have been almost complementary in
the country as a whole so that an increase during
ten years amounting to round about l or 2 per cent.
of the death-rate is all that can be accounted for
by fall in fertility. The rates of puerperal mortality
among the wives of men classified socially according
to their occupations decline in passing from pro-
fessional and middle-classes to the unskilled classes,
this being specially evident for puerperal sepsis
but not for puerperal hemorrhage.
In several of the districts visited it was suggested
that the prevalence of scarlet fever in the area
coincided with prevalence of puerperal fever. On
examination of the evidence the prevalence of puer-
peral sepsis in an individual district did not seem to
depend on the prevalence of other diseases of strepto-
coccal origin although for the country as a whole
conditions favourable to a high prevalence of
puerperal fever seemed to predispose also to a high
FIG. annual rainfall of
3 (from the Report).—Average
England and Wales (1881-1915).
THE LANCET]
prevalence of scarlet fever, erysipelas and diphtheria.
{Fig. 4.)
.CIRCUMSTANCES OF MATERNAL DEATHS IN 1934 IN
THE AREAS VISITED
In all, 775 deaths were investigated, but in 3
pregnancy was found not to be present and in 2
the pregnancy was considered to be incidental to
the death. All available data relevant to environ-
mental, social, and economic conditions of the remain-
ing 770 cases and particulars of death were collected.
The deaths were classified for the most part with
small modification,
according to the recom- +40
mendations of the
Scottish Departmental
Committee. +30
Toxemia.—There were
137 deaths directly due
to toxemia; of these 73
were attributed to
eclampsia. Again the
greatest number of deaths
was found in the third
quarter of the year; the
financial circumstances of
most of the patients
excluded the likelihood
of poverty and conse-
quent lack of food being
the cause. The super-
vision during the ante-
natal period was judged
to be good in only 2
PERCENTAGE VARIATION
eases, reasonably careful - 30 5
in 12, deficient in 37, y a
none in 11, and unknown V Q
in 11. To pre-eclamptic
toxemia 26 deaths were
assigned, 10 of these
occurring in the third
quarter. The ages of 12
of the women were between twenty-five and
forty, and only 1 was over forty; 13 were primi-
parous. The 6 deaths from pyelitis bore out
the statement that pyelitis occurs commonly in
young women, for 5 of them were pregnant for the
first time and all of them were under twenty-nine.
Hyperemesis accounted for 19 deaths, undefined
toxemia for 7, and acute yellow atrophy of the
liver for 6. In no less than 28 per cent. of the 770
deaths investigated toxemia either influenced the
issue or was the cause of death. It is therefore held
to be a contributory factor in a large proportion of
maternal deaths.
Hemorrhage.—Antepartum hemorrhage in which
there was no evidence of abnormal implantation of
the placenta caused 27 deaths; a large proportion
of the women were in the higher age and parity
groups; 15 were over thirty-five years old and 16
were mothers of more than four children; in 4 a
history of from one to four abortions was obtained.
Placenta previa with hemorrhage accounted for
25 deaths; again the women were mainly in the
later years of child bearing, more than half being
over thirty-five; 10 of the women were mothers of
more than four children and 3 had had eleven, twelve,
and fourteen children respectively. Post-partum
heemorrhage was held responsible for 21 deaths. The
report states that the records of treatment of these
cases of P.P.H. demonstrate the need for adequate
consultative and transfusion services. In six instances
the early departure of the attendant after delivery
MATERNAL MORTALITY: THE TWO REPORTS
1927
tions per 1000 population.
conditions = deaths per million population.
[may 8, 1937 1127
or after hzmorrhage may have influenced the
issue.
Trauma and sudden death.—The 92 deaths in this
group were classified into obstetric shock 43, embolism
28, rupture of the uterus 7, extensive tears of cervix,
vagina or vulva 3, deaths associated with anæs-
thetics 6, and deaths from paralytic ileus and intestinal
obstruction after Cæsarean section 5.- Over half of .
these women were between the ages of thirty and
thirty-nine and also over half were primiparous,
but among the group attributed to shock most of the
women were under thirty.
SCARLET
/ FEVER
l
!
j ALLSEPTIC
i g CONDITIONS
i ve
[PS ERYSIPELAS
“İF a PUERPERAL
4 FEVER
> DIPHTHERIA
©
X o È X N B
V Q Q 2 2 D
FIG. 4 (modified from the Report).—Graph showing percentage variations from the average
rate (England and Wales) for 1924-33. Scarlet fever, erysipelas, and diphtheria = notifica-
Puerperal fever = notifications per 1000 live births. All septic
Puerperal sepsis—If the 84 deaths attributed to
post-abortive sepsis are deducted from the total
303 of this group, the remaining 219 represent 28-4
per cent. of the total puerperal mortality. The
records of treatment varied considerably. Blood
transfusion was stated to have been undertaken in
10 cases, and serum to have been administered in
74, while 17 women were treated by Hobbs’s glycerin
method. The report says that conclusions could not
be drawn about serum treatment as in many cases
it was not based on scientific principles; various
types of sera were administered, including humanised
serum, anti-scarlet serum and polyvalent serum.
In a number of instances several kinds of serum
were given to one patient. Conditions which may
have made septic infection more likely were present
in many of the cases classified in this group as normal
deliveries ; some of the women were in poor health,
23 had definite signs of toxemia and in 37 there was
laceration of the soft parts. The report discusses
several aspects of obstetric practice.
Forceps were used in 140 of the 627 cases of the
series reaching the twenty-eighth week; their use
was unsuccessful in 27, They were applied for
occipito-posterior presentation in 12 cases, breech
5, twins 2, contracted pelvis 7, ante-partum hemor-
rhage 11, eclampsia 13, toxemia 4, other illnesses
of the mother 16, and signs of fetal distress 1. In
14 instances the only reason given for the use of
forceps was primiparity, in 25 the indication given
was inertia and prolonged labour, Sepsis was the
1128 THE LANCET]
cause of death in 43 per cent. of these forceps
Cases.
Cesarean sectton had been performed in 52 of the
627 cases; earlier attempts to deliver had been made
in 11 of these and in 3 several attempts at forceps
delivery had been made. In some of the districts
visited an obstetric specialist had not been available
and surgeons with little obstetric experience had been
appointed to act in their stead. They had naturally
been inclined to adopt a procedure which was familiar
to them; the percentage of deliveries by Cesarean
section at three big London hospitals investigated
varied between 0:55 and 3-49, whereas in a hospital
with a small maternity unit 27 of the 104 deliveries
in a year were by Cesarean section, while 52 cases
were normal,
Condition of the infant.—An attempt was made to
find out the toll of infant life represented by the
maternal deaths; 101 mothers of the series of 770
died undelivered and there were 127 abortions;
in all, half of the pregnancies ended in the death of
both mcther and fetus.
The conclusion is reached in the report that in
many instances ignorance or lack’ of coöperation on
the part of the patient or her relatives prejudiced
her chance of recovery. The standard of practice
of midwives in some cases was considered to be
unsatisfactory, the antenatal supervision perfunctory,
medical assistance sought too late and procedures
inconsistent with competent midwifery were
occasionally adopted. The treatment in many
hospitals was efficient and comprehensive, in others
it left much to be desired. The general practitioner,
it was realised, was often called to an emergency
in a patient’s home and faced with probleins of great
difficulty, often without assistance, in unsuitable
surroundings and under unfavourable conditions ;
many of the histories indicate that notwithstanding
the handicaps, careful obstetric procedures were
adopted yet sudden and unforeseen complications
led to a fatal issue. |
After pointing out some of the lessons to be learnt
from this series of deaths the report mentions that
the conclusions agree with those of the Departmental
Committee of 1932; their recommendations have
been implemented in the training of medical students,
in the development of maternity services, and by the
provision of salaried midwives; “‘ but,’ the report
says, ‘‘the role of the general practitioner in mid-
wifery has not yet received the attention it deserves.”
ABORTION
Abortion was investigated by the local inquiries
into maternal deaths, by study of national statistics,
and by collecting impressions. The report concludes
that there does not seem to be any reliable means
of estimating the incidence of abortion and that it
is difficult and often impossible to differentiate in
practice between a spontaneous abortion and one
induced artificially. The impression was gained that
the practice of artificial abortion is common and
appears to be increasing; is more prevalent in some
districts than others and is not restricted to any one
class. In some areas the provision for in-patient
treatment under expert supervision were inadequate.
The dangers of artificially induced abortion do not
appear to be sufficiently realised and there is urgent
need for the education of women about the damage
to health and danger to life from attempts to
terminate pregnancy artificially. Abortion (whether
spontaneous or artificially induced, but excluding
cases classed as criminal) is an important factor in
the puerperal mortality-rate of the country since
MATERNAL MORTALITY : THE TWO REPORTS
[may 8, 1937
approximately 14 per cent. of all puerperal deaths
are due to this cause. The statistics suggest that the
trend of abortion rates is increasing more than that
of other puerperal causes. The death-rate frqm
abortion is higher in the aggregate of areas with
high average mortality-rates than that of England
and Wales as a whole. There are, of course, many
more deaths from abortion among married women
than among the unmarried, but abortion is responsible
for a greater proportion of the deaths among the
latter class and is largely responsible for the higher
maternal mortality-rate of unmarried women.
MATERNITY SERVICES
The report reviews the evolution of the maternity
services up to the present, commenting that at present
the local authorities have no say in the selection
of practitioners who may be called to the assistance
of midwives and to whom they pay fees. The
investigators consider that only those practitioners
who show special interest in and have considerable
practical experience of midwifery should be called to
help a midwife, instead of leaving the choice when
possible to the patient in accordance with the rules
of the Central Midwives Board. Brief reference is
made to the excellent results obtained by the
Rochdale “experiment” and to other general
practitioner schemes.
The investigators suggest that the present pro-
visions for maternity services should be amplified
by the establishment, under the direction of the
medical officer of health, of a service of obstetric
consultants to assist general practitioners and mid-
wives, to conduct consultative antenatal and post-
natal clinics, to supervise the treatment of patients
in hospitals under local authorities, to investigate the
circumstances of each maternal death, and to be
responsible for emergency domiciliary treatment by
flying squads. They also recommend that more
maternity accommodation should be providéd with
beds for antenatal patients, that antenatal clinics
be provided in all but sparsely populated districts
where provision for medical domiciliary supervision
may be made. Satisfactory arrangements should
be made to accommodate patients suffering from
puerperal sepsis and abortion. Education of the
woman and the general public should be borne in
mind to obtain better coöperation, and health visitors
should visit homes to encourage women to obtain
antenatal care. The investigators also suggest that
a service of home helps should be provided where
possible and that many necessary extras such as
supplementary nourishment, laboratory facilities,
and sterile drums of dressings should be available
as required.
The Report for Wales
The investigation in Wales was carried out on similar
lines and is described in a companion report.? The
death-rate from childbirth was found to be -high in
all parts of Wales and for the decade 1924-33. the
puerperal mortality was-35 per cent. above the rate
for England. The rates from sepsis and other causes
were high. The rates in the special areas have
increased substantially, whereas the aggregate in
other areas show a slight decrease. On the whole,
where the total death-rate was high, the puerperal
mortality-rate was high too, and the report points
out that tbe non-puerperal death-rate in Wales is
higher than that in England. It is believed that an
3 Report on Maternal Mortality in Wales. Cmd. 5423.
London: H.M. Stationery Oltice. 1937. Pp. 156. 2s. 6d.
THE LANCET]
excess of intercurrent disease among expecting
mothers has been a contributory cause in producing
the high rate; anzmia and debility are common.
Doctors now attend fewer confinements than
formerly. A good deal of the instrumental delivery
by doctors under modern conditions of practice is
considered to be unnecessary and is held to have
played some part in increasing the maternal mortality.
The suggestion is made that more hospital beds
should be provided, and at them the family doctor
should have opportunity of observing the conduct
of the case by the specialist in charge.
The maternity services of most of the local
authorities are thought to be inadequate and in
many parts of the country very little maternity work
is undertaken by them. The report calls for extension
of the services and attention to the general health
and education of the mothers.
EMPIRE CONFERENCE ON THE CARE
AND AFTER-CARE OF TUBERCULOSIS
AT the first session of this conference on May 3rd
Lord WILLINGDON took the chair and Sir KINGSLEY
Woop welcomed the delegates on behalf of the
Government. Reviewing the position of tuberculosis
in England and Wales, he said that until ten or
eleven years ago, tuberculosis stood foremost among
the killing diseases in this country. Although the
deaths from the disease had fallen conspicuously
there was no reason to view the present situation
with complacency. The improvement had been
brought about by the awakening of the public
consciousness to the problem, by better preventive
measures and better treatment. The occurrence
of tuberculosis in an individual sooner or later affected
the family resources, and care for the family as well
as for the patient played a large part in the treatment
of tuberculosis. Papworth village settlement had
done much in this connexion.
Sir ARTHUR MACNALTY reviewed the change of
outlook on tuberculosis which had taken place both
among medical practitioners and the public in the
last few decades and referred to recent advances in
treatment, diagnosis, and prognosis—notably artificial
pneumothorax, thoracic surgery, improved radiology,
and examinations of the blood. The social and
economic implications of tuberculosis were far reach-
ing; Sir Pendrill Varrier-Jones’s work at Papworth
was a great contribution, but many patients were
unfitted temperamentally or in other ways to live
in a village settlement ; their need for care had been
too long neglected, but was now receiving more
attention from local authorities. —
INDIA
Major-General Sir CUTHBERT SpRAWSON (India)
spoke of the peculiarities of the tuberculosis problem
in India. The steady decline in mortality from
pulmonary tuberculosis in Great Britain had not been
experienced in most overseas countries, and certainly
not in India. The incidence and mortality of tuber-
culosis in India were really unknown because the
vital statistics, except for the Army and the prison
population, were not trustworthy, not even those
relating to the large cities. The public health com-
missioner had recently estimated that there were
about two million tuberculous people in India, but
this was a very rough estimate, comparable to the
estimate of one million for leprosy; the speaker
THE CARE AND AFTER-CARE OF TUBERCULOSIS
[may 8, 19387 1129
thought the number of cases in India was greater.
The vital statistics were likely to understate the
numbers because so many cases were undiagnosed
and unreported. Even so, the cities of Poona and
Ahmedabad reported that one death out of every
twelve was from tuberculosis and in Calcutta the
ratio was even higher. The death-rate from pul-
monary tuberculosis in Ipswich was 52 per 100,000
population and in Chicago 56, while that for Calcutta
the figure was said to be 240, and the real figure was
probably even higher. Sir Cuthbert had estimated
that some ten years ago one in every seven people
in Lucknow died from tuberculosis. At any rate the
number of deaths from that cause was certainly very
large and there was a general feeling that it was
increasing. Twenty years ago Dr. Lankester, an
expert appointed by the Government, had reported
to this effect ; whether the numbers were still increas-
-ing was unknown but by analogy with other countries
this seemed probable. India was still principally
an agricultural country, but industrialisation had
begun in several areas ; experience in other countries
had shown that industrialisation, especially if not
well controlled, and free immigration of a rural
population into city life were accompanied by an
increase in the incidence in tuberculosis. The speaker
. wished to emphasise the magnitude of the danger in
India and the pressing urgency of more energetic
measures in the campaign.
CANADA
Dr. R. E. WopEHOUSE (Canada) said that Canada
was greatly influenced in practice and in the general
view of the tuberculosis problem by the attitude of
her cousins in the United States. Some British
modifications of American practice had been made
but they had as yet no Papworth. The death-rate
from tuberculosis in 1936 would be about 60 per
100,000, having fallen to about a third of its height
of thirty years ago. The rate among North American
Indians was very high, about 700 per 100,000, while
the rate in other parts of the population was as low
as 25. In some areas there was ample accommoda-
tion, free of charge, for anyone with tuberculosis,
and there was a scheme which gave allowances to
wives and creches for the children so that the wives
could go out to work. While a man was in hospital
the State gave the wife the same pension that she
would receive if widowed ; if the wife were in hospital
an allowance was made to the man for a housekeeper
in order to keep the family together. Dr. Wodehouse
felt that tuberculosis among the North American
Indian could be as well controlled as among the
whites if there were enough financial assistance.
SOUTH AFRICA
Dr. A. D, PRINGLE (Transvaal), speaking on behalf
of Dr. B, A. Dormer who was ill, explained that .the
population of S. Africa is preponderatingly native,
the proportions being 2 million Europeans to 7 million
natives, of whom 6 million are the original tribes of
S. Africa. The death-rate among natives was
certainly alarming and the population was hard to
get hold of and to treat, but he did not agree with
Sir Cuthbert Sprawson that the statistics of a native
population were hopelessly inadequate. In S. Africa
the death-rate from tuberculosis for the colour
population was six times greater than for Europeans.
Widely different reports were current about the
incidence of tuberculosis in rural areas; a change
from the tribal way of life had a profound influence
on the health of the natives apart from the effects
of mining and urban life.
1130
THE LANCET]
Prof. S. LYLE Cummins (Wales) said that although
THE CARE AND AFBTER-CARE OF TUBERCULOSIS
[may 8, 1937
5s Air Force in this country. Of recent years non-
the native in South Africa seemed to be very
susceptible to tuberculosis the conditions of work
played a considerable part in this; the women and
children were not so liable to be affected as the men.
It was, he thought, impossible for the State at present
to finance adequate treatment, and apart from that the
natives hated and dreaded being transferred from
their home surroundings to marble halls and hospital
regulations. A few missionary centres with crude
shacks and shelters had achieved much in treating
the natives; their workers seemed to have the clue
to getting the natives’ trust and had been able to
treat natives in circumstances which they understood.
At the afternoon session Lord DAWSON OF PENN,
who presided, said that the care and after-care of
_the tuberculous claimed attention not only from the
humanitarian motive of consideration for the patient
but also for the sake of public health. The growth
of knowledge and social conscience had preserved
many lives which in themselves required every care.
He did not think, however, that these patched-up
lives were good begetters of our future race; unless
this aspect of after-care were considered a great
injustice might be inflicted on the generations to
come.
EUROPEANS IN SOUTH AFRICA
Dr. A. D. PRINGLE spoke of the care and after-care
of the tuberculous among the European mining
population of the Rand and among the non-mining
population of the Transvaal and Natal. His subject,
he said, was linked up with the history of the mining
industry, which had been in existence for about
50 years. About 1903 it became obvious that a large
number of employees were contracting silicotic
fibrosis and tuberculosis. The deaths were mainly
among men from Cornwall, Northumberland, and
Wales. Since those days, four principal institutions to
deal with tuberculosis had come into being: first,
there was the Springkell Hospital, built by the
industry and administered now by a board composed
of representatives of the industry and of the
Government; second, the South African Institute for
Medical Research, also built by the industry. There
was the Miners’ Phthisis Medical Bureau of Examiners
created in 1916 and made up of ten medical men;
their job was to examine every applicant for employ-
ment in the mines. Every year the bureau examined
20,000 men, of whom some 60 per cent. were rejected ;
they also examined every miner every six months ;
if a man contracted silicosis he was warned, if he
became tuberculous he was no longer allowed to
work, and the bureau furnished a report for the
compensating board. The fourth institution was the
Miners’ Compensation Board, consisting of Govern-
ment nominees except for one representative of the
miners. Behind all these was the administrative body
of the industry itself, the Gold Mines Production
Committee with representatives from each mine.
A lump sum was given in compensation to any man
who developed
tuberculosis was given a pension which was con-
tinued, if need be, to his widow and children; he
was offered work on the surface. The sick miner
- was admitted free of charge to a hospital or sana-
torium. Gold-mining was, of course, a business
proposition like any other and these provisions for
the miners cost money; the allowance for com-
pensation this year amounted to about one million
‘pounds. The mortality-rate from tuberculosis among
miners was now no greater than that in the Royal
silicosis, and a man contracting `
mining tuberculous patients had been admitted to
the Springkell Hospital. Outside the industry there
was little provision for such patients.
EFFECT OF CITY ENVIRONMENT
Dr. S. VERE PEARSON (Mundesley) spoke of the
tendency in every country for the rural population to
drain into the cities. This change in distribution of
population contributed three factors to the problem
of tuberculosis: . much time and energy was wasted
in travelling, recreation in the open air became more
and more impossible, and anxiety and worry from
the city environment were imposed. The death-rate
from tuberculosis in the thickly populated areas of
Manchester was almost as high as that for Calcutta,
while nearby, at the garden city of Wythenshawe,
the rate was but one-third of those figures. At
Letchworth the rate was lower than those for
the counties of Hertford and Norfolk. Comparisons
of city and rural communities had to take into
count the source from which the city inmates were
derived.
Dr. F. Hear outlined the main purposes of the
London County Council tuberculosis scheme which
consisted of three parts: domiciliary, dispensary, and
residential. The domiciliary treatment was regarded
as the domain of the general and insurance prac-
titioners. The dispensary service was responsible
for care, after-care, examination of contacts, and
special forms of treatment. Residential treatment
was now provided free although voluntary sub-
scriptions were accepted. Each area had its own
dispensary while ‘the 'L.C.C. arranged for all resident
treatment. This dual control required much codépera-
tion. The after-care work of the dispensaries dealt
with housing conditions, employment, and education
for re-employment. On the whole, provision for
post-sanatorium patients had been sadly neglected ;
some boroughs had lectures in handicrafts but these
provisions were small in relation to the need. For
youths there was a centre at Burrow Hill for training
in clerical work and gardening. The after-care
committee also gave advice and assistance to the
patient and his family. Dr. Heaf quoted an investi-
gation made in 1926 by Sir Frederick Menzies, in
which the death-rates from tuberculosis in three
London boroughs were compared. Although the
rate for all forms of tuberculosis was highest in the
poorest borough, the ratio of death-rates from tuber-
culosis to that for all causes was the same in each.
Environment and social conditions seemed to have
no selective effect on the relative mortality from
tuberculosis. Although the actual cause of break-
down in tuberculosis was obscure, infection did not
seem to be the chief item. Fatigue and under-
nourishment probably called for greater attention
in a civilised, or mechanised, country. Dr. Heaf
quoted figures! showing that the average rate of
incidence of tuberculosis for certain outdoor manual
workers in London and the provinces was greater
than that for indoor non-manual workers. This was
a forcible criticism of the old idea that open air was
essential in treatment. The class which endured
the hardest physical strain, received the lowest
wages, and spent the smallest ammount on food was
the one most prone to tuberculosis. He could not
help thinking that the vast majority of adults would
remain free from active tuberculosis even if frequently
exposed to infection, provided they were well nourished
1 See Lancet, 1936, 2, 1115.
THE LANCET]
or mental. Children, on the other hand, presented a
different problem and demanded protection from the
bacillus. Dr. Heaf thought it was more important
for those responsible for after-care to see that
the patient and his family had sufficient good
food and freedom from worry rather than lay stress
on a few stray bacilli.
ENVIRONMENTAL FACTORS IN CARE AND
AFTER-CARE
Sir PENDRILL VARRIER-JONES felt that after-care
was the most powerful method now available in the
prevention of tuberculosis. He wanted the medical
profession, social workers, and those interested in
economics to realise that after-care must be linked
to hospital sanatoriums. He thought the ‘idea of
environment had been inadequate; it had so often
been taken to include only the material environment.
Many patients contracted the disease although they
had been working in good conditions; the advice
that good food and housing and a light job in the
open air would solve all problems had to be given up.
That raising the standard of living did not necessarily
raise the standard of resistance to disease was shown
by the present unmistakable rise of incidence of
tuberculosis in young women. A definite though
undetermined maximum dose of infection was
necessary to produce clinical disease, and the patient’s
resistance determined the size of this dose. This
power of resistance was governed not only by material
conditions and physical exercise but by a mental
state. For this reason intensive research should be
undertaken into the psychological aspect of the
problem without delay. From his observations at
Papworth Sir Pendrill was convinced that enforced
idleness led to destruction of moral fibre; this
aspect had been neglected by medical men who paid
too much attention to the lung and too little to the
organism in which it was situated. Sir Pendrill was
not advocating indiscriminate exercise nor did he
believe that work as a therapeutic measure acted by.
producing auto-inoculation. In the treatment of the
consumptive the environment had to have some-
thing psychological about it. It was curious how few
people paused to ask why after-care was necessary.
Could it be admitted that it was because we could
not cure and in many cases could not permanently
arrest tuberculosis ? The strange thing was that the
longer the case was under treatment and the more
elaborate the treatment the greater the need for
after-care. |
Good housing was essential to enable the disease
to be arrested permanently, but so were a sense of
well being, work, and a mind free from worry. Work
had to be of the right kind, for a middle-class or
working man had something to sell, and which he
must sell if he is to have well being of mind. It
was disastrous for the man to take on what he con-
sidered to be an inferior grade of work or to put
him to a job with initiative when he had exercised
none before. Many committees imagined that a
patient should give his labour to the Cause, but
why should he? Labour was his only asset. Too
often the medieval outlook was kept that a sick man
was inferior, That was not so and frequently the
tuberculous were victims of civilisation. The best
that could be done for them was to try and com-
pensate for the wrong society had done them by
providing the best environment and restoring their
working capacity. The result would be cheaper than
hospitalisation, in cash and morale,
IRELAND
and were not subjected to excessive strain, physical:
(may 8, 1987 1131
IRELAND
(FROM OUR OWN CORRESPONDENT)
AN EXCLUSIVE POLICY IN NORTHERN IRELAND
A Lawsuit heard in Belfast last week has drawn
attention to regulations made by the Ministry of
Home Affairs in Northern Ireland which restrict
more narrowly than heretofore the qualifications for
office as a dispensary medical officer or district
medical officer of health. Until the issue of these
regulations the usual medical qualifications and
evidence of instruction in vaccination were the only
qualifications required for these offices in Northern
Ireland. The appointments were made by local
boards of guardians but were subject to the approval
of the Minister of Home Affairs. On Nov. 26th, 1935,
the Minister made new regulations which added the
new condition that the officer must have been
resident in the United Kingdom of Great Britain
and Ireland for a period of five years prior to appoint-
ment. It had happened that on Nov. 14th, 1935—
twelve days before the making of the regulations—
the Newry guardians had elected Dr. John Francis
McGeough of Swan Park, Monaghan, to be medical
officer of the Mullaghglass dispensary district in their
union, and had forwarded his name to the Ministry
for approval. After some delay the Ministry refused
approval on the ground that it would be contrary to
the regulations of Nov. 26th, Dr. McGeough not having
resided in the United Kingdom for the requisite
period, and directed the Newry guardians to proceed
to make a fresh appointment. Dr. McGeough obtained
a conditional order of mandamus directed to the
Secretary to the Ministry calling on the Ministry to
sanction his appointment, on the ground that the
regulations having been made after his election they
could not apply to him. Last week the application
was made to make this conditional order absolute,
and it was refused by the two judges, Mr. Justice
Brown and Mr. Justice Megaw. The judges do not
appear to have decided whether Dr. McGeough was
subject to the regulations or not, but holding that
there was an absolute discretion as to approval
resting in the Minister, the issue of an order would
be useless,
Apart from the consideration of the particular case
of Dr. McGeough the making of the regulations has
caused uneasiness among the profession in the Irish
Free State. Hitherto there has been “free trade”
between the United Kingdom and the Irish Free
State as far as the medical profession is concerned.
The qualifications of the universities and the licensing
bodies in the Irish Free State carry admission to the
Medical Register equally with the qualifications
granted in Northern Ireland. Conversely all those
whose names are on the Medical Register can claim
admission to the Medical Register of the Irish Free
State. Medical men resident in or educated in
Northern Ireland or Great Britain are free to be
elected to any medical position in the Irish Free
State and many of them hold high positions in the
public medical services there. Until the framing of
these regulations medical men from the Irish Free
State were eligible to hold any public appointment in
Northern Ireland, and in common with their fellows
from the overseas Dominions they are eligible for
admission to His Majesty’s Forces of the United
Kingdom, and in fact have gained distinction and
held high offices in their medical services, as well as
in the Civil Service, and in the service of local
authorities. It is regarded as anomalous that Northern
1132
Ireland should offer the only exception to this general
freedom of employment. As regards many of the
younger graduates who are natives of Northern
Ireland the regulations may cause special hardship.
Many young men from the north come to the Dublin
schools of medicine for their education. On their
return to their homes they will find themselves
debarred from competing for public appointments,
not having been resident in the United Kingdom
for the requisite period of five years. It is under-
stood that the regulations are viewed with repugnance
by the medical profession in the north, and the hope
is expressed in medical circles in the south that
the Ministry may think fit to cancel them.
THE LANCET]
PARIS
(FROM OUR OWN CORRESPONDENT)
TUBERCULIN TESTS OF NURSES AND CHILDREN
THe Academy of Medicine has.been hearing a lot
about tuberculin-testing. On April 6th a team of
workers from the Beaujon Hospital in Paris pre-
sented a report on Pirquet and Mantoux tuberculin-
testing of 100 nurses between the ages of nineteen
and thirty. It was found that 23 of them were
negative reactors even when large doses of tuberculin
were given by intracutaneous injection. When they
were classified according as they had or had not lived
for many years in Paris, no difference was demon-
strable in the proportion of negative reactors; but
when they were classified according to age, it was found
that whereas 28 per cent. of those under twenty-three
were tuberculin-negative, the corresponding figure
for those above that age was only 15 per cent. This
confirms old teaching that the proportion of negative
reactors dwindles with age; but it seems remarkable
that as many as 23 per cent. of these nurses should
have remained uninfected despite the countless
opportunities provided by a big general hospital.
On April 13th the Academy received a report
on the tuberculin-testing of 1048 children under the
age of fourteen—among them 119 who in infancy
had been given BCG by mouth. Dr. Armand-
Delille, who was responsible for this study, undertook
it because he wanted to verify the now common
assumption among his colleagues that B C G makes the
Pirquet reaction positive, and that it is therefore
useless to employ this test in children who have
been given BCG. This assumption seems unjustified,
for the proportion of tuberculin reactors was almost
the same among the BCG children as among the
controls. Be it noted, however, that the observation
applies only to BCG given by the mouth at birth
in three doses, and not to B C G given by subcutaneous
injection. This communication from Armand-Delille
and his collaborators drew some interesting remarks
from Dr. Guérin, who dealt at some length with the
allergic responses of the tissues to B C G given by the
mouth. He was inclined to think that more frequent
and larger doses of B C G given by the mouth may be
advisable.
PROFESSORSHIPS IN MEDICINE
What may be described as a preliminary and quite
tentative taste of immortality is the recent creation of
a new class of professor—professeur de classe excep-
tionnelle. As from Oct. Ist, 1937, eight professors
of the first class have been promoted to this rank,
which allows them to remain in oflice till they reach
the age of seventy. The distinction has been conferred
on two provincial professors, Bérard of Lyons and
PARIS
[may 8, 1937
Bouin of Strasbourg. The six Parisians are Bezangon,
Carnot, Claude, Gosset, Ombrédanne, and Tiffeneau.
Another event of importance in: the academic
world is the creation of a new chair of medicine.
Its occupant is to be professor of “ assistance médico-
sociale”? or ‘“‘ médecine sociale.” This being inter-
preted means sickness insurance and all the new
machinery which has grown up around it. The
new professor will be expected to teach fifth-year
medical students the elements of social medicine.
Such teaching should save the young medical prac-
titioner of the future much racking of brain and
insurance officials much revision of il-drafted certi-
ficates. The new professor, who will enter on his duties
next October, will rank as a third-class professor in the
Paris faculty of medicine, and his emoluments will be
60,742 francs. :
LEPROSY IN PARIS
At the end of 1934 the leprosy service of the
Saint-Louis Hospital in Paris was confided to Dr.
C. Flandin who, in association with Dr. J. Ragu,
presented a disquieting report on the subject at a
meeting of the Academy of Medicine on March 16th.
When Dr. Flandin took charge of this service there
were only 4 lepers in it; now it houses 26, and 69
others are under his observation either at the hospital
or elsewhere. There are several reasons for this
remarkable rise in so short a period from 4 to 95 cases
of leprosy. In the first place, the greatest tact has
been shown in dealing with the lepers, who are most
sensitive to being treated as exhibits for medical
students. In the second place, these patients have
been assured that professional secrecy will be pre-
served with regard to them and that no step will be
taken to intern them against their wills. A third
inducement to lepers to come forward and submit
to diagnosis is the success here believed to result
from intravenous injections of a new preparation of
chaulmoogra oil and cholesterol. Among the 95
patients were 41 whites who had passed some time
in the colonies, 17 whites who had been born in the
-colonies, and 6 whites who had never left France.
The remaining 31 patients were coloured or half-
breeds. Four of the Europeans who had contracted
the disease in the colonies had stayed there only
4 to 10 months; their incubation period ranged
from 8 months to 25 years. The enormous differences
in the length of the incubation period may in part
be explained by a reference to the mode of infection ;
the comparatively short incubation period of 6 to 8
months is to be observed in patients contracting ~
the disease by sexual intercourse with a leper,
whereas comparatively long incubation periods are
the result of mere residence in a leprous milieu.
This was the case with 2 of the 6 cases of leprosy
in persons who had never left France. In the remain-
ing 4 cases the infection was conjugal. Now that it
is definitely proven that leprosy can be contracted
in France there may be a renewed clamour for com-
pulsory notification and isolation; but Dr. Flandin
is definitely opposed to such a course, being convinced
that it will defeat its own object by driving leprosy
underground. The measures he favours include
facilities for diagnosis and treatment at a hospital,
such as the Saint-Louis, which should be in touch
with all the bodies working on behalf of lepers in
France. In the course of the discussion following
this communication to the Academy, Dr. Marchoux
agreed with Dr. Flandin as to the undesirability of
compulsory notification, and he considered the best
solution of the problem to be the leprosy dispensary
and supervision of the lepers by visiting nurses. His
THE LANCET]
suggestion that a commission should be appointed by
the Academy to deal with this problem was accepted,
and Dr. Flandin and Dr. Ragu’s report was referred
to a commission on which five leading members of the
Academy will sit.
UNITED STATES OF AMERICA
(FROM AN OCCASIONAL CORRESPONDENT)
PUBLIC HEALTH IN NORTH AMERICA
On April 3rd health officers from the several
States and from the Canadian provinces began to
arrive in Washington. They stayed.long enough to
see the famous Japanese cherry blossoms give their
brief annual display around the tidal basin at the
end of the following week. l
The rapid expansion of public health programmes
under the Security Act has thrown a great strain
upon the postgraduate teaching facilities of the
U.S. medical schools. Professors of public health
administration and other members of the faculties
were present from Harvard, Gale, Johns Hopkins,
Columbia, Vanderbilt, Michigan, Minnesota, Duke,
the Massachusetts Institute of Technology, and the
University of California. The University of Penn-
sylvania was represented by Miss Katharine Tucker
of the School of Public Health Nursing. Short courses
of training for health officers lasting for three to four
months have been given as an emergency measure.
Their value is variously estimated. Some educators
believe that older men have scarcely time in three
months to rediscover themselves in a school environ-
ment. Others felt that the courses do have a limited
usefulness. All agreed that they were designed only
for the ‘“‘ emergency,” but it was obvious that in
some States the “‘ emergency ” is not yet over.
The suggestion that the ‘‘long”’ course, lasting for
one academic year and leading to the degree of
C.P.H., might prove an expensive investment by the
Government, since many of the graduates might
return to private practice, led to a rapid compilation
by Dr. Allen Freeman of the present status of C.P.H.
graduates from his school. He shortly announced
that of the 464 men who have taken the C.P.H.
degree from Johns Hopkins only 26 have gone back into
private practice; 17 are practising in the U.S. ; and
9 in foreign countries. Dr. Haven Emerson said that
Columbia University is getting an increasing number
of private practitioners who study public health at
their own expense but without any idea of ever
leaving the private practice of medicine.
There was general agreement that despite the
larger increase in the number of physicians studying
public health, their quality as students compared
well with that of previous classes. Very general
agreement was expressed also with the view that in
addition to the year’s training in a school of public
health the would-be health officer should serve an
apprenticeship in the field under the direction of an
experienced administrator.
In the training of public health nurses emphasis
was placed on the importance of a good basic training
in nursing as a pre-requisite to admission to post-
graduate work. The general work of a public health
nurse should also be completed before courses are
offered in specialised nursing as, for example, in
tuberculosis or syphilis. If short courses are to be
given they should not be condensations of the regular
courses but units which can eventually be added
together into a “long” course.
UNITED STATES OF AMERICA
[may 8, 1937 1133
On the morning of April 5th we enjoyed two
addresses by visitors from Great Britain. Dr. Thomas
Anwyl Davies, director of the Whitechapel V.D. Clinic,
was introduced by Surgeon-General Parran and
described to us the encouraging results of the work
in London with which you must be familiar. He also
spoke of his experiments with an antitoxin for gonor-
rhea that has so far received no experimental con-
firmation in America, but which is now under
investigation at Columbia University. Dr. Ambrose J.
King was introduced by Dr. R. E. Wodehouse,
deputy minister of health of Canada. He spoke on
the public health control of gonorrhwa in Great
Britain.
Dr. Rufus Cole, director of the hospital of the
Rockefeller Institute, reported the latest progress in
the development of pneumonia serum. It is found
that antibodies developed in one species of animal
differ from those developed in another species: one
difference noted being in regard to the size of the
molecule. The molecule of the antibody developed
in a rabbit is smaller than that of the antibody
developed in the horse and, as might be expected, the
rabbit antibodies appear to diffuse more rapidly.
Rabbit serum is also produced much more cheaply
since rabbits are rapidly immunised and respond
quite consistently. The use of rabbit serum so far
has been limited but is promising.
Dr. F. W. Jackson, deputy minister of health of
Manitoba, gave a thorough epidemiological descrip-
tion of an outbreak of poliomyelitis in his province.
The provision of free diagnostic service had had a
most salutary effect in bringing cases promptly under
care. After this service was made available treat-
ment was commenced in every case within 24 hours
of the onset of symptoms, and no more deaths or
cases of residual paralysis were observed. An unusual
feature of the epidemic was the high rate of secondary
cases in the quarantined families.
Dr. Estella Ford Warner opened a discussion on
the place of health education in schools and among
adults. The 48 States all provide some programme
of health education, but there is no uniformity of
practice. Insufficient use is made of the facilities of
existing educational agencies. Dr. Parran announced
the inauguration of a consulting service of health
education in Washington. A service to give advice
on the progress of the science of nutrition will also
be provided. Nutritionists—or specialists in this
science—are employed already in several States. The
need for a special division of a State health department
in this field is not yet generally accepted.
THE CHILDREN’S BUREAU
I wrote a year ago of the expanding field of public
health activity. Reports given by the Children’s
Bureau to the State health officers on April 9th
marked the extent to which this expansion has
progressed during the year. $280,000 of federal
funds and $47,000 of State funds have been paid out
to private practitioners for conducting clinics for
well babies or for expectant mothers or for crippled
children. Dental clinics have also been subsidised
and 54 dentists are employed on the staffs of State
health departments. Consultation services in obstet-
rics have been very cordially welcomed by the
practising profession, and in several States ‘‘ insti-
tutes ” conducted by members of university faculties
in obstetrics or pediatrics have been well attended.
Important recommendations were adopted at this
session looking to analysis of the causes of maternal
deaths by the State health departments in coöperation
1134 THE LANCET).
' VIENNA
[may 8, 1937
with the State medical societies with a view to
raising the standards of obstetric practice, and also
to the public employment of “ qualified ” nurses for
maternity service. The American method of attacking
the problem of providing medical care for the indigent
begins to shape itself. Care will come in categories.
The tuberculous, the syphilitics, the insane, are
already widely recognised as social responsibilities.
Cancer is being added. Heart disease is recognised
in some States. New York and Massachusetts have
broached the case of pneumonia. The work of the
Children’s Bureau extends the conception of social
responsibility to obstetrics and pediatrics. The full-
time medical employees of the State and Federal
Government will not increase greatly in numbers,
but will as rapidly as possible be raised to higher
standards of professional qualification, and it is to be
hoped will be removed further from partisan political
influence and given greater security of tenure. In
the growth of this programme the help of the private
practitioner will be sought and will be rewarded.
Every effort will be made to see that he, too, has
opportunities to keep abreast of the times. and to
improve his professional technique. If health
insurance has any place in this American scheme it
will only be as one far from dominating feature of
the whole plan. Probably it will be tried out first
on a small and experimental scale, to be judged by its
ability to conform to the general outline of the
larger plan of what has been described as “limited
State medicine with private practice.”
VIENNA
(FROM OUR OWN CORRESPONDENT)
WELFARE OF THOSE WITH HEART DISEASE
A COMMITTEE consisting of the foremost patho-
logists, medical men, and philanthropists, and also
including the leaders of the Government and the
Church, has recently founded a Society for the Welfare
of Heart Patients, which at first will be active in
Vienna itself, but will soon be able to extend its
scope to the whole republic. In the pamphlet issued
by this society, competent authors point out that the
statistical data prove the alarming increase of cardio-
vascular trouble amongst the population. Whereas
formerly tuberculosis and neoplasms were the
principal causes of death heart disease now heads
the mortality statistics. A few figures will serve
as illustration: In 1932 there died in Austria
28-62 persons from tuberculosis against 86:26 who
succumbed to cardiovascular diseases (per 10,000
living). The percentual picture is the following:
In 1905 10:4 per cent. of the deaths were due to
tuberculosis and as many to heart disease; in
1932 only 7-5 per cent.. died from tuberculosis, but
22-7 per cent. from heart disease. Thus in 27 years
the mortality in the one had decreased by 30 per cent.
but in the other it had doubled. Furthermore,
investigation amongst apparently healthy labourers
showed that 15 per cent. of all factory hands aged
20-30 had more or less definite symptoms of circulatory
disturbance. In the age-group 50-60 this figure
went up to 65 per cent.; in other words, two-thirds
of these persons doing physical work during their
adult life have suffered definite damage to their
cardiovascular system. A follow-up of patients
observed in the Vienna Herzstation within the last
two years has proved that 17:5 per cent. were
incapacitated in their occupation or profession.
This was due partly to the disease itself, partly to
social, economic, and dwelling conditions, such as
lack of means to buy expensive medicines, and
living in high-storied houses without a lift, with -
overcrowded rooms and want of rest and quiet.
The new society has therefore decided to make the
following its aims: the erection of special homes for
heart disease, with sanatoriums providing appropriate
rest and exercise; the training of special nurses,
and instruction of heart specialists; the collection
of funds for future improvements, including the
setting up of welfare centres in the country, of
ambulatory classes for instruction of affected persons,
and of a special museum. This society will of course
coéperate with the existing clinics and similar welfare
centres, to prevent double-track work.
AN INTERNATIONAL CONGRESS
Under a patronage of the Austrian Federal
Government, and with Prof. d’Arsonval and Marchese
Marconi as honorary chairmen, the first International
Congress on Short Waves will be held in Vienna
on July 12th-17th. Its transactions will deal
with the relationship of short waves to physics,
biology, and medicine. In the first section, therefore,
the congress will discuss their properties, generation,
conduction, detection, and measurement, their action
on chemical systems, and finally the different methods
of application and the uses of short waves. The
biological section will bring papers on the action of
short waves on plants and animals, on tissue cultures,
on enzymes and ferments, and on their thermic effects.
The third section will discuss the indications and
contra-indications of short-wave therapy in the various
branches of medicine and surgery. All the latest
achievements and the technical methods and apparatus
will be described. There will also be social functions,
and interesting excursions through the Alps will
be provided for the members. The secretary of the
congress, Dr. Liebesny, may be addressed at his
office in the Vienna Allgemeines Krankenhaus.
A DOUBLE CHANGE OF SEX CHARACTERS
At a recent meeting of the ‘Gesellschaft der
Aerzte,” Prof. Nowak and Dr. Wallis demonstrated
an unusual and interesting condition in an unmarried
woman aged 32. Two years ago her hitherto regular
menstruation ceased and considerable changes in her
appearance took place. The growth and distribution |
of her hair became masculine in type, the face became
coarse, the voice deep, the muscles firmer, and the
clitoris grew in size. . Besides this an extensive acne
appeared on the body, the typical fat deposits dis-
appeared, and the mamm*e diminished in size. The
effect was a very noticeable masculinisation of the
woman. More detailed examinations showed an
increase of erythrocytes (6,600,000), a rise in blood
pressure to 145 mm. Hg and in blood-sugar to
150 mg. per 100 c.cm. Folliculin could not -be
detected either in the urine or in the blood, and
prolan was also absent in the urine, but on the
other hand no masculine sex hormone was discovered.
The patient was found to be suffering from a tumour
of the right ovary, which was removed. Four weeks
after the operation menses began again and have
since remained regular. All the masculine attributes
soon receded, the voice and the habitus becoming
once again female in type. This included also a drop
in the erythrocytes, in the blood pressure and blood-
sugar. Folliculin could now be found in the urine
in normal quantity, but prolan remained absent.
The histological examination of the tumour proved
it to be built up of the so-called lutein cells, but its
THE LANCET]
histogenesis is not yet clear. This case of sex-
alteration, with increase of blood pressure, of the
number of red blood-cells, and with hyperglycemia,
is most likely to be a case of ‘ interrenalism.”’
Probably the tumour that was removed from the:
ovary originated from isolated cortical adrenal tissue ;
such tumours are not uncommon and their effect
on the sexual status is well known. In this case,
however, histologists could not agree about the
GRAINS AND. SORUPLES
[may 8, 1937 1135
exact nature of the tumour. Since the adrenal
cortex and the tissue of sexual glands originate from
the same matrix, it is possible that in certain instances
a tumour can form from this fundamental substance,
which differs from the adrenal gland and the sexual
gland but contains functional qualities common to
them both. A remarkable feature in this patient
was the rapidity with which the changes took place
in both directions.
GRAINS AND SCRUPLES
Under this heading appear week by week the unfettered thoughts of doctors in
various occupations. Each contributor is responsible for the section for a month;
| his name can be seen later in the half-yearly index.
FROM A MEDICAL ECONOMIST
II
KINGS are anointed with oil for the same reason
as sacrifices used to be anointed—to ensure burning.
The symbolism, in these days, is obscure but in
earlier days all men understood and approved.
In earlier days a king was his people’s most valuable
possession. This was no embellishment of courtiers ;
every man knew it. Every man saw, in the King’s
grace, his own dearest interest and was eager, there-
fore, that the utmost honour should be accorded to
Majesty. It may sound an overstatement, but is
sober fact that only those peoples could be strong
and secure who possessed good kings.
The point is worth making at a moment when it
seems to be generally accepted that the world is
faced with a choice between democracy and dictator-
ship. What is democracy? What is dictatorship ?
And how does it come about that these two exhaust
all the political possibilities? The answer which is
commonly given is that, in fact, there is no third
choice because a constitutional monarchy is a form
of democracy whereas an autocratic monarchy is
a form of dictatorship, :
x x æ
This, it is worth recalling, was not Disraeli’s view.
That great statesman proclaimed that monarchy
was not only the most recent, historically, of all
forms of government but was also so exalted a form
that only men of real understanding could measure
its worth. He was not speaking of constitutional
monarchy; he was certainly not speaking of the
kind of monarehy which, for example, the Tarquins
bestowed upon Rome, What Disraeli had in mind
was a king whose power proceeded, in the first
instance, from himself alone without reference to
armies or parties or factions—without reference
even to popular election. Ibsen had the same idea.
He made one of the characters in one of his historical
plays declare of a Norse king that he possessed
“ the King-thought.”
It is matter of knowledge that dictators are always
party leaders. They command a class, whether
the army or the nobility or the merchants or the
“ proletariat”? or persons of some special political
complexion. The dictator has come to power, as a
rule, because his party has come to power. He
acts for and by his party and professes to see in
its philosophy the only means of national salvation.
If he is a soldier, the moral virtues of soldiers are
exalted and the ‘structure of society is remade on
military lines. If, on the contrary, he is the leader of
Jacobins or Bolshevists the opponents of these
factions will be attacked and destroyed.
Parties, however, parties of the Right as well as
parties of the Left, have one feature in common—
all possess secret funds. None, except a small circle,
knows who are the subscribers to the party funds
and none therefore can really say whether or not the
policy of the party is sincere. The chief subscriber
to a party of the extreme Left, for example, might be a
millionaire of the extreme Right and that fact
might be known only to a handful of party managers
—it is conceivable even that not a single manager
might know the real source of the support. But
what would happen, in such a case, would be that if
the party began to act in a way contrary to its backer’s
wishes, its money would evaporate and all its officials
would be ruined. In such circumstances a break-up
of the party could scarcely be avoided.
It is when dictatorship is viewed, steadily, from this
point of view that its likeness to, rather than its
difference from, some forms of democracy becomes
apparent. Democracy consists, usually, of a group
of parties, each possessed of financial backers ;
dictatorship arrives often enough when one of these
parties savages all the others by reason of its more
substantial backing or because the backers of the
opposing parties have withdrawn their support.
It will be objected that parties compete for popular
support and cannot be returned to power unless they
secure it. But popular support in these days of mass
electorates means propaganda on the great scale and
propaganda on the great scale is exceedingly costly. .
Unless a party possesses backers it cannot hope to win.
It does not follow, of course, that all backers are
interested persons. The backers of a party may be as
sincerely convinced of the value of its aims as the
humblest members. Nor need they, necessarily, be
rich men. The point is that there must be backers
of one kind or another if the party is to come to
power and this applies to military as well as to
civil parties. |
The dictator, therefore, like the democratic govern-
ment, is elected on what Americans call “‘ the party
ticket ” and will be compelled to consult the interests
of the party. This will be easy for him so long as
party interests and national interests are the same or
rather so long as he remains convinced that they are
the same. But it is always on the cards that an issue
may arise whereby the party and the nation are set in
opposition. In that hour the dictator will have to
choose between the body which made him dictator
and the people upon whom his leadership has been '
imposed whether by force or by persuasion.
It is a choice which comes, sooner or later, to almost
every dictator. It came to Cromwell, weary of the
tyranny of Puritanism in arms, who wanted to make
himself King of England and would have done so
had not the Ironsides prevented him. It came to
1136 THE LANCET]
PANEL AND CONTRACT PRACTICE
[may 8, 1937
Robespierre when, sickening of the Terror, he tried
to quell the Jacobins. The Jacobins destroyed him
and historians ever since ‘have pointed the moxal
that revolutions tend to eat their own children—
an erroneous reading. It came later to Napoleon,
when he felt himself being forced back upon the
soldiers of the Revolution. He succeeded in bringing
all the parties, including the soldiers of the Revolution,
into subjection. One modern dictator is now experi-
encing the same choice and has turned against the old
guard of the Communist party—successfully as it seems.
Another a few years ago attacked and broke the
old guard of his own party. The old guard of the
Democratic Party in the United States continues to
assert that the President has undermined the party’s
position and strength.
That these are events of great significance few will
dispute. What do they mean ? The dictator who
refuses to obey his party and its backers can look
for support in one direction only—namely, the
nation. Only if he can secure the nation’s support
can he hope to survive.
Æ a *
It is matter of history that the support of nations
is given to very few men and that these men bear,
always, a close likeness to one another. That likeness
does not reside in intellectual power, though intellect
is usually highly developed. Rather it is an emotional
quality of rare and potent nature by which a man
is able to make himself the beloved and trusted of -
millions of his fellows. I do not doubt that Ibsen
` was right when he declared that only he who possesses
the King-thought can exercise such power. In other
words the power belongs to the leader and proceeds
out from him to the people. Disraeli identified this
power with love and looked upon Kingship, in
consequence, as a marriage of one man to a nation.
‘there is no people;
The King was the people’s bridegroom. Like
a bridegroom he was ready—and the people knew it
—to sacrifice himself for them. His people called him
lover and father and made his consecration manifest
by anointing him with the sacrificial oil. “The
grace of God in a King,” said Pope Gregory the
Great, “is the power to protect the sheep from the
wolves. If a King does not possess that power he is
without grace and is no King.” Napoleon said the
same thing in different words: ‘‘ Without a King
there are only parties. The
party with the most money wins when it has to
reward its financial backers.”
The King then is a leader who has wooed and won
his people by virtue of his King-thought. This is no
party dictator nor popularly elected party chief,
but a being in ecstasy who, by mystical process of
love, has ceased to care for self or safety and become
father and comforter. Every notable man in the land
will now be forced to serve the people, for King
and people united are irresistible. For this reason
symbolism set crowns also, the garlands of sacrifice,
on noblemen’s brows. For this reason noblemen who
attempted to oppose the King, to seize their lands in
absolute title, and to make of their folk serfs and
chattels, were attacked by Majesty. For it was, as it is,
the first business of a king to bend all the notable
men, the barons, to the people’s service.
There is the world of difference between Kingship
in this real sense and representation. It is obvious
that power cannot, in fact, originate with the people
since, without leadership, the people is helpless and
falls, always, into the hands of wolves. But it is
equally obvious that without the people’s love the
King is helpless. King and people therefore are one,
like father and children. It is the King who creates
the people since it is his King-thought, his word,
which is made flesh in them.
PANEL AND CONTRACT PRACTICE
The Practitioners’ Fund
THE negotiations for an increased capitation fee
as well as “the controversy regarding the payment in
_ respect of the 14-16 year adolescents has focused
attention upon the capitation fee. There are few
practitioners, if any, who receive from their insurance
committee exactly nine shillings multiplied by the
number of persons on their list in any year and,
doubtless, many have wondered exactly how their
remuneration is calculated. Many committees send
out a detailed statement with each cheque, but this,
after all, merely explains the distribution of the areal
practitioners’ fund and not how the fund itself is
calculated. The chairman of the London medical
benefit subcommittee has just answered a question on
this subject at a meeting of the insurance committee,
and his reply provides a concise statement of the
method adopted in calculating the practitioners’ fund.
The method by which the amount of the areal
practitioners’ fund is arrived at is broadly speaking
as follows: Out of the sums available for medical
benefit the central practitioners’ fund is set up at the
beginning of each year. It is calculated on an estimate
made by the government actuary of the number of
insured population entitled to medical benefit multi-
plied by 9s. The estimate is arrived at mainly on
the basis of sales of health insurance stamps. The
final amount of the central practitioners’ fund is not
known until after the end of the year, but each year
the committee are notified during February of the
amounts which may be distributed quarterly within
the final determination of the fund. The balance
usually becomes known towards the end of February
in the succeeding year, and a final settlement is
effected as soon as the necessary calculations can
be completed.
The central practitioners’ fund is distributed
among insurance committee areas by the Minister of
Health after considering the report of the medical
distribution committee which consists of repre-
sentatives of insurance practitioners, of insurance
committees, of the government actuary, and of the
Ministry. This committee have before them par-
ticulars as to the insured population in each area
(this being based upon what is known as the count
of the index register). It is their duty to make a
fair and just apportionment of the total fund between
the several areas. They take into consideration such
factors as the incidence of temporary residents (this
in London invariably means a deduction but in some
areas it causes quite an appreciable addition). Deduc-
tions are also made in respect of insured persons
obtaining medical benefit through approved insti-
tutions and making their own arrangements, and also
for members of the mercantile marine. A final net
proportion is then ascertained and the central prac-
titioners’ fund is distributed on this basis. The areal
practitioners’ fund has to be distributed among
practitioners on the basis of their respective figures
of credit, but even here there are various adjustments
to be made—e.g., in respect of the administrative
THE LANOET]
expenditure of the local medical and panel com-
mittee and of payments to practitioners for the cost
of the provision of anesthetists and emergency
treatment.
It will be clear that, although at the source the
central practitioners’ fund has been based on an
estimate of the insured population multiplied by 9s.,
the areal practitioners’ fund as calculated does not
necessarily represent the local insured population
multiplied by 9s.; it may be either above or below
this figure. In the administrative county of London
up to 1933 the unit value was actually less than
the nominal 9s. value, but the clearance of the medical
register, which took effect as from Jan. Ist, 1934,
AMBULANCES AND STRETCHERS
[way 8, 19387 1137
reduced the number of units of credit upon which
practitioners’ remuneration was based without affect-
ing the calculation of the areal practitioners’ fund.
The result was that whereas for 1933 the value of a
unit of credit in London was 7s. 11:46524d., in 1934
the equivalent value was 8s. 7-4932d. This was at
a time when economy deductions were being made
from the remuneration of practitioners. For the
year 1935 the figure rose to 9s. 1-:17192d., but this
increase was accounted for mainly by the restoration
of the economy deduction of 5 per cent. which
operated only for the first six months of that year.
For the year 1936 the total payment will amount
to 9s. 2-5254d.
CORRESPONDENCE
AMBULANCES AND STRETCHERS
To the Editor of THE LANCET
Sir,—I am glad that Dr. Lockhart noticed my
letter because it was his letter, published in your
columns two years ago, which stimulated my interest
in this subject.
I quite agree with him that the universal adoption
of a standard stretcher with telescopic or folding
handles would simplify our problem, but I do not
think that the fighting services of any nation would
agree. They would not consider such stretchers
capable of standing up to the rough usages of war.
I realise the great advantages of short stretchers when
it comes to carrying them in lifts, railway-carriages,
air-ambulances, and boats (we in the Navy have a
short stretcher), but I cannot envisage the abolition
of long stretchers and I still think that ambulances
capable of carrying long or short stretchers should be
adopted where practicable.
Standardisation of gauge, as Dr. Lockhart points
out, is essential, .
I am, Sir, yours faithfully,
R. A. W. Forp,
Surgeon-Commander, Royal Navy.
H.M.S. Hood, May 3rd.
INSULIN AND GASTRIC SECRETION
To the Editor of THE LANCET
Sir,—At a meeting at the Royal Society of Medicine
on March 9th Prof. E. C. Dodds and Dr. R. L. Noble
reported! observations on the action of insulin on
the gastric secretion of cats. Having several years’
experience with insulin as ‘‘ meal” for fractional
tests I should like to bring out the following points.
1. Insulin stimulates gastric secretion sufficiently to
enable one to discriminate between pseudo-anacidity
and true anacidity just as often as one can with histamine.
2. The stimulus to the stomach is the hypoglycemia,
acting through the vagus (as stated, for example, by
Heller? and by Dodds and Noble,! but questioned by
Meyer 3). The test is therefore not suitable for diabetic
patients. ,
3. Whereas histamine sometimes produces undesirable
side-effects which may’ be difficult to overcome, the
insulin test, using the doses stated below, rarely causes
symptoms requiring treatment. In the few cases which
developed hypoglycemic symptoms that were at all serious
I have nearly always been able to control them by oral
administration of sugar, and it has very seldom been
necessary to give intravenous glucose injections.
2 Dodds, E. C., and Noble, R. L. (1937) Proc. R. Soc. Aled.
30, 815; see also Lancet, March 20th, p. 692.
è Hellor, H. (1931) Med. Klinik, 27, 1451; (1931) Z. ges. exp.
Med. 99, 607.
3 Meyer, P. F. (1930) Klin. Wschr. 9, 1578.
4. It is an advantage that the secretion obtained is not
mixed with any fluid given as test stimulus.
5. The optimal amount of insulin was found to be
12-15 units (Heller ?). The secretion starts about 20—40
minutes after intravenous (or about one hour after sub-
cutaneous) injection. In patients with normal gastric
secretion 55-75 are the highest values for free acidity,
and 75-95 the highest values for total acidity.
6. The stimulating action of insulin on the gastric
secretion shows that the administration of insulin is
contra-indicated in fattening cures in patients with
hyperacidity.
Each of these points has already been made by
Meyer and/or Heller.
May I take this opportunity to remind your readers
that in distinguishing hyper- from hypo-glycemic
coma a positive Babinski sign proves the coma to
be hypoglycemic. Whereas the differential diagnostic
value of flaccidity in hyper-, and of spasticity in
hypo-glycemic, coma is mentioned in many text-
books and papers, a reference to Babinski’s sign is
very rarely to be found.
I am, Sir, yours faithfully,
HERBERT LEVY.
Telford-avenue Mansions, S.W., May Ist.
PRURITUS ANI
To the Edttor of THE LANCET
Smr,—Surgical news about pruritus ani is as
attractive as it is varied, and the announcement
in your issue of April 17th, of the “ prepruritic stage
of pruritus ani” is quite delightful. I suspect that
Mr. Riddoch wrote his article with his tongue in his
cheek, but he has allowed fiction so heavily to outweigh
fact that some little protest must be entered. The
codema of the skin which might seem to give the stamp
of reality to his theory is in fact the finding common
to all itching and rubbed skins though it is more
readily provoked in the skin of the genitalia and
perineum and of the areolæ. It is not true that
“itching is apt to occur more frequently about
the various body orifices than elsewhere ” ; it is not
even true of the vulva and anus, it is less true of the
eyes, ears,- nose, mouth, and urethra. Does Mr.
Riddoch seriously suggest that X ray therapy is
curative because of its destructive effect on the
vessels ? This is alarming.
With thea courage characteristic of the surgeon he
dismisses the psychological side of the problem, but
Carlyle was wiser than Mr. Riddoch imagines. There
is no doubt of the pleasure associated with itching,
especially anal itching, as the majority of subjects
with pruritus ani will confess, Indeed it. is the
s
1138 THE LANCET]
PERNICIOUS ANÆMIA IN AN INFANT
[may 8, 1937
indulgence in this pleasure which too often creates
the habit which is so difficult to break.
I am, Sir, yours faithfully,
Leeds, May 3rd. JOHN T. INGRAM.
To the Editor of THE LANCET
SIR, —In your last issue Dr. Browne-Carthew
mentions that I did not refer to radium in the treat-
ment of pruritus ani. I could not possibly mention
all the various forms of treatment that have been
tried in this condition and I have come across only
one reference to the use of radium (O’Donovan, W. J.
(1936) Practitioner, 136, 148). However the fact that
O’Donovan claims good results from its use, coupled
with Dr. Browne-Carthew’s remarks, lends further
support to my thesis. Well over 90 per cent. of cases
can be cleared up by the simpler method of sclerosing
injections in the internal hemorrhoidal area if these
are efficiently carried out, and the remainder must
be dealt with to suit the individual case, as for example
when one has to stretch a fibrosed anal canal or remove
tags or fibrosed internal hemorrhoids, &c., as well as
destroy the subcutaneous veins by undercutting of
the skin, sclerosing injections, or possibly radium,
| I am, Sir, yours faithfully,
Birmingham, May 4th. J. W. Rrppocu,
PERNICIOUS ANÆMIA IN AN INFANT
To the Editor of THE LANCET
SIR, —I was interested to read in your issue of
May Ist an account of a case of macrocytic anemia
which occurred in infancy in association with achlor-
hydria and high icterus index and which responded
rapidly to treatment with liver. I venture to doubt
however whether the authors are justified in labelling
the case ‘“‘ pernicious anemia,” and I would suggest
that it is one of subacute hemolytic ansmia,
During the past few years macrocytosis has been
recognised and described in an increasingly large
number of disorders of the blood. In a series of
hemolytic anæmias in infancy and childhood admitted
to the wards of the Birmingham Children’s Hospital
and to be published shortly, I have observed several
examples of macrocytic anæmia some of which have
failed to respond to transfusions of blood or the
administration of iron. They have, however, reacted
well to treatment with liver, as did the case described
by Prof. Langmead and Dr. Doniach. In each
case treatment with liver was discontinued after
complete hematological recovery, but the anæmia
did not relapse. This fact differentiates the pernicious-
like picture of subacute and chronic hemolytic
anemia from true Addisonian pernicious anæmia,
for in the latter condition the anemia will always
recur unless sufficiently large doses of a petent
liver preparation are given regularly. Time and
further blood éxaminations alone will tell whether
or not the case of Prof. Langmead and Dr. Doniach
can be accepted as one of true pernicious anæmia of
infancy. I am, Sir, yours faithfully,
W. CAREY SMALLWOOD.
The Children’s Hospital, Birmingham, May 3rd:
PRISONERS AND CAPTIVES
To the Editor of THE LANCET
9 3
Sır, —I regret having to inform Dr. Masefield that
I weighed my Grains and Scruples very carefully
indeed. The result was disconcerting. However,
I can relieve his distress in at any rate one respect :
my criticism was, and is, directed at the system,
not directly at any of my medical colleagues. The
system does seem to me to be needlessly cruel, in
that it shuts away indefinitely young people who are
a danger neither to themselves nor to anybody else.
And—this I feel acutely—few, not being official
people, ever see the inside of the institutions referred
to. Official people, however humanitarian, tend to
become more and more official; specialists, however
kindly, do come to look through ever-narrowing
spectacles. “i 8
I know, from bitter experience, that it is infinitely
more easy to get a young person into an institution for
the mentally defective than it is to get him out. I
am convinced that there are, at this minute, young
people in such institutions who would be better in
every way if they were outside. I interviewed one
of them recently in an institution.
There are some of us who feel, strongly, that all
is not well. That is why I wrote as I did, and why
I hope to write further when,. and where, the
opportunity arises. a .
I am, Sir, yours faithfully,
April 30th. TADDYGADDY.
Se TS, ;
INFECTIOUS DISEASE
IN ENGLAND AND WALES DURING THE WEEK ENDED
APRIL 24TH, 1987
`. Notifications.—The following cases of infectious
disease were notified during the week : Small-pox, 0 ;
scarlet fever, 1647 ; diphtheria, 1027 ; enteric fever,
32; pneumonia (primary or influenzal), 864;
puerperal fever, 41 ; puerperal pyrexia, 114 ; cerebro-
spinal fever, 23 ; acute poliomyelitis, 3; acute polio-
encephalitis, 2 3 encephalitis lethargica, 4 ; dysentery,
33 ; ophthalmia neonatorum, 111. 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 April 30th was 3146 which included: Scarlet
fever, 846; diphtheria, 904; measles, 45; whooping-cough,
508 ; puerperal fever, 13 mothers (plus 10 babies) ; encephalitis
lethargica, 284; poliomyelitis, 1. At St. Margaret’s Hospital
there were 21 babies (plus 9 mothers) with ophthalmia
neonatorum.
Deaths.—In 123 great towns, including London,
there was no death from small-pox or from enteric
fever, 12 (0) from measles, 5 (2) from scarlet fever,
22 (7) from whooping-cough, 30 (3) from diphtheria,
39 (12) from diarrhoea and enteritis under two years,
and 47 (5) from influenza, The figures in parentheses
are those for London itself. |
Four deaths from measles were reported from Kingston-
upon-Hull, 5 deaths from influenza at Birmingham. Liverpool
had 4 deaths from diphtheria and 3 from Manchester. There
were 4 deaths from diarrhea and enteritis under two years
at Birmingham and 3 at Newcastle-upon-Tyne.
The number of stillbirths notified during the week
was 291 (corresponding to a rate of 41 per 1000
total births), including 53 in London.
MEDICAL CONFERENCE IN SWITZERLAND.—A third
international medical week has been arranged by
the Schweizerische Medizinische Wochenschrift' and will
be held at Interlaken from August 29th to Sept. 4th.
The speakers will include Prof. Hugh Cairns (results of
treatment of intracranial tumours) ; Prof. Clovis Vincent,
Paris (treatment of subacute and chronic abscesses of the
brain); Prof. O. Loewi, Graz (the chemical transmission
of nerve stimulus); Prof. K. J. Anselmino, Wuppertal-
Elberfeld (relation of the pituitary to carbohydrate
metabolism and to diabetes); Prof. L. Lichtwitz,
New York (disturbances in the regulation of carbohydrate
metabolism); ‘and Prof. H. Spemann, Freiburg-in-
Breisgau. Further information may be had from the
secretariat, Klosterberg 27, Basel.
THE. LANCET]
OBITUARY
[may 8, 1937 1139
SIR PATRICK HEHIR, K.C.LE., F.R.C.P.,
F.R.C.S., F.R.S. Edin. |
MAJOR-GENERAL, I.M.8.
Sir Patrick Hehir, who died on Saturday last,
May Ist, at Hove, was a distinguished member
of the Indian Medical Service, holding at different
times high and responsible office and being deeply
interested in both the social and scientific side of
tropical medicine.
Patrick Hehir was the son of Robert Martin Hehir
of Ennis, Co. Clare. He received his medical educa-
tion in Edinburgh and at Guy’s Hospital, qualified
as M.R.C.S. Eng., L.S.A. in 1885, and took the
? diploma of F.R.C.S.
Edin. in the same
. year. He graduated
later as M.D.
Brux. He joined
the Indian Medical
_ Service in 1886 and
immediately saw
service in Burma
and Tirah, He was
engaged in the
latter campaign
during 1897 and
1898 and received
a medal with clasps.
He was next serv-
ing on the Moh-
mund- expedition,
but in 1898
returned to Burma
as Assistant
Director of Medical
Services,
afterwards he was
. transferred to
Poona, holding the-same position in the Bombay
presidency, while at the outbreak of the war he was
at headquarters, Simla, as Deputy Director of
Medical Services. He was therefore a very experienced
officer when his eventful career during the war
commenced. He was engaged in the campaign in
Mesopotamia, and was several times mentioned in
dispatches for his excellent work. At the surrender
of Kut he was taken prisoner by the Turks and until
his release did valuable work in caring for the sick
and wounded, especially the Indian contingent.
Released by the Turks he took up his appointment at
headquarters in India as D.D.M.S., and in recognition
of his fine work received the orders of C.B. and C.M.G.
In the second Waziristan campaign he was again
to the front as A.D.M.S., and in 1919 further hostilities
in Afghanistan gave him an opportunity of earning
credit, for he was mentioned in dispatches and
promoted K.C.I.E., having received the C.I.E.
the previous year. |
Throughout his long service in India Sir Patrick
Hehir was engaged in efforts, scientific and social,
to prevent and control malaria in India. He made
many personal researches into the life-history of
mosquitoes, and in 1910 produced his work “ Prophy-
laxis of Malaria in India ” in which he went with much
detail into the methods employed by the malaria
sanitarian in towns and cantonments. The results
of this work, with many additions and with coépera-
tion from numerous authorities,
after his retirement in a comprehensive volume
entitled ‘‘ Malaria in India.” This book, not issued
SIR PATRICK HEHIR
(Photograph by Elliott & Fry
Shortly
were published |
until 1927, detailed the general history of malaria,
its geographical distribution in India, its contributory
causes, prevalence, and mortality. It furnished
‘a very full history of the habits of Indian anopheline,
this section of the work being supplied with a large
quantity of admirable illustrations. The clinical
history and diagnosis of malarial fevers and the
various methods of prevention were all set out, and
among a group of appendices important matter was
added bringing the subject up to date. The work
was the outcome of much personal knowledge and
great industry, calling the attention of the economists
and statesmen to the many sides of a menacing
problem. Its production was a fine exploit during
the closing years of a distinguished career,
Sir Patrick Hehir, in addition to the distinctions
enumerated, possessed the life-saving medal of
St. John of Jerusalem, was a Knight of Grace
of the Order, and a F.R.S. Edin. He married in
1908 Dora, a grand-daughter of Edward Lloyd,
who founded the Daily Chronicle, by whom he had
one daughter, He was in his 78th year at the time
of his death.
GEORGE PARKER, M.D.Camb.
WE regret to announce the death of Dr. George
Parker, consulting physician to the Bristol General
Hospital and a physician of distinction well known
outside his immediate circle. |
. He was born at Claverdon, Warwick, the son of
Mr. George Parker. He was educated at Stratford-
on-Avon and St. John’s College, Cambridge, where
he had a successful academic career, graduating
as B.A. in 1877, with honours in the History and
Moral Science Triposes. He was an assistant master
at Rugby for a short period and then went to
St. Bartholomew’s Hospital for medical training.
He graduated as M.B. Camb. in 1880, proceeding
to the M.D. degree in 1884. He followed a post-
graduate course in Vienna and held several resident
appointments, being medical officer to the Paddington
Green Children’s Dispensary and the Bristol Dis-
pensary before going into practice in Clifton in
1887. He was appointed assistant physician to the
Bristol General Hospital in 1892, and was a member
of the staff until his retirement on seniority and
election as consulting physician. He was an impor-
tant member of the University of Bristol, lecturing
in particular on medical jurisprudence, a subject
in which he was also an examiner at the University.
He had marked literary gifts, wrote a history of
surgery in Great Britain, showing his antiquarian
knowledge and delivered the Thomas Vicary lecture
before the Royal College of Surgeons of England.
We owe to Dr. J. A. Birrell the following apprecia-
tion: ‘‘ During the years 1892—1920 of his association
with the Bristol General Hospital as assistant and
full physician, his friendly personality endeared him
to all with whom he came in contact—perhaps one
would not say for forcefulness of character but
rather for the frankness of his nature and approach-
ability was he so liked. He was appointed to the
visiting staff of the Bristol General Hospital in
1892, becoming full physician in 190]. He was
president of the Association of Physicians when
that body met in Bristol, and of the Bristol Medico-
Chirurgical Society in 1915-16. Being particularly
interested in the various manifestations of chronic
rheumatism and osteo-arthritis he had charge of the
1140 ‘THE LANCET]
physiotherapy department of the hospital from
1901 until his retirement, doing much work, and
making contributions to literature, upon these
maladies. As a consultant he came to be regarded
as always giving of his best, with a most likeable
unaffected straightforwardness,
no pains to do the utmost for the patients coming
under his supervision, often, as the nature of their
ailments so frequently required, for lengthy periods.
For many years he had a very large following of out-
patients, by whom he was greatly beloved for the
individual interest and sympathy which he extended.
‘““Qutside his work he was keenly interested in
archeology, and, since his retirement from the
- active hospital staff, went out on several occasions
as medical officer to the Flinders Petrie Expedition
in Syria. Of late years, too, he became greatly
interested in the University medical library, acting as
honorary librarian until his death. With great
courage he persisted in his activities in spite of a
progressing physical enfeeblement leading to the
end. His death is a sad loss to many; his con-
temporaries and a host of others will retain affectionate
memories of him.”
JOHN DALLAS EDGE, C.B., M.D.R.U.L., F.R.C.S.1.
MAJOR-GENERAL, R.A.M.C,
THe death occurred on May Ist at his home in
Dublin, at an advanced age, of Major-General John
Dallas Edge, whose military record was a remarkably
fine one. He was born in 1848, the son of the late
Joseph Edge of Timahoe, Queen’s County, and
received his medical education at the Meath Hospital,
Dublin, graduating as M.D. R.U.I. in 1870. He
entered the Royal Army Medical Corps at once and
was attached to the lst West India Regiment. The
_ regiment was stationed at Orange Walk, British
. Honduras, and
shortly became the
centre of a fierce
little Indian revolt.
The military com-
mander was
wounded, and
young Edge took
his place and suc-
cessfully organised
the defence, being
specially promoted
for gallantry. In
the Zulu war of
1879 and in the
second Afghan war
which followed
rapidly, Edge was
again in the thick
of the fighting, and
for his work at
Maiwand and Kan-
dahar he received
the thanks of the
Government of
India. In 1882 he was serving in Lord Wolseley’s
expedition to Egypt, was present at Tel-el-Kebir,
and was again a marked man for the value and
bravery of his services. He received the Tel-el-Kebir
medal with clasp and the Khedive’s star. The out-
break of the South African war found Edge a
lieutenant-colonel and with that rank he accom-
panied Sir Redvers Buller’s army to Natal. He was
present at the battle of Stormberg and was responsible
for removing the bulk of the wounded from the field
in circumstances which required much and deter-
MAJOR-GENERAL EDGE
[Photograph by Elliott & Fry
OBITUARY
and would spare -
[may 8, 1937
mined bravery. He was promoted colonel, awarded
the C.B., and at the end of the war was appointed .
P.M.O. of the South African Command. On return
home he became P.M.O. of the Irish Command and
retired in 1908 on the age-limit. At the outbreak of
the European war he volunteered for service despite
his seniority, and was placed in charge of the Queen
Alexandra Military Hospital with the rank of major-
general, a post which he held until his second retire-
ment in 1917.
Major-General Edge married in 1890 Jane, daughter
of John Ruskell of Arklow, Co. Wicklow, by whom
he had one son. He had reached his ninetieth year.
JOHN GALLETLY, M.B., C.M. Edin.
THE death occurred on April 10th of Dr. John
Galletly, well known in South Lincolnshire for his
activities in the promotion of public health. He
graduated as M.B., C.M. in the University- of Edin-
burgh in 1886, having already studied at Marburg
and at Vienna. He then went into practice in South
Lincolnshire where he remained until his death
48 years later. In 1895 he took the D.P.H. Camb.
and was appointed M.O.H. to the Bourne R.D.,
following on an inquiry into the sanitary conditions
in those parts of Kesteven. Thanks largely to his
persistent and patient endeavours the area was
transformed from the worst to the best in the county.
An isolation hospital was provided and new schemes
for housing and water-supply devised, so that when
following the war, a progressive drive was made the
ground was well prepared. Throughout Galletly by
a fine example showed what the work of a part-time
medical officer can produce when an independent
spirit is backed by an intimate knowledge of the
conditions and the people in his area.
We have received the following personal tribute :
“A well-grounded scholar in the humanities, Dr.
Galletly was fond of reading and of travelling. He
was of the old school of general practitioner, hard
working and finding his hobby in his work. He
gave his best to his patients, never sparing himself
and being always ready to take up the cudgels on
their behalf when officialdom pressed. Impatient of
humbug or conceit, he was loyalty itself to his fellow-
colleagues. He excelled in midwifery and had the
art and knowledge and massive experience of a
lifetime behind him, to help and guide and teach
those that followed him. He was of a retiring dis-
position, but his integrity, kindliness, and generosity
made him the friend of all who came to seek help
at his hands.”
LUKE GERALD DILLON, O.B.E.,
M.D. R.U.I., M.Ch.
Dr. Luke Dillon, who died on April 27th, was a
son of Charles Blake Dillon of Springlawn, Co. Ros-
common. He received his medical education at
Queen’s University, Dublin, where he graduated as
M.D. R.U.I. and M.Ch. in 1882. His career was
spent largely in Seaham where he was at one time
medical officer of health to the U.D.C. He was
also surgeon to the Seaham Harbour Infirmary,
Admiralty surgeon, and at one time surgeon to the
Londonderry Collieries. He served during the war
as a major, R.A.M.C. (T.), and received the O.B.E.
He was a man of wide interests, a F.S.A., and a J.P.
for the county of Durham. He married Elizabeth
Mary, daughter of the Hon. Hubert Dormer, by
whom he had one son. Dr. Dillon had an interesting
pedigree, being descended from Theobald Viscount
Dillon, who was born in the Tower of London in
THE LANCET]
1591 and who in 1642 took the Oath of Association
with the Irish Confederation. Dr. Dillon had retired
from the profession for some time before his death,
which occurred at Oxford.
HERBERT VICTOR HORSFALL, M.B., Ch.B. Leeds
THE death took place on April 18th of Dr. Herbert
Horsfall at the early age of 42. He was the son of
the late Mr. A. W. Horsfall of Halifax, and received
his medical training at Leeds University. He
graduated as M.B., Ch.B. Leeds in 1917 and acted as
house surgeon and resident surgical officer to the
Leeds General Infirmary. During the war he served
as medical officer to a combatant unit in East Africa,
holding the rank of captain. Thereafter he was in
practice for a time at Cleckheaton, after which he
went into partnership in Otley. While at Otley he
was actively associated with the Otley St. John
Ambulance Association. He became: medical officer
to the New Hall Infirmary and held a high place
socially in the Otley district. His death was unex-
pected, as he was in the prime of middle life, but he
had been in failing health for some time.
HENRY PRESCOT FAIRLIE, M.D. Glasg.
THE death occurred at the end of March of Dr. H. P.
Fairlie, the well-known Glasgow anesthetist. He
was president of the section of anesthetics of the
Royal Society of Medicine, 1933-34, and was a valued
member of the council of the Association of Anæs-
thetists, as well as of the editorial board of the
British Journal of Anesthesia. These offices had
brought him into contact with many anzsthetists
in London and the result had always been to establish
in them warm feelings of friendship.
A correspondent writes: ‘‘ Fairlie’s professional
PARLIAMENTARY INTELLIGENCE
[may 8, 1937 1141
excellence was accompanied by an unusual degree
of modesty and charm. His text-book, written in
elaboration of Ross’s work, was widely read and
esteemed. He may well be regarded as one of the
pioneers of modern anesthetics in Glasgow. His
example and his teaching did much to break down a
traditional adherence to the routine use of chloroform
and Fairlie fearlessly exposed the ill results which
this practice had inflicted in the city where he
practised. He contributed freely to the periodic
literature of his subject and his writing was always
free from padding and of practical value, His death
is a severe loss to anzsthetics in general and leaves
many English friends and colleagues the poorer.”
JOHN LUKE JACKSON, M.B., B.Ch. Belfast
THE death occurred on April 5th of Dr. J. L.
Jackson, medical superintendent of the Knowle
Mental Hospital, Fareham. He received his
medical training at the Queen’s University, Belfast,
and graduated with honours as M.B., B.Ch. Belfast
in 1910. He showed early his interest in psychological
medicine, and shortly after qualification was appointed
as assistant medical officer to the Knowle Mental
Hospital. At the outbreak of war he joined the
R.A.M.C. and had an eventful military career, seeing
service in France and Gallipoli and receiving the
Croix de Guerre. He had the unpleasant experience
of being for a time a prisoner of war. On the
cessation of hostilities he returned to his appointment at
the Knowle Mental Hospital, and became medical
superintendent in 1922. He was principal medical
adviser to the Hants Joint Mental Health Insti-
tutions Committee and earned the reputation from
all with whom he came into contact of being an
energetic and sound administrator.
PARLIAMENTARY INTELLIGENCE
MILK PASTEURISATION
THE POOLE EXPERIMENT
In the House of Lords on April 22nd, on the motion
of Lord Marks, the Poole Corporation Bill was read
a second time. |
An Opponent of the Bill
Lord CRANWORTH moved that it be an instruction
to the committee to which the Bill might be referred
to strike out Clause 21 (by-laws as to pasteurisation,
&c., of milk), He said that this Bill raised a matter of
grave national importance and he had always under-
stood that a matter of general principle should
never be brought forward in a private Bill. Such
powers as were asked for in this Bill had never before
been given or asked for in England. If Parliament
granted such powers in this case it would seem
logically impossible to refuse them in any other.
The real reason for bringing Clause 21 into this huge
Bill of 52 clauses was an outbreak of typhoid in
Bournemouth, Poole, and Christchurch. It was
therefore admittedly panic legislation, and for that
reason somewhat to be deprecated. He had been
at some pains to find out whether milk really was
responsible for that outbreak ; the Poole corporation
said it was, but his local informants had told: him
that in their opinion it-was not. The Dorset County
Council were opposed to the Bill.
The main effects of pasteurisation were four.
(1) It killed most of the obnoxious germs in milk.
(2) It enabled dirty milk to keep for three or four
days, whereas otherwise it turned sour after about
twelve hours—which was in itself rather a safeguard
to the public. (8) It put out of action all small
producer-retailers because they had not the money.
to provide the necessary plant to do their own
pasteurising. (4) Most important of all (he thought)
it devitalised the milk and destroyed some of its
component parts. It remained a very good beverage,
but it did not remain milk, and not such a good
substance as milk, and that was the reason why
another large section of the medical profession,
and a very much larger section of milk drinkers,
preferred raw milk. i
If properly treated pasteurised milk was quite
safe immediately after it had been pasteurised.
But it was not always properly treated. Further
pasteurised milk was subject to recontamination not
only as quickly as raw milk, but even more quickly.
Generally speaking, the reason for pasteurisation was
said to be the prevention of tuberculosis. But
many more people suffered and died from tuber-
culosis through not drinking milk at all than those
who suffered from drinking bad milk. In‘ the
country districts, where pasteurised milk was unobtain-
able, not only was there less tuberculosis but tuber-
eae had gone down in a greater degree than in the
Owns.
The Diseases of Animals Committee said that
if vitamin C was destroyed it could be returned by
giving the children lime-juice or orange-juice. Did
their lordships think that in the poorer parts of our
great cities the children were going to get orange-
juice or lime-juice whenever they got a glass of milk ?
The loss in the milk through pasteurisation was
first in vitamin C, the loss of which caused scurvy,
and secondly, in vitamin D, a loss which caused
rickets. The chief medical officer of Dr. Barnardo’s
Homes, Dr. A. H. Macdonald, had made an exhaustive
1142 THE LANCET]
study of this subject and had come to the following
conclusions :—
“ (a) The child on raw milk is very fit. (b) Chilblains
are practically eliminated. (c) The teeth are less likely to
decay. (d) The resistance to tuberculosis and other infec-
tions is raised. (e) In one of his homes containing 750
delicate boys who were fed on raw milk for five years,
only one case of non-pulmonary tuberculosis occurred,
while in the preceding five years with similar types of
children fed on pasteurised milk fourteen cases of non-
pulmonary tuberculosis occurred.”
There might be a case, said Lord Cranworth,
for prohibiting the sale of unclean milk unless it
had been pasteurised, but there was an equally good
case, where clean milk was available, why it should
not be pasteurised at all. ‘The farmer had been
asked to clean up his milk. He had been forced
to spend large sums of money. He had been induced
to have a new system, a higher grade of milk, and
under the Accredited Scheme no fewer than 20,000
herds already participated. Were they going to take
the retrograde step of saying that all this expenditure
had been unnecessary, and say in effect ‘‘ Produce
as dirty milk as you like so long as you put it in the
pasteurisation plant, when it will be just as good as
the other’? ? Pasteurised milk could now be obtained
wherever it was asked for. In Poole 80 per cent.
got it. He could not see why people who disapproved
of pasteurisation should be forced to do something
which they believed to be to the harm of their
children. l
A very grave step was proposed in this clause.
Surely if it was right, the Government should set
up a committee—not a committee of producers or
distributors, nor yet of doctors, but a committee
of good common-sense people accustomed to weigh
evidence—and ask them to present a report. Then
let the Government, after consideration, produce the
necessary legislation.
Case for Local Legislation
Lord MARKS said that anyone who had lived, as he
had done, through the recent typhoid epidemic,
when 900 people were affected and 51 died, would
not imagine that the Poole corporation were doing
anything panicky but were simply doing their duty
in trying to ensure that such an epidemic should not
occur again. Milk might be clean but not safe, and
what the Poole corporation, was seeking to do was to
make the milk not only clean but safe. It had been
suggested that they should put this off until the
Government brought in a measure to deal with the
whole community. If that were done, the Govern-
ment would find themselves up against difficulties
that they were not up against in this Bill, What
might be done easily for a municipality with 500,000
people would be a very difficult and doubtful thing
to do for a village with 200 or less. Their lordships
had already given a Second Reading to the Glasgow
Corporation Bill which contained a similar clause.
There was no petition to the House against it, and no
memorials against it, but 44 municipalities in England
and Scotland had sent to the Ministry of Health
memorials and petitions in favour of Clause 21 of
this Bill, which it was now said should be deleted.
A Government Bill Promised
Viscount HALIFAX, Lord Privy Seal, speaking for
the Government, said that the report of the Economic
Advisory Council’s Committee on Cattle Diseases,
presided over by Sir Gowland Hopkins, made certain
recommendations which did not correspond with the
proposals in the Bill promoted on behalf of Poole.
He understood that if this Bill received a second
reading in its present form it would be referred to a
Select Committee of the House so that the proposals
as to pasteurisation might be specially examined.
In the Government’s view such an inquiry would be |
unsatisfactory and probably inconclusive. Such
an inquiry ought not to be held in connexion with any
PARLIAMENTARY INTELLIGENCE
[may 8, 1937
particular locality, for the question was general,
affecting the country as a whole. The Government’s
intention therefore was to bring forward long-term
legislation dealing with general milk policy in the
near future. In that connexion the question of
pasteurisation would be examined in the light of all
the evidence available. When. the proposals were
brought forward Parliament would have’ oppor-
tunities for examining them in a form more satis-
factory than was open to it at the present time.
There was no reason for supposing that in the absence
of compulsory pasteurisation the people of Poole
would be in any different position as regarded the
possibility of infected milk from that of persons
in any other part of the country. Therefore, pending
general legislation, there seemed to be no necessity
to make special provisions in the case of Poole in
order to prevent a recurrence of the outbreak the town
had experienced.
The Earl of ONSLOW (chairman of committees)
said he did not think it would be fitting to hold a
long inquiry by a Select Committee into the question
of pasteurisation, which had already had so many
committees sitting on it. In the absence of any
special necessity in Poole, the matter might safely
be left to be dealt with by Public Bill. oo:
Lord Dawson’s Speech
Viscount DAWSON OF PENN said that the Poole
experiment would have been very valuable. No
indication had been given as to how long it would be
before a general measure came before them. This
matter had been under consideration for the whole
of the century, and the position was really grave.
Lord Cranworth was confusing clean and infected
milk. Milk might be perfectly clean and yet be
infected. On the other hand, it might be uninfected
and yet not be clean. He entirely agreed with Lord
Cranworth that if pasteurisation was not to be
efficient it would be better not to have it at all.
But here was no question of using pasteurisation
except effectively ; and there was an overwhelming
body of evidence that if it was carried out effectively
pasteurisation prevented the conveyance of certain
infectious diseases,
The mortality from tuberculosis had steadily
declined ; but there was one blot on the picture—
namely, that there had not been the same
improvement in the bovine type of infection as in the
human type. In 1931 in this country there were
6000 fresh cases of milk tubercle, with 2600 deaths—
a perfectly needless death-rate. It had to be
remembered that milk tubercle attacked not only the
weaklings, but also the strongest children; therefore
they were wasting 2600 children that need not be
sacrificed. In Scotland, for the same year, there were
1000 children affected and 465 deaths. By not
dealing with this matter they were continuing this
death-rate. There was a satisfactory movement for
extending the supply of milk to children. But this
made it doubly important to see that the milk-supply
was clean and free from infection. He entirely agreed
that it must be made clean: it would be the duty
of the medical officer of health of Poole to see that
it was clean. But the worst of this tubercle was
that tuberculosis in cattle might occur in apparently
healthy cows. The Department of Health in Scotland
took the churns which went into one city and found
that 10 per cent. of the samples contained not dead
but living tubercle bacilli, so that every time a child
drank a glass of milk—a child at its most susceptible
age—it was likely to be imbibing tubercle bacilli.
In Glasgow, over 13 per cent. of the samples
contained living bacilli, and therefore each glass of
milk was an active source of infection to the children.
Mention had already been made of the Bournemouth
outbreak, and the deplorable number of deaths which
occurred, ‘There were others. It might almost be
asked, in the words spoken of Pharoah: ‘“ How much
persuasion does he require to let the people go? ”
In Brighton and Hove there was an outbreak in
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PARLIAMENTARY INTELLIGENCE
[may 8, 1987 1143
1929 of septic sore-throat, due to milk infection
subsequently to its being withdrawn from the cow.
A thousand families were affected, and there were
65 deaths. Then there was the Epping epidemic of
paratyphoid in 1931 with 260 cases, and there was the
famous Chelmsford epidemic of scarlet fever and sore-
throat, in 1935, with its 1600 cases, and then followed
this Bournemouth outbreak. Therefore it must be
realised that milk might be perfectly clean and still
be infected owing to handling subsequently to being
milked from the cow. He was bringing this matter
forward really to stress the urgency of this problem—
that if it was not desirable to allow Poole to work
this out on a small scale and prove it, yet it was an
urgent matter which should be brought to an issue.
If they could secure that. milk should be controlled
and that herds should be perfectly healthy, that would
be the ideal way of dealing with this question, but it
was impracticable except in a few selected spots.
The ‘expense of making good all the tuberculous
. cows in this country was one that no reasonable
Government could face. For these reasons, therefore,
protected herds could only be few in number, and
could be maintained only where conditions were very
favourable. In Denmark they did allow raw milk
to go to children, but for the rest of the population
they insisted on milk being pasteurised. But the
raw milk that went to the children—less than 20
per cent. of the total—had to go to specially con-
trolled dairies. A further reason for pasteurisation
was that even when milk was free from tubercle
bacilli, it was still liable to get infected. by handling.
The Bournemouth, Epping, and Chelmsford epigemics
were all due to infection reaching the milk after
it was taken from:the cow. That was why he saw no
alternative to a properly organised system for
- pasteurising milk. He sympathised with the one-
sixth of the milk producer-salesmen in the country
who would suffer. It would be a change for them to
have to pasteurise the milk, but they could imitate
Denmark and go in for coöperation. Or, if necessary,
they should be compensated. The price would be a
very small one to pay. He could not see what good it
was to spend vast sums on health services and leave
_ this bad sore open year after year.
In conclusion, Lord Dawson said he very much
regretted that this experiment could not be made
in Glasgow and in Poole, so that when the Govern-
ment came to consider their more general legislation
(and they had no information as to when that would be
they would have gained some experience. .
The Debate Concludes
Lord STRABOLGI said that the Medical Committee
which advised the London County Council were
very anxious that the powers in Clause 21 should
be given to the Poole corporation. When were
they to expect this legislation of the Government ?
He understood that the time-table was alread
overcrowded. They had had a great deal of tal
recently about malnutrition and the health of the
population ; they had a special committee to consider
how to improve the physical fitness of the people ;
and here was an attempt to stop at its source a cause
of sickness and death. Yet Lord Halifax said they must
wait until the whole matter had been examined once
more and a general Bill was introduced for the whole
country.
‘ Lord CROMWELL wished to correct any impression
that the House generally accepted the principle that
pasteurisation must come sometime and that. the
only issue at this stage was whether it should be
introduced through a local authority or by the
Government. He regarded the -pasteurisation of
milk as a very doubtful cure at its very best.
Lord MARKs said that if the Bill were taken as an
opposed Bill it would entail considerable expense.
The Poole corporation would be satisfied for it to pass
with the instruction to the committee that Clause 21
should be deleted.
The motion to delete Clause 21 was agreed to.
MATERNITY SERVICES IN SCOTLAND
In the House of Lords on April 27th Lord
STRATHCONA and Mount ROYAL moved the second
reading of the Maternity Services (Scotland) Bill.
It. covered, he said, a wider field than the English
Midwives Act of last year. Scottish medical men
took a much larger part in midwifery practice than
their English confréres, and the Bill was therefore
not limited to a midwife service only. It proposed
that any woman who desired to be confined in her
own home would be entitled to the services of a mid-
wife and a doctor. If the need arose, the doctor could
call for the advice or help of an obstetrician of
recognised standing.- A thorough system of ante-
natal and post natal care would be a fundamental
feature of the scheme. Local authorities would be
free to select the type of arrangements they preferred
so long as the services were adequate. In some
areas medical arrangements—other than those
relating to obstetricians—might be made with all
general practitioners in the area who were willing
to take service on the terms offered. In other
areas the antenatal and postnatal examinations
might be carried out at the authority’s clinics, and
arrangements made either -with all practitioners
or with a limited number of them to provide the
intranatal service. No insuperable difficulty was -
anticipated in securing the services of qualified
obstetricians in most areas, but adjoining areas might
sometimes find it desirable to combine for the purpose.
The local authorities were required to consult with any
local organisation representing the medical prac-
titioners in the area before submitting their proposals
for the Department’s approval. The remuneration of
midwives and doctors participating in the service
would be a matter for negotiation between them
and the local authorities. One of the beneficial
aspects of the scheme would be the elimination of
“bad debts,’ which had been a source of much
worry, particularly to midwives.
Clause 6, the object of which was to prevent the
attendance of unqualified persons on women im
childbirth, contained a proviso excepting from the
prohibition medical. students and pupil midwives
attending as part, of their course of training. Fears
had been expressed about this permission but the
department was assured that the arrangements
for training in every Scottish university were such as
to ensure the safety of the patients. It was clear
that neither medical students nor pupil midwives
were sent out to the homes of the people until they
had been properly tested in the maternity ward, and
had satisfied their teachers that they could be trusted
with outside cases.
Lord STRABOLGI welcomed the Bill which he said
was a very long step towards a State medical service.
It was a very much larger step than was contemplated
for England, and he congratulated the Scottish
Office upon its courage in introducing the Bill.
The Bill was read a second time,
NOTES ON CURRENT TOPICS
In the House of Lords on May 4th the Hydrogen
Cyanide (Fumigation) Bill, on the motion of the
Marquess of DUFFERIN and AVA, was read the third
time and passed. On the same day the Maternity
Services (Scotland) Bill passed through committee
without amendment.
In the House of Commons on May 4th Sir KINGSLEY
Woop, Minister of Health, introduced the Local
Government Superannuation Bill, a measure to make
further and better provision with respect to the
payment of superannuation allowances and gratuities
by local. authorities and certain statutory under-
takers, and with respect to the persons entitled to
participate in the benefits of a local authority’s
superannuation fund or scheme.. The Bill was read
a first time. |
1144 THE LANCET]
PARLIAMENTARY INTELLIGENCE
[may 8, 1937
QUESTION TIME
“WEDNESDAY, APRIL 28TH
Mouthpieces of Public Telephones
Colonel GoopMan asked the Postmaster-General what
action was taken to cleanse the mouthpieces of the
instruments in public telephone boxes, and at what
intervals.—Sir W. WoMERSLEY, Assistant Postmaster-
General, replied: The mouthpieces and earpieces of
telephones in call offices provided with an attendant are
wiped with a clean cloth moistened with suitable dis-
infectant every morning. At other call offices the frequency
depends on the location of the kiosk and the extent to
which it used.
Colonel Goopman: If no official is handy are these
call offices’ mouthpieces ever disinfected ?
Sir W. Womerstey: A full investigation has been
made into this question by a committee upon which
medical men sat and their decision was, that the infection
was more psychological than actual. (Laughter.)
Mr. THORNE: Can the hon. Member give any guarantee
that everybody’s mouth is clean before using the
telephone ?
Sir W. WoMERSLEY :
friend.
I will leave that to my hon.
THURSDAY, APRIL 29TH.
The Birching of Juvenile Offenders
Mr. SHort asked the Home Secretary if he was aware
that a further six boys were ordered to be birched by the
West Riding juvenile court, Doncaster, on April 2ist ;
whether the sentences had been carried out; and whether
he would now reconsider his decision not to advise magis-
trates not to impose such sentences having regard to the
appointment of the committee of inquiry.—Sir JoHn
Stmon replied: Yes, Sir. Six boys were ordered on
April 21st to be birched ; five have been birched and the
police surgeon found that the sixth was unfit for the
punishment. I cannot do more than say that I am sure
that justices will realise that I regard the whole subject
as one which needs investigation.
Mr. T. Witu1ams: Is the right hon. gentleman aware
that the boy who was not fit to be birched on the day
when the other five were birched has been invited to
attend the police-court on Tuesday next to be birched ?
Does the right hon. gentleman regard it as consistent
with the law for a boy to be sent home and be called
upon to return a week later to receive his birching ?
Sir J. Smmon: I do not know the circumstances to
which the hon. Member refers but will make inquiries.
Mr. SHort: Would the right hon. gentleman send a
circular to clerks of the peace calling their attention to the
fact that he has set up this committee of inquiry ?
Sir J. Smion: I could not do that; the fact is per-
fectly well known, and I think that when an inquiry has
been set up it is very essential that the authorities should
not seem to pronounce judgment before the inquiry is
completed.
Training of Blind Children
Sir WILLIAM JENKINS asked the President of the Board
of Education if he had any record of the number of blind
boys and girls who, on leaving school, were being trained
for some trade or any other occupation, and the number
of these wholly employed for the years 1935 and 1936 in
England and Wales, separately.—Mr. OLIVER STANLEY
replied: It is estimated that at present the number of
blind boys and girls, as distinct from the partially sighted,
who leave the schools for the blind each year at the age
of 16 is about 200. The Board do not have a statistical
record, but it is known that practically all of these who
are likely to be employable enter vocational courses of
training. On March 3lst, 1936, the total number of boys
and girls from schools for the blind who were being trained
was 693. The Board have no statistics concerning the
employment of the blind, which is a matter for my right
hon. friend the Minister of Health.
Sir WILLIAM JENKINS asked the President of the Board
of Education what was the number recorded of border-
line cases of pupils in schools for the blind ; and was the
test for certification of blindness causing a hardship on
certain types of children who were educationally blind,
but on reaching a certain age were marked sighted for
industrial purposes.—Mr. OLIVER STANLEY replied : The
Board have no statistical record of the number of such
` cases, but I agree with the conclusion of the Committee
on Partially Sighted Children that such children should
be taught in schools or classes for partially sighted children
and that hardship is involved if they are educated and
brought up as blind and have later to enter the sighted
world, for which their education has not fitted them.
Hospital Arrangements in Staffordshire
Mr. MANDER asked the Minister of Health the present
position with regard to the protests against the arrange-
ments made by the Staffordshire County Council in
Wednesfield, Willenhall, and other districts for the treat-
ment of invalids-and old people ; and whether he would
endeavour to arrange that negotiations should be reopened
between the Staffordshire County Council and the Wolver-
hampton Borough Council, with a view to arrangements
being made for Wednesfield and Willenhall residents to
have the same facilities for obtaining treatment at the
New Cross institution as were possible prior to April lst,
1937.—Sir KinestEy Woop replied: I would refer the
hon. Member to the answer which I gave to his question
about these arrangements on April 8th. I am in com-
munication with the county council regarding the repre-
sentations which I have since received on this subject,
and will inform him further of the position when I have
received their reply.
Mr. ManpER: Will the right hon. gentleman bear in
mind that there is still plenty of room in the New Cross
institution where invalids can go in a few minutes instead
of having to travel 14 miles to Wordsley ?
Sir K. Woop: Yes, Sir.
Old Age Pensioners in Poor-law and Mental
Hospitals
Mr. LracH asked the Secretary to the Trony if he
had considered the copy sent to him of a resolution of the
Eastbourne pensions committee, and supported by other
committees, asking for a reform of the old age pensions
law so as to provide a fairer method of calculating the
means of persons who had been inmates of poor-law
institutions or mental hospitals; and if he was prepared
to comply with the wishes so expressed. —Lieut.-Colonel
CoLvILLE replied: The resolution to which the hon.
Member refers is presumably that which asked that the
cost of maintenance should be excluded in calculating
the means of a pensioner who is in a poor-law institution
for medical or surgical treatment and that the disquali-
fication in certain circumstances from receipt of pension
of a person in a mental hospital should be removed and
the cost of his maintenance there disregarded in calculating
his pension. This would have the effect of giving the
pensioner free maintenance as well as a pension calculated
on the basis that he is maintaining himself; and in so far
as the pension is appropriated by the local authority, it
would operate merely as a grant in aid of local expendi-
ture. I am afraid, therefore, that the Government are
not prepared to introduce the legislation which would be
necessary to effect these changes.
Mr. Leaom: Is it not reasonably argued that old age
pensioners who need medical or mental treatment of this
sort are in such poor conditions and circumstances that
they should have this concession made by the Government ?
Lieut.-Colonel CoLvILuE : I have given the hon. Member
a long and careful answer and I am afraid I cannot add to it.
MONDAY, MAY 3RD |
Health Insurance and Maternity Benefit
Mr. DE Rorsscuip asked the Minister of Health
whether he would introduce legislation to amend the
National Health Insurance Acts so as to increase the
amount of maternity benefit payable by approved societies,
seeing that the Midwives Act, 1936, by making compulsory
the attendance of a qualified midwife at all confinements,
threw an added financial burden on insured contributors
at such times.—Mr. Hupson, Parliamentary Secretary
to the Ministry of Health, replied : The position of a
woman entitled to maternity benefit as regards the
arrangements for attendance at her confinement is not
materially affected by the provisions of the Midwives
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[max 8, 1937 1145-
Act, 1936. The National Health Insurance Acts have
always contemplated that such a woman should be
attended either by a medical practitioner or a qualified
midwife. Moreover, the Midwives Act expressly provides
that the fees charged by local authorities for the services
of their midwives may be remitted in whole or in part
where the circumstances justify such remission. My
right hon. friend does not, therefore, consider that the
coming into operation of the new Midwives Act affords
any reason for the suggested amendment of the National
Health Insurance Act.
TUESDAY, MAY 4TH
Prevention of Silicosis
Mr. JAMES GRIFFITHS asked the Secretary for Mines
the precise nature of the preventive measures that had
so substantially reduced the incidence of silicosis in the
Rand mines; whether these preventive measures were
made obligatory upon the Rand mine-owners by statute
or regulations; in how many collieries in Great Britain
and South Wales, respectively, these preventive measures
were in use ; and whether he proposed to issue the regula-
tions to make their adoption obligatory upon the mines
of this country.—Capt. CROOKSHANK replied: In South
Africa those mines which are scheduled under the Miners’
Phthisis Benefits Law are subject to regulations requiring
special preventive measures to be taken. I cannot, within
the limits of an answer, state those preventive measures
‘precisely, but the general purport is to provide for initial
and periodical medical examination of persons exposed
to the risk and for the suppression of harmful dust which.
might be breathed by such workers. I have not sufficient
statistical information to enable me to answer the third
part of the question. As regards the fourth part, the
South African regulations apply only to the scheduled
mines which, generally, I understand, are the metalliferous
and not the coal-mines ; and, as at present advised, I do
not propose, as regards the coal-mines of this country,
to displace the method of differentiating requirements
‘according to risk in favour of applying the same require-
ments to all these mines. The whole matter is, however,
under consideration by the Royal Commission now sitting.
Maternal Mortality
Mr. GEORGE GRIFFITHS asked the Minister of Health
the number of deaths in childbirth for 1936, and the
number of deaths arising out of childbirth for 1936.—
Mr. Hupson, Parliamentary Secretary to the Ministry of
Health, replied : For 1936 the deaths classified to pregnancy
.and childbearing were 2302, while the deaths not classified
to those causes but returned as associated therewith
were 677. These figures relate to England and Wales, and
are provisional.
Typhoid Fever in Liverpool
Mr. Groves asked the Minister of Health how many
.cases of typhoid fever had been notified at Liverpool
this year; and whether the outbreak was now at an end.
—Sir Kinestry Woop replied : 123 cases of typhoid fever
(including paratyphoid) have been notified in Liverpool
during the present year up, to April 24th, the majority
‘of which occurred in an outbreak of paratyphoid fever in
January. I am informed that that outbreak is regarded
by the local authority as being now at an end.
Employment of Boys in Coal-mines
Mr. TINKER asked the Secretary for Mines how many
‘boys there were under 16 years of age working under-
ground in coal-mines that come under his department.—
Capt. CROOKSHANK. replied: At Dec. 12th, 1936, the
latest date for which the information is available, 17, 044
boys under 16 years of age were employed below ground i in
-coal-mines in Great Britain. .
Experiments on Living Animals
Mr. Leacu asked the Home Secretary how many
inoculations had been performed in contravention of the
‘Cruelty to Animals Act, 1876, by the experimenter referred
to in the Home Office Return of Experiments on Living
Animals for 1935; and what period of time had been
covered by the illegal inoculations.—Mr. GEOFFREY
Lxuoyp, Under-Secretary, Home Office, replied: 14, and
all were given on the same day.
week ?—286;
THE LANCET 100 ‘YEARS AGO
May 13th, 1837, p. 264..
FROM THE EVIDENCE RELATING TO THE MEDICAL RELIEF
OF THE SIOK POOR IN THE PAROCHIAL UNIONS, given before
the SELEOT COMMITTEE OF THE HOUSE OF COMMONS, in
1837. Tenth Day. Wednesday, April 14. Mr. Fazakerley
in the Chair.
MR. THOMAS BOURNE,
4324. Examined by the Chairman.] You are master
of the Fareham workhouse ?— Yes.
4328. In what state were the boys Cooke, Warren, and
Withers, when they were sent to you ?—They appeared
healthy.
4330. Who is the medical man of that house ?—Mr. John
Blatherwick.
4332. Had those children dirty habits ?—They com-
menced their dirty habits the first or second night after
their admission.
4334. What observation did the medical man make
upon hearing of that ?—None in particular.
4336. What did you do to correct those habits !—With-
held part of the food.
4342. Were the visiting guardians made acquainted
with the food being diminished ?—Yes, they did not
object to it. Half of the food for the day was stopped.
4348. Was any punishment also had recourse to?
—The children were placed in the stocks frequently, both
standing and sitting, and were kept in them from meal
to meal, at the same time that their food was diminished,
I believe. When the schoolmistress intimated to: me
that it did not appear to have any effect upon their filthy
habits, I desired her to discontinue withholding their food,
or any other punishment,
4359. How soon after they were in the house did the
schoolmistress observe to you that their health appeared
to decline ?—I suppose a month. ...
4639. Will you read the dietary of the workhouse
for young children ?—On the Sunday, children under
nine years of age have three ounces of bread for breakfast,
and one pint of gruel with milk; the dinner is one pint
of meat soup, half a pound of potatoes, and three ounces |
of bread; supper, four ounces of bread, one ounce of
cheese, or half an ounce.of butter ; Monday, for breakfast,
five ounces of bread, one pint of gruel with milk; dinner,
eight ounces of suet pudding; supper, five ounces of
bread, one ounce of cheese, or half an ounce of butter.
4641. On Monday were these children almost always
deprived of half that sustenance?—-The Monday was the
same as any other day; they were not punished more
than twice or three times a week. (The dietary of the
other days in the week was detailed by the witness.)
4643. By Mr. Murs] Are the Committee to under-
stand that, with this dietary those dirty children were
punished frequently three times a week by half that
allowance being stopped ?—Yes.
4645. Give the number of ounces of food for the whole
nine ounces of which is meat; potatoes,
32 ounces ; cheese, 7 ounces; pudding, 8 ounces ; three
pints of soup; and a pint of gruel every morning.
4689. By Mr. Harvey.] You received back one-half
of the allotted food of the diminished meals of children ?
—Yes.
4694. What is done with it ?—It is put up for the next
meal.
4696. Is it at the discretion of the mistress to with-
hold food as a punishment ?—Yes, and also to put children
-in the stocks.
4717. You have stated that the children were taken to
an outhouse ; is it a room, or a stable, or a washhouse ?
—It is a plastered room on the other side of the yard,
originally intended for a workshop, with a stone floor.
4720. Is there any fire-place in it ?—No..
4722. At what period of the year were the children
confined in that room ?—In January.
** “ Oliver Twist’ was first published in 1837 in
Bentley’s Miscellany.—Ep. L.
1146 THE LANCET]
ROYAL SOCIETY CONVERSAZIONE
AMONG the exhibits at the Royal Society’s conver-
sazione on May 4th was one by Prof. H. H. Woollard,
who showed radiograms of lymphatics made opaque
by injection of thorotrast and barium. They demon-
strated the longitudinal pattern of the vessels in the
extremities and the circular arrangement around the
trunk. The lymphatics above were seen to converge
on the axilla and those below on the groin, the
dividing line being about the middle of the trunk.
The injection of lymphatics near a carcinoma showed
that normal lymphatics traverse the mass, that
. many lymphatics about the carcinoma remain patent
and contain no carcinomatous cells. Normal lym-
phatics pass from the growth to lymph glands
found to contain metastases; it was concluded that
carcinomatous cells occasionally rupture into a
lymphatic vessel and are carried as emboli to the
gland. Injections of thorotrast into the living had
been used to investigate lymphatic odema and
obstruction, and also the lymphatic flow in skin
transplantation and pedicle grafting: This part of
the work had been done in coöperation with Sir
Harold Gillies. Recently another opaque material
which contained no thorium had been devised for
injection.
“Mr. F. C. Bawden and Mr. N. W. Pirie of the
Rothamsted Experimental Station and the depart-
ment of biochemistry, University of Cambridge,
showed some of the peculiar physical properties of
nucleo-proteins obtained from virus infected plants.
These proteins are believed to have the largest
molecules yet known, the molecular weight being of
the order of 17,000,000. They are obtainable only
from infected plants and are capable of transmitting
the disease even in extremely high dilutions (1 in 10?°).
They are prepared from the plant by solution and
_ precipitation ; the precipitate is dissolved again and
` the final material bears a quantitative relation to its
infectivity. It is specific in its relation to the plant
and, when injected in great dilution into rabbits, can
produce antigens. Another exhibit, by Mr. J. D.
Bernal and Dr. I. Fankuchen, was of the X ray
pictures of this protein in various states. The
molecules had been shown to be rod shaped with a
cross-section diameter of 15 uu but with lengths
probably greater than 100 uu.
During recent years several substances having
growth-promoting properties have been isolated from
plants. Three, called auxin a, auxin b, and hetero-
auxin, are now recognised, the last being B-indolyl .
acetic acid, a substance which has been synthesised.
It is only known to promote growth in plants. It
was the object of an exhibit by Imperial Chemical
Industries Ltd. When painted on one side of
seedlings grown in the dark it caused them to grow
crookedly from overgrowth of that side ; when applied
to tomato plant stalks it had induced root formation
quite high on the plant; when put on cuttings it
was found to assist the vigorous formation of rootlets.
Lieut.-Colonel A. J. Peile showed the dart-like
radulæ of a mollusc which lives in the Indian Ocean ;
the animal uses them for injecting a poisonous sub-
stance into its prey but occasionally, it is said, the
poison has caused paralysis and even death in man.
Other exhibits were of models of protein molecules,
including ones for pepsin and insulin (Mrs. Dorothy
Wrinch, D.Sc.) and modifications of dominance in
mice (Prof. R. A. Fisher and Mr. K. Mather, Ph.D.),
while for the delight of the curious there were bells
which sounded when touched with solid carbon
ROYAL SOCIETY CONVERSAZIONE.—THE SERVICES
[may 8, 1937
dioxide, human teeth fluorescing in ultra-violet light,
and earphones with which to listen to beetles in
timber,
THE ‘SERVICES
ROYAL NAVAL MEDICAL SERVICE
Surg. Comdrs. A. de B. Joyce and W. G. C. FitzPatrick
to President for Medical Department.
Surg. Comdr. (D) S. E. Brown to Resource.
Surg. Lt.-Comdr. (D) E. R. Longhurst and Surg. Lt. (D)
W. R. Knott to Caledonia, -
- The following have been appointed Admiralty Surgeons
and Agents :—
Mr. B. E. Hawkins (Anerley-road, S.E.20) for London
District No. 8 (Catford, Dulwich, &c.) ; Mr. F. A. Anderson
(Stranraer) for Stranraer ; Mr. F. E. Higgins (Sudbury,
Suffolk) for Sudbury; Mr, J. Cullen (Northampton)
for Northampton ; and Mr. A. C. Ainsley nee Hartlepool)
for West Hartlepool.
ROYAL NAVAL VOLUNTEER RESERVE
e Surg. Lt.-Comdr. (D) G. P. Monk placed on the Retd.
ist.
L. F. Donnan entered as Proby. Surg. Lt.
ROYAL ARMY MEDICAL CORPS
Short Service Commissions.—Lts. to be Capts.: J. A.
MacDougall, J. C. A. Marchand, and D. Wright..
Lt. (on prob.) A. F. H. Keatinge is confirmed in rank,
ARMY DENTAL CORPS
Short Service Commission : E. Smith, B.D.S., to be
Lt. (on prob.). ve
TERRITORIAL ARMY
Capt. W. H. G. Park to be Maj.
Capt. F. Lawrence resigns his commission.
Lt. A. Bennett, from 7th Bn. Cheshire R., to be Capt.
To be Lts.: H. R. J. Donald (late Cadet Corpl.,
Winchester Coll. Contgt., Jun. Div., O.T.C.); Edwin
Fulford (late Ofir. Cadet, Univ. of Lond. Contgt. (Med.
Unit), Sen. Div., O.T.C.); R. J. McGill (New Zealand
Forces, Res. of Off.); W. B. Evans; H. B. Collins;
and K. G. Sugden.
| ROYAL AIR FORCE
Group Capt. T. Montgomery to Headquarters, R.A.F.,
India, New Delhi, for duty as Principal Medical Officer.
Flight Lts. S. B. S. Smith to Central Medical Establish-
ment, London ; R.C. H. Tripp‘to No. 1 School of Technical
Training (Apprentices), Halton ; C. A. Rumball to R.A.F.
Institute of Pathology and Tropical Medicine, Halton ; and
J. S. Wilson to No. 8 (Bomber) Squadron, Aden.
Flying Offrs. D. F. Cameron to Home Aircraft Depdt,
Henlow ; W. T. Buckle to No. 5 Flying Training School,
Sealand; J. D. Milne to No. 9 Flying Training School,
Thornaby ; J. C. Taylor to No. 10 Flying Training School,
Tern Hill; H. O’B. Howat to No. 11 Flying Training
School, Wittering; and C. E. G. Wickham to R.A.F.
Station, Marham. .
AUXILIARY AIR FORCE'RESERVE OF OFFICERS
Flying Offr. T. E. Cawthorne relinquishes his commission
on completion of service. —
INDIAN MEDICAL SERVICE
‘The War Office announces that with the approval off{the
Government of India, Major-Gen. G. G. Tabuteau, D.S.O.,
late R.A.M.C., Deputy-Director of Medical Servi ices,
Northern Command, York, has been selected to succeed
Major-Gen. E. A. Walker, C.B., M.B., F.R.C.S. Edin.,
K.H.S., I.M.S., as Director of Medical Services, India,
with effect from August 10th, 1937, when the latter will
vacate the appointment. (Vide also Lancet, April 10th,
p. 895.) Major-Gen. Walker has been granted leave
pending the vacation of his appointment.
Col. W. J. Powell, C.I.E., I.M.S., V.H.S., is appointed
Hon. Surg. to the King, vice Major-Gen. A, W. M. Harvey,
I.M.S., retired.
Lt.-Cols. H. B. Scott, O.B.E., and A. L. Sheppard retire.
Indian Medical Department.—Maj. (Sen. Asst. Surg.)
A. L. Elloy retires.
(Continued at foot of next page)
THE LANCET}
[may 8, 1937 1147
MEDICAL NEWS
University of Cambridge
On May Ist the following degrees were conferred :—
M.B., B.Chir.—*G. D. Pirrie, *A. B, Evans, *P. J. Wenger-
Byrne, A. H. Knowles, N. A. Buxton, L. A. Collins, G. C. L.
» H. T. H. Wilson, F. I. Evans, L. N. G. Lytton, A. C.
Blandy, A. A. D. La Touche, I. W. MacKichan, D. S. Scott,
E. D. Hoare, and R. J. Porter.
M.B.—*H
Mason Payne,
*F. H. Morrell, *H
Smith, A. B. R
. Briggs,
Ryley, *D. A
University of London
At a recent examination for the diploma in psychological
medicine G. A. FitzPatrick passed with special knowledge
of mental diseases. G. L. Ashford and Augusta G. Harrison
passed in part A of the examination.
Royal College of Physicians of London
At a meeting of the college held on April 29th, with
Lord Dawson, the president, in the chair, the following
members were elected fellows :—
Arthur Cecil Alport, M.D. Edin. (London); Thomas Pearse
Williams, M.D. Lond. (London); William Noel Goldsmith, M.D.
Camb. (London) ; Henry Fitzgerald Maudsley, M.D. Melb.
(Melbourne); Lewis Ralph Yealland, M.D. Ontario (London);
Francis Joseph Bentley, M.D. Durh. (London); Ernest Noble
Chamberlain, M.D. Liverp. (Liverpool) ; Francis Wiremu Brian
Fitchett, M.D. Edin. (New Zealand); Jeffrey Ramsay, M.D.
Lond. (Blackburn); Frank Dutch Howitt, M.D. Camb.
(London) ; Oscar Brenner, M.D. Birm. (Birmingham) ; Benjamin
Branford Morgan, M.D. Edin. (Norwich); Douglas Kinchin
Adams, M.D. Glasg. (Glasgow); Percy Selwyn Selwyn-Clarke,
M.D. Lond. (Nigeria) ; William Sydney Charles Copeman, M.D.
Camb. (London); Sidney Smith, M.B. Lond., Brevet Lieut.-
Colonel R.A.M.C. (Hong-Kong); Edward Humfrey Vere Hodge,
M.D. Camb., Lieut.-Colonel I.M.S. (Calcutta); Charles Cady
Ungley, M.D. Durh. (Newcastle-upon-Tyne); Richard Desmond
Curran, M.B.Camb. (London); Allan William Spence, M.D.
Camb. (London); Robert Stevenson Aitken, M.B. N.Z.
(London); Arnold Ashley Miles, M.A. Camb. (London); Harry
Edward Mansell, M.B. Oxon. (London); Thomas Anwyl-Davies,
M.D. Lond. (London); Dame (Anne) Louise McIlroy, M.D.
ere (london): Edward Johnson Wayne, M.B. Leeds
(Sheffield); Henry Ashbourne Treadgold, M.D. Lond., Group
Captain, R.A.F.M.S. (Elstree); Harold Kingston Graham-
Hodgson, M.B. Durb. (London); Reginald St. Alban Heathcote,
M.D. Oxon. (Cardiff) ; Philip Graham Stock, M.B. Brist. (London);
John Frederick Wilkinson, M.D.Manch. (Stockport); and
under By-law xxxvil (b) Ernest Laurence Kennaway, M.D.
Oxon., D.Sc. Lond., .R.S. (London); William Porter
MacArthur, D.Sc., M.D. Belf., Major-General R.A.M.C. (London).
The following were admitted members of the college :—
Mohammed Attia Abboud, M.B. Cairo; Sitaram Damodar
John Bennet, Major R.A.M.C.,
Ewan Lawrie Corlette,
M.B.Sydney; Guy Pascoe Crowden, M.Sc. Lond., L.R.C.P.;
drew Danino, M.D. Lond.; Leslie John Davis,
M.D. Edin.; William Alexander Elliott, M.B.Camb.; Ahmed
Mahrhoud El Nakah, M.B. Cairo ; Noel Gordon Harris, M.D. Lond.;
George William Hearn, M.B.Lond.; Charles Anthony Hinds-
Howell, M.B. Oxon. ; Kenneth Tamworth Hughes, M.B.
Sydney; Archibald Louis Percy Jeffery, M.D. Lond. ; Manoah
Robert Kark, L.R.C.P. ; Heneage Marchant Kelsey, M.B. Lond. ;
Frederick Harold Kemp, M.B. Birm. ; Phyllis Margaret Kerridge,
M.Sc., Ph.D. Lond., L.R.C.P.: Samuel Lazarus, M.D. Glasg. ;
Archibald Jobn McCall, M.B. Liverp.; Murray McGeorge,
M.B.N.Z.; Richard Alfred Amyas Pellew, M.B. Adelaide ;
‘William Gwynfryn Rees, M.B. Oxon. ; John Samuel Richardson,
M.B. Camb. ; Charles Ronald St. Johnston, M.B. Birm.;
Joseph Smart, M.B. Camb. ; Seth Kenneth Squires, M.B. Lond. ;
Stephen James Lake Taylor, M.B.Lond.; Henry Renwick
(Oontinued from previous page)
DEATHS IN THE SERVICES
The death occurred on April 29th of Lt.-Col. FREDERICK
JOSEPH GARLAND, D.S.O., R.A.M.C. (retd.), of Lydd,
Kent. Son of the late James Garland of Rathmines,
-Co. Dublin, he was born in 1877 and was educated at the
Royal University of Ireland and qualified M.B. in 1901.
He joined the R.A.M.C. in January, 1904, and became
capt. in July, 1907. For a time he was at Ahmadnagar,
Bombay, and then at Colchester. He served in the
European War, 1914-18, was mentioned in dispatches
and in 1918 was created D.S.O.
Guy’s;
Vickers, M.B.Sheff.; Denis Jobn Williams, M.D. Manch. ;
and Reginald Alexander Wilson, M.D. McGill.
Licences to practise were conferred upon 212 candidates
(193 men and 19 women) who have passed the final
examination of the Conjoint Board and have complied
with the by-laws of the college. The following are the
names and medical schools of the successful candidates :—
G. Bourne, Camb, and
I. G
P. J. Burke, Manch. ; H.
Camb. and Lond.; C.S. Cane, St. Bart.’s; C. A.
Thomas’s; H. W. Chaifetz, Middlesex; A. Chambers, West-
minster; L. R. Chaperon, Univ. Coll.; Norah H. C. Clarke,
Roy. Free; O. W. W. Clarke, Lond.; May D. C. Clifford,
Roy. Free; N., F. Coghill, Camb. and Westminster; A. Cohen,
Univ. Coll.; S. M. Cohen, Cape and King’s Coll.; J. C. A. L.
Colenbrander, Guy’s; D. G. Cracknell, St. Thomas’s; F. M.
Crawshaw, Camb, and St. Thomas’s; N. C. Creighton, Guy’s;
J. A. Currie, St. Thomas’s ; J. B. Cuthbert, Cape and St. Bart.’s ;
Mary D. Daley, Roy. Free; A. J. Dalzell-Ward, Char. Cross ;
J. B. Dancer, St. Bart.’s; S. B. Darbishire, Camb. and Liverp., ;
A. R. Darlow, Guy’s; C. M. Dickins, Camb. and St. Bart.’s ;
Cecile R. Doniger, Univ. Coll.; V. Drosso, Guy’s; Katherine
W. Dunn-Pattison, Roy. Free; A. E. H. Eades, Birm.; J. D.
Ebsworth, Guy’s; Violet E. Elam, King’s Coll. ; M.El S. M. El-
Shanawany, Univ. Coll.; G. E. Ennis, St. Thomas’s; P. G. L.
Essex-Lopresti, Lond. ; Kathleen J. Evers, Univ. Coll.; G. A.
Fairlie-Clarke, St. Bart.’8; Rachel D. Fidler, Roy. Free;
R. D. Flintan, Middlesex ; ` G. A. Fowler, Camb. and Leeds ;
Audrey U. Fraser, Roy. Free; R.T. R. Freshwater, Birm. ;
H. W. C. Fuller, King’s Coll.; E. Garland-Collins, Lond. :
S. Garnjana-Goonchorn, Guy’s; R. G. Gibson, St. Bart.’s;
D. S. Gideon, St. Mary’s; J. C. Gilson, Camb. and Lond. ;
Dorothy M. Gladwell, Roy. Free; M. Glick, Leeds; E. G.
Godwin, St. Mary’s; B. H. Goodrich, St. Bart.’s; C. W. O.
Gough, Camb. and St. Thomass; G. W. V. Greig, Leeds ;
A. C. Grey, Oxon, and St. George’s; A. Griffiths, Car ;
G. L. Gryspeerdt, St. Thomas’s; I. A. Ġuest, Camb. and Birm. ;
D. V. Hague, Birm. ; H. Haigh and S. G. Hamilton, Camb. and
Lond.; H. E. W. Hardenberg, Guy’s; D. W. T. Harris, Univ.
Coll.;’R. W. H.-G. Harris, Cape and St. Mary’s; G. F. C.
Hawkins, Oxon. and St. Thomas’s; M. J. M. Heap, Manch. ;
S. H. Heard, Char. Cross; J. A. Herd, Manch.; A. J. Heriot,
King’s Coll.; J. Herman, Lond.; P. S. A. Heyworth, Camb.
and Liverp.; A. P. Hick, St. Thomas’s ; K. R. Hill, West-
minster; G. B. Hollings, St. Thomas’s; J. N. Horne, Camb.
and St. Thomas’s; N. C. Horne, King’s Coll.; J. G. Humble,
Westminster; Sybil M. Humphreys, Univ. Coll.; K. K.
Hussain, Leeds; D. L. Isaac, Camb. and St. Mary’s; D. N.
Jackman, Univ. Coll.; G. James, Guy’s; N. E. James, Lond. ;
D. Jefferiss, Oxon. and Middlesex ; S.T. H. Jenkins, St. Bart.’s ;
W. H. R. Jeremy, Camb. and St. Bart.’s; J. G. Jesson, Camb.
and St. Thomas’s; A. W. Johnson, Lond.; G. M. Johnson,
Guy’s; J. S. Joly, St. Bart.’s; D. W. G. Jones, Camb. and
St. Bart.’s; J. D. Jones, St. Thomas’s; R. A. Jones, Univ.
Coll.; O. Jordan, St. Mary’s; P. T. Joseph, Madras and
Lond.; N. Jungalwalla, Rangoon; L. C. Kalra, Char. Cross ;
B. K. Kapur, Punjab and Lond. ; J. Kastelian, Westminster ;
J. H. H. Keall, St. George’s; Gladys E. Keith, Roy. Free ;
P.M. Kelly, Camb. and St. Thomas’s ; G. M. Kerr, St. Thomas’s ;
P. Kidd, Camb. and Lond.; J. R. Kilpatrick, Guy’s; E. J.
Lace, Brist.: H. B. Lal, Rangoon and Manch.; E, V. Lambert
and L. P. Lassman, Lond. ; N. G. Latey, Bombay ; J. M.
Lea and A. R. Leask, Guy’s ; A. R. Lee, Sheff.; I. Libman,
Liverp.; A. E. Loden, Guy’s; Christia F. Lucas, Birm.;
G. L. St. A.McClosky, Middlesex; T. . McKane and
M. E. Mankin, St. Bart.’s ; A. J. Martin, Camb. and
St. Thomas’s; D. Matthews, Cardif; E. Maung, Rangoon
and Birm.; R.M. Miller, Camb, and Lond. ; D, Moss, Lond. ;
S. N. Mukherjee, Calcutta and West Lond.; Winifred F. G.
Murray, Roy. Free; B. Mushin and R. H. Neeve, Lond. ;
Elizabeth A. Nettell, Roy. Free; C. P. Nicholas, Birm.; M, P.
Nightingale, Cape and St. Thomas’s ; A. J. Nimmo, St.
Thomas’s; W. A. Owen, St. Bart.’s; L. B. Paling, Camb. and
St. George’s; E. A. Pask, Camb. and Lond. ; R. W. J. Patterson,
Rangoon ; Constance E. Peaker, Camb. and Leeds; C. C. S.
Pike, St. Mary’s; C, S. Pitt, Guy’s; G. E. J. Porter, St. Mary’s ;
H. L. Porter, Camb. and St. Thomas’s; H. C. Price, Birm.;
S. H. Raza, Guy’s; J. A. Rhind, Leeds; G. R. Richards
Oxon and Cardiff; ‘I, D. Riley, Leeds; R. Roaf, Oxon. and
Liverp.; G. M. Robertshaw, Lond.; Annie I. B. Ross, Roy.
Free and Birm.; Mary C. Rowe, Roy. Free; K. C. Royes,
Oxon. and St. Thomas’s; N. Sacks, Lond.; A. R. Samuel,
Camb, and Lond.; F. H. Scadding, ‘Middlesex ; C. G. Scorer,
Camb. and Lond.; C. W. Seward, Oxon. and Middlesex ;
Constance M. B. Shaw, King’s Coll. ; G. Shneerson, St. Mary’s ;
R. J. Simms, Guy’s; D. A. Slade, Univ. Coll.; J. M. Small,
-Birm.; A. W. Stewart, Camb. and Lond. ; J. F. Stokes, Camb.
and Univ. Coll. ; H. Stoll, Guy’s; W. G. Sutcliffe, St. Thomas’s ;
S. Tarlovskis, Univ. Coll.; W. Taylor, St. Mary’s; I. E. J.
Thomas, Guy’s; J. H. Thomas, Cardiff; L. C. Thomson,
R.W. Thomson, St. Bart.’s ; G. G. Thyne, St. Thomas’s ;
D. J. D. Torrens, Camb. and St. Thomas’s; R. L. Townsend, .
Camb. and Univ. Coll.; I. S. Varma, Bombay and West Lond. ;
1148 THE LANCET]
E. Vernon, Manch.; F. H. Vollam, Birm.; G. M. Ward, Lond. ;
S. Ward and R. W. Watts, Camb. and St. Thomas’s; G. V.
Webster, Birm.; T. Weiner, St. George’s; R. A. Whit
Bart.’8; E. H. L. Wigram, St. Thomas’s; O. G. R. H. Williams,
Oxon. and Westminster ; S. I. Williams and A. D. Willis, Guy’s ;
I. N. Winer, Middlesex ; F. A. J. Woodland, Guy’s; E. Woolf,
Univ. Coll.; and A. S. Woolstone and R. O. Yerbury, Guy’s.
- Diplomas in tropical medicine and hygiene were con-
_ ferred (jointly with the Royal College of Surgeons) upon
the following :—
H. Akhtar, S. Amarasinghe, R. H. Barrett, A. H. Booth,
d W. Bowden, J. C. Busby, K. L. Buxton, Dorothy G. Cowie,
. H. Fisk, A. B. Gilroy, S. A. Hasib, A. D. Hodges, W. H.
Jeffrey, A. Mizrahi, P Murphy, V. T. Pasupati, M. G.
Pearson, C. Ponnambalam, J. D. Prasad, J. T. Robinson,
M. Roushdy, C. A. Rumball, A. G. Rutter, S. Shrikhande,
L. M. de Silva, M. Singh, D. W. Soman, A. S. Syed, A. L. F.
Thomson, G. I. Watson, and J. G. Webb.
Lord Dawson was re-elected representative of the
college on the governing body of the British Postgraduate
- Medical School and Dr. Archibald Malloch the repre-
sentative at the celebration of the fifteenth anniversary
of the founding of the College of Physicians of Philadelphia
on May l4th. Dr. Edwin Bramwell will deliver the
Croonian lectures on clinical reflections. upon muscles,
movements, and the motor path at the college at 5 P.M.
on May 25th, 27th, and June Ist. .
Society of Apothecaries. of London
At recent examinations the following candidates were
successful :—
Surgery.—A. A. Beazeley, Guy’s Hosp.; N. Bickford, Univ.
of Camb. and Middlesex Hosp.; P. H. Denton, Guy’s Hosp. ;
S. M. M. Niall, Royal Colleges, Edin.; and W. G. Tillmann,
Guy’s Hosp. l
edicine.—P. H. Denton, Guy’s Hosp.; G. Howell, Welsh
National School of Medicine; L. W. La Chard, St. George’s
Hosp. ; J. F. Mason, Univ. of Calcutta and London Hosp.; A.P.
Ne ey, Royal Colleges, Edin. ; and F. L. Skinner, Univ. of
c A
Forensic Medicine.—P. H., Denton, Guy’s Hosp.; G. Howell,
Welsh National School of Medicine ; L. W. La Chard, St. George’s
Hosp.; J. F. Mason, Univ. of Calcutta and London Hosp. ;
ee T Motley, Royal Colleges, Edin. ; and F. L. Skinner, Univ.
o c A
` Midwifery—D. R. Daniel, Middlesex Hosp.; J. B. Good,
Guy’s Hosp.: J. F. Mason, Univ. of Calcutta and Londo
Hosp. 3 and F. D. Pitt Palmer, Middlesex Hosp.
The following candidates, having completed the final
examination, are granted the diploma of the society
entitling them to practise medicine, surgery, and
midwifery :— |
N. Bickford, S. M. M. Niall, P. H. Denton, F. L. Skinner, and
L. W. La Chard,
Royal Faculty of Physicians and Surgeons of Glasgow
At a meeting of the faculty on May 3rd, with Prof.
Archibald Young, the president, in the chair, the following
were admitted to the fellowship: Joseph Alexander Bell
(London), Hatimbai Shaikh Abdulally Malik (Bombay),
and George Broughton Smart (India),
National Hospital, Queen-square
The Lord Mayor, Sir George Broadbridge, took the
chair on April 27th at a festival banquet given at the
Mansion: House in aid of this hospital. The guest of
honour was the Duke of Kent, who made a moving speech
describing the work of the hospital and its great needs.
It was, he said, the oldest and largest hospital for nervous
diseases in the world. The speed at which life was lived
nowadays made a great toll upon everyone’s reserves of
nervous energy and caused many forms of illness. The
hospital had a special claim on those interested in the
industrial life of the country. Every step forward in
science and mechanisation produced a new source of
nervous strain for the workers. Leaders of industry,
who had been generous in the past in providing money for
research into the application of science to business, would
not be deaf to an appeal on behalf of research into the
causes and cure of nervous diseases due to the increase
of scientific methods in industry. The Rockefeller
Foundation would give £120,000 to the new research
department if a like sum were raised in this country.
The British people could not fail to take up that challenge.
Sir Walter Monckton, K.C., supporting the toast, gave
figures for the work of the hospital : 1500 in-patients with
300 operations a year. The hospital played, he said,
a great part in the propagation of British methods, for
4260 British doctors from all over the world had studied
MEDICAL NEWS
[may 8, 1937
there in the last ten years. A film was then shown
illustrating the activities of the hospital and the difficult
conditions which the obsolete buildings imposed upon the
workers. The amount realised by the appeal at the
festival dinner came to about £25,000.
University of Manchester
. The Rockefeller Foundation bave made a grant of
£5000 to be spread over four years, in support of the
research work in biochemistry being carried out at the
university under the direction of Prof. Heilbron.
Royal Medico-Psychological. Association
The examination for the Gaskell gold medal and prize,
and the examination for the certificate in psychological
medicine, will be held at the Maudsley Hospital, London,
on May 26th and 27th. Further information will be
found in our advertisement columns. ;
South-West London Medical Society
The meeting of this society which was to have been held
on May 12th has been postponed until May 19th, when
Dr. Wilfrid Sheldon will read a paper on abdominal
distension in children. The meeting will be held as usual
at the Bolingbroke Hospital at 9 P.m.
Gresham College
Four lectures on physic will be delivered at the College,
Basinghall-street, London, E.C., by Dr. J. Alison Glover
on May 10th, llth, 13th, and 14th at 6 r.m. He will
speak on some aspects of the school medical service, and
the lectures will be open to all without fee.
West Kent Medico-Chirurgical Society
The annual dinner of this society will be held at
Chiesmans Restaurant, High-street, Lewisham, S.E.,
on Thursday, May 20th, at 8 p.m. Dr. H. V. Morlock
will be in the chair. Tickets may be had from the hon.
secretary, 267, Baring-road, Grove Park, S.E.12.
City of London Hospital for Diseases of the Heart
Queen Mary opened the new surgical wing .of this
hospital on April 29th. The, accommodation includes
ten single-bed wards specially designed for serious chest
operation cases. Patients in these wards will be selected
irrespective of whether they are paying patients or not.
Palmer Memorial Hospital, Jarrow
This hospital, which has been in danger of closing down,
now has its continuance assured. Itowed a sum of money,
consisting of loan and interest, amounting to £2875 to
Palmer’s Shipbuilding and Iron Company, but with the
consent of the debenture holders and the High Court
this has been cancelled.
Fellowship of Medicine and Post-Graduate Medical
Association
The following courses have been arranged to take
place during the latter part of May, and during June:
thoracic surgery at the Brompton Hospital (May 24th
to 29th); urology at St. Peter’s Hospital (May 3lst
to June 12th); gynecology at the Chelsea Hospital for
Women (June 14th to 26th). Week-end courses will be
held as follows: physical medicine at the St. John Clinic
and Institute of Physical Medicine (May 22nd and 23rd) ;
children’s diseases at the Princess Elizabeth of York
Hospital (May 29th and 30th); general medicine at the
Prince of Wales Hospital (June 5th and 6th), and general
surgery at the same hospital (June 19th and 20th);
obstetrics at the City of London Maternity Hospital
(June 12th and 13th). A clinical and pathological
M.R.C.P. course will take place at 8 P.M. on Tuesdays
and Thursdays at the National Temperance Hospital
(June Ist to 17th). Other M.R.C.P. courses include chest
diseases at the Brompton Hospital (twice weekly at
5 P.M., June 7th to July 13th); heart and lung diseases
at the Victoria Park Hospital (Wednesdays and Fridays
at 6 P.M., June 9th to July 3rd); neurology at the West
End Hospital for Nervous Diseases (June 21st to July 3rd).
Detailed syllabuses of all courses can be had from the
secretary of the fellowship at 1, Wimpole-street, London,
W. The annual dinner-dance of the fellowship will take
place at Claridge’s Hotel, on Friday, May 28th. l
THE LANCET]
THE Central Council of Recreative Physical Training
should in future be addressed at Abbey House, Victoria-
street, London, S.W.1.
Merseyside Medical Practitioners’ Association
At a recent conference of medical practitioners held
at the Liverpool Medical Institution the aims and objects
of this association were unanimously approved and the
support of its work was recommended (see THE LANCET,
April 24th, p. 1006).
National Institute of Industrial Psychology
Under the Heath Clark bequest three lectures under the
general title of time and movement study will be given
at the London School of Hygiene and Tropical Medicine,
Keppel-street, W.C. at 5.30 p.m. on Mondays, May 24th,
3lst, and June 7th. The lecturers will be Mr. G. H.
Miles, D.Sc., formerly director of the institute, Miss A. G.
Shaw, investigator to the Metropolitan-Vickers Electrical
Company, and Mr, J. A. Edgell, investigator to the
institute.
Royal Institute of Public Health
The council of this institute have awarded the Harben
gold medal to Sir Gowland Hopkins, O.M., F.R.S., pro-
fessor of biochemistry in the University of Cambridge.
The medal is awarded triennially to the person who in
the opinion of the council has rendered the most eminent
services to public health. Past recipients include:
Louis Pasteur, John Simon, Max von Pettenkofer,
Lister, Koch, Metchnikoff, Behring, Roux, Ronald Ross,
Sherrington, and Kitasato.
Treloar Hospital and College
On April 29th the trustees of the Lord Magar Treloar
Cripples Hospital and College at Alton entertained the
honorary medical board to dinner at the Barbers’ Hall.
Colonel Frederick Lawson, the chairman, said that eight
years had passed since the last occasion of the kind, and
spoke of the appropriateness of meeting in the City.
One lord mayor, Sir William Treloar, was the founder
and inspirer of the work; another, Sir William Dunn,
had served as treasurer; and many of their successors
had recognised their paternal duties. The work of the
medical board, he continued, had expanded since the
definition of “‘cripple”’ had been extended to almost
every kind of disability ; and the devotion of its chairman,
Mr. O. L. Addison, for all these years ‘is beyond my
power to describe.” The first of the board’s two functions
was to put the ideas of Sir Henry Gauvain, the medical
superintendent, before the trustees—ideas that had won
the hospital a world-wide reputation. Their second
function was to engage in the actual work of the hospital,
and Colonel Lawson expressed the trustees’ high apprecia-
tion of the services thus given. Mr. Addison, responding
for the board, spoke of changes in the type of patient
and the severity of the disease seen at Alton. The hospital
had been founded to deal with surgical tuberculosis, which
was then unprovided for otherwise, the cases being
crowded into children’s hospitals under unsuitable condi-
` tions. Other institutions had since been started and
surgical tuberculosis was now a disappearing disease
unfamiliar to the younger medical generation. At
Alton, instead of a nine months’ waiting-list, they now
had very few cases of tuberculosis waiting to come in,
and they had therefore enlarged the scope of the hospital
so that they were prepared to take almost any kind of
disease. Sir Henry Gauvain, who proposed the health of
the City Corporation, disclaimed credit for the hospital
but said his life there had been very happy. Sir Charles
Batho, responding, said that the City had never dispensed
rnoney to better purpose than to Alton. Sir Charles Gordon-
Watson, proposing The Worshipful Company of Barbers,
gave his reasons for thinking that their picture of
Henry VIII presenting the charter, though they think
it is by Holbein, is really only a copy of the one belonging
to the Royal College of Surgeons of England. But Mr.
Maurice Hovenden, the master, refused to be drawn into
the controversy and contented himself and his hearers by
showing some of the company’s other treasures.
Those present ees Sir Frederick Menzies, Miss | Florence
Treloar and Mr. . Harrowing (trustees), Miss D. H
Holborow (matron), and the following members of the medical
MEDICAL NEWS
[may 8, 1937 1149
board or consulting staff: Mr. Addison, Mr. P. Maynard:
Heath, Dr. R. S. Frew, Dr. Reginald Lightwood, Mr. A.
Lindsay, Dr. L. S. T. Burrell, Dr. J. T. Hunter, Mr. T. Pomtret
Kilner, Sir Charles Gordon-Watson, Prof. E. W. He aoe eet Groves,
Dr. J. H. Thursfield, A. Simpson- -Smith, Dr.
Mr. N. A. Jory, Mr. J. H. Doggart, Dr. R.
Mr. R. L. Vollum, D.Phil.
Birmingham Hay-fever Clinic
At the annual meeting of the Birmingham Ear and
Throat Hospital it was announced that a clinic has been
established there this year ‘where treatment will be
available for those who suffer from hay-fever.
Birmingham United Hospital
This hospital (formerly the General Hospital and the
Queen’s Hospital) during last year treated 121,395 patients.
There was a small surplus on the year’s workings, and an
increase of nearly £6000 in ordinary income. ‘The con-
tributory association gave £76,923, an advance of £3000
on the previous year.
Tuberculosis in Sweden
The Swedish National Anti-Tuberculosis Association
is arranging an inquiry into the incidence of tuberculosis
in various trades and occupations, especially among
workers aged 18-25. An inquiry carried out by students
on their own initiative showed that at least 2 per cent.
were infected, most of them having no knowledge of the
fact. Since then typographers, tobacco-workers, and
bus employees have been investigated and are said to
have proved surprisingly free from the disease. According
to the Swedish International Press Bureau a study of
14,000 children going on in the Norrland provinces shows
that in those regions of the far north the death-rate from
tuberculosis is three times as great as in more southern
provinces: Recently, however, the number of fatal cases
has considerably dropped.
Golden Jubilee of St. John Ambulance Brigade
The St. John Ambulance Brigade will celebrate its
jubilee after the coronation, beginning with a reception
at St. John’s Gate on May 14th. It was formed in 1887
and by its connexion with the Order of St. John of
Jerusalem is part of the oldest order of chivalry in the
world, having its commencement in the eleventh century.
The strength is now 101,917 (men, women, and cadets)
in this country and overseas. As commandant-in-chief
of the nursing corps and divisions, the Queen will take
part in the jubilee celebrations by reviewing the Brigade
in Hyde Park on May 22nd. Other arrangements include
a garden party at St. James’s Palace on May 18th, given
by the Duke of Connaught as grand prior of the "Order,
a service at St. Paul’s on the 23rd, and an investiture at
Buckingham Palace on the 25th.
Tuberculosis Association
The annual provincial meeting of this association will
be held at the Central Library, Manchester, on June 10th,
llth, and 12th under the presidency of Dr. S. Roodhouse
Gloyne. The first session will begin at 2.15 p.m. on June 10th
when Dr. Geoffrey Marshall and Mr. H. Morriston Davies
will read a paper on how long collapse therapy should
be delayed. Mr. J. E. H. Roberts will also speak on
bronchiectasis in pulmonary tuberculosis, and Dr. O. M.
Mistal (Montana) on pleural effusions after thoraco-’
plasty. On the following morning the first paper will be
given by Dr. P. J. L. De Bloeme (Laren, Holland) on the
treatment of unilateral pulmonary tuberculosis, Afterwards
there will be a symposium on difficulties in dealing with
the tuberculosis problem at which Prof. A. Ramsbottom
will speak as a consulting physician, Dr. W. F. Jackson
as a general practitioner, Dr. A. Dove Cormac as medical
superintendent of a mental hospital, Dr. R. E. Lane as
medical officer to a large factory, and Dr. D. P. Suther-
land as a tuberculosis officer. In the afternoon a visit
will be paid to the Manchester Sanatorium at Baguley.
At the last session Dr. J. B. McDougall will read a paper
on the tomograph, and Dr. C. D. S. Agassiz a paper on
artificial pneumothorax in children. Problem cases will
be presented by Dr. E. H. A. Pask and Dr. G. Jessel.
In the afternoon visits will be paid to other sanatoriums
in the neighbourhood. Further information may be
had from the hon. secretary of the association, Manson
House, 26, Portland-place, London, W.1.
a Trier and
1150 THE LANCET]
V acancies
For further information refer to the advertisement columns
Aberdeen Royal Infirmary.—Second Hon. Ophth. Surgeon.
Altrincham General Hosp.—Sen. and Jun. H.S.’s, at rate of
£150 and £120 respectively.
sear rir y iad ig District Infirmary.—Res. Surg. O., at rate
o
Barnsley, Beckett Hosp. and Dispensary.—Cas. O., £250.
Battersea General Hosp., Battersea Park, S.W. —Res. H. S; at
rate of £130. Also H.P. and Cas. O., at rate of £120.
Bedford County Hosp.—Second H.S., at rate of £150.
Benenden, Kent National Sanatorium.—Med. Supt., £600.
Birmingham, Ear and Throat Hosp.—Second H.S., £150
Birmingham, Queen’s Hosp.—Res. Surg. O., 0.”
Bolingbroke H osp., Wandsworth Common, S.W. T OAR:
, each at rate of £120.
Bootle General Hosp.—Hon. Orthopedic Surgeon.
Botleys Park Colony, near Chertsey, Surrey.—Med. Supt., £1000.
OUR Royal National Sanatorium.—-Res. Asst. M.O.,
200.
Bradford Children’s Hosp.—H.S., £100.
Brighton, Royal Alexandra Hosp. "for Sick ee —H. S., £120.
Brighton, Royal Sussex County Hosp.—H.S., £150.
Bristol Royal Infirmary and Bristol General Hosp —Two Hon.
- Radiologists. Also Radio-Diagnostician, £500.
| British Postgraduate Medical School, Ducane-road, W.—Asst.
in Bacteriology in De PF of Pathology, £300.
Cardiff, King Edward VII Welsh National Memorial Assoc.—
Three Area Asst. Tuber. Physicians, each £500.
ee anes for Children, Heswall, Cheshire.—Res. Asst.
M.
Connaught Hosp., Walthamstow, E.—Cas. O., at rate of £100.
Coventry and Warwickshire Hosp.—Hon. Asst. Surgeon. Also
- Res. H.S., Cas. O., and Res. H.S. for Aural and Ophth.
Depts. as each £125.
Crt behest Borough.—Deputy M.O.H. and Deputy School
Derby, County Mental Hosp., Mickleover.—Laboratory Asst.
Dewsbury and District General Infirmary.—Second H.S., £150.
DOUT DE O Down County Mental Hosp.—Jun. Asst. M.O.,
Dudley, Guest Hosp.—Second H.S., £120.
East Ham Memorial Hosp., Shrewsbury-road, E.—H.S. to
Spec. Depts., and Cas. O., at rate of £120
anama pon. for Sick Children, Southwark, S. E.—H .P., at rate
o
Exeter, Royal Devon and Ezeter Hosp.—H.S. to Ear, Nose,
and Throat Dept., at rate of £150.
Farnborough Public Assistance Hosp.—Res. Asst. M.O., £250.
French Hosp. and Dispensary, Shajtesbury-avenue, W.C. —Hon.
Radiologist.
Gloucestershire Royal Infirmary, &c.—H.P., at rate of £150.
Gordon Hosp. for Rectal eee Vauxhall Bridge-road, S.W .—
Res. H.S., at rate of £150
Great Barr Park Colony, near Birmingham.—Jun. Asst. Res.
5
Hampstead General and North-West London Hosp., Haverstock-
_ kill, N.W.—Cas. M.O. and Cas. Surg. O. for Out-patient
Dept. each at rate of £100.
Hastings, Royal East Sussex Hosp.—Jun. H.S., at rate of £150.
O. and
Hosp. for Tropical Diseases, 25, Gordon-street, W.C.—Hon. Asst.
Physician. Pathologist, £750. Also H. P., at rate of £120.
Huddersfield County Borough. —Asst. School M. O., £500
Hull Royal Infirmary.—First H.S., H.S. to Doth. and Ear,
Doro ana Throat Dept., and Second Cas. O., each at rate
o
Ilford, King George Hosp.—H.S., at rate of £109.
Kettering and District General Hosp .—Res. M.O. and Second
Res. M.O., at rate of £160 and "e140 respectively.
Leeds General Infirmary. ——Hon. Physician.
Leicester City Mental Hosp., Humberstone. —Locum ‘Tenens
Asst. M.O., 10 guineas per week.
Liverpool City.—Pathologist, £750.
Liverpool Heart Hosp.—Hon. Asst. Physician.
London County Council—Temp. District M.O., £250. Also
Temp. M.O., at rate of £10
Lonäon omaopathic Hosp., "Great Ormond-streel, W.C.—
Gyneecological H.S., at rate of £100.
London Jewish Hosp., Stepney Green, E.—Res. M.O. and H.P.,
at raeo £150. Also Res. H.S. and Res. Cas. O., each at rate
o
London University. —University Readership in Obstetrics and
Gynecology for British Postgraduate Med. School, £800.
MONE Preston Hall Sanatorium.—Asst. M.O., at rate of
Maidstone, West Kent General Hosp.— H.S., £175.
Manchester, Ancoats Hosp.—Hon. Reg. for Ear, Nose, and
Throat Dept. Also Orthopmxdic Reg., £50.
Manchester City Education Commitiee.—Psychiatrist, £500.
Manchester, Park Hosp., Davyhulme.—Second Res. M.O., at
rate of £225.
Manchester Royal Eye Hosp.—Jun. H.S., £120.
Manchester A ea Hosp. for Skin Diseases.—Two Asst.
2B,
Middlesex Hosp., W.—Jun. M.O. for Radio-thera apy Dept. and
Asst. for Dept. of Physical Medicine, each £30(
Miller General Hosp., Greenuich-road, S.E.—Two H.P.’s. Also
H.S., each at rate of £100.
Newport, ’ Mon., Royal Gwent Hosp.—H.S., at rate of £135.
Northwood, Mount Vernon Hosp.—Clin. ' Pathologist, £500.
Nottingham General Hosp.—H.S. to Ear, Nose, and Throat
Dept., and Two Res. Cas. O.’s, each at rate of £150.
Oldham Municipal Hosp.,—Res. Raat. M.O., at rate of £200.
VACANCIES.—BIRTHS, MARRIAGES, AND DEATHS
{may 8, 1937
Oldham Royal Infirmary. —H. S., at rate of £175.
Oxford ue Hosp., Walton-street.—H.S. to Ophthalmic Dept..
Plymouth, Prince of Wales’s Hosp.—Res. Surg. O., H.S., at rate
of £225 and £120 respectively. Jun. H.S., at rate of £120.
Also Hon. Physician, Hon. Physician with charge of Out-
patients, and Hon. Ophth. Surg.
Queen Charlotte's Maternity Hosp., Marylebone-road, N.W —
Res. Anæsthetist, at rate of £100, Res. Anæsthetist and
Dist. Res. M.O., at rate of £90. Also Asst. Res. M.O., £80.
UEN E an osp. for Children, Hackney-road, E.—H.S., at rate of
Reading, Royal Berkshire Hosp.—Res. Cas. O., and H.S. to
Spec. Depts., each at rate of £150.
Rotherham Hosp. —Cas. H.S., £150.
Royal Chest Hosp., City-road, E.C.—Clin.
Royal Free Hosp., Gray’s Inn-road, W.C. i A Physician.
Also Sen. Res. ’M.O., £150.
Royal Naval Medical Service.—M.0.’s
Royal Waterloo Hosp. for Children and Women, W aterloo-road,
S. ri nee Cas. O., at’ rate of £150. Also H.S., at rate
St. Bartholomew’s Hosp., E.C.—Asst. Physician and Asst.
Director to Med. Professorship Unit.
Salisbury General Infirmary.—Res. M.O., £250.
Shrewsbury, Royal Salon Infirmary. — Res. H.S., at rate of £160.
Southampton, Royal South Hants and Southampton Hosp.—
Sen. H.S., £200. H.P., H.S., Res. Ansesthetist and H.S., &e.,
and Cas. O., each at rate of £150.
Stoke-on-Trent, Burslem, Haywood, and Tunstall War Memorial
Hosp —Res. H. S., at rate of £175.
Stoke-on-Trent, North Staffs. Royal Infirmary. —H.S. for Aural
and ‘Ophth. Dept., at rate of £150
Sundara ng Royal Infirmary. —Two H. S? s and one H. P., each
12
Surrey County Council.—Asst. M.O., £600. Also Jun. Asst. M.O.
for County Sanatorium, at rate of £350.
Taunton and Somerset Hosp.—H.P., at rate of £100.
University College Hosp., Gower-street, W.C.—Hon. Physician
to Physio-therapy Dept.
Uxbridge, Hillingdon County Hosp.—Jun. Res. Asst. M.O., at
rate of £250.
Ficaria Hosp. for Children, Tite-street, S.W .——Physio-therapist,
Weir Hosp., Grove-road, Balham, S.W.—dJun. Res. M.O., £150.
West Ham County Borough. —M.O.H. and School M.O., "81500.
rept 2nd Asst. Res. M.O. for Central Home, Leytonstone,
K ee area Council. —Asst. County M. O. and Asst.
choo
Wickford, Runwell pede: —Asst. Res. Physician, £350. Also
H.P., at rate of £150
Wolverhampton, New Cross Hosp Res. Asst. M.O., £200.
Wolverhampton Royal Hosp.—H.8S.’s, at rate of £100.
Woolwich and District War Memorial Hosp., Shooters-hill, S.E.—
Three Hon. Anesesthetists.
The Chief Inspector of Factories announces a vacancy for
a Certifying Factory Surgeon at Longridge, Lancashire.
Births, Marriages, and Deaths
BIRTHS
NIcoLson.—On April 13th, at Portsmouth, the wife of Surg.
- Lt.-Comdr. J. H. Nicolson, R.N., of @ son.
NORMAN.—On April 23rd, at Eton, the wife of Dr. H. Bathurst
Norman, of a son
PICKEN.—On April 27th, the wife of Dr. C. B. Picken, Bassett
Southampton, of a daughter.
MARRIAGES
COLTART—ASKEW.—On April 24th, at the Church of St. Bartho-
lomew-the-Great, E.C., William Derrick Coltart, F.R.C.S.
Eng., to Margaret Askew.
ForSYTH-—RULAND.—On April 16th, at St. Mary’s River,
Labrador, Charles Hogarth Forsyth, M.R.C.S. Eng.,
International Grenfell Association Service, to Clayre Louise
an
TEARE—GRACEY.—On April 24th, at Burrington, Devon
Robert Donald Teare, M.R. C.S. Eng., of Ramsey, Isle of
Man, to acces Agnes, youngest daughter of Lt.-Col.
and Mrs. T. Gracey. l
DEATHS
DILLON.—On Apm 27th, at Oxford, Luke Gerald Dillon, O.B.E.,
M.D. R.U.I., Bodicote, Oxon., in his 76th year.
LE PELLEY.—On A ril 30th, at West Bridgford, Notts, Amelia
' Maitland le Pelley, M. B. Lond.
PARKER.—On April 26th, at Clifton, Bristol, George Parker,
M.D. Camb., LL.D.
SARRA.—On April 30th, in London, William Henry Sarra,
M.R.C.S. Eng., of Leigh- on-Sea, Essex.
N.B.—A fee of 78. Gd. is charged for the insertion of Notices of
Births, Marriages, and Deaths.
GIFT OF MATERNITY HospitaL.—A maternity hos-
pital is being given by Mrs. Fyfe-Jamieson to the county
of Angus. It is estimated it will cost £7000.
THE LANCET]
(may 8, 1937 1151
NOTES, COMMENTS, AND ABSTRACTS
THE MEDICAL HISTORY OF WILLIAM THE
CONQUEROR
By R. R. JAMES
AS a general rule it is an unprofitable venture to
speculate on the pathology of a hypothetical case
such as that of the last illness of the Conqueror.
But William’s death offers food for reflection and
may even be of interest to such minds as suffer
t: from a taste for general information, not promptly
checked,” of which type the classical example is
Mr. Joseph Finsbury.
Everyone knows that the Conqueror died as the
result of an abdominal injury received during the
sack of Mantes in 1087. At this time he was about
sixty years of age. Of exceptional strength, he had
been a warrior from his youth upwards; even from
the moment of his birth his strength was apparent,
for when he was laid on the floor after delivery, the
** gossips ’’ noticed how he grasped the rushes in his
little fists. His life gave ample opportunities for
receiving hard knocks.
Before discussing his last illness I should like to
draw attention to two serious illnesses of which we
have records. The first of these occurred most
probably in the year 1062. It is not mentioned by
any of the chroniclers and we only know of it from a
charter in the cartulary of the cathedral church of
St. Mary, Coutances. A transcript of this deed is
given by Round in his ‘“‘ Calendar of Documents in
France,” of which great series it is No. 957. It is
undated and is a recital of a charter of William, Duke
of the Normans, to the Church of St. Mary... .
William ‘“ while lying ill at Cherbourg, vowed that he
would establish three Canons in the church, if God
and St. Mary would raise him from his sickness,
when his life was wholly despaired of and he was
laid on the ground, as at the point of death, and gave
the Canons of that church the relics of the Saints
which he carried (about) in his own chapel.”
One can only suppose, in view of William’s after-
history, that this must have been some acute infec-
tion, but I would not like to offer a diagnosis.
Laying a patient on the ground when at death’s
door would not seem to be the best treatment for
such conditions as enteric or pneumonia; but, what-
ever was the matter, the crisis of the illness seems to
have coincided with the patient being turned out of
bed on to the floor. William’s second illness occurred
in the year of the Conquest. After Hastings, the
Conqueror had made his base secure by occupying
Dover, the castle of which, according to William of
Poitiers, he had made into a hospital for invalid
soldiers, the army having been seriously infected by
dysentery. He then marched towards London along
the Roman road, but when at Canterbury, or thereby,
he was seized by violent illness, which kept him out
of action for a month. I imagine that this illness
may have been an acute gastro-intestinal infection.
In spite of these illnesses William must have made
a complete recovery, as is instanced by his long march
to Exeter early in 1068, by his harrying of the North
in the following year, and by that ghastly march
across the Pennines from York to Chester in the mid-
winter of 1069-70. Coming now to the last year of
his life, we know that William had become exceedingly
corpulent. He was resting at Rouen, when some kind
friend repeated to him the jest of the King of France.
This was to the effect that William was lying-in like
æa woman just delivered from travail. William came
out with more than his usual oath, for he swore that
“ by the resurrection and splendour of God, when
I go to Mass after my confinement I will light him
up a hundred thousand candles.” And about the
middle of August, before August 15th, according to
Florence of Worcester, he invaded French territory
and sacked Mantes.
It should be remembered that most of the English
chroniclers were writing at a date later than that of
1087. Even that old gossip Orderic, who was more
or less contemporary with the event, does not say
anything about any abdominal injury. I suspect
that the authority for the statement is William of
Poitiers, but his works are not accessible to me.
Roger of Wendover and William of Malmesbury,*
the former probably copying the latter, both mention
the fact that the Conqueror received an injury while
his horse was leaping a ditch. But most of the other
chroniclers merely allude to the heat of the flames
and the unequal temperature, while Roger of
Hovenden states that, on his return from Mantes,
William was attacked by dreadful pains in the
intestines from which he grew weaker every day.?
William of Malmesbury states that the physicians at
Rouen,’ on examining the urine, predicted certain
death. The Conqueror did not die till the morning
of Sept. 9th} so that at least a month intervened
between the injury and death.
If one examines a reproduction of the Bayeux
tapestry one gets some idea of the type of saddle of
the period. It had a high pommel in front and
apparently behind also. In one picture it looks as if
the pommel reached nearly up to the level of the
umbilicus in front and well into the lumbar region
behind. William, of course, would have been clad in
mail at the time. He was conscious and able to
speak until the end. What lesion could have been
produced in such a case? I think we may rule out
any perforation of a hollow viscus. Was the extreme
pain renal or biliary colic? Was there blood in the
urine which made the physicians so sure of death ?
No one can say for certain, but I do not think the
case can have been one of intestinal obstruction from
such a condition as strangulated hernia. The possi-
bility of injury to the. perineum, bladder, or urethra
has to be considered as well as an umbilical hernia,
but: I should like to suggest biliary or renal colic.
The last scene is in the Abbey of Caen. When they
came to put William in his coffin, the monks, antici-
pating the lament of Mr. Sowerberry, that a few
inches over ‘one’s calculations make a great hole in
one’s profits, had made the stone coffin too: small.
In the attempt to force the body in, the abdomen
burst and a horrible stench filled the whole church.
In writing this paper I have consulted Freeman’s
‘‘ Norman Conquest” and the “ Life of the Con-
queror’”’ by Prof. Stenton, as well as the chroniclers
mentioned.
REFERENCES
1. William of Malmesbury gives the hearsay report: ‘‘ Dicunt
... rupturit, quod in anteriori parte sellæ venter protuberat.’’
2. Florence of Worcester, who is almost contemporary with
the event, states that on William’s return to Normandy,
after the sack of Mantes, dirus viscerum dolor illum
apprehendit.
3. The physicians were Gilbert Maminot and Guntard of
Jumièges.
MEDICAL EVIDENCE AT LONDON OMNIBUS
INQUIRY
ON May 3rd, at the first meeting of the court of
inquiry appointed by the Minister of Labour. to
investigate and report on the issues of the London
omnibus strike, Mr. Bevin, in presenting the case
for the men, called attention to the uncertainty of
meal reliefs and said that the physical reactions of
the men were such that they made the men different
from those found in other industries, different in the
sense'that the reactions produced a psychology all
its own. He added that there had been a suggestion
that carbon monoxide was the principal cause of the
trouble and the union had succeeded in getting the
problem referred to the Industrial Health Research
Board, where it had been now for a couple of years.
Dr. James Woodall, chief medical officer at Manor
House Hospital, said that from his work there he had
1152 THE LANCET]
the impression that there was an altogether undue
incidence of gastric illness among both drivers and
conductors, but admitted that he had not had time
to analyse the hospital records. Dr. H. B. W. Morgan,
medical officer to the Trades Union Congress, said he
had also been struck by the number of men in
transport work who complained of gastric symptoms.
At the second meeting of the court on May 4th
Prof. Millais Culpin, M.D., who was called by Mr.
Bevin, said that he had made a study of occupational
circumstances and physical types of patients with
organic diseases of the stomach. Three years ago he
took the opportunity of examining a number of bus
drivers at the Manor House Hospital diagnosed as
suffering from gastric conditions. He saw 17 cases
himself and 14 were examined by an assistant—
primarily to ascertain the extent of nervous symptoms.
The interviews lasted from 30 to 40 minutes, the
men being allowed to talk freely. He found that in
some cases the nervous symptoms were really the
ones that mattered. He did not always agree with
the hospital diagnosis. Of the 31 cases there were 4
whose nervous symptoms were severe enough to call
for treatment, some of them being, in his opinion,
unfit to drive.
symptoms, but added a note implying his opinion
that the men were of stable type but might break
down. In reply to the chairman, Dr. Culpin said
that 17 of the men complained spontaneously about
speed, 10 of inspection, 9 about fumes, 7 about
vibration, and 5 complained of being afraid of the
company’s medical officer.
In reply to a question from Mr. Bevin, Dr. Culpin
said that this preliminary examination had led him
to the view that there was at least a strong prima-
facie case for a very thorough investigation into the
effect of all these things on the men. .
The court consists of Mr. John Forster (chairman),
Sir Arthur Pugh, and Mr. Basil Sanderson.
DANGEROUS DRUGS REGULATIONS
WE have received from the Home Office copies of-
draft regulations which it is proposed to make under
Sections 3 and 7 of the Dangerous Drugs Act, 1920.
The proposed new regulations under Section 3 which
relates to raw opium, coca leaves, and Indian hemp,
will make no change in the existing law and are
solely for the purpose of consolidating the rules in
force by which the distribution of the substance
named is controlled and restricted. The main
purpose of the proposed new regulations under
Section 7 of the Act is to make substantive the pro-
visional rules which were made a year ago with the
object of bringing the regulations of 1928 into
conformity with the Poisons and Pharmacy Act,
1933, but it is also proposed to make certain other
amendments. We will refer only to those which
have a bearing on the prescribing of dangerous
drugs. In Regulation 8 a slight alteration is
made so that the provision exempting prescribers
of medicines under the National Health Insurance
Acts from fulfilling certain obligations shall be
extended to prescriptions given in connexion with the
health services of local authorities.
THE MEANING OF ‘f TWO OR THREE TIMES”
Amendments are being made in paragraphs 2 and 3
of Regulation 9 for the purpose of resolving doubts
which have arisen as to the meaning of “two or
three times.” The proposed new paragraphs are
as follows :—
(2) If a prescription expressly states that it may, subject
to the lapse of a specified interval or of specified intervals,
be dispensed a second or third time, the drug or prepara-
tion thereby prescribed may, as the case may be, be
supplied a second or a third time after the specified interval
or intervals and no more, but, subject as aforesdid, a
prescription shall not for the purposes of these regulations
be taken to authorise the drug or preparation prescribed
to be supplied more than once.
NOTES, COMMENTS, AND ABSTRACTS
From 6 men he elicited no nervous:
[may 8, 1937
(3) The person dispensing a prescription shall, at the
time of dispensing it, mark thereon the date on which
it is dispensed, and in the case of a prescription which
may be dispensed a second or third time, the date of
each occasion on which it is dispensed, and shall, unless
it is a health prescription, retain it and keep it on the
premises where it is dispensed and so as to be at all times
available for inspection.
Alterations proposed in Regulation 11 are the
insertion of the common names (eucodal) for
dihydrohydroxycodeinone, (dicodid) for dihydro-
codeinone, and (dilaudid) for dihydromorphinone.
AN AMENDMENT AND A REDRAFTING
Regulation 14 is being amended in order to make it
clear that signed orders for dangerous drugs must
be preserved for a period of two years in the same
way as other documents relating to such drugs.
Regulation 16, as redrafted, is as follows :—
Nothing in these Regulations shall apply to—
(a) any of the drugs or preparations mentioned in the
fourth schedule (see below) to these regulations or to a
drug or preparation which has been denatured in manner
approved by the Secretary of State ;
(b) (i) any prescription issued for the purposes of a
scheme for testing the quality and amount of the drugs
and appliances supplied to insured persons under. the
National Health Insurance Acts, 1924-1935, and the
regulations made thereunder; (ii) any prescription
issued to a sampling officer for the purposes of the Food
and Drugs (Adulteration) Act, 1928. |
THE FOURTH SCHEDULE
The amendment to the Fourth Schedule is one of
the most important being made in these regulations.
In order to bring English legislation into line with
the International Conventions with regard to
“ exempted preparations,” a Declaration by His
Majesty in Council is being made with effect from
July Ist, exempting from the Acts (and consequently
the regulations) all the preparations which have been
exempted from the International Opium Convention,
1925, on the recommendation of the Health Com-
mittee of the League of Nations. The effect of this
Declaration in Council is that from July Ist the
Dangerous Drugs Acts will not apply to the prepara-
tions named in the Schedule to the Declaration, and
therefore export licences will not be required for the
export of such preparations. The Fourth Schedule
is as follows :— 7
Pulv. Cretæ Aromat. c. Opio, B.P. 1932.
Cocaine Eyedrops—a ‘preparation consisting of an
admixture of cocaine in castor oil with mercuric chloride
in a proportion of not more than one part in 200 of cocaine
and not less than one part in 3000 of mercuric chloride.
Methylmorphine and ethylmorphine and their respective
salts and any preparation, admixture or other substance
containing any proportion of methylmorphine or ethyl-
morphine associated with an inert substance whether
solid or liquid; and preparations and admixtures or other
substances containing more than 2-5 per cent. of methyl-
morphine or ethylmorphine (calculated as pure drug)
associated with other medicinal substances.
Methylmorphine and ethylmorphine will be
exempted from these regulations because they are
subject to a separate code of regulations which
remains unaltered. Certain preparations of these
drugs are also included in this Schedule because, as
the result of an Order in Council, Part III of the
Dangerous Drugs Act, 1920, is being applied to them
as from May lst, but they are not being brought under
these regulations which deal only with the home
trade. A further amendment to this Schedule is
the insertion of cocaine eyedrops. The effect of
this amendment is to remove this preparation from
control by the regulations. In consequence, factory
owners and others will be free to purchase this
preparation and the authorities granted in 1921 to
these persons will be revoked as from the date on
THE LANCET]
which these regulations come into operation. Pulv.
Crete Aromat. c. Opio will continue to be exempt
from the regulations. Licences will be required,
however, for the export of drugs in this schedule
from the United Kingdom.
PRESERVATION OF MENTAL HEALTH
For the prevention or avoidance of a mental
break-down Dr. ©. C. Easterbrook recommends that
the person with a nervous predisposition should
clearly recognise his weakness and that others with
whom he comes into important contact should
recognise it as well (Med. Offr, April 17th, p. 161).
The personal or direct evidence of instability will
include a previous history of any psychosis or neurosis
or of morbid tendencies, faulty habits, and vices ;
some congenital or nervous defect; a neurotic or
degenerate physiognomy or physique, or an abnormal
reaction to the ordinary experiences of life. The
great consolation which he sees for the person with a
nervous constitution is that the neurotic is the
otential pioneer ; neurosis and. psychosis are weeds,
indicating a fertile soil which will produce genius
and inventive ability. If the neurotic would avoid
a break-down, says Dr. Easterbrook, he must lead a
quieter life and take greater care of his health than his
more stable brother. There are, of course, types of
neurosis which have as their principal expression a
pampering of the body or mind and a shrinking
from stress and responsibility, and Dr. Easterbrook
would probably admit that for patients like this
it is more important to get outside themselves
and experience the rough-and-tumble of life.
There are many psychoses, minor as well as major,
which cannot be avoided by any amount of care
or self-knowledge; illnesses which in fact forbid
self-knowledge by their very nature.
RECALCITRANCE AT MEAL-TIMES
AMONG journals of practical puericulture the
monthly magazine called Parents, now in its fourth
volume, has won itself a good place. Those who
bave children on their minds will nearly always
find something enlightening in its pages, and the
contributions are’ apt to be both sane and interesting.
Contributors to the March issue include Dr. Victoria
Bennett, Dr. Winifred de Kok, Dr. A. Morris Johns,
Dr. L. Appell, and Dr. Lindsey Batten. ‘Dr. Batten’s
article entitled ‘‘Do you dread mealtimes? ” is
concerned with the child who does not respond to
the suitable food provided for him, and his advice
deserves wider circulation. He. begins by pointing
out that food requirements vary enormously and
that the parent must not insist too much on con-
vention: ‘‘some children seem to have a natural
preference for the continental breakfast.” The real
question is whether the child thrives on what he
takes. If he is actually eating too little for his
health, and if his small appetite is a cause rather than.
a symptom, it will be necessary to look into his
motives for refusing food. The self-assertive instinct
—the desire for fame, notoriety, or power—causes
most of the trouble, and Dr. Batten’s rule is that it
is always wrong to comment on a child’s behaviour
in his presence. ‘“‘ We should treat him in this
respect exactly as we treat a respected friend or
guest. We do not comment, in his presence, on
our guest’s small appetite, or his habit of not eating
fat; it would offend him and it will either offend our
child or it will make him feel important and
encourage him to do it again. ... There is very
little to choose between praise and blame, all comment
is bad.” A warning is also given against conflicts,
and it is here that the adult should exercise: his far-
seeing sagacity. ‘‘Is it to be a row about pudding ?
Offer no pudding at all. Who knows but by tea-
time it may be regarded as a treat. Is it some
particular article of diet? Banish it from the child’s
plate, or even from the table for some weeks and try
again.” As for discipline, Dr. Batten holds it per-
fectly reasonable to make and enforce a rule that
NOTES, COMMENTS, AND ABSTRACTS
[May 8, 1937 1153
& child who refuses his meat-course shall have no
pudding, or that he shall finish what he has asked
for; ‘‘ but orders must be reasonable, polite, and
unemotional, the mother ought to have a shrewd
idea that they are likely to be obeyed without a fuss
and (once more) there must be no comments at all.
The child must be induced to believe that whether
he eats or leaves his dinner is a matter of indifference
to everyone present, but at the same time everyone
does, as a matter of fact, eat their dinners, and he
will do the same.”’ | l
Parents of younger children may get more immediate
profit from an article on Peaceful. Bedtimes, by
Mary Chadwick, S.R.N., which appears in the May
issue of the same journal.
. THE LURE OF LONDON
In his third report on the special areas the com-
missioner, Mr. Malcolm Stewart, drew attention
to the recent immense growth of the outer ring of
London, the population of which, in the twelve
years 1921-33, increased by 1,066,222 as compared
with an increase of 1,397,078 in the rest of England
and Wales. This increase was due mainly to migration
from inner London and from the provinces. The
reduction of the congestion of inner London is, of
course, wholly desirable. Migration from the provinces
depends largely on the fact that London, the best
market in Europe, provides an irresistible attraction
to new ventures. To the Londoner this concentration
of population brings with it increasing difficulties,
expense, and loss of time in the transport of himself
and his goods and makes him increasingly vulnerable
to attack. To the rest of England and Wales this
removal of a largely young adult population to
London and the setting up of most new industries
in that area is a serious matter and is well exemplified
by the returns of the Port of London, which has
increased its share of the foreign trade of England
and Wales from 15 per cent. in 1913 to 20 per cent.
in 1935, while the west.coast ports have shown
a fall of 11 per cent. in the same period.
We see then that the lure of London, the favourite
theme of the Victorian novelette, is a very real
thing at the present day and that the ‘‘ streets paved
with gold ” legend persists in a practical form. In
“ Metropolitan Man’?! Mr. Robert Sinclair sets
himself to demolish this legend and to show that
every institution and habit of life that the Londoner
holds dear is muddled, inefficient, or undesirable.
His business, his leisure, his sewers, hospitals, public
health organisation, education, town-planning, and
transport are discussed in turn and the general
impression conveyed is one of unmitigated gloom.
The most casual reader is soon driven to remark
that things really cannot be as bad as all that. Mr.
Sinclair’s method of producing his effect is: firstly,
to omit any evidence which may show a satisfactory
or improving state of affairs; and, secondly, to warp
or to state his statistics in’ such a way as to give
an alarming and often misleading impression to the
mind of the reader. He omits or explains away
such things as the care of the pre-school child at
infant welfare centres, the steady fall in infant
mortality and tuberculosis, and by confusing nutrition
with nourishment, arrives at the startling result
that one in six of London’s children is under-
nourished. By further arithmetical gymnastics he
shows that the children in schools found to be
verminous amounted to 14 per cent. when the true
figure was 3 per cent. When his figures are correct |
the lay mind may still be led astray. One may
quote: ‘‘ 50 per cent. of children and 97 per cent.
of adults are infected with tuberculosis.” ‘‘ One
in three of Londoners dies. in the workhouse.” ‘“ For
every miner’s chance of being killed in a mine the
Londoner has six chances of injury in the street.”
He adds to the horror by referring to hospitals as
lazar-houses, to errors of refraction as blindness and
l Metropolitan Man. By Robert Sinclair. London: Alen
and Unwin. 1937. Pp. 353. 103. 6d.
1154 -THE LANCET]
APPOINTMENTS. —MEDICAL DIARY
{may 8, 1937
to minor ailments as disease,and he comes to the
conclusion that ‘‘the greatest metropolis of the
twentieth century is dirty, poor, unorganised, factious,
ignorant, aimless, and leaderless.’’ If this does not
deter Mr. Malcolm Stewart’s migrating thousands,
nothing will.
INACTIVITY IN THE TREATMENT OF
PUERPERAL FEVER
THE essence of the ‘‘ absolute abstention ” method
of treating puerperal fever, according to an exponent,
J. B. Gonzalez, is to refrain from all local examination
or treatment, trusting to the patient’s own resistance
to overcome the infection. The medical attendant
must be content, therefore, with a presumptive
diagnosis and must be prepared to persist in his
course of masterly inactivity even . when the
patient’s condition appears to be growing worse.
Writing in the Semana Médica for March 4th Gonzalez
says that, since 1919, he has treated all cases
of pu erperal fever _in the maternity department
of the hospital at Durand in this way, with results
which he describes as excellent. He gives no figures,
however, and while he must have credit for early
condemnation of unnecessary interference, it jis,
unfortunately, impossible to believe that the patients’
own resources, if left entirely to themselves, can
generally be relied upon to reduce the mortality,
as in his experience, almost to nil.
THE DIRECTOR OF RESEARCH
THE Deutsche Medizinische Wochenschrift for
March 19th devotes several pages to a discussion of
mentalities and tendencies in such centres of learning
as Heidelberg, Würzburg, and Jena. Writing from
the Würzburg Medical and Neurological Hospital,
E. Grafe asks: “ Are the collaborators of the heads
of hospitals and institutes to work as an orchestra
with a definite programme and playing previously
chosen music under the baton of a conductor ? Are
we to train members of an orchestra or soloists and
prospective conductors ?” In support of the latter
alternative, reference is made to two great German
physiologists living at the end of the last century.
Carl Ludwig and Eduard Pflüger may rank as equals
as far as their own contributions to science are
concerned, but their influence on their surroundings
was as dissimilar as possible. Pflüger had need
only for assistants willing to work on the lines he
laid down, and he parted with them as soon as he
caught them straying. The result of this policy was
that he founded no great school. Ludwig, on the
other hand, filled many a chair of learning throughout
the world with his pupils, some of whom followed
disciplines quite different from his own. He was
satisfied with merely stimulating his pupils to stimulate
themselves, and he left it to them to follow their own
bent. He believed in developing the individuality
and gifts of his pupils in as congenial a scientific
atmosphere as possible. It is pleasant to-day to
see this contrast drawn by a German who leaves no
doubt that it is Ludwig’s method that has his
sympathies.
THE COLORIMETRIC DETERMINATION OF OXDA-
TION-REDUCTION BALANCE.—A communication from
the B.D.H. Analytical Laboratories. Second edition,
revised. Published by The British Drug Houses Ltd.,
Graham-street, London, N.1. Pp. 19. A compact
introduction to the theory and practice of the use of
indicators to determine oxidation-reduction potentials
is provided by this little book. It describes simply
the nature of electrode potentials, gives the oxidation-
reduction curves of some of the more usual indicators,
and briefly indicates for what purposes these indicators
may be employed. Practical methods such as the
testing of sewage effluents, the testing of milk by the
methylene-blue test, and the recent applications of
the indophenol indicators to assay of vitamin C are
mentioned. A brief guide to a few of the numerous
publications on this subject is included. The book
is free to medical men..
Appointments
ABERNETHY, CHRISTINE, M.B. Glasg., D.P.H., D.M.R., Radio-
logical Officer at Ancoats Hospital, Manchester.
ALLEN, J. S., M.B. Belt., D.P.M., Second Assistant Medical
Officer at the Manor, T, Epsom (i (L.0.C.).
BELL J., M.B. Lon Second Assistant Medical
oN at Park DEORE Mental Hospital, Basingstoke.
DUCKWORTH, G., M.R.C.P. Lond., Hon. Dermatologist to
St. John’s Hospital, Lewisham.
LISNEY, A. A., M.B. Dubl., D.P.H., De uty Medical Officer of
l Health and De uty School Medical Officer for Leicestershire.
MITCHELL, M.B. Belf., F.R.C.S. Edin., Resident Surgical Officer
at the Beckett Hospital and Dispensary, Barnsley
MURRAY, R. C., M.B. Camb., F.R.C.S. Eng., Registrar ‘to the
Orthopædic and Fracture Department of the Royal
firmary, Liverpool.
RUDOLF, G. DE M., M.R.C.P. Lond., D.P.H., D.P.M., Hon.
Physician to the British Hospital for Functional Mental
anii Nervous Disorders (Forbes Winslow Memorial),
ondon.
SANDS, D. E., M.R.C.P. Edin., D.P.M., Becca Assistant Medical
Officer at Claybury Hospital (L. C.C -):
PUAI, S. C., M.B. Lond., F.R.C.S. Eng., Assistant Surgeon
- ‘the Royal Ear Hospital, University College Hospital,
ondon.
TIPPETT, G. O., M.B. Lond., F.R.C.S. Eng., Assistant to the
a< Orthopedic Department of the Croydon General Hospital.
WARDLE, E. N., M.Ch. Orth. Liverp., F.R.C.S. Eng., Hon.
Assistant Orthopedic Surgeon to the Royal Southern
Hospital, Liverpool.
Medical Diary
SOCIETIES
MEDICAL SOCIETY OF LONDON, 11, Chandos-street, W.
MONDAY, May 10th.—8 P.M., Annual General Meet
l > 30 P.M., Dr. R. A. Young : Perspective and Poise
n Practice. (Annual oration. )
MEDICAL SOCIETY OF INDIVIDUAL PSYCHOLOGY.
TEUR DAT, May 13th.—8.30 P.M. (11, Chandos-street, W. ys
T. Ross: The Ps chological Approach.
WEST KENT MEDICO -CHIRURGICAL SOCIETY.
FRIDAY, May 14th.—8.45 P.M. (Miller General Hospital),
Dr. H. V. Morlock: Advances of Modern Medicine.
(Presidential address. )
LECTURES, ADDRESSES, DEMONSTRATIONS, &c.
UNIVERSITY OF Gt
MONDAY, May 10th.—5 P.M. (St. John’s College), Prof.
A. V. = R.S.: The Heat-production of Muscle
and Nerve. (Linacre decture.) —
UNIVERSITY OF BIRMINGHAM.
TUESDAY, May 11th.—4 P.M., Prof. L. G. Parsons : General
N utrition : Nutrition "and Nutritional Diseases of
the Erythron : the Inter-relation of Iron and Calcium
in Nutrition.
THURSDAY.—4 P.M., Prof. Parsons: The Rôle of Vitamin C
in Disease ; Multiple Deficiency States, the Effect
of Certain Alimentary Disorders on the Absorption of
_ Carbohydrates. (William Withering lectures.)
BRITISH POSTGRADUATE MEDICAL SCHOOL, Ducane-
road,
MONDAY, May 10th.—2.30 P.M., Dr. C. W. Buckley :
Arthritis. 4.30 P.M., Dr. W. E. Gye: Experimental
Cancer Research.
THURSDAY.—2.15 P.M., Dr. Duncan White: Radiological
Demonstration. 3.30 P.M., Mr. A. K. Henry: Demon-
strations of the Cadaver of Surgical Exposures.
3.30 P.M., Dr. Helena Wright: Birth Control.
FRIDAY.—2 P. M., operative obstetrics. 3 P. M., Clinical
end pathological conference (obstetrics and gynæ-
cology
Daily, 10 A.M. to 4 P.M., medical clinics, surgical clinics
ene opora One: obstetrical and gyneccological clinics
and operati
WEST LONDON HOSPITAL POST-GRADUATE COLLEGE,
Hammersmith, W.
MONDAY, May 10th.—10 A.M., Dr. Post: X Ray Film
Demonstration, skin clinic. 11 A.M. -, surgical wards.
2 P.M., operations, surgical and gynecological wards,
medical, surgical, and gynecological clinics.
TUESDAY.—10 A. M., medical wards. 11 A.M. , surgical wards.
a 1 i operations, medical, surgical, and throat
clinics.
THURSDAY.—10 A.M., neurological and gynecological
clinics. Noon, fracture clinic. 2 P.M., operations,
medical, surgical, genito-urinary, and eye clinics.
Fripay.—10 A.M., medical wards, skin clinic. Noon,
lecture on treatment. 2 P.M. -» Operations, medical,
surgical, and throat clinics.
SATURDAY.— 10 A. M., children’s and surgical clinics. 11 A.M.,
medical wards.
The lectures at 4.15 P.M. are open to all medical prac-
titioners without fee.
MANCHESTER ROYAL INFIRMARY.
TUESDAY, May 11th.—4.15 P.M, Mr. W. R. Douglas:
Lesions of the Common Bile-duct.
FrRIDAY.—4.15 P.M., Mr. D. M. Sutherland: Demonstration
of Surgical Cases.
THE LANCET |
[May 15, 1937
ADDRESSES AND ORIGINAL ARTICLES
OBSERVATIONS ON
MALIGNANT DISEASE OF THE
THYROID GLAND*
By ALFRED Haas, M.D.
OF MUNICH
THE proper study of human life, to paraphrase
Pope, is the study of human relationships. When
human beings, either as a community or as indi-
viduals, fail to develop and maintain adequate
reciprocal relationships neurosis makes its appearance,
as may be observed in current European history or
amongst the visitors to any medical consulting-room !
When the cells of which the human organism is
composed default in the same way, there is engendered
disease—inflammation, degeneration, neoplasm—as
may be seen in any operating theatre or post-mortem
room,
In no cell community is this better illustrated than
in the thyroid gland which has to bear a large share
of the stresses that the human frame is called upon
to endure, psychological and chemical. There is no
need then for surprise that the thyroid gland reacts
in many curious ways, some of which it is my purpose
to describe here. The results of its failure to function
or of its over-activity are familiar to all, but it is
not quite so well known what happens when hyper-
trophic and degenerative changes pass over the
narrow borderline between degeneration and malig-
nancy. It is this aspect which forms the burden of
this communication.
There is general agreement that in mountainous
countries where goitre is endemic carcinoma of the
thyroid is relatively common, because it always
develops in a gland already the subject of degenera-
tive changes, very often the so-called adenomatous
or nodular goitre.
Estimates of the frequency of this malignant
FIG. la.—Metastasis of a papillary adenocarcinoma of the
thyroid with very large alveoli; the stroma is very rich
in fibroblasts.
short statistical summary gives a general idea of its
frequency. Of 3500 cases published by Kocher, 235
were proved malignant and 75 were doubtful (6-8 to
8-8 per cent.). Wilson investigated 10,682 goitres,
and among these 297 were malignant (2-78 per cent.).
I myself observed that among 5000 goitres operated
upon between 1920 and 1936, 35 of them were cer-
* A clinical lecture given at the Middlesex Hospital on
Maroh ge, 1937.
tainly malignant, that is to say, 1 in 143 (0:7 per
cent.). Among these every kind of malignant change
was fairly evenly represented. Only true sarcom
were rare (2).
Speaking generally, malignant thyroid tumours are
rare, The New York State Institute for Cancer
%
ve “eZ MEG
‘Seat as
f
FIG. 1b.—The small primary tumour of the thyroid. The
picture shows the typical buds of the papillary cancer.
Research reports that in twenty-four years there
have only been 42 cases, that is 0:37 per cent. of all
malignant tumours.
Carcinoma of the thyroid has one important
characteristic which distinguishes it from carcinoma
elsewhere ; it relatively seldom gives rise to metas-
tases in the lymphatic system, but frequently the
large thin-walled veins on the surface of the goitre
are invaded, and dissemination takes place by the
blood stream.
According to Bartels the lymphatics of the thyroid
are arranged in two groups. One runs upwards
medially and laterally following the perivascular
lymphatic channels, and secondary deposits may be
found in the corresponding lymphatic glands. The
- second group runs downwards anterior and lateral to
the trachea, and finally drains into the deep cervical
and supraclavicular glands; and this latter is the
commonest site for secondary lymphatic deposits.
As I have said before, invasion of the veins is the
most frequent path of dissemination and the bones
are the most frequent sites for metastases ; osseous
secondary tumours are as common as in carcinoma
of the prostate. The bones are involved in the
following order of frequency: skull, spine, sternum,
humerus, femur, ribs, pelvis, clavicles, jaw, radius,
calcaneum. Visceral metastases are well known to
occur, often in the lungs, sometimes in the liver, and
are not at all uncommon in the brain.
Another well-known and important characteristic
of thyroid tumours is that the primary tumour may
be very small, so small that apart from a histological
examination it may not be found, yet the secondary
deposits may be large and widespread. It is of
interest that bronchial carcinoma sometimes behaves
in the same way.
Last year I operated on a patient who had a tumour
of the left frontal bone the size of half a crown; this was
removed with a large piece of surrounding healthy bone
and of the underlying dura which was involved. When
I looked at the section it was that of a papillary carcinoma
which I thought, considering its histological structure,
U
1156 THE LANCET] DR. ALFRED HAAS: MALIGNANT DISEASE OF THE THYROID GLAND [may 15, 1937
had its origin in the thyroid gland. As a logical sequel,
ten days later I removed a fair-sized nodular goitre from
the patient’s neck. This was cut in serial sections, and
after the most laborious examination of each piece the
primary tumour was found, hardly larger than a pea.
Its histology corresponded exactly with that of the tumour
in the skull. Figs. 1 a and 1 b show these two tumours.
On the whole the best classification of epithelial
RRON
FIG. 2a.—Metastasis of a malignant adenoma of the thyroid.
The metastasis shows only more adenomatous parts rich
in cells with compression of the acini, and also many alveoli
and production of colloid on other parts.
tumours of the thyroid is that of Wegelin, which is
based on that of Langhans :
(1) Metastasing malignant adenoma.—(a) The saosi.
adenoma. (b) The large-cell adenoma.
(2) The proliferating goitre of Langhans.
(3) The papillary epithelial tumours.
(4) The true thyroid cancers.—(a) Carcinoma solidum :
(i) the scirrhus form; (ii) the medullary form; and
(iii) carcinoma simplex. (b) Cylindrical-cell carcinoma.
(c) Squamous-cell epithelioma.
Formerly all these malignant tumours were grouped
together on account of. their sinister reputation, and
even to-day this view is held by many surgeons. It
has been shown recently however by de Quervain
and others that with a combination of operation and
deep X ray therapy some remarkable results can be
obtained in epithelial tumours.
METASTASIS IN BONE
There is one type of malignant goitre which does
not easily go into this general classification, and it is
of great interest to surgical pathologists. In the last
few years I have seen two patients each with large
bone tumours, which on section gave the histological
picture of a nodular goitre. When the goitre was
removed only adenomatous changes were found, and
nothing to suggest malignancy. This is, of course,
not an original observation; Cohnheim in 1876
published an autopsy case and thereafter quite a num-
ber of further cases were recorded, though in many of
them a really adequate examination of the thyroid
gland was not made.
In dealing with these cases most surgeons content
themselves with either removing the metastatic
tumour or irradiating it without removing the
thyroid, This attitude, which may have been justified
in some metastatic tumours, should now be modified
because it is certainly possible by the combination of
operation and radiation to considerably prolong the
lives of these patients. As an illustration of this, a
short account of the two patients just mentioned is
appended.
A woman, aged 61, was admitted to my clinic on
Sept. 14th, 1933. Her story, which extended over ten
years, was as follows : She complained of slowly increasing
right-sided headaches accompanied by giddiness and
frequent vomiting. Later a tumour developed in the right
parietal bone which steadily increased in size. She
became increasingly nervous and was troubled by an
audible bruit in the tumour; there was a medium-sized
goitre to which she paid little attention because they are
so common in Bavaria. Over the right parietal bone was
a fixed pulsating tumour the size of a tangerine; the skin
over it was blue, and pulsation could be heard and felt ;
it was slightly diminished by compression of the temporal
artery. Pressure on the tumour produced no discomfort ;
at its edge a distinct bony wall could be felt. There were
no signs of intracranial pressure ; cranial nerves were not
involved. The knee- and ankle-jerks were increased on the
left side.
In the neck was an ordinary rather- hard goitre, each
lobe about the size of a fist, the left a little larger than the
right. There were no signs of malignancy or compression
of adjacent structures. There was a slight increase in
the pulse-rate (102) and some cardiac dilatation.. Radio-
graphy showed a circular defect of the left parietal bone.
To sum up, here was an elderly woman with a
very common type of goitre, who had a slowly
growing, pulsating tumour of the skull which caused
slight headache and giddiness. A secondary thyroid
tumour was the most probable diagnosis. The
patient’s general condition was good, and so without
any particular risk she was operated on, using a local
anesthetic after a preliminary injection of Eucadol
and scopolamine. When the tumour was exposed it
looked just like an ordinary vascular goitre, and was
removed together with a wide margin of normal bone
and the underlying dura which was also involved.
When the dura was partly raised the anterior aspect
of the cerebral sulcus was also seen to be invaded,
and a thin layer of brain was resected with a
diathermy loop.
The patient recovered comparatively quickly; there
was a post-operative paresis of the left arm and leg, but
in a month this was so far recovered that she could use
her left hand to perform simple movements. One month
later a symmetrical goitre was almost completely removed,
a very small amount of unchanged thyroid tissue being
left onthe right side. She recovered uneventfully from the
goitre operation and was soon walking about the clinic,
FIG. 2b.—The goitre gives the same picture, presenting structures
of small alveoli without definite lumina, and zones in which
alveoli were more adult and contain masses of colloid.
training her partially paralysed arm and leg, and having
intensive deep X ray therapy. Eleven weeks after the
first operation she left the clinic and was able to do her
ordinary housework.
Here then is a case interesting enough from a
technical point of view, the sort of thing that any
surgeon likes to do and report; but the major and
real interest lies in the pathological examination of
THE LANCET]
these two tumours. The secondary skull tumour,
both grossly and histologically, was just like an
ordinary nodular goitre, adenomatous areas without
colloid-alveolar aréas containing colloid secretion.
The thyroid itself was examined with great care, but
serial sections failed to show any signs of malignancy.
Many parts exactly resembled the skull tumour.
FIG. 3.—Destruction of the ischium by metastasising malignant
adenoma of the thyroid.
The stroma showed marked and extensive hyaline
degeneration and some of these degenerated areas
were calcified (Figs. 2a and 2 b)..
In June, 1934, nine months later, she returned, com-
plaining of pain in the back. There was tenderness of the
fifth lumbar area; radiography however was negative.
The pain was very severe and as it was presumably due
to a metastasis she was given deep X ray therapy.
After three weeks of this the pain had gone. She came
back again in March, 1936, nearly two years later, with
violent pain in the right lower limb, especially severe
round the hip. This time a radiogram showed widespread
destruction of the ischium and a secondary in the second
lumbar vertebra (Fig. 3). She was again given intensive
irradiation and since then has been well and able to do-
her work.
This case illustrates the typica] course of such a
malignant adenoma, showing its nature only by a very
slowly developing secondary deposit in the skull,
without signs of malignancy in the primary growth
itself, and what was left behind of the thyroid showed
no change in spite of the growth of further secondary
deposits months later—and with it all, the patient
can do her work.
I have had another similar case. _
A man, aged 42, came in September, 1936, complaining
of pain in the left leg for three years, and subsequently
his right leg became painful. For the last three years
there had been a slowly growing painless tumour over the
sternum, and about a year previously a goitre had been
removed in another hospital. During the war he was
said to have had tuberculosis, but had recovered.
On examination he was a strong man with no signs of
disease except those I am about to describe. Over the
manubrium sterni at the level of the left sternoclavicular
joint there was a tumour the size of an apricot situated in
and expanding the bone, which pulsated and a systolic
murmur was audible. In the upper lobe of the left lung
there was dullness, and on auscultation sibilant and
coarse rhonchi. There was tenderness on palpation over
the third, fourth, and fifth lumbar vertebrre ; movement
was limited and the muscles were rigid. Pressure on the
head produced intense pain in the back. Both ankle-
jerks were absent and knee-jerks diminished, and there
was hyperzsthesia on the external aspect of the dorsum
of the foot (second sacral) and a peri-anal anzsthesia.
X ray films of the lumbar spine showed a large area of
bone destruction in the body of the fourth lumbar. It
DR. ALFRED HAAS: MALIGNANT DISEASE OF THE THYROID GLAND [may 15, 1937 1157
will be seen that only a thin shell of bone remained
(Fig. 4).
This clinical picture is, as you see, very charac-
teristic of malignant goitre; only the absence of
recurrence in the neck was against it. I found out
that it was a large adenomatous goitre which had
compressed the trachea and on this account was
removed. Microscopical examination was done by a
distinguished pathologist, Prof. Oberndorfer, now
in Istanbul, who found no sign of malignancy in
many sections.
Fig. 5 shows a section of such a goitre. Most of
the acini are compressed so that the lumen is
obliterated and many parts are without colloid ;
there is no penetration of the basement membrane
and no invasion of the vessels. Further to elucidate
this case, a piece of tissue was removed with a
diathermy loop. It was a vascular goitre-like tumour,
and so on microscopic examination proved to be a
colloid adenoma with colloid-filed acini (Fig. 6).
The stroma showed hyaline degeneration and there
‘was a thick, strong capsule.. . a .
After intensive irradiation the chest tumour diminished
rapidly ; three weeks later it was below the level of the
sternum. The symptoms of compression of the cauda
equina were relieved by extension, but in order to prevent `
collapse of the vertebral body an Albee operation was
done on Oct. 14th, 1936, a solid bone-graft from the tibia
being used. Three weeks later the spinal metastasis was
irradiated with the expected result that the pain dis-
appeared. The reflex and sensory changes remained
unaffected. Four weeks after the Albee operation he was
walking with a light spinal brace, and in six weeks he left
the hospital. | S
This second case has some interesting points of
difference from the first. The patient was a com-
paratively young man who, four years ago, had an
ordinary nodular goitre removed, but a year later
began to have sciatica, which despite treatment slowly
increased
until it was
evident
that his
cord was
com-
pressed.
Again, one
year after
the pains
began he
had de-
veloped a
tumour in
the chest,
and this
localisation
suggested
a primary .
thyroid
growth
which was
confirmed
by biopsy.
Intensive
irradiation
and spinal fixation relieved the symptoms. I think
that before long he will have a further recurrence,
not only on account of his youth but because the
tumour seems very malignant.
TWO TYPES OF MALIGNANT ADENOMA
Reference to the classification above shows that
there are two types of malignant adenoma, which
are both extremely rare. These two cases just
FIG. 4.— Destruction of the body of the 4th
lumbar vertebra by metastasising malignant
adenoma of the thyroid.
1158 THE LANCET]
DR. ALFRED HAAS: MALIGNANT DISEASE OF THE THYROID GLAND
e,
[may 15, 1937
described belong to the small-cell type; the large-
cell type is even rarer still, Under the microscope
their appearance is surprisingly uniform. Langerhans,
when he was describing them, said: ‘‘ When you
_ have seen one field you have seen the lot”; the
cells are strikingly large and their protoplasm richly
granular.
To look at they are very much like the suprarenal
gland and have characteristic small alveoli, appearing
as isolated knobs in the middle of the goitre. Getzowe,
who is the continental authority on the subject,
believes that they arise from tissue rests of the
branchial arch, which give rise to tumours having a
syncytial character: groups of cells having these
characters, but without tumour-formation, are often
found in the normal thyroid gland. This view is
however disputed by other authorities.
When they grow they form a hard, isolated tumour
either in a normal gland or in nodular thyroid.
Later they become fixed and infiltrate widely so that
they are often mistaken for an inflammatory con-
dition. Their prognosis is relatively good because, if
they are removed with the capsule, they are usually
cured, especially if they are irradiated afterwards.
- I myself have not seen a case and reports of them
are rare.
In this rare type and also in the ordinary malignant
thyroid the onset of malignancy produces quite
definite physical signs. The tumour increases in size
and produces symptoms of pressure on the trachea
and cesophagus, such as dyspneea and dysphagia.
The patient goes rapidly downhill as the tumour
increases in size and fixity. Contrast this with the
cases I first described, a perfectly ordinary adenoma
with a long history, a solitary, equally slow-growing
tumour in a bone, the two apparently unconnected
until someone explores the bone tumour and finds
that histologically it is identical with a colloid goitre.
FIG. 5.—A picture of adenomatous and colloid goitre.
If the surgeon is enterprising enough to remove the
goitre, not a trace of malignancy is found. What
explanation is there for this? If one considers the
nodular goitre to be a true adenoma, it must be
logically admitted that here we are dealing with a
malignant adenoma. But if this view be entertained,
it must not be confused with the precancerous con-
ditions which we find in the breast and rectum,
described in this country by Cheatle and Dukes.
If these adenomata undergo malignant degeneration
they themselves have the characteristics of a true
carcinoma and their metastases are histologically
malignant. :
There is however another explanation advanced
by Ribbert, who suggests that the entry of goitrous
FIG. 6.—The metastasis is the exact copy of the goitre.
tissue into the veins is, so to speak, in the nature of
an accident; it is the result of pressure atrophy and
not true active infiltration. Hence the rarity of this
condition. Graham, discussing thyroid malignancy,
believes that invasion of the blood-vessels is the true
criterion of malignancy.
Schworer has made an attempt to prove that
trauma is mostly the cause of this invasion of the
vascular system. He points out that many cases of
metastasis appear after an operation for goitre. My
second case would perhaps support this idea.
Dunhill has emphasised an important fact in con-
nexion with malignant disease of the thyroid. He
has shown that such changes only take place after a
long period, much longer than in other types of
carcinoma, often 30-40 years. In this type of
“ malignant adenoma ” the history extends from 5-10
years—a marked contrast with the true carcinomata,
The metastases often occasion curious mistakes in
diagnosis ; they may, by their pulsation, resemble an
aortic aneurysm, and histological diagnosis may be
difficult and inadequate on account of the hemorrhage
caused by excision of a small piece. This however
is the only way in which the diagnosis can be made,
Finally I want to make another distinction
between these malignant adenomata and true cancer
of the thyroid; this concerns their prognosis and
reaction to treatment. Von Ejiselsberg, a master
surgeon with an unrivalled experience, gives it as his
opinion that in every case of malignant goitre the
metastasis should be irradiated and the gland either
removed and irradiated or, if this is impossible,
simply irradiated. This, I think, represents the
general opinion to-day.
Now with true cancer of the thyroid cures are by
no means uncommon. I myself in 1926 was able to
show 11 cases free from recurrence after more than
six years. In one of these a segment of the trachea
had been removed ; another patient who had a total
thyroidectomy is alive and well eleven years later,
but has to take thyroid extract daily. But I do not
THE LANCET] DRS. PATON & EATON: SULPHAEMOGLOBINAMIA AFTER SULPHANILAMIDB [May 15,1937 1159
think you will find any cases of malignant adenoma
which can really be called cured ; their lives can be
prolonged and their comfort increased by operation
and irradiation, but they cannot be cured.
In sarcoma of the thyroid the course is still more
rapid. Six to nine months is the limit, and they are
unaffected by either operation, irradiation, or a
combination of these two; so we must come to
the reluctant conclusion that, excluding sarcoma,
malignant adenoma is, in spite of its initial response
to treatment and its slow course, in fact the most
sinister of all thyroid tumours.
e
SULPHAMOGLOBINAMIA AND
METHAMOGLOBINAMIA
FOLLOWING ADMINISTRATION OF
p-AMINOBENZENESULPHONAMIDE
By J. P. J. Paton, M.B. Glasg.
RESIDENT MEDICAL OFFICER, BELVIDERE ISOLATION
HOSPITAL, GLASGOW ; AND
James C. Eaton, B.Sc., M.B. Glasg., A.I.C.
BIOCHEMIST AND ASSISTANT PHYSICIAN FOR METABOLIC DISEASES,
l THE VICTORIA INFIRMARY OF GLASGOW
A SEVERE toxic effect resulting from one of the
-amino benzenesulphonamide drugs (Prontosil Album)
recently came under the observation of one of us
(J. P. J. P.).
~ It has been suggested that poisoning from this
substance is associated with administration of
sulphates (Colebrook and Kenny. 1936, Discombe
1937). Ten cases of cyanosis following administra-
tion of p-aminobenzenesulphonamide (hereafter
referred to as sulphanilamide, for brevity) have been
proved to be associated with sulphemoglobinemia
(Colebrook and Kenny 3, Discombe 6, Frost 1).
Of these, 8 received magnesium sulphate by mouth
and 1 had a dressing of sodium sulphate. We have
investigated this and 19 other cases treated with
sulphanilamide with or without magnesium sulphate
administration to determine whether sulphates are
actually concerned in the toxic effects of these drugs.
Of our cases 4 developed sulphemoglobinzemia, of
which 3 had had sulphates before admission. Four
patients who received no sulphates developed
methemoglobinemia. This condition has not pre-
viously been recorded after sulphanilamide.
A CASE RECORD
The history of the original case is as follows :
Case 1.—Female aged 28. Gave birth to a child on
Feb. 23rd, 1937, after. long rotation from an occipito-
posterior position and application of forceps. The
puerperium was uneventful from then until March 65th,
when she developed pain in the left breast. From
March 7th until admission she received 0:3 gramme
prontosil album every two. hours apart from the night
hours—i.e., 2°4g. per diem, total désage 9-6 g.—and from
March 8th till llth inclusive she had 1 to 2 teaspoonfuls
of magnesium sulphate in the morning. On the 8th the
breast was incised and pus evacuated. A dressing was
applied, the nature of which is unknown, but which may
have contained magnesium sulphate.
The patient was admitted on March llth as a case of
puerperal pyrexia with an alarming degree of cyanosis
and apparently moribund. The temperature was 97°F.,
the pulse-rate 116 per minute, and the respiration-rate 27.
Cyanosis was particularly conspicuous in the face, lips,
and finger-nails. Pulse volume was very poor. Cardiac
dullness was slightly increased to right and left. Heart
sounds were pure but of poor quality. For two days after
admission there were some fine rales at the base of the right
‘lung and the percussion note over this area was slightly
impaired. There was slight tenderness in the lower
abdomen. The urine was dark, cohtained a trace of
albumin, pus, and B. coli, and reduced Fehling’s solution ;
Rothera’s test was positive. No hydrogen sulphide could
be detected. There was a deposit of pink urates.
Treatment was begun at once with administration of
oxygen through a Haldane’s mask but without apparent
effect on the cyanosis. A pint of saline and 5 per cent.
glucose was given intravenously at 4 P.m. on March 11th,
after which the cyanosis diminished and the pulse improved.
By 3 a.m. on the 12th the cyanosis was again more obvious
and the pulse poor. Half a pint of unusually dark blood
was withdrawn from a vein and one pint of citrated blood
transfused. This caused a definite diminution in the
cyanosis. By 10 a.m the patient’s condition had much
improved. Potassium citrate, rectal salines, and glucose
were given freely and oxygen for 20 minutes every four
hours. On examination of the urine, Rothera’s test was
now negative but there was still a reduction of Fehling’s
solution. A sample of blood withdrawn from the median
basilic vein had a peculiar dusky brown colour.
The administration of oxygen was continued as above
until March 15th by which time the cyanosis was much
less marked though still distinct. Cyanosis was still
apparent clinically though in progressively diminishing
degree until the 18th after which it was not possible to
say with certainty that it was present. Smears from the
breast showed Staphylococcus aureus. A cervical smear
showed anaerobic streptococci. On March llth trans-
illumination of the lobe of the ear and spectroscopic
examination showed a well-marked band in the red
part of the spectrum. A sample of venous blood was
examined spectroscopically on this date and showed
a very well-marked spectrum of sulphemoglobin. Spectro-
scopic examination of the blood was made daily until
March 30th and then on alternate days until April 26th—
i.e., until 46 days after stopping administration of prontosil
album—but the characteristic band of sulphzemoglobin
in the red part of the spectrum was still faintly visible.
The sulphemoglobin was entirely intracorpuscular. The
patient made a perfect recovery.
The findings for the other cases are shown in the
accompanying Table. All the patients were females
in the puerperium except Case 13 (who was a child
with streptococcal interlobar empyema), and were
diagnosed as puerperal fever or septic abortion,
Cases 6 and 12 being complicated by bilateral mastitis
and phlegmasia alba dolens respectively, |
Sulphemoglobinzmia associated with giving sulphur
or its compounds has been noted after drugs other
than sulphanilamide. Van den Bergh and Revers
(1931) recorded sulphemoglobinemia in a patient
following treatment with Pyridium (phenylazo-«-«!-
diaminopyridine) and showed that this was asso-
ciated with administration of sulphates. Harrop
and Waterfield (1930) found sulphemoglobinemia
after acetphenetidine (this is discussed more fully
below). By means of in-vitro experiments van den
Bergh and Revers showed that pyridium accelerates
formation of sulphemoglobin by hydrogen sulphide.
This property of catalysing sulphemoglobin forma-
tion is apparently shared by a large variety of sub-
stances, most of which are amino compounds or
derivatives of amino compounds (van den Bergh and
Weiringa 1925). We have repeated and confirmed
these in-vitro experiments with pyridium and have
made similar experiments with sulphanilamide. From
our observations, however, no appreciable acceleration
of the formation of sulphemoglobin could be detected
by the simple method used, on the addition of
sulphanilamide to the mixture of oxyhxmoglobin
and hydrogen sulphide.
EXPERIMENTAL
Spectroscopic examination of the patient’s blood was
performed by means of a Leitz microspectroscope. The
1160 THE LANCET] DRS. PATON & EATON : SULPHAIMOGLOBINAIMIA AFTER SULPHANILAMIDE [may 15, 1937
SUMMARY OF THE FINDINGS
| Dose of mag.
Age. sulph. (by mouth)
|
Dose of sulphanilamide
reckoned from day of
admission.
Case
GROUP 1
2nd day at 1 P.M., SHb
2 : 26 3viii duri 5 | 2nd day, at 6 AM., 6 g.i
Total 20 g.
Spectrum of blood.
5th day normal,
Remarks.
2nd day cyanosis marked. Detectable
Received hydrochloric acid.
: days prece at 10 aM, 6 g. Total| present. Detectable till | till 20th day.
| admission. dose 12 g. 23rd day.
3 | 27 | 3i daily for | lst day 40 ml. Prontosil | 3rd day SHb present. | 3rd day cyanosis marked. 50 ml. ATE
i 4 days preced- soluble (Bayer) intra- Still detectable on cent. methylene-blue intravenously ed
| ing admission. muscularly. 2nd day 24 g. 43rd day. , to relieve cyanosis or sulphsmoglobin-
| | sulphanilamide by mouth. æmia. Cyanosis detectable till 17th day.
|
4 | 31. Nil. Variable 33rd—48th days. | Trace of SHb on 48th | 48th day very slight cyanosis following
i Total 108 g. in 16 days. day. Detectable till 66th dose of 24 g. sulphanilamide on 46th day.
Average 6'75 g. per day. da Marked secondary ansemia.
GROUP 2
5-11 | CA Nil. 12 g. daily for periods from Normal. No cyanosis.
; | 6 to 22 days. Total dose
| 72 to 264 g.
12 | 29 | 3i just before | 12 g. daily 4th—25th days. 53 is i
| admission. Total dose 264 g.
13 | 3 Nil. 3 g. daily for 19 days. R P
14 | 32 ` z 2nd day 12 g. 3rd day 24 g. R 4th day cyanosed. Much diminished on
4th day nil. 5th & 6th days 5th day. Bronchitis.
12 g.each. Total dose 60 g.
i ,
15 | 25 ' ae 2nd—-13th days 12 g. daily. a 13th and 14th days slight cyanosis.
Total 144 g.
16 | 31 | 3i daily for 3 | 12 g. daily 2nd—-10th days. 5 No cyanosis.
! | days before Total 108 gœ.
| admission. -
GROUP 3
17°) 42 | Nil. lst day 8 g. 2nd day 12 g. 5th day MHb present. | 5th day cyanosis marked ; mental con-
3rd day 36 g. 4th day 6th day normal. fusion. 6th day slight cyanosis. Tth
24 g. 5th day 6g. Total day no cyanosis; mentally normal.
86 g. 5 grains quinine hydrochlor. t.i.d.
18 | 30 | j5 | 2nd day 24 g. 3rd day nil. 7th day MHb present. | 3rd day cyanosed. 4th day no cyanosis.
i | 4th day 24 g. Total 48 œ. 8th day normal. 5th-8th days slight cyanosis.
19 | 30 oe | Ist day 4 g. 6th—9th days 10th day MHb present. | 3rd day cyanosed. 4th-8th days no
` ' ' 12 g. daily. Total 52 g. 11th day normal. cyanosis. 9th day cyanosis marked.
| Received hydrochloric acid.
20 | 24 | ;3 3rd day 12 g. 4th day 8 g. 4th day MHb present. | 4th day cyanosed. 5th day no cyanosis.
|
SHb =sulphemoglobin.
spectra were compared with that of a known solution of
methemoglobin in the comparison tube and the alpha
band of the sulphzmoglobin shown to persist after addition
of ammonium hydroxide, sodium cyanide, or ammonium
sulphide to the blood (Wood Clark and Hurtley 1907,
Harrop and Waterfield 1930). Blood from a finger-prick
was used, and was laked with a few millilitres of water.
The alpha band was seen to lie between 6150 and 6280
Angstr6m units and could be readily distinguished in
position from that of methzmoglobin.
To determine whether sulphanilamide would accelerate
sulphemoglobin formation, 2 ml. oxyhzemoglobin solution
were placed in each of two test-tubes. To one tube 5 drops
of a solution of sulphanilamide in water, saturated at room
temperature, were added and then a few drops of hydrogen
sulphide solution to each of the tubes. One of the prepara-
tions was then placed on the microscope stage, the other
being placed in the comparison tube of the spectroscope.
In this way the spectra of the two samples could be
watched simultaneously and the development of the
spectra of sulphemoglobin observed. The greater the
quantity of H,S added to the oxyhemoglobin the more
rapidly did the spectrum of sulphzemoglobin appear,
but even using minimal quantities of H,S sulphemoglobin
did not appear to be formed more rapidly in the sample
containing sulphanilamide. The action of pyridium
was observed similarly, adding a 0-25 per cent. solution
of this substance in water in place of sulphanilamide.
In this case the spectrum of sulphemoglobin appeared
in a few seonds compared with several minutes for the
eample without pyridium.
MHb =methemoglobin.
DISCUSSION
The 20 cases fall into three groups:
Group 1 comprises Cases 1 to 4. These patients
all developed sulphemoglobinemia. In Cases 1 to 3
magnesium sulphate had been given, there was marked
cyanosis (in Case 1 very extreme) and the spectrum
of sulphzemoglobin in the blood was pronounced. In
Case 4, where no sulphates were given, cyanosis was
slight and the sulphemoglobinemia only just
detectable. f
Group 2 comprises Cases 5 to 16. In none of these
was any abnormality found on spectroscopic examina-
tion of the blood and only in two (Cases 14 and 15)
was any cyanosis seen. Of these 12 patients only
2 had received sulphates, and in one of these the
administration of sulphates was stopped three days
before giving sulphanilamide. Case 16 received
sulphates until the day before giving sulphanilamide
but failed to develop sulphemoglobinzmia.
Group 3 comprises Cases 17 to 20. These patients
became cyanosed though none had had sulphates.
On examination of the blood it was found that
methemoglobin and not sulphemoglobin was present.
: Comparing Groups 1 and 2, it is seen that while
the patients in Group 2 received large doses of sul-
phanilamide for a long period without developing
sulphemoglobinemia, those in Group 1 (Case 4
THE LANCET] DRS. PATON & EATON: SULPHZXMOGLOBINAIMIA AFTER SULPHANILAMIDE
excepted) received much smaller total doses and
rapidly developed sulphemoglobinemia. This was
particularly noticeable in Case 2 where only seven
hours after giving the first dose of sulphanilamide
the patient was markedly cyanosed and the blood
contained sulphzemoglobin. A possible explanation
of the appearance of sulphemoglobin in Case 4,
although no sulphates had been given, is that intestinal
stasis allowed reduction of other sulphur-containing
substances in the bowel as is supposed to occur in
‘‘enterogenous cyanosis’’ and that these permitted
sulphemoglobin formation in a similar fashion to
exogenous sulphates. This is supported by the
findings of Harrop and Waterfield mentioned below.
The formation of methemoglobin in Cases 17 to 20
was quite unexpected. As is well known, drugs
containing the sulphone group —SO,— such as Sul-
phonal and Trional, produce methemoglobinemia
in susceptible persons and probably in anyone
provided the dose is sufficiently great. Harrop and
Waterfield (1930) have shown that while various
aromatic organic compounds produce methemo-
globinzemia, if these substances are given along with
sulphur, the result is sulphemoglobinemia. Appar-
ently methemoglobinemia is the true toxic result of
a large dose of sulphanilamide or possibly of quite a
moderate dose in an unusually susceptible person.
Formation of sulphemoglobin takes place only when
sulphur compounds are available, as happens when
they are present in the bowel in unusually large
amounts.
We are unable to offer an explanation of the
appearance of methemoglobinemia in Group 3 where
the dosage of sulphanilamide was, on the whole,
less than in Group 2. One of the patients had had
quinine. Plasmoquine has been responsible for
methzemoglobinemia but we are not aware of any
such effect following administration of quinine
despite its very wide use in the tropics. Nevertheless,
we have tried to eliminate this as a causative factor
by giving Case 17 large doses of quinine without |
simultaneous administration of sulphanilamide. This
did not result in a recurrence of the methemoglo-
binemia, Two of the patients received hydrochloric
acid for the purpose of aiding absorption (Foulis and
Barr 1937). It may be that these patients received
a greater effective dose. For the other cases, we are
forced to that confession of ignorance, “‘ idiosyncrasy
on the part of the patient.”’
The relative persistence of sulphsemoglobinemia
and methæmoglobinæmia is of some interest. While
sulphemoglobin could be detected for more than
six weeks after stopping administration of sulphanil-
amide, methemoglobin could not be detected after
24 hours. This corresponded approximately with
the cyanosis. When cyanosis was due to methamo-
globin it disappeared very rapidly while that due to
sulphemoglobin was much more persistent. These
findings correspond with those of Waterfield (1928)
in a patient in whom sulphemoglobin and methamo-
globin were found alternately. Waterfield noticed
that attacks of cyanosis associated with methzemo-
globin were transient, the patient’s colour rapidly
becoming normal in the intervals; with sulphsemo-
globin the cyanosis was persistent.
The persistence of sulphemoglobin is the more
surprising on consideration of its mode of formation.
Methzemoglobin is the result of oxidation of the iron-
containing part of hemoglobin but sulphemoglobin
is believed to be an addition product. Carbon
monoxide hemoglobin is also an addition compound
of hemoglobin and is decomposed by oxygen, so that
in poisoning by carbon monoxide a few hours suffices
[may 15,1937 1161
to remove it from the blood (Sollmann’s Pharmacology,
5th ed., p. 752). The persistence of sulphæmoglobin
in these patients implies that this substance cannot
be so decomposed and that the H,S cannot be
excreted from the lungs. Probably the sulphæmo-
globin must be eliminated by the liver. Since
methsmoglobin disappears so much more rapidly, it
is unlikely that it is removed in similar fashion.
Owing to its nature, removal could scarcely occur in
the lungs and it would seem not improbable that it
can be reduced again to hemoglobin. If, however,
this is correct, it is difficult to understand why
oxygen should appear to relieve cyanosis in patients
who have methæmoglobinæmia.
The detection of sulphsmoglobin in the blood of
the affected patients long after the disappearance of
clinical signs of cyanosis points to the spectroscope
as being a much more delicate means of detecting
poisoning from this group of drugs than the clinical
observation of cyanosis.
CLINICAL AND THERAPEUTIC NOTES
In 3 of the patients (Nos. 1 to 3) the cyanosis was
alarming ; but all recovered. The impression gained
from these cases is that although the cyanosis
appears serious, danger to life is not great. Of the
cases already reported which became cyanosed after
the use of sulphanilamide or its derivatives, only one
(Frost 1937) has ended fatally. Though magnesium
sulphate was not given to the patient during adminis-
tration of the drug in Frost’s case, it is not stated
whether the patient had had sulphates before coming
under observation.
Further symptoms noted in our cases were nausea,
headache, and discomfort in the upper abdomen.
In Case 17, where there was methsemoglobinemia,
mental confusion was a conspicuous symptom but
it disappeared on stopping administration of sul-
phanilamide. Mental symptoms were a marked
feature of Waterfield’s case.
The treatment for alleviation of the symptoms
depends on whether sulphemoglobinemia or
methemoglobinemia is present. In the former case
oxygen has little effect (as might be expected), but
intravenous administration of saline and glucose
relieves the cyanosis, temporarily at least. If the
patient’s life appears to be in danger transfusion is
indicated. If there is methzmoglobinemia oxygen
appears to be of value. The cyanosis accompanying
methemoglobinemia disappears rapidly.
Before giving sulphanilamide a careful inquiry
should be made to find whether magnesium sulphate
or preparations containing it have been used, owing
to the common use of this substance to stop lactation.
SUMMARY
1. Administration of magnesium sulphate simul-
taneously with, or within two or three days.
preceding, administration of sulphanilamide gives
rise, in most persons, to sulphemoglobinemia. The
formation of sulphemoglobin takes place very rapidly
even after small doses of the drug.
2. In the absence of sulphates large doses of the
drug are well tolerated, but in a considerable propor-
tion of persons doses of 12 to 24 grammes per diem
result in methxmoglobinemia. Some patients may
have an increased susceptibility to the drug.
3. The removal of sulphemoglobin from the blood
is much slower than removal of methzemoglobin,
The former has been detected six weeks after adminis-
tration of sulphanilamide ceased. The latter dis-
appears in approximately 24 hours.
‘
1162 THE LANCET] MR. TIMBRELL FISHER: PATHOLOGY OF RHEUMATOID ARTHRITIS
[may 15, 1937
4, Spectroscopic examination of the blood is a
more delicate means of detecting sulphemoglobinemia
than clinical observation of cyanosis.
5. Oxygen is of little value in treatment of severe
cases of sulphemoglobinemia. If the patient’s life
is in danger blood transfusion is indicated. In
methemoglobinemia oxygen appears to be of value.
REFERENCES
Colebrook, Ha and Kenny, M. (1936) Lancet, 1, 1279.
Discombe, G. (1937) I Ibid., March 13th, p. 626
Foulis, M. A Barr, J. B. (1937) Brit. med. J. Feb. 27th,
p.
Frost, L. D. B. (1937) Lancet, Feb. 27th, p
Harrop, a ai and Waterfield, R. L. nR TT. ` Amer. med. Ass.
Van den Bergh, A. A. H., and Revers, F. E. (1931) Dtsch. med.
Wschr. 57, 706.
— and We piringa, B (1925) J. Physiol. 59, 407.
Waterfield, R. L. (1928 ) Guy’s Hosp. Rep. 78, 265. :
Wood Clark, T., and Hurtley, W. H. (1907) J. Physiol.
»
A CONTRIBUTION TO THE PATHOLOGY
OF THE
RHEUMATOID TYPE OF ARTHRITIS
AND OF RHEUMATIC FEVER *
By A. Q. TIMBRELL FISHER, M.C., F.R.C.S. Eng.
ORTHOPEDIC SURGEON TO THE ST. JOHN CLINIC AND INSTITUTE
OF PHYSICAL MEDICINE, LONDON, AND TO THE
LONDON COUNTY COUNCIL ARTHRITIO UNIT,
ST. STEPHEN’S HOSPITAL
ALTHOUGH, from time to time, contributions have
been made to our knowledge of the pathology of the
rheumatoid type of arthritis of unknown etiology
(synonyms : rheumatoid, chronic infective, atrophic,
or proliferative arthritis), most of these have dealt
with the later stages. The disease is rarely fatal
per se and opportunities for post-mortem examination
in the acute or earlier periods are therefore rarely
provided. Post-mortem examination of patients
who have succumbed to rheumatic fever is more often
possible, but it is often observed that the pathology
of the heart is studied in detail and that the joints
receive scant consideration. In the case of the
rheumatoid type of arthritis, the classical patho-
logical descriptions of Nichols and Richardson (1910)
and of Strangeways (1918), and others, detailed as
these are, are based to a large extent upon examina-
tion of material from the later stages of the disease.
The pathological changes in such are complex since
secondary degenerative or osteo-arthritic changes
are often superimposed, a theory of the cause of which
will be put forward in this paper.
The work of Allison and Ghormley (1931) was
based largely upon material obtained at operation
upon joints affected with the rheumatoid and other
types of arthritis at a somewhat earlier stage, and
merits careful study. They drew particular attention
‘to the “focal collections of lymphocytes” often
observed in this disease and previously described
by Hoffa .and Wollenberg (1908) and by myself
(1923), and claimed that these collections are a
specific diagnostic feature.
A series of important papers has recently appeared
from Klinge and Grzimek (1932). These authors
are among those who maintain that rheumatic fever
and arthritis of the rheumatoid and osteo-arthritic
types are different forms of the same underlying
pathological process. It is my view that a principal
cause of the confusion that exists concerning rheumatic
* Based on a lecture delivered at the St. John Clinic on
Nov. 13th, 1936.
diseases is that we have neglected the Hunterian
principle of basing our treatment upon a firm founda-
tion of anatomical, physiological, and pathological
knowledge. The present work is a sequel to former
work on the pathology of the osteo-arthritic and
rheumatoid types of arthritis and upon joint
physiology.
SOURCE OF MATERIAL AND SCOPE OF INVESTIGATION
My investigations have been carried out upon
synovial tissues removed at operations during the
last fifteen years upon patients suffering from the
rheumatoid type of arthritis. These operations
include the ordinary excisions and synovectomies
in cases of long standing and, in addition, the newer
method of lavage of the affected joints with normal
saline or with antiseptic solutions combined with
removal of portions of synovial membrane. The
pathological changes in the articular cartilage and
bone have also been studied, but as operative and
post-mortem material of this nature has only been
obtained from the later stages which have been
previously described by myself (1929) and others,
these changes will not be described in this paper.
Arthrotomy and lavage is a valuable means of treat-
ment in carefully selected earlier cases of the disease
which have proved resistant to the usual medical and
physical treatment, when the brunt of the disease
falls mainly on one or both knees and when the
articular surfaces are uninvolved or present early
changes. It is of great value also in providing an
opportunity for investigation of the joint tissues
and fluids. Itisa procedure which presents consider-
able advantages over mere aspiration, since the
rheumatoid joint, even at a comparatively early
stage, contains a variable amount of necrotic material
due to fibrinoid degeneration of the synovial membrane
and which it is impossible to remove through a needle
or trocar, even when of large calibre, Many joints
which give the sensation of fluctuation and which
on clinical examination appear to be full of fluid,
yield on aspiration but a moderate quantity, owing
to the large amount of necrotic material present.
It is for this reason that the operating arthroscope
has proved disappointing in my _ experience.
Occasionally, if conditions are favourable, arthro-
scopy enables a good view of the anterior compart-
ment of the knee-joint to be obtained, but it possesses
no special advantage over routine clinical and X ray
examination. The main drawback to the use of the
G af”
okt
` 4 o —" ‘ a é .
r O- om, T
NEET at moa gy AO a
| f RA
EE N Re
~ re y
>. æ s Ar rr z!
è a $ MN A ~ ;
ms. è eb e? > f L P 4 23
l 2 y* > ~-* 3 la Sa
“as i ao Le
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b X ee R Sd á
\
\ & é t ~€ . `
a t nue eS x ;
&
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J g z *
X ‘. 4e L -a
` ~ o . t af e { PANN
foot r ee oe wee
“a Me ee, Be we
SG nS, os
FIG. 1 (Case 1).— Rheumatoid — of arthritis. Perivascular
aaa of cells in deeper layers of synovial membranes.
x
THE LANCET]
arthroscope lies in’the fact that the masses of necrotic
material to which reference has been made obstruct
the view and cannot be completely removed through
the cannula of the instrument, even after frequent
irrigation. In many patients, the symptoms have
completely disappeared after arthrotomy and lavage
and they have remained cured for periods as long as
12 and 14 years, and, in the majority, there has been
a most gratifying amelioration of symptoms. This
method of surgical treatment will be described in
detail elsewhere.
Bacteriological examination.—The research into
the ztiology of the rheumatoid type is being carried
out by Dr. Hardy Eagles of the Lister Institute. The
purpose of this combined research has been to correlate
the pathological findings with examination of joint
fluids and synovial membrane, removed at operation,
for evidence of a possible virus extiology, and to
investigate the possibility of a pathological and
zetiological relationship between acute rheumatic
fever and the rheumatoid type of arthritis. After
suitable manipulation of the specimens and high-
speed centrifugation, Dr. Eagles has obtained
suspensions which are indistinguishable from
elementary bodies demonstrable in similar suspensions
” Cig Mh! bhian So
y N! ARSA re:
* ‘+ P
5 Ae eaa
Py $ b -A z
BEI E ya
RAA ar
te" Re
ae SAP
ie, (ft ath
FIG. 2. (Case 2).—Rheumatoid type of arthritis. Section of
Synovial membrane. (x 70.) Showing large area of
fibrinoid degeneration above and to the left, and several
focal collections of cells in the deeper layers.
from recognised virus diseases. Similar bodies have
been found in the pericardial and pleural exudates
and joint fluids from rheumatic fever. These
suspensions have been examined for agglutination
with rheumatic sera using the hanging-drop technique.
Tests have been carried out with material from
rheumatism of the rheumatoid type and rheumatic
fever. This aspect of the work will be described by
Dr. Eagles in a forthcoming publication.
It is proposed in this preliminary paper to describe
shortly the pathological histology of the rheumatoid
type of arthritis of non-specific or unknown etiology
and to compare the changes with those seen in the
joints in rheumatic fever, a few representative cases
only having been selected for description.
Some of the rheumatoid group were private patients
but the majority were patients at the L.C.C. Arthritic
Unit, St. Stephen’s Hospital, and the histological examina-
tion of the joint tissues removed from the latter was carried
out at the Central Histological Laboratory of the London -
County Council. Prof. H. M. Turnbull and Dr. W. G.
~
MR. TIMBRELL FISHER: PATHOLOGY OF RHEUMATOID ARTHRITIS [may 15,1937 1163
FIG. 3 (Case 2).—Rheumatoid type of arthritis. Section of
synovial membrane. (x 210.) Small focal collection of
cells under higher power showing giant cells of Aschoff type.
Barnard kindly provided material from autopsies for the
investigation of the synovial changes in the arthritis
occurring in the course of rheumatic fever.
EARLY RHEUMATOID ARTHRITIS
My first case is one of the rheumatoid type of
arthritis, of. unknown etiology.
For two years, the patient, an unmarried woman
aged 38, had complained of pain and stiffness of both
knees of moderate severity. She had also experienced
occasional pain and stiffness of the neck. For two weeks
before operation she had complained of severe pain,
stiffness, and swelling of the right knee and difficulty
in walking. No toxic focus could be discovered.
The right knee had a synovial effusion, with painful
limitation of flexion, increased temperature over the
joint and tenderness over the deep fibres of the internal
lateral ligament. Radiographically the knees showed no
osseous changes.
Operation.—Small incision on the inner aspect of the
joint. Smears of synovial fluid taken. Small portions
of the infrapatellar pad of fat were removed and the
joint washed out with normal saline. No changes seen
in the articular surfaces beyond very early pannus on
the internal femoral condyle.
The sections of the synovial membrane from this
case show proliferation of the synovial villi and of the
specialised synovial cells lining the villi. There is
degeneration of the superficial cells at one or two
spots. In the deeper layers of the synovial membrane
are several small focal collections of cells which are
in the main perivascular (Fig. 1.) The cells constitut-
ing the collections are lymphocytes and histiocytes,
and, occasionally, among these cells, large histiocytes,
somewhat triangular in shape and resembling the
giant cells seen in the Aschoff nodule of rheumatic
fever, can be recognised, In the region of these
collections, areas of focal hyaline degeneration of the
connective tissue can occasionally be seen which
often involve the adventitia of the blood-vessels.
Proliferation of the vascular endothelium is a
prominent feature, and in some cases the arteriole
or capillary is completely blocked by endothelial
proliferation. An important feature is the complete
absence of the polymorphonuclear cells which are
a feature in the forms of arthritis associated with the
presence in the joint of pyogenic organisms. The
bacteriological examination of the joint fluid and
tissues was negative.
1164 THE LANCET] MR. TIMBRELL FISHER: PATHOLOGY OF RHEUMATOID ARTHRITIS
FIG. 4 (Case 3).—Rheumatic fever. Section of synovial
membrane. (x 120.) Above and to the left are several
blood-vessels showing fibrinoid degeneration of the sub-
intimallayer. Below and to the right are two Aschoff bodies
with typical giant cells.
A LATER ACTIVE STAGE
The pathological histology of the rheumatoid
type at a later, but still active, stage will now be
described and comparison made with a case of
rheumatic fever which shows many similar patho-
logical features. In particular, attention is drawn
to a peculiar form of degeneration of the connective
tissues known as “‘ fibrinoid ’’ which has been observed.
in the lesions of rheumatic fever for many years,
although its occurrence in the rheumatoid type has
only been recently described by Klinge and Grzimek
(1932). Perivascular collections of cells are seen,
as before, but, in the cases to be described, giant-
cells of the Aschoff type are a prominent feature,
not only in the case of rheumatic fever, but in the
rheumatoid type of arthritis—a phenomenon which
does not appear to have been described before in the
latter disease.
In my second case of the rheumatoid type of
arthritis the patient was a married woman aged 62.
Nine months before operation, painful swelling in the
right. ankle suddenly developed, followed two weeks later
by similar symptoms in the right knee. She received
electrical treatment for several weeks and the joints
improved ; but soon the left knee, the right wrist, and the
metacarpophalangeal joints of the right index and second
fingers became involved. All joints, except the left knee,
responded to medical and physical treatment. No toxic
focus could be discovered.
Operation.—Long parapatellar incision on inner side
of left knee. The synovial membrane showed hyper-
trophy of the synovial fringes and was oedematous in
places. Much fibrinoid material was present, not only
in shreds in process of exfoliation from the synovial
membrane, but free in the joint. Early pannus extended
for a short distance over the lateral portions of the femoral
condyles, but the articular surfaces were otherwise
uninvolved. Synovectomy was performed and the joint
irrigated with Dakin’s solution. Bacteriological investiga-
tion of synovial tissues and fluid was negative. The infra-
patellar pad of fat was chosen for microscopical examination
Several large areas of fibrinoid degeneration
(Fig. 2) not only of the superficial area, but lying
more deeply were clearly shown. At this stage of
the disease it is usually to be noted that the synovial
membrane is diffusely infiltrated with
inflammatory cells, principally lymphocytes, plasma
chronic -
{may 15, 1937
cells, and epithelioid histiocytes, in addition to the
typical perivascular collections of cells previously
described. In this type of case, giant-cells of the
Aschoff type can usually be observed (Fig. 3), if
the smaller perivascular collections are examined,
rather than the areas diffusely infiltrated with chronic
inflammatory cells.
RHEUMATIC FEVER
The third illustrative case is one of rheumatic
fever in a girl aged 9.
She was admitted to St. Charles’ Hospital a fortnight
after the onset of illness with temperature and pain in right
elbow which, however, ceased on admission. Pain and
swelling of both ankles commenced three days before
admission and the ankle-joints were hot, swollen, and
painful. The temperature on admission was 99-8, the
pulse-rate 144, and respirations 26. The heart was not
enlarged, but a mid-diastolic mitral murmur was present.
Two weeks later, the patient became gravely ill with
extreme restlessness and incontinence. The heart was
now enlarged with canter rhythm and loud apical systolic
bruit. The patient gradually sank and died. The post-
mortem examination by Dr. Barnard revealed cdema of
medulla, pons, mid-brain, basal ganglia and parietal lobe
of brain, rheumatic synovitis of sternoclavicular articula-
tion, partially organised fibrinous pericarditis with Aschoff
FIG. 5 (Case 5).—Rheumatoid type of arthritis. Section
of synovial membrane. (x 112.) Showing several lymph-
adenoid nodules some of which have a clear central area.
nodes in myocardium, rheumatic mitral endocarditis,
cedema of lung with fibrinous pleurisy and congestion of
liver and kidneys.
Sections of the synovial membrane of the sterno-
clavicular joint (Fig. 4) reveal many of the specific
histological features of acute rheumatism that ‘have
so often been described in connexion with the heart.
Fibrinoid degeneration is a prominent feature (a) of
certain of the synovial villi and of the surface of the
synovial membrane, (b) scattered diffusely throughout
the synovial membrane, and (c) in connexion with the
inner coats of many of the blood-vessels so that the
wall appears to be thickened. Many of the
capillaries are blocked by proliferation of the endo-
thelial layer. Around many of the blood-vessels
are collections of cells in connexion with the
adventitia. These cells are mainly large and small
lymphocytes and _ epithelioid histiocytes, with
occasional plasma and mast cells. Among the
histiocytes are some giant-cells which have two,
three, or even more nuclei. These collections of
THE LANCET]
cells resemble, therefore, the Aschoff bodies seen in the
heart.
FIBRINOID DEGENERATION
Fibrinoid degeneration was apparently first
described by Neumann in 1880 and again in 1896.
In the latter paper, he states that it is a substance
which at first sight has the appearance of fibrin
but which is in reality a form of degeneration of the
connective tissue. It is usually stained a diffuse
blue by the Weigert-Gram stain and is, like fibrin,
stained a deep blue by Mallory’s phosphotungstic
acid hematoxylin and red by Mallory’s acid-fuchsin
aniline-blue. Klinge and Grzimek (1932) state
that it gives the fibrin staining reactions for the most
part.
With Klinge, I maintain that the fibrinoid degenera-
tion of the synovial membrane, here described, is an
important feature of the rheumatoid type of arthritis
. of so-called unknown etiology and that this form of
degeneration is not therefore confined to acute rheu-
matism. In the latter condition, it is seen not only
in the synovial membrane but in the heart and in
other regions affected by the disease. The degenera-
tion affects principally the collagenous connective-
tissue bundles and forms a striking histological
picture. Dawson (1933) states that with Masson’s
trichrome stain it presents a fibrillar structure, which
stains a brilliant red, in striking contrast to the vivid
green of the normal collagen. My investigations
show that this form of degeneration is, therefore, a
characteristic feature of the rheumatoid type of
arthritis of unknown etiology, except in the very
early and in the more chronic stages.
G@DEMA OF THE SYNOVIAL MEMBRANE IN RHEUMATOID
ARTHRITIS
Another interesting and important feature which
appears to have hitherto escaped general notice is-
that at operation the synovial membrane can often
be seen to be edematous. This is well shown in the
following case (No. 4), which presents also other
interesting features.
The patient, a married woman aged 60, had complained
of pain and swelling in the right knee for ten years, of
gradual onset. For the last three years, she has only been
able to walk with two sticks and has gradually become
worse. For eleven years, both wrists and hands have been
painful, stiff, and swollen. Has had eight children, with
FIG. 6 (Case 5).—Rheumatoid type of arthritis. Section
of synovial membrane to show structure of central zone of
a lymphadenoid nodule seen in Fig. 5. (x 215.)
MR. TIMBRELL FISHER: PATHOLOGY OF RHEUMATOID ARTHRITIS [may 15,1937 1165
no miscarriages; one bad confinement with instruments,
and leucorrhœa for several years. Climacteric at age of
48. Bowels always constipated. All teeth removed
eight years ago for severe pyorrhea. Tonsils normal.
Operation.—Synovial membrane cedematous and general
hypertrophy of synovial fringes. Synovectomy followed
by irrigation of the joint with Dakin’s solution. Some
turbid free fluid present in the joint. Considerable
destruction of the articular cartilage of the patella and
condyles of the femur present with extensive pannus.
The bacteriological investigation of the synovial tissues
and fluid was negative.
Sections of the synovial membrane in this case
show the chronic inflammatory infiltration with
perivascular collection of cells and areas of fibrinoid.
degeneration to which attention has been already
drawn. The sections of the synovial membrane show,
in addition, the edema which is often such a prominent
feature in these cases. Near the surface of the
synovial membrane are a large number of clear areas
varying in size. These areas are ‘surrounded by
fibrinoid degeneration of the connective tissue and
interspersed in this area are large numbers of giant-
cells which themselves often occupy spaces. These
giant-cells vary in size; some being of the typical
Aschoff variety and having two or three nuclei,
while others have many nuclei and resemble foreign-
body giant-cells. The giant-cells appear to be
destroying the fibrinoid material, and many of the
smaller spaces appear to be formed in this manner.
RHEUMATOID ARTHRITIS IN ITS LATER STAGES
The changes in the synovial membrane in more
chronic cases of the rheumatoid type of arthritis
of unknown etiology constitute a very striking
and, in my opinion, specific appearance and will
now be described. They are illustrated in the
following case (No. 5) :—
Married woman aged 54. Onset of rheumatoid type
of arthritis in right knee 2} years ago during a time of
mental and physical stress. No obvious toxic focus
present, but the majority of her teeth were removed
shortly after the onset of the arthritis owing to pyorrhea.
Examination showed chronic arthritis of rheumatoid
type of right knee—far advanced. Practically a flail
joint and any attempt to flex the knee is accompanied
by a sudden lateral displacement of a tibia with a painful
jerk. Triple displacement of the tibia is present and there
is 14 in. wasting of the right thigh. Wassermann test
negative. Arthritis of the rheumatoid type was also
present in the metacarpophalangeal joints of both thumbs
and in the proximal interphalangeal joints of both middle
fingers. Owing to the gross destructive changes the joint
was excised.
The sections of the synovial membrane from this
case (Figs. 5 and 6) demonstrate clearly the lymph-
adenoid nodules often with a clear centre that are
such a conspicuous feature of this type of arthritis.
The nodules are formed as follows: in the first place
there is a perivascular collection of lymphocytes,
histiocytes, and plasma cells with an occasional
Aschoff giant-cell as has been previously described.
This is followed by proliferation of the vascular
endothelium so that the clearer central area contains
many cells of endothelial type interspersed with
strands of fibrin (Fig. 6). A close connexion of these
‘‘lymphadenoid’’ nodules with the blood-vessels
is clear on careful examination and seems to disprove
the view of Allison and Ghormley that these nodules
are not primarily perivascular. It has been suggested
that the appearance of these nodules lends support
to the tuberculous theory of origin of this form of
arthritis. I cannot PEE to this view as these |
U
1166 THE LANCET] MR. TIMBRELL FISHER: PATHOLOGY OF RHEUMATOID ARTHRITIS
nodules never contain the characteristic tuberculous
giant-cells and caseation is absent. The bacterio-
logical investigation of the synovial tissues and
fluid was negative.
In the later stages of the rheumatoid type, the
synovial membrane and villi become fibrotic. Many
of the blood-vessels are blocked, and, in some cases,
„and the same diathetic state,”
there is a striking development of connective-tissue
around the vessels in the form of concentric rings
(pericapillaritis diffusa of Shattock and Fisher (Fisher
1922-23). As similar changes can be seen in the sub-
articular blood-vessels, it is clear that the nutrition
of the articular cartilage and of the whole joint must
be seriously impaired and this interference with the
nutrition of the joint is probably the cause of the
secondary osteo-arthritic changes that so often
supervene in the later stages of the rheumatoid type
of arthritis. A large number of the specimens in the
Strangeways collection at the Royal College of
Surgeons of England demonstrate this fact very
clearly.
There is evidence also that in some cases the
arthritis of rheumatic fever, instead of disappearing,
persists in a form indistinguishable from: the
rheumatoid type of arthritis and secondary osteo-
arthritic changes may eventually supervene.
COMMENTARY
The results obtained in the course of this investiga-
tion show that the pathological histology of the
synovial tissues of uncomplicated forms of the
rheumatoid type of arthritis of so-called unknown
ætiology and of acute rheumatism presents a
similar and specific picture. The similarity of the
pathological reactions in the synovial membrane
in these clinical conditions supports the theory
that they- are manifestations of the same fundamental
pathological process. Charcot (1881) wrote in this
connexion: ‘‘ There are not two fundamentally
distinct diseases but only two manifestations of one
and Hawthorne
(1900) considered that the presence of similar sub-
cutaneous nodules in the two diseases showed that
they were intimately related. Of recent years, these
subcutaneous nodules have been subjected to close
pathological study by Coates and Coombs (1926)
Freund (1928), Dawson (1933), Clawson and Wetherby
(1932) and others, and it has been established that the
pathological histology is identical in the two diseases.
McEwan (1933) has studied by means of supravital
stains the cells of the subcutaneous nodules of both
rheumatic fever and rheumatoid arthritis and claims
that the staining reactions of the cells in the two condi-
tions are similar and differ from the cells in other
granulomatous conditions such as syphilis and
tuberculosis. He has found the same specific staining
reactions in the cells of the synovial membrane in
rheumatoid arthritis.
'gIt is interesting to observe that the changes that
have been described in the synovial membrane, both
in acute rheumatism and in the rheumatoid type of
arthritis in their early stages show a strong resemblance
to the foci in the interstitial tissue of the myocardium
in rheumatic fever first described by Poynton (1899)
but further elaborated by Aschoff (1906), Carey
Coombs (1911), and others. In this investigation,
the pathological picture, the negative results of
bacteriological examination of the joint tissues and
fluid in uncomplicated cases, together with the
absence of polymorphonuclear reaction in the synovial
tissués—so characteristic of other forms of arthritis
associated with the presence of pyogenic organisms—
[may 15, 1937
is not in agreement with the hypothesis that the
rheumatoid type of unknown atiology is due to the
actual presence in the joint itself of streptococci or
other pyogenic organisms. It is a significant fact
also that in a few cases in which streptococci were
isolated from the synovial membrane, typical pyogenic
membrane was observed, intensely infiltrated with
polymorphonuclear cells, and it is important to note
that definite toxic foci were present in these patients
in contradistinction to the previous group. It
would appear that in these cases secondary infection
has been superimposed upon some other factor, the
nature of which is still undecided. I am unable
therefore, although some of my work is confirmatory
of that of Klinge, to subscribe to his view that in
uncomplicated forms of rheumatic disease the tissue
changes are similar to those in septic diseases with
a demonstrable exciting cause.
Are the peculiar and apparently specific histo-
logical changes that occur in uncomplicated rheu-
matic disease allergic phenomena associated with a.
focus of streptococcal infection ? In this connexion
it may be noted that Klinge has described similar
changes in serum-sickness, On ‘the other hand,
are they due to some other factor acting either alone
or in conjunction with the streptococcus? The
results of Schlesinger, Signy, and Amies (1935)
tend to show that a virus might play some part in
the ztiology of rheumatic fever. It would, however,
be unwise to disregard the rôle of streptococci in
rheumatic infection in view of accumulated evidence,
and it is probable that both virus and streptococci
are concerned in the ætiology. My research-associate,
Dr. G. Hardy Eagles, will deal with these problems
in a forthcoming paper.
In conclusion, I wish to express my indebtedness to
Sir Frederick Menzies for kindly placing the resources of
the London County Council hospital services at my disposal;.
to the Medical Research Council for financial assistance
towards the expenses of the research; to Dr. D. S.
Sandiland, medical superintendent of St. Stephen’s
Hospital, Prof. H. M. Turnbull, and Dr. W. G. Barnard,
chief histologist to the London County Council, for much
help; to Sir Leonard Hill and his other colleagues at
the St. John Clinic and at the L.C.C. Arthritic Unit.
for their kind assistance.
REFERENCES
Allison, N., and Ghormley, R. K. (1931) Diagnosis in Joint
Disease, New York and London.
Aschoff, L., and Tawara, S. (1906) Brit. med. J. 2, 1103.
Charcot, J.-M. (1881) Clinical Lectures on Senile and Chronio
Diseases, New Sydenham Soc., London.
Clawson, B. J., and Wetherby, M. (1932) Amer. J. Path. 8, 283.
Coates, V., and Coombs, C. F. (1926) Arch. Dis. Childh. 1, 183.
Coombs, C. (1910-11) J. Path. Bact. 15, 489.
Dawson, M. H. (1933) J. exp. Med. 57, 845.
Fisher, A. G. T. (1922-23) Brit. J. Surg. 10, 52.
(1923) Brit. med. J. 2, 102. ;
(1929) Chronic (Non-Tuberculous) Arthritis, London.
Freund, E. (1928) Wien. Arch. inn. Med. 16, 73.
Hawthorne, C. O. (1900) Rheumatism, Rheumatoid Arthritis,
and Subcutaneous Nodules, London.
Hoffa, A., and Wollenberg, G. A. (1908) Arthritis Deformans und
sogenannter chronischer Gelenkrheumatismus, Stuttgart.
Klinge, F., and Grzimek, N. (1932) Virchows Arch. 284, 646 ;
286, 333 and 344.
McEwen, C. (1933-34) Amer. Heart J. 9, 101.
Neumann, E. (1888) Arch. mikrosk. Anat. 18, 130.
(1896) Virchows Arch. 144, 201.
Nich E. H., and Richardson, F. L. (1909-10) J. med. Res.
49.
(1910) Arthritis Deformans, Boston.
Poynton, F. J., and Still, G. F. (1899) Trans. path. Soc. Lond.
50, 324.
Schlesinger, B., Signy, A. G., and Amies, C. R. (1935) Lancet,
145.
>
Strangeways, T. S. P. (1919) Trans. med. Soc. Lond. 42, 12.
(1920) Brit. med. J. 1, 661.
THE LANCET]
ACQUIRED HAMOLYTIC JAUNDICE
WITH UNUSUAL FEATURES .
By E. S. Dutmtm, M.B. Dubl., Ph.D.
ASSISTANT PATHOLOGIST, ROYAL HOSPITAL, SHEFFIELD, AND
DEMONSTRATOR IN PATHOLOGY, SHEFFIELD UNIVERSITY
THE following case, observed continuously for nine
months, is recorded because unusual features in the
blood picture made the diagnosis at first uncertain,
and because few similar cases have been described
with autopsy findings.
CLINICAL RECORD
The patient, a widow aged 70, was admitted to the
Royal Hospital, Sheffield, on Nov. 15th, 1935, with a
history of breathlessness, palpitation, and pain in the
legs and back for the past year. She also complained of
a continuous nagging pain in the upper abdomen, unre-
lated to food. About six months previously she had
found that she was becoming pale, and since then
had been unable to do the housework. During the past
three months she had had weekly injections of Campolon,
and had improved slightly, the pain becoming less severe.
She had always been pale, but could remember no previous
attack of ansmia; nor was there any family history of it.
She was slightly deaf.
Condition on admission.—She was a well-built, well-
nourished -woman, with definite jaundice of the skin and
sclera. She looked pale and ill and was very weak. Tem-
perature, 97-2° F.; pulse-rate, 84; respirations, 20. Tongue
clean and moist, not atrophic. Mouth and fauces normal.
Nails striated and brittle. Liver not enlarged. On per-
cussion the spleen was found to be slightly enlarged, but
it was not palpable. The muscles over the left upper
abdomen were somewhat rigid, and there was slight
tenderness there. No enlargement of glands could be
detected, and the heart, lungs, and nervous system were
normal.
Laboratory tnvestigations.—Blood examination showed :
Red cells... 1,190,000 Polymorphs 76%
White cells ay 10,400 Lymphocytes 21°5%
Heemoglobin 26% Mononuclears 2%
Colour-index 1:1 Eosinophils 05%
Halometer reading 8'Ou
Reticulocytes .. 67%
Fragility range .. 0°44-0°36%
Films showed macro- and micro-cytosis. Almost two-thirds
of the cells showed polychromasia, and nucleated red cells were
numerous. The van den Bergh reaction was indirect positive,
and the Wassermann reaction negative.
Several stools were examined and all were of normal
consistence and failed to show blood by the benzidine
test. The urine was dark brown and acid. The stomach
juice was greatly reduced in quantity—not more than
50-60 c.cm. being obtainable in three hours after hista-
mine stimulation in the fasting state—but normal in com-
position. Radiography of the long bones showed nothing
unusual. A Isevulose-tolerance test on Feb. 7th, 1936,
showed an initial hypoglycemia followed by a biphasic
response, resembling that found in von Gierke’s disease,
but well within normal limits. It suggested that the
glycogen had been mobilised with some difficulty. The
icterus index on Jan. 8th, 1936, was 10 units.
Clinical course.—The blood picture remained much the
same for a month but the patient then began to improve.
Campolon 2 c.cm. daily was given from Dec. 18th, 1935,
onwards, being supplemented by ferrous sulphate grains 3
t.d.s. until Feb. 9th when Marmite alone was administered.
The improvement continued until finally she was dis-
charged on March 22nd, 1936, with a hemoglobin figure
of 54 per cent. and reticulocytes 8 per cent. Campolon
was resumed before her discharge, and she continued to
receive campolon, marmite, and ferrous sulphate. She
attended hospital once a fortnight for blood examinations,
the first made on March 3lst showing a maximum of
60 per cent. hemoglobin and reticulocytes 8 per cent.
She was not seen after this until April 27th, when the
hemoglobin had fallen to.66 per cent. and reticulocytes
were 10 per cent. She said that she had been confined to
bed by a recurrence of the pains in her legs and back.
DR. E. S. DUTHIE : ACQUIRED HASMOLYTIC JAUNDICE
Liver enlarged (3 lb.);
[may 15, 1937 1167
The fall in hemoglobin continued with a progressive rise
in reticulocytes, and she was advised to return to hospital
but refused. On July 31st she was readmitted with the
following blood picture :—
Red cells .. -- 1,020,000 Polymorphs .. -- 92%
White cells ea 38,000 Lymphocytes ig 5%
Hb. ey de 29 % ononuclears ee 3%
C.I. S $
Reticulocytes 81%
Price-Jones curve gave a mean corpuscular diameter of 7°155
with v= 18'113% and o= 1'298. The blood film showed
polychromasia, macrocytes, microcytes, and numerous normo-
lasts, many with moniliform distortion of the nucleus. Poly-
morphonuclears included many banded forms. No primitive
cells. Indirect van den Bergh, 2 units.
She was again very pale and jaundiced and visibly
distressed. Her mental condition was confused and she
was at times comatose. The pulse-rate was 90-100 and
respirations 30. Temperature 99°. Blood transfusions of
250 and 320 c.cm. were given and she improved con-
siderably, her mental symptoms and respiratory distress
disappearing. A further transfusion four days later was
followed by an attack of dyspnea, but she recovered and
remained well for six days, after which she again became
extremely ill with a hemoglobin value of 30 per cent.
A further 250 c.cm. of blood was given but she died next
day.
POST-MORTEM FINDINGS
Adipose tissue in fair amount everywhere. Heart
enlarged (14 oz.). Musculature pale, but no fatty
striation. Aorta atheromatous with severe ulceration
in abdominal portion. Lungs normal, except for some
cedema of the bases. Stomach and intestines normal.
on section it had a mottled
appearance due to areas of congestion. Microscopically
the centres of the lobules were congested, with hamo-
fuchsin in the central liver cells, and iron pigment mainly
at the periphery. Biliary tract normal.
Kidneys.—The left kidney was almost completely
replaced by a large hydronephrotic cyst. It was apparently
of the floating type. The right showed a mild chronic
nephritis, with an iron-containing exudate (hemoglobin)
in the tubules, and iron in the cells of the convoluted
tubules. In the remaining substance of the left kidney
iron was also present. The spleen was enlarged (15 oz.)
and had numerous fibrous adhesions. The cut surface
had a rich dark red pulp; trabecule and Malpighian
corpuscles showed distinctly. A single small infarct was
present on the left border. Microscopically the pulp was
engorged with red cells, the venous capillaries being
moderately distended or collapsed. There was little iron
pigment and only a moderate amount of hemofuchsin ;
no fibrosis or increase of the reticulum. Irythrophago-
cytosis common. Cells of the myeloid series not numerous.
Malpighian bodies small. Many normoblasts and a few
megaloblasts seen. No Gandy-Gamna nodules,
Lymphatic system.—In the glands examined, which
were mainly thoracic and abdominal, iron was found in
moderate quantity in large macrophages lying in the
sinuses. Considering the degree of blood destruction the
. quantity was not very great.
Marrow.—Rich red bone-marrow in the shafts of the
humerus and femur but not in the tibia. Centre of the
shafts occupied apparently by solid mass of dark red blood,
fading at the periphery into a more organised and less
darkly stained portion. On section the picture was very
similar in both bones. Adipose tissue was almost absent,
being replaced by large collections of erythrocytes lying
in what appeared to be deeply congested capillaries and
sinusoids. Here and there among the erythrocytes,
especially at the edge of the marrow, were small active
erythropoietic foci, or less often groups of myeloblasts.
The walls of the sinusoids containing the erythrocytes
were not clearly defined, though with azan staining reti-
cular fibrils with cells could be determined, apparently
dividing the erythrocytes into groups. Megakaryocytes
were numerous and evenly distributed. There were few
nucleated red cells in these collections of erythrocytes,
whereas in other organs such as the liver and kidney
nucleated red cells were usually conspicuous inside the
vessels. A similar lack of nucleated red cells was noted in
the congested sinusoids of the spleen. It seems that some
mechanism is at work which separates them out.
1168 THE LANCET]
Ribs, vertebre, and sternum showed similar pictures,
except that the erythrocytes were fewer in proportion to
the nucleated elements, and that they tended to be within
well-defined sinusoids and capillaries. Hzemopoiesis was
very active in these bones. LErythrophagocytes were
fairly common. Megakaryocytes were numerous and well
distributed.
No hemopoietic foci were found outside the bones.
The thyroid showed colloid changes with degeneration
and calcification of the lower portion of the right lobe.
DISCUSSION
Fig. 1 shows the hæmoglobin and erythrocyte and
reticulocyte counts in the nine months before death.
A fall in the reticulocytes was reflected in a rise in
the first two, and vice versa. Since on the scale
5,000,000 red cells per c.mm. is equivalent to 100 per
cent. hemoglobin, a rise in the colour-index is indi-
cated by the red blood-cell curve lying below the
hæmoglobin curve. Mean cell diameters measured
by the method of Price-Jones (1933) were on Dec, 16th
7-25 u, on Feb. 28th 7-023 u, on March 31st 7-075 u,
and on July 3lst 7:155u. The curves on Feb. 28th
(when reticulocytes were only 4°5 per cent.) and on
July 3lst (when the patient was severely ill and
reticulocytes. were 81 per cent.) are compared in Fig. 2.
The curve made during the acute hemolytic crisis is
remarkable for the greatly increased variability, due
mainly to the large numbers of macrocytes and
microcytes. In the recovery stage these cells dis-
appeared and the curve lay almost within normal
limits. In form the curves are essentially similar
to those given by Hawksley (1936), though in none
of his cases was there any megalocytosis. The halo-
meter reading made during the first crisis was appa-
rently incorrect. The large numbers of megalocytes
seem to be equally balanced by the large numbers
of microcytes and by the Price-Jones method the
mean diameter is almost normal. Fragility tests
MARMITE +
RE-AOMITTED
<<
CAMPOLON
<— DISCHARGED
x Š
F
= Ë
1
<— MARMITE
20 60 00 140 18Ò 220 260 300
DAYS
FIG. 1.—Graphs showing the result of blood investigations
over the observation period.
showed little variation from normal. The highest
result 0:475 per cent. to 0-300 per cent. was obtained
by the method of Beebe and Hanley (1936), and is
little above the normal standard they give. Unfortu-
nately the mean cell volume measurements made
were inaccurate.
The picture of a severe hemolytic anemia with
raised colour-index, high reticulocyte count, and
normal or almost normal fragility, suggested acholuric
sjaundice.. A similar case described by Reynolds
(1930) had a colour-index of 1-3, a reticulocyte count
of 95 per cent., and fragility of 0-40 per cent. to 0-32
per cent. This was cured by splenectomy, making the
diagnosis of acholuric jaundice almost certain. In
DR. E. S. DUTHIE: ACQUIRED HZMOLYTIC JAUNDICE
[may 15, 1937
the terminal attack especially, in which the tempera-
ture was usually 97-0°-99°8° and prostration and
mental symptoms were severe, the disease bore a
certain resemblance to those cases described by
Lederer (1925, 1930), and classified by him as being
acute hemolytic anemia. There is, however, little
œ O
oO oO
NUMBER OF RED CELLS
D
=
3 4 5 6 7 8 9 0 i
DIAMETER IN MICRONS
FIG. 2.—Price-Jones curves in the recovery eriod (interrupted
line) and during the terminal crisis (continuous line). The
actual values are as follows. Recovery period, Feb. tite
1936: M.D.=7° ; o = 0°784; v=11'164 pe oon
megalocytosis, 0 per cent.; microcytosis, 1
Reece 4% per cent. During the crisis J uly 28th, wire :
M. 98; v=18°113 per cent.; megalo-
microcytosis, 15 per cent.; reticulo-
= g =
cytosis, i ae cent. ;
cytosis, 81 per cent.
doubt that the anæmias he describes are merely
acute attacks of acholuric jaundice—a view taken by
Scott (1935), Murray-Lyon (1935), and Vaughan
(1936)—and there is apparently no real basis for a
separate classification. Whitby and Britton (1935)
consider the good transfusion results in Lederer’s
anzmia to be a valuable diagnostic point, as is also
the experience of other authors and of Lederer him-
self. In the present case the results of transfusion
were unsatisfactory, recalling in some ways those
obtained in two of Dawson’s cases (1931). While
the first two transfusions of 250 c.cm. and 320 c.cm.
given 13 days before death were followed by a definite
improvement in the general condition, this was not
maintained. A further transfusion 4 days later was
followed by a crisis, the patient becoming more
deeply jaundiced, but without the unpleasant symp-
toms seen in Dawson’s last case. A consideration of
the first attack, in which no transfusions were given,
might suggest that they should be withheld as long
as possible, though in the terminal attack the patient
was much more ill. None of the other remedies given
seem to have been useful. When they were first
administered the patient was in a recovery stage,
and their continuance did not prevent a second attack.
Splenectomy, which was not feasible owing to the
patient’s age and general condition, was the only
treatment likely to have been successful.
The autopsy findings agree with those of the six
cases given by Turnbull (1936). Similar collections of
erythrocytes were found in the marrow at autopsy,
though he does not appear to be certain, especially
in the last two cases, whether they always lay within
definite vessel walls or not. The condition, while
resembling hemorrhage into the marrow, clearly
differs from it, since active hemopoietic islets are to
be found all through the mass of erythrocytes, and
there is no evidence of degeneration. The process
as seen near the edge of the marrow fat, where such
exists, is due to a congestion and widening of the
marrow capillaries as the fat disappears, so that the
. `
THE LANCET]
blood comes to be in sinusoids lined by the former
capillary walls. This is confirmed by the fact that
the congested sinusoids are about equal in area to
the fat cells they replace. The engorgement of the
splenic pulp is another feature that seems to be
common to all cases.
SUMMARY
1. A case of hemolytic icterus was observed for
nine months before death. 2. Mean cell diameter
measurements by the Price-Jones method showed a
high coefficient of variability, reaching 18 per cent.
during the terminal crisis. Macrocytes and megalo-
cytes were then equally balanced, so that the mean
diameter remained within normal limits. 3. Autopsy
findings were enlargement of the liver and spleen,
the splenic pulp being engorged with erythrocytes.
The femur and humerus contained a rich red bone-
marrow all through their length, composed mainly
of sinusoids filled with mature erythrocytes, and
apparently derived from the pre-existing capillaries.
The tibia was normal. |
I should like to thank Prof. A. E. Naish for permission
to publish this case and for his help during the period of
the observations. I also wish to thank Dr. Alice Stewart
of the Royal Free Hospital, London, for making one of
the Price-Jones determinations and for her interest and
advice. |
REFERENCES
Beebe, R. T., and Hanley, E. P. (1936) J. me lead Med. 21, 833.
Dawson, Lord (1931) Brit. med ; ; .
Hawksiey, J. C. (1936) J. Path. Bact. 43, 565.
i 5)
— (1930) Ibid, 179, 228.
Murray-Lyon, R. M. (1935) Brit. med. J. 1, 50.
Price-Jones, C. E Red Blood Cell Diameters, London.
Reynolds, G. P. (1930) Amer. J. med. Sci. 179, 549.
J. M. (1936) The Anæmias, London.
; L. E. H., and Britton, C. J. C. (1935) Disorders of the
Blood, London.
Clinical and Laboratory Notes
LYMPHOSARCOMA SIMULATING
DUODENAL ULCER
By S. Keys, M.R.C.S. Eng.
ASSISTANT PATHOLOGIST TO THE QUEEN MARY’S HOSPITAL
FOR THE EAST END, LONDON; AND
W. W. WALTHER, M.B. Lond.
DIRECTOR OF PATHOLOGY AT THE HOSPITAL
THIS case shows under what a simple disguise
lymphosarcoma may appear to the clinician. As a
rule it is possible to diagnose general lympho-
sarcomatosis before the patient comes to the post-
mortem room, but in this case the disease showed
symptoms referable to one organ only, and the true
nature of the condition was only suspected a few days
before death.
The patient was a man aged 23, lorry driver by occupa-
tion. He was admitted complaining of abdominal pain
of five years’ duration. The pain was just below the
umbilicus and passed to either side of the abdomen. At
first it came on 4—1 hour after meals and lasted up to
2 hours. The attacks came on spontaneously and used
to last for 3-4 weeks. There were free intervals of 3—4
months. Lately the attacks had come on with greater
frequency and five weeks before admission he vomited
for the first time. The vomiting became more frequent,
usually occurring up to 15 minutes after a meal, and
made no difference to the pain. There was no hematemesis,
Although the patient looked thin he did not complain
of loss of weight. His appetite was good and bowels were
regular. He had never noticed signs of melena,
Occasionally he had attacks of flatulence.
CLINICAL AND LABORATORY NOTES
{may 15, 1937 1169
The patient looked anemic. The blood count was :
hemoglobin 44 per cent., red colls 3 million, colour-
index 0-73, leucocytes 18,600 per c.mm. (polymorphs
' 77 per cent., lymphocytes 19 per cent., monocytes 3 per
cent., eosinophils 1 per cent.). There was no abdominal
tenderness present and no other abnormal physical signs.
Below the left angle of the mandible there was an oval,
mobile swelling, l in. by 4 in., which the patient appeared
to have had as long as he could remember.
A provisional diagnosis of duodenal ulcer was made
and the patient was treated by drip transfusions and diet.
Frequent occult blood examinations were strongly positive,
but a fractional test-meal could not be estimated owing
to the gastric juice containing abundant altered blood.
There was no improvement whatever. In spite of the
drip transfusions the hemoglobin fell, although at times
a rise of 1-3 points was recorded. He vomited on several
occasions and each time the vomit contained altered
blood. Three weeks before death a white cell count was
11,500 per c.mm. with the differential count of polymorphs
74 per cent. lymphocytes 25 per cent., and monocytes
l per cent. A week before death the blood-serum was
noted to be icteric and gave a direct positive van den
Bergh reaction. This suggested the possibility of malignant
disease obstructing the flow of bile, and on examination
a tumour was discovered in the epigastrium. There was
also general enlargement of the cervical glands. A
fixed mass in the pelvis was found just before death.
Altogether the patient was in hospital about seven weeks.
POST-MORTEM FINDINGS
Emaciated young man. Slight fullness of the thyroid
gland. A few visibly enlarged glands in the neck.
Abdomen distended. Tonsils not enlarged. The peri-
cardial sac contained about 6 oz. of clear straw-coloured
fluid. The heart was normal in size, but the pericardial `
surface was covered by many patches of secondary growth ;
the chordæ tendinixw also contained a few nodules, but
the rest of the endocardium was normal. The lungs were
congested ; there were secondary deposits of growth in
the right and left fourth ribs. The left lobe of the thyroid
was normal; the right lobe was somewhat enlarged and
contained a hard growth about the size of a walnut ;
the cut surface was hard and homogeneous.
The abdomen contained numerous loculated collections
of faintly purulent fluid. The omentum was invaded by
growth and was lying rolled across the epigastrium. All
the abdominal lymphatic glands were greatly enlarged
and matted together. A large mass of glands was present
in the pelvis. The inguinal glands were enlarged. The
stomach was infiltrated by growth and the mucous
membrane showed numerous round ulcers with raised
edges. One very large ulcer, 1} in. in diameter, had
completely perforated the posterior gastric wall and its
edges were adherent to the liver.
The pancreas was one mass of growth. Glisson’s capsule
contained a secondary deposit, but the liver itself appeared
normal. The spleen was also of normal size and looked
healthy. Neither of these two organs contained macro-
scopical deposits of growth. Both kidneys were greatly
enlarged and contained circumscribed neoplastic deposits
of various sizes. There were a few enlarged glands along
the left ureter. The bladder was normal. Both testicles
were normal. The brain and skull showed no abnormality.
MICROSCOPICAL EXAMINATION
Glands in neck.—Filled with large round cells, contain-
ing a well staining nucleus almost filling the cell. The
cells are attached to a faint, branching reticulum, and show
active mitosis. The very scanty lymphoid tissue is
compressed at the periphery of the gland. Bands of
fibrosis can be seen traversing the gland.
Stomach.—The mucous membrane shows partial destruc-
tion by sarcoma cells. There is derangement of the
alveolar structure of the mucosa. The spread appears
to take place through the submucosa, which contains
an uninterrupted solid mass of sarcoma cells. The gastric
muscle is partially invaded by growth.
Omentum.—Complete invasion by growth.
Liver.—The liver cells contain a considerable amount of
pigment, but appear otherwise normal. The hepatic
1170
THE LANCET]
CLINICAL AND LABORATORY NOTES
[may 15, 1937
arteries are clear but the portal veins contain numerous
malignant cells, which as yet show no evidence of invasion.
Spleen.—The lymphatic element is replaced by large
round cells with deeply staining nuclei. There is consider-
able congestion. The sinuses are filled with blood
corpuscles and the sinusoidal walls appear normal.
Heart.——Shows the growth infiltrating between the
muscle strands and separating them. A coronary artery
shows invasion of the adventitia, but media and intima
are free of growth.
Thyroid.—Shows invasion of the right lobe.
left lobe appears normal.
It is impossible in this case to determine the site
of the primary growth, the enlarged gland in the
neck being the only lymphatic abnormality to have
existed for any length of time. It seems unlikely
that the gastric symptoms could have been due in
the first place to a neoplasm of such undoubted
malignancy, for the patient would probably not have
lived for five years. :
It is interesting to note that generalisation of
the disease occurred without alteration of the
lymphocyte count. The raised polymorph count
can be accounted for by the local peritonitis caused
by the gastric ulceration.
We are grateful to Mr. H. W. B. Wright for permission
to publish this case.
The
LYMPHATIC CYST OF THE MESENTERY
AND VOLVULUS IN A CHILD
By REGINALD C. JEWESBURY, D.M. Oxon.,
F.R.C.P. Lond.
PHYSICIAN IN CHARGE OF THE CHILDREN’S DEPARTMENT,
ST. THOMAS’S HOSPITAL, LONDON
THE patient, a little girl aged 5 years and 8 months,
was well until 2 years of age when she first complained
of abdominal pain. Six months later she had another
attack of pain accompanied by vomiting. At the age
of 3 years and 9 months she was seen for the first
time by a doctor. She then complained of acute
umbilical pain and suffered from retching but did
not vomit. Her pulse-rate was 100 and her temperature
98:4° F.; the only physical sign was some epigastric
tenderness. The bowels were regular. Taking only
fluids by mouth (with lemon and glucose solution
to combat acetonuria +--+) this attack was over in
three days. During the attacks of abdominal pain
she always adopted a kneeling position keeping her
head bent down.
After this attack further medical advice was sought,
a diagnosis of ‘‘ acidosis’’ was made, and the appro-
priate treatment ordered. Following this she had
several minor attacks for which it was not necessary
to call her doctor. When aged 4? years she had
another fairly severe attack and was given glucose
by mouth and per rectum. Two months later came
another less severe attack and there was another
one again after two more months’ interval. At this
period the urine showed coli bacilluria which re-
sponded to treatment.: There were no further attacks
for about 7 months, after which she again suffered
from abdominal pain and vomiting ; during this attack
the pulse rose to 110, and there was some abdominal
distension.
I saw the child for the first time on the third day
of this attack; the abdomen was distended and
rigid, but free from pain or tenderness. The pulse-
rate was 120 and the facies was ‘‘ abdominal” ; in
fact the signs were those of acute obstruction with
general peritonitis. Laparotomy was performed that
same day, as speedily as could be arranged, by Mr
Max Page.
The whole of the small intestine was distended and
deeply congested, as was also the whole of the mesentery.
The bowel was completely obstructed after having become
rotated on the mesentery. The strangulation was reduced
by rotating the whole of the small intestine through three
complete turns. In the cavity of the pelvis, and rising
slightly out of it, was a large butter-yellow-coloured
cyst which at first looked like a distended bladder; the
cyst was opened and about 15-16 oz. of thin milk-like
fluid was evacuated ; the cyst was situated in the mesentery
close to its attachment to the small intestine about 2 ft.
above the ileocecal valve. The cyst wall was removed
and tied off, and the abdominal wound closed, a drainage
tube being left in.
The child died about four hours after the operation.
The following are notes from post-mortem report
by Dr. S. Wyard.
The whole of the small bowel from the duodenojejunal
flexure to the ileocecal valve is enormously distended ;
the wall is plum-coloured and there are numerous subserous
and submucous hemorrhages. The surface is smooth and
shining. About half an inch above the ileocecal valve is
a mark encircling the bowel obviously due to a tight
strangling constriction. The cecal and ascending meso-
colon is congested and shows many hemorrhages, the
whole’ of the mesentery is also congested and hamorrhagic.
About two feet below the duodenojejunal flexure is a
surgical incision about four inches long, involving the
mesenteric border of the bowel; the incision has been
completely closed by sutures. Fluid removed from cyst,
pale yellow and turbid, contained much albumin but no
organised elements. The wall of the cyst on section
appeared to consist of mesenteric tissue.
The time of origin of this cyst is doubtful, it may
have begun when the child was two years old, or it may
have been congenital. Its recognition during the early
stages was obviously difficult, but the recurrent
attacks of abdominal pain and sickness were probably
due to it. Refuge in the diagnosis of ‘ acidosis”?
was a misleading factor in this case as it has been in
others.
Lymphatic cysts of the mesentery are rare and not
many cases have been recorded in children.
Bland-Sutton (1922) comments on “a rare but
interesting lesion known as chyle cyst of the mesen-
tery.” He compares them to omental hydroceles and
ovarian cysts, and he states further that in infants
or children, where many of them are found, these
cysts are connected closely to the mesenteric border
of the intestine and push their way between the layers
of the mesentery. He concludes that these cysts
are important, for they have caused fatal intestinal
obstruction.
Swartley (1927) has written an interesting article
on ‘‘ mesenteric cysts’? and describes the case of
a girl, aged 7 years, which is very similar to the
case which I now publish.
Eve (1898) reports the case of a cyst between the
layers of the mesentery. of the jejunum in a male child
aged 11 weeks; and also in a child aged 3 years and
8 months, who had been admitted to hospital for
“intestinal obstruction.” Braquehaye (1892) classifies
mesenteric cysts as follows :—
1, Sanguineous cysts—usually traumatic and occurring
as diffuse haemorrhages into the mesentery, into pre-
existing cysts, or into solid tumours.
2. Lymphatic cysts, comprising chylous and most of
the serous cysts. These arise in the thoracic duct, in the
chylous vessels, or in the lymphatic glands of the
mesentery.
3. Congenital cysts, chiefly dermoid, but occasionally
cysts of the Wolffian body.
Lymphatic cysts are usually situated in the mesentery
of the small intestine, usually near the spinal border,
THE LANCET]
ROYAL SOCIETY OF MEDICINE: OTOLOGY
[may 15, 1937 1171
but they have also been reported to occupy the
mesocolon.
Pederson (1928) has reported the case of mesenteric
cyst in a gitl, aged 7 years, which ruptured after
an injury and in whom there was a history of previous
intermittent attacks of abdominal pain. Collins and
Berdez (1934) report the case of a mesenteric cyst
in a boy, aged 4 years, in whom a diagnosis of appen-
dicitis had been made. Friend (1912) states that
cysts of this nature may occur at any age and in
either sex. In 52 cases, the youngest was a child
of 5 weeks and the oldest 80 years. Rasch (1890)
. MEDICAL
ROYAL SOCIETY OF MEDICINE
SECTION OF OTOLOGY
AT a meeting of this section on May 7th, the
president, Dr. DOUGLAS GUTHRIE, in the chair, a
discussion took place on
Otitis Media in Early Childhood (under 5 years)
Dr. Le M&s (Paris), opening the discussion, dealt
almost exclusively with the kind of cases seen at
15 months of age and under, based upon twelve
years’ experience at the children’s hospital in Paris.
He said he had to include mastoiditis, as no infection
of the tympanic cavity occurred without infection
of the mastoid too. Infection extended from the
pharynx to the mastoid. The Eustachian tube was
very short, but in the infant its calibre was larger
than in the adult; the mastoid antrum in the infant
was also larger than in the adult, and its external
wall was a mere thin lamina of bone. In the first
stage of otitis the rhino-pharyngitis spread to the
Eustachian tube, and the change of colour in the
tympanic membrane indicated its participation in the ©
reaction. Usually a few days after the performance
of paracentesis the condition improved. A more
serious type of otitis was the primary purulent
oto-mastoiditis. To this condition Dr. Le Mée gave the
name “unsuspected otitis,” as the symptoms, instead
of being localised in ear and pharynx, were systemic
and general. In an infant febrile with no apparent
cause, this type of mastoiditis must be suspected.
A third and less frequent type was an otitic mastoiditis,
and here a bone lesion was present, requiring removal
of bone. A skiagram was useful in this type, but every
care must be taken in interpreting it. Dr. Le Mée
had found it best to do the mastoid operation in
two stages. He wished, generally speaking, to insist
that the surgery in infants must be done with great
speed. The routine in his hospital was first to incise
the periosteum and a day or two later to remove the
portion of bone.
Dr. T. RitcH1E RopGER (Hull) analysed the 599
cases of acute otitis media seen in children under
3 years of age at the Victoria Hospital for Children,
Hull, since the ear and throat department was
established there nine years ago. Of these cases
249 were bilateral, involving 848 affected ears;
185 cases were of infants under one year of age,
80 being bilateral infections. There were 200 cases
in children between one and two, 86 of them being
bilateral. Of the 214 cases between two and three,
83 were bilateral, and 26 per cent. required mastoid
operation. The bilateral condition was most frequent
in the first four years of life, and thus both ears should
be examined, even when the mother drew attention
to one only; and further thorough examinations
reports the case of “‘ a cyst between the two layers of
the mesentery ” containing 6 pints of fluid which
he thought had been caused by rupture of a chylous
vessel of the mesentery.
e REFERENCES
Bland- Uton; J. (1922) Tumours, Innocent and Malignant,
Braquehays, J. (1892) Arch. gén. Méd. 2, 291.
come. A.N RET? Berdez, G. L. (1934), Arch. Surg. 28, 335.
Eve, F. (1898) Med.-chir. Trana, ne 51.
Friend, E. Aa Surg. Gynec. O stet. As, 1.
Pederson, T ae FH deal ik ote baie , 85 7.
Rasch, A. (18 90) Trans. obstet. Soc. oma 31,
Swartley, W. B. (1927) Ann, Surg. 85, 886.
311.
SOCIETIES
should be made at intervals during the whole time
the patient was under observation. Sometimes the
appearance of the tympanic membrane was deceptive.
Probably many members could recall cases in which
the temperature remained high or malaise continued
despite myringotomy on one side, and this was
explained by a discharge from the other ear. The
incidence of mastoiditis requiring operation proved
to be higher than was expected—namely, 19 per
cent. of all infected ears at an age under one year ;
in the third year it was 26 per cent., in the fourth
year 21 per cent. The proportion of cases operated
upon was sure to be affected somewhat by the
personal views of the surgeon. Every effort was made
the prevent chronic otitis; if conservative measures,
including removal of adenoids, were not successful,
operation was recommended at a time which varied
with the nature of the case. When mastoid tenderness
or high temperature did not abate, operation was
carried out without further delay. A bilateral infec-
tion did not necessarily mean a more virulent form of
case. Otitis media was often associated with diarrhea
and vomiting, and sometimes a coincident chest
condition had to be excluded as the cause of the
symptoms and signs before the mastoid was explored.
The incidence of tuberculosis in these cases had proved
to be surprisingly small, under 5 per cent. in the
series described ; in a discussion on the subject in 1914
the incidence given was 50 per cent. of cases in
Edinburgh up to one year of age and 27 per cent.
in the second year of life. Dr. Rodger attributed
this vast improvement to better sanitation and
hygiene, and the active educational work of child
welfare and other clinics. When tubercular otitis
did occur, the treatment must be radical.
Dr. J. H. Espgs (Birmingham) presented an analysis
of the results of consecutive post-mortem examination
of the middle ear and mastoid antrum of 880 children,
80 per cent. of whom were aged 2 years or under.
The rest ranged between 2 and 14 years, but the
number over 5 years was small; 52-8 per cent.
of the children were found to have a purulent infection
of the middle ear and mastoid antrum. Of children
dying in their first year as many as 62 per cent. had
otitis media, in the second year 53 per cent., in
the third year 33 per cent.; otology might thus
play some part in reducing the mortality. The
incidence of otitis media decreased progressively
with the child’s age; a slight rise between the 5th
and 6th years might be related to school entrance.
Among 496 children in whom one or more accessory
sinuses were examined post mortem, a purulent
infection was found in 152 (30:6 per cent.); 280 had
otitis media and 161 had no sinusitis. In 200 cases
examined bacteriologically, some had two or three
kinds of virulent organisms; by far the commonest was
the streptococcus. Tubercle bacilli were demonstrated
1172 THE LANCET]
in 2 cases, the diphtheria bacillus in one; 238
infants under 2 years of age had severe diarrhwa and
vomiting, either as a major complaint or a com-
plicating factor. Dysentery organisms were found
in 4 of these cases, 2 of which showed definite
evidence of bacillary dysentery. Dr. Ebbs did not
attribute the gastro-enteritis to otitis media but
suggested that it was a serious factor in bringing
about the fatal issue. A high temperature was
nearly always associated with acute otitis media.
Many patients showed their infection by a steep
rise in the pulse-rate; in certain infants, who main-
tained a temperature of 96° and 97°F. for some
days, the onset of-the infection was marked by a
jump in the pulse-rate. The ears of all infants with
pronounced gastro-intestinal disturbance should be
examined ; drums should be freely incised but more
extensive operation should be delayed when possible.
In prophylaxis, breast-feeding was very important.
Only 2 among this series of autopsies were of infants who
. had been breast-fed for an appreciable time. The danger
of exposing these infants to respiratory affections
suffered by adult contacts must not be forgotten. Dr.
Ebbs said that the results of his investigation pointed to
a possible codperative effort between the pzediatrician
and the oto-laryngologist which might be of very
great value in the reduction of infant mortality.
Mr. W. STREK ApAmMs (Birmingham) spoke particu-
larly of medical as contrasted with surgical otitis.
Patients admitted to hospital because: of something
else who developed otitis caused considerable anxiety.
Of 15 cases of secondary otitis developed in his hospital
during the last two years 10 belonged to the diarrhea
and vomiting group. Of the infants who had diarrhea
and dysentery about a third died; thus the
problem was very serious.
Mr. C. E. Scorr (Edinburgh) said that in the
ear and throat department of the Royal Edinburgh
Hospital for Sick Children, he and Dr. R. B. Lumsden
had treated 564 cases of suppurative otitis media
between 1934 and 1936 inclusive; 145 of the children
were under a year old and 419 were over one but
under five years old. 154 required operation; of
136 who were subjected to the Schwartze operation
132 recovered. As to complications, 2 developed
erysipelas, 4 measles, 4 scarlatina, 2 kidney trouble.
The only intracranial complication was thrombosis
of the lateral sinus (4 cases). Myringotomy was
carried out 52 times, and 14 of those patients subse-
quently required a Schwartze; 22 per cent. of the
total number had a Schwartze done without previous
myringotomy. They had been impressed with the value
of the X ray picture of the mastoid, even in such
young infants. Tuberculous infection of the middle
ear was formerly much more common in young
children than now; in the period under review
the incidence was only 1:5 per cent. of the total.
Dr. LUMSDEN, referring to the occurrence of tubercu-
lous infection of the ear, said that at a hospital 35 miles
from Edinburgh the incidence was nearly 40 per cent. ;
yet a careful inquiry showed that the disease was
fairly evenly distributed between town and country
dwellers.
Mr. Eric WATSON- WILLIAMS (Bristol) said that the
results of an analysis of a series of cases of mastoid
disease made by him had suggested that the incidence
was highest in children under a year old; the highest
incidence of otitis media was in the first two years of
life. Otitis media meant infection of the whole middle-
ear tract. There was no barrier dividing the tym-
panum from the mastoid, which became infected a
few minutes after the tympanic cavity was diseased.
If a child’s condition caused it one sleepless night,
ROYAL SOCIETY OF MEDICINE : OTOLOGY
- Importance.
[may 15, 1937
that was an indication for myringotomy. Quick
operation was essential; a good average was a minute
for each month of age—e.g., for a child of 7 months,
a 7-minute operation. A 20-minute operation was a
severe ordeal for a young infant.
= Dr. McNarr Scott said that, as a paediatrician,
he was sometimes puzzled, when looking at the ears
of infants, to know what to do. A child perhaps
had an upper respiratory infection and a red ear-
drum, but showed no indication of being in pain.
Should that ear be opened? If left without opening
a certain number of infections subsided; in others
general symptoms increased and the ear had to be
opened next day. A red ear-drum was commonly
associated with pneumonia, but often no local inter-
vention was required. Type 3 pneumococcus seemed
to have a special predilection for the ear, and perhaps
the drum should always be opened when the infection
was of that type.
The PRESIDENT said that this subject had attracted
too little attention from otologists. Otitis media was
found in a large proportion of infants in hospitals,
whatever the disease which brought them there,
and at autopsy pus was found in the middle ear in
many of them. The question arose whether this was
a primary or a secondary condition, whether it was
responsible for the malnutrition, pneumonia, or gastro-
enteritis from which so many suffered, or was a
secondary phenomenon of comparatively slight
Ten years ago he had prepared a chart
to show the extraordinary prevalence of otitis in
infants; from 75 per cent. to 90 per cent. of infants,
who died from all causes before completing their
first year, had otitis. One reason for this high pre-
valence was that when the child was born there often
remained fragments of embryonic connective tissue,
such as filled the middle ear during embryonic life
and became absorbed at about the time of birth.
Portions might remain in the corners of the tym-
panum, however, and that embryonal tissue was very
liable to become infected. The President asked
why Dr. Le Mée did the mastoid operation in two
stages. He agreed with Dr. Ebbs that the mastoid
operation was seldom justifiable in children suffering
from gastro-enteritis. He did not think X ray evidence
very useful in connexion with mastoiditis in children,
but it might show the position of the lateral sinus,
and its state of pneumatisation.
Dr. LE MEE, in reply, said that since the mastoid
operations were done in two stages at his hospital
complications had been fewer; this experience was
shared by Neumann. He used as an anesthetic agent
very cold water or ice applied to the back of the ear ;
he was sure it prevented the infant feeling pain.
Dr. RITCHIE RODGER said that when he referred to
speeding up the operation he was not thinking of the
simple incision. |
ROYAL SUSSEX COUNTY HOSPITAL, BRIGHTON.—
At a special court of governors of this hospital on
May 5th it was announced that the electrical and massage
work which is carried out at present in a basement of the
hospital is to be transferred to an adjoining property
at a total cost of £8000, towards which Mrs. H. G. Latilla
has contributed £3750. A balance from a fund has
reduced the sum required to £2000, and the governors
are appealing for this sum. The new department is
to be called the Latilla department of physical medicine,
and it is hoped it will be opened early next year. The
transference will allow of a further extension of the X ray
department at the hospital, and provide room for the
installation of the Chaoul apparatus presented by the Sussex
branch council of the British Empire Cancer Campaign.
THE LANCET]
ROYAL ACADEMY OF MEDICINE IN
IRELAND
AT a meeting of the section of obstetrics on April 9th,
with Dr. T. M. HEALY in the chair, a paper on the
treatment of
Varicose Veins in Pregnancy
was read by Dr. EDWARD Sotomons. Sixty
patients, he said, were selected at the antenatal
department of the Rotunda Hospital for treatment
of varicose veins by injection. They were chosen
either on the ground that the veins would be easier
to inject during pregnancy or because of symptoms
such as cramps or swelling of the legs, irritation of the
skin, pain in the veins, or mental or physical dis-
coinfort. The condition was bilateral in 38 cases
and unilateral in 22, while.4 had varicosities on the
vulva as well. A history of phlegmasia was regarded
as a definite contra-indication to treatment, and in
all cases where impairment of the deep circulation
was suspected special investigation was made.
The injection was done with the patient lying down
and the leg slightly elevated; thus the empty-vein
technique was used, but a tourniquet was not required
since only clearly visible veins were injected. The
fluid injected was a sterile solution of quinine hydro-
chloride (0:266 g.) and urethane (0-133 g.) in 2 c.cm.
of distilled water, made by Parke Davis and Co.,
and the maximum amount given at one time was
- 2 c.cm., usually distributed in four doses at different
sites. In 15 of the 60 patients the veins were very
large and an Elastoplast bandage was applied to the
whole leg below the knee immediately after injection.
This was removed in three weeks’ time, and in 7
patients no further treatment was required. In the
other 8, further injections were given and the bandage
again applied. The interval between injections was
never less than a week, and at least a fortnight was
allowed between injections at the same site, so as to
let any reaction settle down. It was usually
advised that injections should begin near the foot and
work upwards, but in these cases the veins most
enlarged were injected first.
The results, said Dr. Solomons, were very satis-
factory, but not all the women were free from
subsequent discomfort. In 6 patients there was
enough inflammatory reaction to necessitate treat-
ment, and 2 of these said they would have rather
remained untreated. In 4 cases varicose veins of
the vulva were treated by injection with very good
results, and in 2, dramatic relief was obtained from
severe pruritus. It had only been possible to follow
up 45 out of the 60 patients, but these had no complica-
tions in the puerperium, and 3 had subsequent
confinements without recurrence of the condition.
The CHAIRMAN asked why the treatment was
stopped in the seventh month of pregnancy. He
also asked whether Dr. Solomons would limit injection
to cases in which there was actual pain. He regarded
the results as extremely good, and believed that
almost complete success might be expected among
patients who could afford to have more rest during and
after pregnancy.
Dr. A. H. Davipson said he understood that
urethane gave rise to a lot of pain if the injection did
not all get into the vein. Had Dr. Solomons
any experience of sodium morrhuate ?
Dr. O’DONEL BROWNE asked Dr. Solomons how
he decided on the site of injection, and said that
varicose. veins in the vulva, were often very difficult
to deal with.
ROYAL ACADEMY OF MEDICINE IN IRELAND
[MAY 15, 1937 1173
Dr. F. DOYLE had seen a patient who had had
injections for varicose veins and suffered great
trouble in subsequent pregnancies. He was rather
antagonistic to injections during pregnancy, though
they might sometimes be beneficial.
Dr. G. TIERNEY was in favour of the injection of
varicose veins after pregnancy, but was not
enthusiastic about injection during pregnancy. . If
it was done in the last three months he doubted
whether much relief would be obtained. For
varicosities of the vulva, especially during the early
months, it had a very definite place.
Dr. J. S. QUIN said that if the treatment of vari-
cose veins in pregnancy would allow a woman who
would otherwise be more or less bedridden to
get about, he thought it should be used; but if
the subsequent reaction, or the period that had
to elapse before recovery, was such that no obvious
benefit would accrue in the last two months of
pregnancy, then it seemed that the treatment was
unnecessary. In these cases one must consider not
only the patient but also the doctor. If anything
happened after the injection of a varicose vein, the
injection would certainly be blamed, whether or not
it had the remotest connexion with what had
happened. |
Mr. R. M. CoRBET said there were apparently two
classes of patient—the one with bad varicose veins
who kept them after delivery, and the one with bad
varicose veins who showed no sign of them six months
later. In the second type injection was probably
unnecessary, but in the first he was sure it was very
useful.
Dr. SOLOMONS, in reply, said that if he saw a case
in the eighth month that he thought could be cured
by injections in a fortnight’s time, then he gave a
course ; but otherwise he only treated patients up
to the sixth or seventh month. He did not attempt
injections unless the veins were causing discomfort.
One of the most severe. reactions he had got was in
a case in which he used sodium morrhuate. In
patients who had very large veins, especially near
term, injection treatment was foolish ; the treatment
then was an elastoplast bandage. He thought that
with the gradual advance of injection treatment,
sloughing would be much less frequent than at present.
If there was any doubt as to whether one was in the
vein it was best to withdraw the needle. He did not
consider that patients who were bedridden derived
any benefit from injections. Although certain veins
might go away after pregnancy, it had to be
remembered that the next time the patients became
pregnant they would suffer similar discomfort.
The best time to inject was when the veins could
be seen fairly easily.
Diabetes and Pregnancy
Dr. H. V. TIGHE read notes on three pregnancies
in a diabetic.
The patient came under his care in January, 1935.
She was aged 27 years, married 15 months, and pregnant
for the first time. She had been under treatment for
diabetes mellitus during the previous four years and two
months, and before becoming pregnant had been admitted
to hospital in diabetic coma. She was receiving 75 units
of insulin daily, and despite this her urine was rarely
sugar-free and her blood-sugar remained high. In April,
1935, when 32 weeks’ pregnant she went into labour.
The baby, weighing 4 lb., lived half an hour. Five months
later she again became pregnant and at 32 weeks gave
birth to a baby weighing 5 lb. which died shortly after
delivery. The third pregnancy began two months later,
and with a more stringent diet and larger doses of insulin
proceeded to 37 weeks when labour was induced. This >
1174 THE LANCET]
baby when born weighed 84 lb. and appeared healthy,
but died 48 hours after birth. At autopsy the cause of
death was found to be suprarenal apoplexy.
Dr. Tighe said that nothing was observed in this
case to support the view that the diabetic mother
benefits from an additional supply of insulin from the
foetus or that pregnancy produces a lasting exacerba-
tion of the diabetes. While insulin has greatly
lowered the maternal mortality, it has not proved
so effective in reducing the fetal mortality. The
causes of foetal death were poor control of the maternal
disease during the later months, hydramnios,
congenital abnormalities and over-development of the
foetus. Neonatal hypoglycemia, following hyper-
trophy of the islands of Langerhans, had also been
suggested as a cause of fœtal death, but no enlarge-
ment of the islands was found in the baby which
came to autopsy. Where there was dystocia due to
the large size of the babies he preferred induction to
Cesarean section.
Dr. O’DoNEL BROWNE knew of no recorded case
of diabetes with three pregnancies. This case was
characteristic in that the labours were premature,
hydramnios was present in each of the pregnancies,
the children were overweight, and while two were
born dead the other did not survive long. It would
have been interesting if Dr. Tighe had been able to
test the liquor amnii for glucose—particularly if
footal urine had also been. tested, for some authorities
claimed that the presence of glucose in the liquor
amnii indicated its origin as a transudation from the
maternal system since fetal glycosuria was extremely
rare, As regards treatment, Dr. Browne’s view was
that the diabetes should be treated irrespective of
the pregnancy and that induction should be practised
if disproportion was likely to arise owing to the size
of the fœtus.
Dr. QUIN disagreed with Dr. Tighe’s view that there
was no objection to a diabetic patient becoming
pregnant. The results of pregnancy in diabetes
were such that it should be discouraged unless means
could be found for obtaining more fortunate results.
Dr. Micxs referred to two cases of diabetes under
his care in which labour had been induced, in both
of which the baby had been strong and over the usual
weight at birth, and the mother had done very well.
In diabetes during pregnancy the urine should always
be tested for ketone bodies ; acute cases which went
too far were liable to become quite uncontrollable.
There was nothing to be gained by giving very large
amounts of insulin.
Dr. CoRBET said that of two diabetic cases under
his care during the last year one had had no trouble
at all, whereas the other was fatal; the patient
had been getting 90 units of insulin a day before
she became pregnant. The lesson to be learned
was that one must not allow oneself to do anything
in connexion with the pregnancy while the diabetes
was very severe. In these cases he always refused
to induce labour. In his case that died, the patient
came into labour herself, produced a macerated
fœtus, and died very quickly.
Dr. TIGHE, in reply, said that the diabetes should
be treated as a thing quite apart from the pregnancy,
and the pregnancy should be allowed to proceed |
normally. As the children of diabetic women were
not likely to be diabetic, there could not be any
plea for sterilisation of diabetics on eugenic grounds.
Face Presentation
Dr. Davipson, master of the Rotunda Hospital,
showed an X ray film of a primary face presentation»
ROYAL ACADEMY OF MEDICINE IN IRELAND
(may 15, 1937
and also presented an analysis of face presentation
at the Rotunda for the previous forty years. There
were 175 cases, excluding anencephalus, a frequency
rate of 1 in 450. A quarter of the patients were
primipare. The fetal mortality-rate was 8-6 per
cent. In 134 cases the foetus was delivered
spontaneously as a face presentation; 11 were
treated by internal version, 6 by Schatz and 7 by
Thorn’s conversion to vertex. Forceps were applied
to the face in 6 cases. Cesarean section was carried
out in 3 cases, perforation was required in 4, and
pubiotomy in 1. There were only 3 cases of impacted
face, a frequency of 1 in 58. During the ten years
1926-36 there were 77 cases of face presentation
of which 71 were born spontaneously as face presenta-
tions. If there was no disproportion the case should
be left to nature and spontaneous delivery expected.
Interference was required, however, if the face was
arrested at the brim or on the perineum. With
arrest at the brim conversion to vertex or preferably
internal version should be adopted; with arrest
on the perineum forceps might be applied. There
were very few cases of major disproportion in this
series, Cesarean section only being adopted on
three occasions.
Dr. O’DoNEL BROWNE pointed out that the
Rotunda incidence of face presentation, as given
by Dr. Davidson, was approximately half the incidence
generally reported—namely, 0-42 per cent. He
strongly advocated non-interference except in the
relatively rare instance when the fact became
impacted in the pelvic cavity as a mentoposterior.
In these circumstances conversion to vertex, or if
necessary internal version, was the treatment of
choice. In the earlier stages of labour, he practised
Schatz’s manœuvre and had been gratified by the
results. He strongly condemned forceps delivery
in cases of face presentation when the chin was
posterior, quoting the maternal fatality-rate
associated with such treatment as 12 per cent., with
a minimum fetal fatality of at least 50 per cent.
Dr. CORBET said that Dr. Davidson’s figures
were very good. He had only seen one case of true
impacted face, and this was terminated success-
fully by a forceps delivery after partial rotation ;
the mother and the baby both lived. He had seen
two face presentation cases where the neck was so
stretched that the baby could not hold its head up.
Most cases were diagnosed when the face was on the
vulva. The conversion of a primary face presenta-
tion in a multipara depended very largely on the
contraction of the uterus and on the actual position
of the face itself. Internal version could be exceed-
ingly difficult. It was safe to leave the vast majority
of face presentations alone, but one must be sure that
the face was the whole problem, and that the primary
fault was not disproportion. One should not wait
too long, but should watch the cases carefully so
as to be able to interfere in time if interference became
necessary.
Dr. DAVIDSON, in reply, said he thought the reason
why so few Cesarean sections were done was because
face presentation was a very uncommon result of
flat pelvis.
—
OPHTHALMIC HOSPITAL IN JERUSALEM.—This hos-
pital, which is under the auspices of the Venerable Order
of St. John, is planning large additions and an appeal
is being made for at least £20,000 to provide funds for the
erection of a new block to contain eight wards for paying
patients, and a new out-patient department.
THE LANCET | |
[may 15, 1937 1175
REVIEWS AND NOTICES OF BOOKS
Handbook of Hygiene
By JosePpH W. BIGGER, M.D., D.Sc., F. R.C.P.L,
D.P.H., Professor of Bacteriology and Preventive
Medicine, University of Dublin. London: Bailliére,
Tindall and Cox. 1937. Pp. 406. 108. 6d.
THis book is intended primarily for medical
students, but the author hopes with justification that
it will also help the practitioner who is not a specialist
in public health to play his part in the prevention
of disease. For such readers the prevention of
disease has a more direct appeal than the promotion
of physical fitness, and Prof. Bigger wisely approaches
most of his topics from the former angle. Not that
the promotion of health is neglected. The last
chapter is entirely devoted to the assessment of
normal health, a pursuit which is one of the greatest
contributions the general practitioner can make to
the study and practice of preventive medicine.
About a third of the book deals with communicable
diseases, their character, mode of transmission,
epidemic behaviour, and prevention. Separate
chapters are given to insects and vermin, to parasitic
worms and to diseases of uncertain etiology, including
rheumatism, diseases of the heart and blood-vessels,
ansmias, nephritis, diabetes, and cancer; goitre is
briefly discussed in the chapter on water. Water,
food, ventilation, disposal of waste, environment
—i.e., climate, soil, building, construction, heating,
and lighting—occupational hygiene, ‘and personal
hygiene receive consideration in separate chapters.
Maternity, infant, and child hygiene have brief, but
probably adequate, attention. A separate and infor-
mative chapter is devoted to poisonous gases,
especially those used in warfare. Vital statistics
are the subject of the first special chapter.
It is essential that a book on hygiene, with which
students have little practical contact, should be
easy to read, and that any dogmatic statements
made in it should be capable of substantiation. This
book answers these requirements. The author makes
it clear whether he is expressing a personal opinion
or an accepted thesis, The chapters on communicable
disease are carefully put together and modern in
their substance. The brief discussion of vital statistics
is excellent for the purposes of the medical student.
With the reservation made by the author himself—
that occasional errors are inevitable in a book of
such wide scope—it can be cordially commended
to teachers and students of public health, as well as
to general practitioners.
Passive Vascular Exercises
By Lovis G. HERRMANN, A.B., M.D., Assistant
Professor of Surgery, University of Cincinnati ;
Director of Vascular Disease Clinic of the Cincinnati
General Hospital. London: J. B. Lippincott Co.
1936. Pp. 288. 20s.
DISAPPOINTMENT has followed most surgical pro-
cedures designed to save limbs affected by structural
arterial disease. Any alternative method which
offers a substantial degree of palliation by con-
servative means is therefore of interest, and an
authoritative evaluation of ‘‘ Pavaex” therapy by
its inventors deserves careful consideration by
those who have to undertake the management of this
prevalent disorder. Dr. Herrmann’s book has been
divided almost equally into two parts, one historical
and theoretical and the other practical; the applica-
tion of the method is described and hints are given
on the selection of cases suitable for its use. The
development of the therapeutic use of positive and
negative pressures is traced back to the eighteenth
century. This portion of the book, though of great
interest, seems to us unduly long. The physiology
of the circulation also might have been more briefly
(and more accurately) described since the success
of “ Pavaex ” therapy depends on the precise degree
and rhythm of the changes in pressure required to
produce the best results.
The clinical section of the work gives the i impression
that the author has based his opinions upon
theoretical considerations rather than upon the results
of treatment. He states clearly the contra-indications
to the method—spreading phlebitis, infection, and
extensive thrombosis of the small vessels; and he
advocates its use in embolic obstruction of main
vessels. It is well known, however, that the risk of
gangrene in a case of main vessel obstruction is
in any case comparatively slight, whereas Dr.
Herrmann gives numerous examples of gangrene due
to small vessel obstruction which have been amazingly
improved by ‘‘ Pavaex”’ therapy. There seems to
be no doubt that this is a valuable aid to conservatism
in the treatment of threatened gangrene, but the book
fails to indicate clearly the clinical criteria whereby
those cases may be selected which should derive most
benefit from it.
1. Oral Diagnosis and Treatment Planning
By Kurt H. THoma, D.M.D., Charles A. Brackett
Professor of Oral Pathology, Harvard University.
London : W. B. Saunders Co. 1936. Pp.379. 25s.
2. Oral Diagnosis and Treatment Planning
By S. C. Mrtter, D.D.S., and Twenty-two Contri-
butors. London: J. and A. Churchill. 1937,
Pp. 620. 30s.
1. IT is unusual to find two books published within
a few months of each other, having the same title and
covering so closely the same ground. Prof. Thoma’s
book, being by one author, has the advantage of
a continuity which works written by many con-
tributors often lack. It is essentially a book of
diagnosis and pathology is reduced to a minimum.
The salient feature of the book is the description
under various headings of the method of systematic
diagnosis : the chapters on general physical examina-
tion, laboratory tests, and radiology give the practi-
tioner sufficient information to keep his knowledge up
to date and to enable him to correlate the various
methods of diagnosis, The remainder of the book
is devoted to a clinical study of the various dental
and oral diseases. The common conditions familiar
to every dentist are described as. well as the more
unusual oral ones which may give rise to some
difficulty in diagnosis, The numerous illustrations,
many of them in colour, deserve high praise.
2. Mr. Miller’s work is more limited in scope.
It deals chiefly with dentistry proper and discusses
such aspects as caries, parodontal disease, bridge-
work, orthodontics, and denture design. It is
more practical if more diffuse than Prof. Thoma’s
book. Some of the chapters are excellent, such as
that on surgical conditions by T. Blum, and lesions
of the hard tissues by <A. Walker. The
three chapters on parodontal disease show how
firmly the concept of traumatic occlusion, or as it
is now termed, traumatogenic occlusion, is held in
1176 THE LANCET]
REVIEWS AND NOTICES OF BOOKS
[may 15, 1937
America and how much it has influenced treatment.
According to this book almost the whole treatment
of pyorrheea consists of correcting this hypothetical
malocclusion which is regarded as the chief cause of the
disease. Infection is only a secondary factor and
does not appear to call for any special treatment.
Extraction is only advised for teeth denuded of their.
periosteum to the apex, and gingivectomy is held
to have but a limited application. The large number
of illustrations are mostly good and the book is well
produced. For reference purposes both of these
books will be found useful though we must confess
to some doubt as to how far they are likely to help
the dentist in planning his treatment.
Synopsis of the British Pharmacopeceia
Thirteenth edition. With addendum, 1937.
By H. WrePELL Gapp, Barrister-at-Law, Middle
Temple and Western Circuit. London: Bailli€re,
Tindall and Cox. 1936. Pp. 200 + 12. 3s.
Tus useful little book has been brought up to
date by the introduction of a twelve-page leaflet
dealing with the Addendum, 1936, to the British
Pharmacopeia, 1932. All the important modifica-
tions of the text of the Pharmacopeia have been
included with the addition of certain changes in the
Poisons Rules.. Some difficulty will be experienced
in applying to the main text of the synopsis the
alterations given in the leaflet. It is to be hoped
that an entirely new edition will be forthcoming
with these alterations included. The remainder of the
leaflet will be found useful as a source of speedy
reference to the more important features of the
new drugs and preparations of the Addendum.
Meditatio Medici
A Doctors Philosophy of Life. By W. CECIL
BoSANQUET, D.M. Oxon., Fellow of the Royal
College of Physicians; formerly Fellow of New
College, Oxford. Aldershot: Gale and Polden.
1937. Pp. 162. 7s. 6d.
THE aim of philosophy, according to Herbert
Spencer, is to make science “‘a system of completely
unified knowledge.” William James defined it more
brightly as the response to the “desire to attain a
conception of the frame of things which shall on the
whole be more rational than the somewhat chaotic
view which everyone by nature carries about with
him under his hat.” Judged by these standards
Dr. Bosanquet’s little book has certainly a claim to
contain a philosophy. His condensed and objective
summary of general scientific knowledge is written
with a remarkable sweep and elegance. It is not
clear why the title ‘‘ meditatio ” should have been
chosen for we have come to apply the term to a highly
individual mental act and the essay is about as
impersonal as it well could be. Perhaps the author
wishes to convey to us that any attempt to make a
“frame of things” must in the end be a personal
construction. And with all his efforts at self-elimina-
tion Dr. Bosanquet’s ‘‘ Weltanschauung ” gives us
in reflex something like a portrait of his mind—in
dry-point perhaps—but none the less arresting
in its finish and poise. In so far as he can be referred
to a school he appears to lean to the doctrine of
Heracleitus, to whom the central fact of the universe
was that all things change ; and as with most of those
who are preoccupied with the mutability of things
there is an undertone of pessimism to his thought.
This does not prevent his summing-up of things
from being on the whole both just and sympathetic,
It is only when he treads on the treacherous ground
of sociology that he makes an occasional false step
—for example, his statement that under modern
democracy ‘‘ Freedom of labour is rigorously restricted
in order that the clever and efficient may be duly
handicapped to the level of the idler and the weakly.”
This is the sort of ‘‘ loose stuff” off which it is easy to
score.
Organic Chemistry for Medical Students
Second edition. By GEORGE BARGER, M.A., D.Sc.,
LL.D., F.R.S., Professor of Chemistry in Relation
to Medicine in the University of Edinburgh.
London: Gurney and Jackson. 1936. Pp. 251.
10s. 6d.
IN the preface to the first edition of this book,
which appeared in 1932, Prof. Barger explained that
in his view ‘‘ the chief reason for including organic
chemistry in the medical curriculum is to provide a
basis for biochemistry or chemical physiology and
pathology.” With this guiding principle in mind he
has passed lightly over some of the more important
types of syntheses employed in organic chemistry,
and has laid greater emphasis upon those aspects of
the subject which are of more immediate biological
interest and which are likely to be of use to the
medical student in his later studies; the text more-
over is replete with somewhat out of the common
facts and observations calculated to stimulate interest.
The chief alteration in the present edition is the
bringing up to date of the salient facts concerning
the chemistry of the hormones and vitamins. The size
of the book remains the same as before but there is
a welcome reduction in price.
Elementary Human Physiology
By SHERBURNE F. Cook, Associate Professor of
Physiology, University of California. London:
Harper Brothers. 1936. Pp. 539. 12s. 6d.
THis attractive volume is stated to be designed
for students who require a less advanced treatment
of the subject than do medical students. The
author’s estimate of his work is too modest. It is
true that it falls just short of the type of text-book
one recommends as being thoroughly adequate
for a medical course, but many teachers of physiology
would be relieved if they could be assured that every
student in their class had a complete grasp of its
contents. Prof. Cook’s book must not be confused with
the excellent short ones which present physiology
to the completely uninitiated. It is straightforward
physiology, set out in such a plain way that one
cannot fail to visualise the functions described or
to understand ‘the principles underlying them.
It is a live treatise, written on the assumption that
the reader has a scientific training and a critical
mind. The book will make some wonder if many of
the older texts, which run through edition after
edition in order to be kept up to date, have not
served their period of usefulness. For this work
is a real revelation of what can be done by making
a completely fresh start and presenting physiology
as it is to-day, rather than by regarding new know-
ledge, which sometimes strikes at the very founda-
tions of a subject, as in the nature of an addition to
what is already known. The pictures and diagrams
are refreshing, instructive, and not dictated by
tradition. The coherence and almost ruthless elimina-
tion of irrelevancies in this work make it an excellent
foundation for any course of study comprising
physiology.
THE LANCET]
THE LANCET
LONDON: SATURDAY, MAY 15, 1937
SHALL I GET BETTER?
AMONG many letters praising the articles on
prognosis which appeared in these columns between
1934 and 1936 we had one from a practitioner
who hoped they would soon cease to appear.
Pressed to explain why, he wrote: “In a large
practice one has not a great deal of time for
reading, and I am more interested in diagnosis
and treatment of patients I see every few days
than in knowing what is going to happen to them
perhaps many years hence. Life seems too short
for the leisurely atmosphere of prognosis to appeal
to me.” This critic had assumed, without justi-
fication, that the authors would deal only with
remote and not with immediate prognosis. But
the main interest of his comment lies in his con-
ception of the doctor as concerned with the cross-
section of the patient’s disorder at the time of the
consultation, rather than with any serial story of
its manifestations throughout life. Unfortunately
many doctors must perforce restrict their horizon
in this way, if they are to get through their daily
round. But such an attitude is dangerous, if
only because unless the practitioner makes a
mental picture of the probable course of the disease,
the course of treatment he prescribes may be
unwise or at best unnecessary. In the words of
Hippocrates “he will carry out the treatment
best if he know beforehand from the present
symptoms what will take place later.” Moreover,
it must not be forgotten that to ‚the patient
diagnosis and treatment are merely the technique
of his adviser, used as means to anend ; itis with the
end alone that he himself is deeply concerned, and
to him the prognosis is the essence of any medical
consultation. Indeed all his questions (e.g.,
What is the matter with me? What can you
do for me ?) are really designed to elicit the answer
to one, much more urgent, which he hardly dares
to frame, lest the response should shatter his
confidence: Shall I get better, and soon enough
not to endanger my livelihood, or (on a higher
plane) the completion of the work I have in
hand ?
This, in relation to every patient whose indis-
position is not trivial, is the real problem con-
fronting the practitioner day by day. All his
energy is bent to its solution, though he may not.
realise it. And since the most potent agent at the
doctor’s disposal is his power to give the patient
confidence, he cannot afford to ignore or disregard
this unspoken desire to know something of what
is likely to happen. Not that any statements
made need be specific or unguarded ; to satisfy
the patient requires much less definite information
than might be expected. His need for reassurance
is great and he will not only snatch at a straw
SHALL I GET BETTER ?
[may 16, 1937 1177
of hope but will gain support from it, so buoyant,
to him, is its fabric. Even when the diagnosis is
obscure, and the treatment expectant, such negative
conclusions as an experienced clinician may safely
draw will often suffice to give not only the patient
but his friends the help they need. Even when
it is not possible to say, as it quite often is, “‘ you
are going to get well,” the doctor may be able to
recognise, deep below the surface, the particular
phobia which is a torture and to remove it by an
assurance, for example, that whatever the trouble is
itis certainly not cancer. So twisted and illogical are
our subconscious fears that a man may live contented
for months suffering from a disease far more fatal
than the dreaded one. An example recently before
us was a woman whose slow recovery from an
atypical pneumonia led to suspicion of tubercle.
She would hardly consent to go to a chest hospital
for observation and radiography, so great was her
fear of contracting the infection. A temporary
improvement gave her a respite; and when, soon
afterwards a thoracic growth was diagnosed, she
was so much relieved at the exclusion of tubercle
that she submitted cheerfully to a course of deep
X ray treatment, enjoyed to the full the relief
from symptoms it produced, and, when she became
ill again, remained hopeful of another remission
until her peaceful death.
Similar stories will occur to all of us. They are
relevant to discussions on prognosis in so far as
they show that the patient’s attitude to any
disease is coloured by his previous impressions of
the prognosis it carries. Often these impressions
are incorrect or distorted, and hitherto the family
doctor has not had any convenient means of
reference to authoritative opinion. The series of
articles on prognosis, of which the second group is
published this week in volume form, was designed
to fill this gap. No attempt was made to cover the
whole ground of medicine and surgery. The invited
authors dealt only with subjects on which they
felt they had something to contribute, based either
on wide experience or on a special study. But
we have reason to think that the notes in each of
the selected subjects will provide at best a safe
guide to prognosis in individual cases, and at
least a foundation on which more accurate esti-
mates can later be built based on statistical data.
PRECAUTIONARY ENTEROSTOMY IN
APPENDICITIS
Atmost all deaths from appendicitis are preceded
by diffuse peritonitis, and the mortality of this
condition is estimated at 25-40 per cent. F. G.
CONNELL points out’ that such deaths should be
attributed to septic peritonitis rather than to
the appendicitis from which it originates, and he
argues that as death from peritonitis is preceded
by distension and ileus, and as the treatment of
established ileus is unsatisfactory, we should try
to prevent distension, ileus, and death by prophy-
lactic intestinal decompression and enterostomy at
the time of the appendectomy. This interesting
suggestion is made in a brief editorial article and
1 Surg. Gynec. Obstet. April, 1937, p. 836.
`
1178 THE LANCET]
he does not bring forward evidence in support of
it other than the statement that it seems to
reflect a growing opinion.
When such a procedure is contemplated a
number of considerations arise. The first is that
when one is operating for appendicitis it is
impossible to estimate accurately the extent of
the peritonitis without subjecting the patient to
the serious risk of further spread of the infection
within the abdomen. If we hold to the time-
honoured dictum of Murpuy to, “get in quick
and get out quicker,” if we believe this advice to
be of the utmost importance in our operation, any
such investigation will be precluded. Secondly,
how far would an opening in the intestine be
valuable? We do not know whether there is
greater risk in encouraging the intestine to move
than in fostering the abolition of peristalsis in an
attempt to localise the infection. We do not
know whether more poison is absorbed from the
mucosa of the reflexly immobilised intestine or
from the serous lining on its exterior. We do not
know, in fact, whether it is better to allow the
unaccustomed stagnation of intestinal contents to
persist or to run the risk of some increase in the
area of peritoneal infection by encouraging an
action of the bowels. Then again the ileus concerns
the intestine in the region of the infection. It is
from this pathologically changed gut that any
absorption of toxin is likely to take place; but
every surgeon who has performed enterostomies
knows how useless and ineffectual it is to make
an opening in such bowel. There is no discharge
from the stoma until or unless the peritonitis
subsides ; indeed such a discharge is a sign that
the patient is likely to recover, just as an action
of the bowels in cases of peritonitis has almost
from time immemorial been held to herald recovery.
Hence an enterostomy, to be effective, would
have to be made above the region of peritonitis,
and where this is will be only a guess if the
least possible exploration is carried out, as seems
advisable. Such an enterostomy would do nothing
to drain away the stagnating, decomposing, and
poisoning contents of the paralysed segment of
intestine. It is more likely to give exit to harmless
intestinal content and lead to loss of fluid which
the patient can ill stand.
These reflections are no more than inferences
from the known pathological condition of the |
peritoneum and intestine in diffuse peritonitis
and from the practical results of enterostomy.
The question has almost certainly to be judged
upon such considerations because we have no way
of measuring the degree of toxemia caused by
absorption from the peritoneal surfaces or intestinal
lumen. Without a technique for investigating
such problems we cannot, for example, claim that
enterostomy diminishes the amount of toxic
substances circulating in the blood. Clinical
impressions of the course of appendicitis in patients
with enterostomy may well be erroneous because
we have no means of evaluating the primary degree
of peritonitis. Probably most surgeons would
agree that the difference between the course of
the disease in those with an enterostomy and
PRECAUTIONARY ENTEROSTOMY IN APPENDICITIS
[may 15, 1937
those without an enterostomy is in no way striking,
and many would say that it is difficult to detect.
But if there is a definite feeling that good results
may arise from drainage of the intestine, despite
its many disadvantages, there is obviously a case
for testing this method by such clinical observations
as-we are able to make.
FOUR PHASES IN SYPHILIS
THE differentiation of the venereal diseases
from each other took long to achieve. At the
end of the eighteenth and first half of the nineteenth
century the views of medical authorities on their
nature and the degree to which they were spread
by contagion were so hopelessly confused that
syphilis and soft chancre and. even gonorrhea
were not: really defined as separate entities, and
the “ mercurial disease ” was regarded as a far
more serious condition than the symptoms for which
the metal was prescribed. Even such a careful
observer as JOHN HUNTER (1728-93) is said to
have regarded gonorrhea, syphilis, and soft
chancre as the same, and to have denied the
existence of visceral, tertiary, and hereditary
manifestations. The whole tendency at that time
was to belittle the effects of venereal infection
and it is to the strenuous efforts of PHILIPPE
Ricorp (1800-89) that we owe the clear con-
ceptions that have been established and have
persisted almost unchallenged to the present day.
As a result of his clinical and pathological studies
he wrote a book, “ Leçons sur le Chancre,”” which
appeared in 1858, in which he formulated the
doctrine that “le drame de la syphilis se divise
naturellement en trois actes ou périodes .. .”
Rightly or wrongly this doctrine has now held sway
for some 80 years and has proved its value both
as a basis for teaching and in planning and con-
ducting treatment. Prof. JoHAN ALMKVIST of
Stockholm has challenged’? this classical con-
ception of the pathology of syphilis. His argument
is based almost entirely on histological studies
to which he has devoted a large measure of
his spare time since his appointment. to the
professorial chair in Stockholm in 1911. These
investigations have led him to formulate certain
precepts, which he sets out and supports with
a wealth of illustrative photomicrographs. He
claims that in each kind of tissue spirochetes bring
about a histological reaction which is characteristic
of the tissue in question, but different from the
reaction produced jn other tissues. The changes
attributable to the syphilitic process in each kind
of tissue are, according to ALMKVIST, uniform
throughout the whole course of the disease ; they
are the same in recent and in old-standing syphilis,
and cannot be separated into three stages. Further,
the different clinical manifestations of the syphilitic
lesions are not due to differences in the reactions
between the spirochetes and the tissues, since the
tissues react uniformly throughout the whole course
of the disease; but rather to such factors as the
varying loration of the spirochetes, differences
' 1 Acla derm.-venereol., Stockh. 1937, 18, Fasc. 1; Brit. J.
Derm. 1937, 49, 1.
s
THE LANCET]
FOUR PHASES IN SYPHILIS
[May 15, 1937 1179
in the degree of immunity, toxin-antitoxin reactions,
nutritional disturbances, and so forth.
ALMKVIST postulates that broadly speaking
there are only two types of reaction to the spiro-
chete demonstrable by microscope—proliferative
and degenerative. In the epidermal layer there is
a proliferation of new cells of the same type as
the mother cells, with resultant hypertrophy of
the rete Malpighii and the interpapillary epithelial
` processes, which is the process mainly responsible
for the initial chancre. The connective tissue
responds similarly, but here we find a more varied
microscopic picture, for new-.cell elements—plasma
cells, round cells, and lymphocytes—make their
appearance, and the resulting histology is therefore
not always the same. For this type of reaction
ALMKVIST proposes the term “ infiltration,’ and
as connective tissue is more widespread than any
other in the body, we find it, as we should expect,
the commonest of all syphilitic processes throughout
the entire course of the disease. Lymphatic
vessels and blood capillaries are similarly stimulated
to proliferate, but the specialised and more highly
organised cells, such as the nervous, muscular,
hepatic, and renal, cannot do so. Their connective
tissue framework will react as described above ;
they themselves however in course of time, either
in response to the toxic effects of spirochetal
invasion or as a result of circulatory deprivation,
undergo “late degenerative alterations.” Infiltra-
tive and degenerative changes are similarly
observed in the walls of the larger blood-vessels and
may later account for the symptoms of aneurysm
and arterio-sclerosis. Two other subsidiary changes
have to be noted—the pustular and necrotic.
The pustule is less commonly met with than
formerly. . It is never a primary reaction but always
occurs in previous infiltrations of the connective
tissue. When well developed it is the histological
background of so-called malignant syphilis. Necrotic
changes are similarly superimposed. In his con-
. clusions it would seem that ALmxvisT is still
inclined to favour a phase or period progress of
the disease. In place of the established division
into three stages he now proposes a classification
on a “real pathological basis’ into four stages:
1. Initial or humoral stage, when the spirochetes
are in the blood (the disease is held to be ‘“‘ con-
stitutional ” from the outset) and other fluids, and
in the chancre. In this stage therefore are included
the former primary and secondary periods of Ricord,
with chancre, fever, splenic enlargement, albuminuria,
and so forth.
2. Heematogenous syphilis. All the organs and
tissues, especially the lymph glands, are now invaded
by the spirochetes conveyed to them by blood or
lymphatic channels. (It seems to us that this phase on
the author’s own showing is practically the same
as the preceding.)
3. Serpiginous or creeping syphilis. From a former
“ infiltration ” as a focus, the spirochetes creep or
insinuate themselves into the interstices of tissues
in their neighbourhood, initiating visible cutaneous
changes, and hidden transformations at a deeper
level. Clinical’ examples of the former are the old
tertiary circinnate syphilide, the condylomata, and
various forms of rarer occurrence—e.g., impetiginous
syphilide of the scalp, pustular syphilides, and
gummata, which may be either superficial or deep.
4. Late degenerative syphilis, in which are included
all the various forms of cerebro-spinal lues—tabes,
G.P.I., and so forth—and the vascular lesions which
develop in the walls of the larger blood-vessels.
The new conception excludes such theories as the
allergic of von Pirquet as applied to syphilis and
according to ALMKVIST renders the three-stage
doctrine of RicorpD no longer tenable. Time will
show whether these elaborate histological studies
will prove a sufficient reason for so radical an
alteration as is proposed, especially in view of the
fact that on the author’s own showing phase 2
differs very little from phase 1. There can be no
doubt, however, that that histological approach is
one to which insufficient importance has been
attached in the past and that the new ideas
elaborated on this foundation by Atmxvist will
materially assist the labours of those engaged on
the many problems of prognosis and treatment in
all parts of the world.
IS -PASTEURISATION HARMFUL?
T remained a very good SONOS: but it did not remain
mil
Tuus Lord CRANWORTH in the Lords’ debate on
pasteurisation reported in our last issue; his
opinion was forcibly supported by the Bishop of
Norwicu when the debate was resumed (see p. 1196)
and is widely shared in the medical profession.
But how far is it justified ? Of the published evidence
very little is convincing and much is contradictory. In
elaborate experiments! at the National Institute for
Research on Dairying rat families tended to die out
on a diet of sterilised milk (and biscuits), while those
on pasteurised milk showed some inferiority including
signs suggesting deficiency of vitamin B,. Such
results, however, require very cautious application
to human nutrition, and it will be easier to form a
judgment from the more comprehensive inquiries
lately made at the same institute, and at the Rowett
Institute, on behalf of the Milk Nutrition Com-
mittee which was established in 1934 with Lord
Astor as chairman. The object of these inquiries ?
has been to determine the effect of commercial
pasteurisation on the various constituents of milk
and also to decide whether a pint of pasteurised milk
is equal to a pint of raw milk from the nutritional
standpoint. Their answers? are that the changes
caused by pasteurisation are not serious. Thus
moderate heat does not (as has been alleged) affect
the nutritional availability of the calcium and the
phosphorus, or the biological value and true digesti-
bility of the nitrogen. Neither vitamin A nor its
precursor carotene is damaged by pasteurisation.
There is some loss of vitamin B—probably in the B,
fraction—and about 20 per cent. of the vitamin C
disappears if (as is usual) the milk has been exposed
to light before heating. The committee does not
propose to discuss the bearing of these laboratory
results on human nutrition until it has published
complementary observations on calves and school-
children. But they already show that milk suffers no
damage by pasteurisation that is important, compared
with the risks of drinking it raw.
1 Mattick, E. C. V., and Golding, J., Lancet, 1931, 1, 662 ;
1936, 1, 1132 ; 1936, 2, 702.
2 Milk and Nutrition. Part I: Effect of Commercial Pasteurisa-
tion on the Nutritive Value of Milk, as determined by Laboratory
Experiment, 1937. Obtainable from the National Institute for
Pecar, on Da irying, Shinfield, Reading. Pp. 67. 2s. 6d.
y post 3s.
(may 15, 1937
ANNOTATIONS
PERSPECTIVE AND POISE IN PRACTICE -
PERSPECTIVE—defined by Webster as the capacity
to view things in their true relations or relative
proportions—was the text of the annual oration
delivered before the Medical Society of London
last Monday by Dr. R. A. Young. He said that his
interest in perspective as applied to medical problems
had been stimulated many years ago by the assess-
ment of a distinguished physician by one of his
pupils, himself a man of great practical ability.
The pupil had summed up the teacher, for whom he
had a real admiration, as having “ very wide range
but no perspective”: a man, that is, whose standards
of the relative importance of details were often
faulty. His opinion on a case was learned, but
unhelpful in practice ; he could not see the wood for
the trees. In.medicine as an art, said Dr. Young,
we want an horizon and the idea of a vanishing point,
or at any rate a point of focus. He dealt in turn with
perspective in anamnesis and examination, in diag-
nosis, in prognosis, and in treatment, ending with
some wise comments on the value of poise in a
physician. Only an “i” he declared, distinguishes
poise from pose; but it-is a capital “I,” for while the
poseur is an egotist, the man with poise is usually a
philosopher and often an altruist. Dr. Young had but
little praise for the physician who concentrates at
once on the establishment of what appears to be an
obvious diagnosis, neglecting the routine review
of all the systems that may reveal an essential if
“ unexpected feature. Specimens, including human
ones, are best surveyed under the low power of the
microscope to get a general impression, before using
the high power to focus details and refinements.
In diagnosis also it is essential to remember the
variations in interpretation of observed data. Too
often an attempt is made to fit subsequent develop-
ments to the original diagnosis, even if they seem ~
to contradict it, instead of starting again, regarding
the ‘problem as a fresh one, and looking at it from a
different standpoint. A building situated half-way up
a hill looks very different when seen from above and
from below; everything depends on the point of
view. A double or composite diagnosis in a difficult
case is always suspect—like a picture with two
horizons it is usually out of drawing.
In Dr, Young’s experience, physicians with great
experience of post-mortem work rarely make “ tall”
diagnoses. Knowledge of the distribution of the
effects of disease tends to increase clinical acumen
and the modern tendency in aspirants to hospital
posts to escape a period of apprenticeship in routine
post-mortem work is, he finds, to be deplored. Prog-
nosis depends upon many factors, some capable of
statistical expression, others almost imponderable.
The individual experience of the practitioner is liable
to influence his opinion more than any numerical
statement of the probabilities based on figures.
That it is wise to remain hopeful even if the outlook
is grave, and if possible to infuse that hopefulness
into the patient and those around hin, is a lesson which
Dr. Young learnt from his seniors, notably Dr.
G. F. Still and Sir James Goodhart. This Dr. Young
has confirmed for himself, and passes on the know-
ledge with conviction. Even when faced with an
obviously lethal disease, for example, malignant
disease of the bronchi or mediastinum recognised at
a time when eradication or even prolonged arrest
is improbable, he has been impressed with the fact
that the patient rarely asked a direct question. He
suspects his fate but does not want to have his
suspicions confirmed.
Among the orator’s sagacious precepts the follow-
ing are noteworthy. The reminder that there are
fashions in treatment is timely; the three “good
remedies out of fashion” (antimony, apomorphine,
and aconite) quoted by Dr. Young, using only the
first letter of the alphabet, suggest that the list might
reach formidable dimensions before one reached the
last. In the choice of new remedies he noted the danger
of mistaking enthusiasm for experience, a danger
to which the specialist without general knowledge is
peculiarly liable. It is still true that they that are
sick need a physician, that is, one person in charge of
them even though he calls in specialised help in
diagnosis and treatment where necessary. In the
medical curriculum the specialised teaching and
examination now in vogue in all departments needs
overhauling and close scrutiny with a view to simpli-
fication. The paradox, that whereas the doctor as an
individual is trusted, the medical profession as a whole
is not in great favour, is attributed by Dr. Young
partly at least to our traditional refusal to advertise,
and is to this extent irremediable without the loss of
something far more valuable than popularity. In
time the public may learn to understand that it is
for their protection rather than for the physician’s
that the code of reticence has been developed.
SURGERY IN OLD AGE
THE ageing of the population, consequent upon
a declining birth-rate and an increasing expectation
of life, will inevitably have its effect in many economic
and social aspects of life. Not least will be its reactions
on the practice of medicine. Obstetricians and
pediatricians must be increasingly affected by the
reduction in the number of births and of children ; the
physicians may expect an increase in the incidence
of the degenerative diseases, of cancer and of diabetes ;
and the surgeons a general increase in the demands
made upon them, though probably not equally
distributed among the various surgical specialties.
There is a popular belief that advanced age is a
strong argument against operative treatment, and
if in the future an increasing proportion of old people
is to be the material upon which the surgeon must
work it is clearly important to know how far there
is justification for that belief. Starting from these
tenets, Dr. Barney Brooks, of the department of
surgery in the Vanderbilt University School of
Medicine, Nashville, Tennessee, has made a study
- of the results of operations performed in that hospital
during 1926 to 1935 on 287 patients over 70 years of
age. All of these patients except two had been
traced until the date of death or to 1936. The results
he reaches are interesting. Of 172 operations carried
out at ages 70-74 years, 17, or 9-9 per cent., resulted
in death in hospital; of 84 carried out at ages 75-79
there were 13 such deaths, or 15-4 per cent.; and of
37 at ages 80 and over there were 6 deaths, or 16-2
per cent. Surgical diseases in these high age-groups are
clearly associated with a relatively high fatality, but
from the protocols of the conditions and causes of
death in the patients who succumbed, which are
given in detail, Brooks concludes that deaths which
could be reasonably attributed to the operative
treatment are remarkably infrequent. In other
words, increasing the proportion of patients in the
higher age-groups would undoubtedly increase the
R AER ened nee mane eee eee
1 Ann. Surg. April, 1937, p. 481.
THE LANCET]
hospital
the hazard of operative treatment, Further evidence
is afforded by those groups of patients in which
operation was undertaken solely for the relief of
some distressing symptom which presumably would
not necessarily decrease life expectancy—i.e., reducible
hernia, cataract, tic douloureux, gall-bladder disease
without gangrene or perforation, and benign abnor-
malities of the rectum. There were 90 such cases with
only one death, from coronary occlusion on the
seventh day after operation. Most hospital deaths
fell in the genito-urinary and abdominal operative
groups, the results with the latter being the most
discouraging though none of the deaths could be
directly attributed to the operation. One death has a
particular bearing on the subject of the paper.. The
patient was first seen in 1925 with gall-bladder
disease but because of agé, hypertension, and cessation
of symptoms operation was not advised, The attacks
recurred until 1927 when operation was unavoidable
but the gall-bladder was then found ruptured into
the duodenum and the patient died. Given a proper
technique for handling sick old people—an atmo-
sphere of optimism, precautions against exposure
to acute respiratory infection, and pre-operative
treatment for existing disease of the heart and kidneys
—Brooks finds no strong argument against operations
in old age.
THE ROCKEFELLER FOUNDATION
WE have recently been reminded of the bene-
factions of the Rockefeller Foundation by a resump-
tion of their policy of making travelling fellowships
available for medical men and women in this country
on the recommendation of the Medical Research
Council. Since 1915 a sum of nearly four million
pounds has been spent on fellowships in various
subjects all over the world. In a review for 1936,
Mr. Raymond B. Fosdick, the president of the
Foundation, makes it clear that fellowships, valuable
though they are, form but a small part of its activities.
The Foundation, which has been in existence since
1913, has for its aim “the promotion of the well-
being of Mankind throughout the world,” and in
support of this ambitious programme it has an annual
income of some £2,360,000. This vast sum is expended
in financing research, about two-thirds being spent in
the U.S.A. and the remainder in all parts of the
world. The subjects chosen are those which, in the
opinion of the trustees, are likely to be of benefit
to mankind as a whole and include investigations
into problems of public health, medicine, natural
science, the social sciences, and the humanities.
In general the Foundation acts by financing existing
institutions but in the realm of public health it
undertakes research on its own account, appointing
both laboratory and field workers and concentrating
its attentions on. those non-preventable diseases
which offer reasonable prospects of being made
preventable. In 1936 investigations were in progress
in the U.S.A. and some 41 other countries into
yellow fever, malaria, yaws, schistosomiasis, rabies,
influenza, and the common cold. In medicine
the Foundation’s workers are mainly engaged on
the problems of mental hygiene as being, says Mr.
Fosdick, “the most backward, the most needed and
potentially the most fruitful field in medicine to-day.”
Some £339,000 was expended in this direction in
1936, including grants to the Galton laboratory and
the Maudsley Hospital in London. Mr. Fosdick
also remarks, and one may well agree with him, that
if a foundation is looking for immediate results the
field of mental hygiene is not the one to enter. The
THE ROCKEFELLER FOUNDATION.—FAT EMBOLISM
mortality-rate but should not increase l
result of an investigation of 246 autopsies.
(may 15, 1937 1181
natural sciences are represented in the Foundation’s
programme by experimental biology. For research,
especially in genetics, endocrinology, and on the
enzymes, grants of £285,000 were made in 1936.
The social sciences and the humanities, which receive
a very small share of the world’s expenditure for
research in general, received grants of £970,000.
Since 1933 the Foundation has taken under its wing
151 scholars dismissed for political reasons from their
posts in Germany and has contributed £110,000
towards the salaries of these unfortunates who have
found employment elsewhere.
FAT EMBOLISM
Tue fat of the body exists as an emulsion of very
fine particles in the plasma and as deposits of coarser
substance in subcutaneous tissue, around the kidney,
and in the marrow. It is, theoretically at least,
possible for trauma to release the depôt fat from its
encapsulation and lead to its absorption into the
lumen of damaged blood-vessels (veins). It has been .
considered likely that the veins of the Haversian
systems, being held patent by their bony surround-
ings, are particularly suited to injection with fat
emboli. There are certain practical difficulties in
accepting this explanation. The first is that for fat
embolism to occur it is not essential that the bone
should be broken. Manipulation of old contracted
rheumatoid joints has been followed by death, and
autopsy has shown extensive pulmonary fat embolism.
Even in the cases—much the most numerous—in
which there is a fracture, the severity of the lesion
bears no relation to the production of the condition.
The only fact about fat embolism that seems to be
well established is that in its severe form it is always
the result of trauma received before death. This
conclusion was reached by Vance in 19311 as the
A slight
degree of fat embolism may be present in non-
traumatic cases but is probably not of clinical
importance. It is as a sequel to fractures of the long
bones that most cases of fatal embolism have been
recorded, and the natural assumption has been that
the emboli are derived from the fat of the marrow.
Watson 2 records a fatal case which occurred in con-
junction with a serious injury—a compound fracture
of the tibia—that required an emergency operation ;
there was comparatively little comminution of the
bone. Other cases have been reported following
simple fractures. Another difficulty in accepting the
bone-marrow as the source of the fat is that the
amount of fat available in the medullary cavity of a
long bone probably is insufficient to cause any serious
degree of fat embolism. The mechanism of the
absorption of the fat—whether by suction into the
veins, or by pressure from the congested tissues—
is also a matter of debate.
Watson notes that the anesthetic was not an easy
one, and that a considerable quantity of ether was
administered ; he suggests the possibility that the ether
may dissolve the fat of the blood plasma, which
may then be precipitated by evaporation of the ether
in the lungs. A further suggestion made is that the
products of tissue destruction circulating in the blood
may break up the fat present in the plasma as a very
finely divided suspension, and cause it to form
particles large enough to block the capillaries. How-
ever formed, the fat emboli seem to pass first to the
veins, thence to the right side of the heart, and so
` to the pulmonary circulation. Access of the fat to
1Vance, B. M. (1931) Arch. Surg. 23, 426.
Watson, A. J., Brit. J. Surg. April, 1937, p. 676.
t
1182 THE LANCET]
the systemic circulation is more difficult to explain.
It may traverse a patent foramen ovale, or it may
actually pass the barrier of the lung capillaries.
Two main clinical types of case are recognised :
in the pulmonary type the first symptom may be
precordial pain, or a feeling of constriction round the
chest; a cough develops, the sputum being often
streaked with blood, and moist rales are heard.
Occasionally the progress is very rapid, with acute
cedema of the lungs; more often it is gradual and at
first broncho-pneumonia may be diagnosed.. The
cerebral type of embolism tends to mimic delirium
tremens. Death is by coma. Certain organs such as
the kidney seem to be unaffected by the fat in the
capillaries; in the brain the grey matter is not
seriously affected, but haemorrhages are found in the
white matter, with areas of necrosis and of inflam-
matory reaction. Fat appears in the sputum and in
the urine. Pyrexia is usual. The symptoms occur
early—i.e., within two or three days of the accident
or manipulation. In Watson’s case pulmonary and
` cerebral symptoms were combined. The first symptom
was cough and ‘“‘rusty’’ sputum, precordial pain
followed, and twelve hours later the patient was
comatose. Apart from avoidance of ether anæs-
thesia no very useful suggestions have been advanced
for prevention of fat embolism. Once the condition
has developed there is no generally accepted method
of treatment, though various measures have been
recommended.? The condition is not necessarily
fatal.
OXFORD MEDICAL GRADUATES AND THE
UNIVERSITY APPEAL
AT a meeting of Oxford medical graduates recently
held in London to consider how they might best assist
the Oxford University appeal, the opinion was
expressed that many medical graduates would like
to be associated in any contribution which they
might make towards the appeal. It has therefore
been arranged that a special fund will be opened
to include the contributions from all medical graduates
who may so desire it, the names of individuals being |
of course retained. It is felt that, in this way, the
medical graduates of Oxford wil be able more
adequately to express their gratitude to their
University and their desire to come to her assistance.
Sir Farquhar Buzzard, president of the Oxford
Graduates’ Medical Club, writes in the following
words of such a combined effort on the part of Oxford
medical graduates :—
“ So long as the university was devoted in the main
to the study of the humanities she was sufficiently well
endowed to supply the books and the teachers necessary
for these subjects, but during the last 70 years she has been
obliged, in order to keep pace with modern developments,
to spend more and more money on education and research
in scientific and sociological branches of learning, with the
result that she has now found herself unequal to the
consequent financial burden. We medical graduates
recognise, perhaps better than others, how inevitable these
expenses are if any institution is determined to fulfil
its obligations in contributing to the advance of knowledge
and in keeping its place among its rivals. As under-
graduates we were apt, perhaps, only to regard our colleges
as our creditors ; as graduates we cannot forget what we
owe to our university for affording us the opportunity
of sitting at the feet of men like Henry Acland, Burdon
Sanderson, Arthur Thomson, Francis Gotch, Georges
Dreyer, William Osler, and Charles Sherrington—to
mention only a few of those to whom we must always Ô
remain deeply indebted. Now is our opportunity to
show that we are not forgetful of what our old university
3 Clark, G. Norman (1933) Lancet, 2, 77.
OXFORD MEDICAL GRADUATES AND THE UNIVERSITY APPEAL
[may 15, 1937
did for us in our younger days and to give every assistance
in our power to continue her great work for those who
are succeeding us.. Lord Nuffield, with no such obligations
as ours, has endowed with unrivalled generosity a new
school of medical research, and, recognising that this
must increase rather than decrease the university’s
financial responsibilities, has already given £100,000 in
response to her public appeal for money. The least we
can do is follow this generous and far-sighted example
to the best of our abilities and resources.”
Sir Farquhar backs his views in practical manner
by an offer to start the combined effort of the Oxford
medical graduates with a donation of £50.
POST-MORTEM FINDINGS IN KENYA
A VALUABLE pioneer effort has been made by
F. W. Vint! in summarising the findings in 1000
consecutive post-mortems on bodies of natives of
Nairobi, Kenya Colony. Pneumonia was found to be
the most frequent cause of death, accounting for
298 out of the 1000. The right lung was attacked
most commonly, usually the upper lobe. Only 6 of
these patients were under ten years old. Tubercu-
losis was the next in order of frequency, the lungs
being affected in 94 per cent. of the 132 cases.
A hundred deaths were ascribed to septicemia and
toxemia. Only a few (26) deaths were due to
malignant disease, primary cancer of the liver being
rather frequent (8). Spleens were found to be large
and fibrotic, whether the cause of death was malaria
or not. The interesting conclusion reached by the
author—namely, that infective disease tends to be
septicemic among the natives owing to blockage of
the reticulo-endothelial system and diminished kidney
function—would seem to demand further experimental
and histological evidence ; his article should stimulate
work on this important subject.
TARSAL SCAPHOIDITIS
Smets ? draws a distinction between Kéhler’s disease
proper and Köhler’s disease with complications,
the distinction being that only those cases that are
complicated give rise to symptoms. His contention
is that the radiographic appearances characteristic
of Köhler’s disease are in fact variations of normal
ossification. The condition shows a strong familial
tendency and has been observed in uniovular twins;
thus among triplets the uniovular pair were affected
while the other escaped. The case is quoted of a doctor
whose son had Ko6hler’s disease with symptoms and
whose daughter on radiography proved to have similar
changes without symptoms. Many cases have been
discovered accidentally during routine examination
of the foot for other causes—such as a search for
foreign bodies, or a fracture—and Smets emphasises
once more the fact that at least 30 per cent. of cases
are bilateral, though the condition may be painful
only on one side. Furthermore, he draws attention
to the frequent association of Köhler’s disease with
identical changes in the patella. While not denying
that an infective process such as tuberculosis may
give rise to similar appearances, Smets mentions one
or two interesting cases in which a tuberculous
scaphoid on one side, confirmed by the formation
of a cold abscess, with an X ray appearance sug-
gestive of Köhler’s disease, was associated with
typical changes, without symptoms, in the other
foot. Here it is possible, he suggests, that the
tuberculous disease was an added infection. He
discards trauma entirely as an important cause, but
1 E. Afr. med, J. February, 1937, p- 1.
2 Smets, W. (1936) J. Chir., Brux. 7, 377.
THE LANCET].
THE CAPITATION FEE.—CEREBRO-SPINAL RHINORRHEA
[may 15, 1937 1183
suggests that the scaphoid going through this varia-
tion of normal ossification may perhaps be more
vulnerable at a certain stage and- therefore more
susceptible to the influences of minor traumata ;
hence the symptoms.
THE CAPITATION FEE
THE Panel Conference having last year declared
that 9s. is too small a capitation fee for insured
persons, and the Minister having said he thinks it
may well be too much, arrangements have now been
made for arbitration. The arbitrators, constituted
as a court of inquiry, are Lord Amulree (chairman),
Mr. Thomas Howorth, and Mr. D. H. Robertson, with
Mr. E. H. Phillips of the Ministry of Health as
secretary. Their task is to advise what, if any,
alteration should be made next January in the
capitation fee, ‘‘ having regard to any changes which
may have taken place since 1924 in the cost of living,
the working expenses of practice, the number and
nature of the services rendered by insurance prac-
titioners to their insured patients, and other relevant
factors.” The inquiry is to proceed on the assumption
that employed persons under 16 years of age will by
that time be entitled to medical benefit; and the
arbitrators’ findings should help to resolve the conflict
of opinion that has arisen from the Minister’s belief
that a substantially lower fee should be paid for
children than for adults.
MENINGOCOCCAL MENINGITIS TREATED WITH
SULPHANILAMIDE
SULPHANILAMIDE, as p-aminobenzenesulphonamide
is conveniently called, has been proved lethal to
Meningococci,1 and accounts on its use in cerebro-
spinal fever are eagerly awaited. A small series of
cases now reported from Baltimore is encouraging so
far as its goes. Schwentker, Gelman, and Long?
have treated 10 patients with meningitis and 1
with meningococcal septicemia—the series being to
all intents and purposes consecutive—and are able to
record recovery in all but 1 of them. They used
a physiological solution of sodium chloride containing
0-8 per cent. of sulphanilamide, and they gave it by
intraspinal and subcutaneous injection. They began
by withdrawing cerebro-spinal fluid and replacing it
with the sulphanilamide solution, the amount
injected varying from 10 to 30 c.cm. and usually being
5 to 10 c.cm. less than the amount of fluid withdrawn.
A larger quantity of the solution was then given
subcutaneously ; they injected about 100 c.cm. for
each 40 lb. (18 kg.) of body-weight. Both intraspinal
and subcutaneous injections were repeated every
twelve hours for the first two days, and once daily
thereafter until definite improvement was evident.
Sometimes the cell count of the cerebro-spinal fluid
fell rapidly and progressively ; sometimes it remained
high for a few days and descended precipitately. In
no case could organisms be found in the C.S.F.
more than three days after treatment started. No
untoward effects were noted: the subcutaneous
injections gave no more reaction ‘than would be
expected with normal saline, and there were none of
the signs of systemic reaction sometimes reported
after sulphanilamide, such as rashes, methzemo-
globinemia, or sulphzemoglobinzemia.? Schwentker
and his colleagues are rightly cautious in their con-
1 Buttle, G. A. H., Gray, W. H., and Stephenson, D. (1936)
Lancet, 1, 12867 Daun H. Ibid, Jan. 2nd, 1937, 6.
3 Schwentker, F. F., Gelman, S., and Long, P. H., J. Amer.
med. Ass. April 24th, 1937, p. 1407.
; 3 See paper by Paton and Eaton on p. 1159 of our present
ssue.
clusions, but in their 11 cases they found the thera-
peutic response ‘‘ quite comparable to that which
usually follows treatment with specific antiserum,”
and they point out that sulphanilamide has the
substantial advantage over serum that it does not
cause irritation like a foreign protein.
RISKS OF ENDOTRACHEAL ANAESTHESIA
AND OF EXPLOSIONS
A CONTROVERSY has been going on in the last
two numbers of the British Journal of Anesthesia
over the possible dangers of nasal endotracheal
methods. Dr. Massey Dawkins in January asserted
that bacteria lie within the external nares whence
they are normally removed by ciliary action. The
nasal catheter, he thinks, may carry these organisms
directly to the trachea where they may not be effec-
tively dealt with. He quotes two fatal cases of
broncho-pneumonia following endotracheal anesthesia,
which he believes illustrate and support his con-
tention, and he also produces statistical evidence.
His opinion is that “ administration of an endo-
tracheal anzsthetic for every case is becoming too
common,” though he does not deny that the method
is ‘‘ certain, easily controllable and admirably suited
to the needs of the surgeon and of the anesthetist.”
The cudgels in defence of nasal endotracheal methods
were taken up in the April number and wielded
with vigour. Dr. Ivan Magill, who was the originator
of this method and has employed it since 1919,
has not yet met an instance of pulmonary com-
plication that could justly be attributed to it. He
holds that any bacteria present in the nose are
probably already present in the trachea too. He
agrees with Dr. Dawkins that “ indiscriminate use of
the endotracheal method by all and sundry, whether
indicated or not, is to be deprecated.” Mr. W. A.
Mill suggests that the best way to avoid lung com-
plications is to avoid operating until some time has
elapsed after any acute infection of the upper
respiratory tract. Cocainisation of the nares, the use
of a small tube, an anesthesia deep enough for
insertion of the tube without spasm of the cords,
and lubrication of the tube are features of the
technique which other writers to the journal regard
as important.
Another paper in the April number, by Mr. J. H.
Coste, F.I.C., deals with the cognate question of fire
and explosion in operating theatres. It is a valuable
contribution because other investigators have usually
given primary consideration to the source of the
spark or flame which starts an explosion. Mr. Coste,
examining the chemical aspect, has experimented on the
explosibility and inflammability of a number of the
commonly employed inhalation anesthetics. He gives
numerous details and as regards ether draws the
important practical conclusion that ‘‘ explosions due
to dangerous concentrations of ether in the air of an
operating theatre .. . are most unlikely if the possible
source of ignition is a foot or more above the floor
level... .”
CEREBRO-SPINAL RHINORRHCEA
CEREBRO-SPINAL rhinorrhea if rare is a serious
condition since it carries with it the danger of
meningitis. Diagnosis is easy if the possibility is
not forgotten: profuse flow, or free dripping of a
clear fluid which does not stiffen on the handkerchief
is a characteristic sign, confirmed when chemical exam-
ination of the fluid shows absence of albumin and
mucin and the presence of glucose. The cases fall
into three groups: (1) those due to injury, (2) those
1184
which follow operation on the frontal sinuses or
ethmoid region, and (3) those which occur without
previous traumatism.. On May 7th, in a communi-
cation to the laryngological section of the . Royal
Society of Medicine, Prof. Hugh Cairns described
eight cases illustrating these various groups. Two
were the result of airplane crashes, where the face
had come into violent contact with the instrument-
board, causing fracture of both walls of the frontal
sinus. Mr. Cairns suggests that such accidents may
become increasingly frequent. In both subjects rhinor-
rhea ceased after a few days and recovery followed.
In these cases early operation is contra-indicated,
for severe shock is usually present as well as infected
wounds of the neighbouring regions. In other cases
rhinorrhea may not appear for several weeks; if it
persists, there is considerable risk of meningitis
through infection from the nose, which may occur at
any time as the result of a cold. It is therefore wise
to operate, expose the floor of the anterior cranial
fossa, and close the rent in the dura by suture or bya
fascia lata graft.
If a flow of cerebro-spinal fluid is seen during an
intranasal operation on the ethmoidal region, it
means that the dura mater, which is particularly
thin and adherent here, has been torn. The danger
of fatal meningitis is extremely grave, and the safest
course is to open the anterior fossa at once and
repair the wound. Mr. W. M. Mollison pointed out,
in the ensuing discussion, that injury to the dura
during external operations on the frontal sinus and
ethmoids is less liable than injury during intranasal
operations to be followed by meningitis.
Cerebro-spinal rhinorrhea in the absence of
traumatism is sometimes associated with hydro-
cephalus or with cerebral tumour, and may cease
after removal of the latter. Sometimes it is more
truly spontaneous, and is then probably due to
congenital defect in the region of the cribriform plate.
StClair Thomson first called attention to this con-
dition in 1899, when he had seen three cases, all
ending fatally, and remarked that the condition does
not appear to be amenable to any treatment.? In
view of the serious risk of meningitis, probably the
safest course is to expose the anterior fossa and close
the gap with a graft, especially where a deficiency in
the bone is shown by X ray examination.
THE LANCET
ROYAL SOCIETY OF MEDICINE
On May 10th the Royal Society of Medicine gave
a reception at the Society’s house to celebrate the
Coronation and to entertain medical men and their
wives from overseas. The guests were received
by the president, Sir John Parsons, F.R.S., and Lady
Parsons in the library. A film show in the Barnes
Hall was preceded by a short speech in which the
president extended the hospitality of the Society
to all visitors and welcomed guests. Among the
official guests were Mr. James Davies, Commissioner
for Newfoundland, Sir Thomas Barlow, president
of the Royal Medical Benevolent Fund, Sir Edward
Mellanby, secretary of the Medical Research Council,
and the presidents of many of the sister medical
societies which have their headquarters in London ;
there were also visitors from Australia, New Zealand,
Canada, Africa, India, Malta, New York, Straits
Settlements, Palestine, and Greece. By the courtesy
of the General Post Office two excellent films were
shown. The first, ‘‘ Weather Forecast,’ demonstrates
how from meteorological data collected from all over
1 Diseases of the Nose and Throat. Third edition. London,
1926, p. 213. x
ROYAL SOCIETY OF MEDIOINE.—THE HONOURS
[may 15, 1937
Europe a gale is forecast; one follows the “ gale
warning ” through all the departments concerned and
finally sees in outdoor scenes the gale rise and pass
away. In the second, ‘‘ Night Mail,’ are recorded
_ the various stages of the mail as it flies north through
the night on a special express, and there is an exciting
moment when the mail from Holyhead nearly misses
its connexion. A third film, “ Galatea,’ by Miss
Lotte Reiniger, was a clever silhouette made up with
pieces of paper and cardboard, the subject matter of
which had been freely adapted from the classics.
An exhibition of historical interest followed, consist-
ing of tableaux depicting medieval alchemist shops
and the progress of medical science through the
centuries. The tableaux were lent by the Wellcome
Historical Medical Museum as were a collection of
figures of the patron saints of medicine, including
Saint Sebastian, the patron saint of undertakers.
Altogether a successful and entertaining evening.
THE HONOURS
THE Coronation honours list is for the Empire
as well as for this country, and it brings recognition
to many whose work is done in out-of-the-way
places. Medicine in England gains another able
exponent in the House of Lords in Dr. Christopher
Addison, whose long parliamentary service and
tenure of several ministries are fittingly recognised
by a peerage. Sir Cuthbert Wallace receives a
baronetcy ; Dr. Edward Mellanby is created K.C.B. ;
Dr. G. F. Still and Sir John Atkins become knights
of the Royal Victorian Order; and Dr. A. F. Hurst,
Prof. Beckwith Whitehouse, and Dr. A. E. Horn
are among the new knights bachelor. To these and
the other members of the profession named on p. 1204
we offer warm congratulations. In addition, there
are many associated with medical work whose
decorations we are also glad to note. Mr. S. P.
Vivian, the Registrar-General, receives a knighthood ;
Mrs. Ellen Pinsent, late senior commissioner of the
Board of Control, is made a dame of the Order of the
British Empire ; and the nurses honoured include the
matrons of St. Bartholomew’s and King’s College
Hospitals, Miss Helen Dey and Miss M. A. Willcox,
who become officers in the same Order.
THE next session of the General Medical Council
will open on Tuesday, May 25th, at 2 P.M., when
Sit Norman Walker, the president, will deliver an
address. |
ON March 6th we reviewed the report of the Select
Committee on Medicine Stamp Duties which proposed
the taxation of a large range of preparations recom-
mended or advertised as curative or preventive
of illness. This report, is now published by H.M.
Stationery Office with the minutes of evidence and an
index. The price is 7s. 6d.
Tux centenary celebrations of the Liverpool Medical
Institution will be held on May 30th and 3lst and
June Ist, when honorary memberships will be con-
ferred on Sir Cuthbert Wallace, Sir Norman Walker,
Sir Farquhar Buzzard, Sir Ewen Maclean, Prof.
W. Fletcher Shaw, Sir James Barr, Mr. Thurstan
Holland, and Mr. Frank Paul. Prof. R. E. Kelly will
deliver a presidential address on surgery a hundred
years ago. During the meeting the Hugh Owen
Thomas and Robert Jones memorial fibrary of
orthopedic surgery will be opened and afterwards
Mr. W. Rowley Bristow will give the Hugh Owen
Thomas memorial lecture.
THE LANCET]
(may 15, 1937 1185
SPECIAL ARTICLES
——
EMPIRE CONFERENCE ON THE CARE
AND AFTER-CARE OF TUBERCULOSIS
(Concluded from p. 1131) |
Lord HORDER and Lord ALLEN oF HURTWOOD
presided over the sessions of this congress on May 4th.-
Lord Horder said that despite the advance made
against tuberculosis the mortality remained far too
high. Lord Allen, referring to the Papworth experi-
ment, said it interested him because of the humane-
ness and sympathy it brought into administration.
One of the major needs of democracy, he thought, was
emphasis upon the humane.
TUBERCULOSIS IN THE BRITISH ISLES
Various papers were read describing work being
done in the home countries.
Dr. D. A. POWELL (principal medical officer,
Welsh National Memorial Association) said that
the fall in the tuberculosis death-rate in Wales,
though substantial, had not been as great as in
England, This fact must be connected with the
national characteristics of the Welsh, such as the
intense conservatism of their social habits, the
closeness and tenacity of their family relationships,
and their fatalistic outlook. In Wales, broadly speak-
ing, families were either free from the disease or were
riddled with it; and it ran in families because of
excessive opportunities of infection rather than
because of hereditary lack of resistance.
‘woven were town and country that in dealing with
a chronic infectious disease such as tuberculosis,
Wales had to be looked on as a unit. The main
services undertaken by the Association included :
(1) the provision of institutional treatment in sana-
toriums and hospitals ; (2) the provision of dispensary
or out-patient treatment, for which purpose Wales
was divided into 14 areas which disregarded when
necessary local government administrative boundaries;
(3) the establishment of clinics for the continued
treatment and supervision of surgical cases; (4)
the establishment of an educational department ;
(5) after-care ; and (6) the maintenance of a central
research laboratory. The liaison between the institu-
tional and the dispensary sides was extremely close—
administratively through the head office and the
principal medical officer, and clinically through
interchangeability of staff, the appointment of tuber-
culosis officers as visiting physicians, the appointment
of medical officers of surgical institutions as officers
in charge of the surgical after-care clinics, the carry-
ing out of joint investigations such as that into “ coal-
miners’ , lung,” and the holding of periodic staff
conferences. The Welsh National Memorial Associa-
tion was unique in that it combined the advantages
natural to a voluntary organisation with those
inseparable from a State and rate-aided service.
Dr. ERNEST Warr (Department of Health for
Scotland) said that in Scotland there was now, roughly,
1 bed per 900 of the population, but even now there
was often a waiting list. A reat deal had been
learnt about the problem of tuberculosis since the
inauguration of official schemes. It was important
to preserve a critical outlook upon all activities
engaged in the campaign.
The MARCHIONESS OF ABERDEEN gave an account
of the formation of the Women’s National Health
Association in Ireland in 1907, and the organisation
of a travelling anti-tuberculosis exhibition which
So closely
resulted in the establishment of a network of local
branches of the association and a steady decrease
in the tuberculosis death-rate. The rate recorded
for 1936 was the lowest yet reached (1:13 per 1000)
and was approximately 59 per cent. less than that for
1904. With a government grant of £25,000 two
sanatoriums were established near Dublin and
Enniskillen. It was not until 1929, however, that
they were able to make a start by establishing the
Peamount Industries and adopting the Papworth
plan of working for the establishment of a village
settlement. Lady Aberdeen spoke of the remarkable
change of atmosphere which had been brought about
during these seven years—a change that had trans-
formed the work. |
Dr. G. Lissant Cox (Lancashire County Council)
described some of the measures ‘for prevention and
treatment that have been adopted in Lancashire.
If treatment was over-emphasised, he said, they
would have a poor scheme and faulty control. The
importance of prevention was seen when it was realised
that some 60 per cent. of adult pulmonary tuberculosis
cases died within five years of coming under notice.
The Lancashire scheme was built up on the principle
of finding, isolating, educating, and treating the
adult positive case. Finding had to be done by
notification and by active coöperation between family
doctor and whole-time municipal or State doctor.
Isolation was carried out by keeping infective patients
in hospital as long as they would stay. In Lancashire
they had 680 beds, which was just enough for their
855 pulmonary deaths. Education was carried on
by teaching in schools (incidentally all schools ought
to be open-air schools), and teaching by the tuber-
culosis medical service in hospitals, sanatoriums, and
homes of the patients. Treatment included all
modern medical and surgical methods. It was
always free, and Dr. Cox considered that this policy
had helped to give them their reduction in incidence
and fatality. Schemes for the care and after-care
of the patient were an important part of treatment,
and were most highly developed in the village
settlement.
‘THE HOSPITAL AND THE VILLAGE SETTLEMENT
Dr. L. S. T. BURRELL said that when tuberculosis
was recognised either as a primary infection or as a
reinfection, the object of treatment was to make the
lesion heal without spreading, and it was in this
stage that the hospital was valuable. It was impossible
to over-estimate the value of an initial period of rest
in cases of pulmonary tuberculosis. When the
activity of the disease was arrested the function of the
sanatorium would come into play. Secondly, when the
patient was so. ill that he could do little or nothing
for himself, he should be in hospital not only for his
own sake, but also to prevent infection of others.
The third great function of the hospital was as a
centre for diagnosis. At the Brompton Hospital
a large number of patients came merely for this
purpose, and- were subsequently drafted to the
appropriate institution.
Dr. J. B. McDouGaLu (Preston Hall) spoke on the
re-settlement of the tuberculous ex-Service man..
From their early experience of the Preston Hall
scheme they had learnt that for the success of any
village settlement medical principles must take
precedence over every other factor in the life of the
community. Another important lesson they had
learnt was that the leaders of the various depart-
ments should be recruited as far as possible from the
1186 THE LANCET]
tuberculous population. The principles employed at
Preston Hall were substantially the same as at
Papworth. They now had accommodation for 300
patients suffering from pulmonary tuberculosis, and
treatment of every kind was available. With regard
to the purely industrial side, if the products were good
and the price was right, there was no reason why
trading in the open market should rot be as successful
in a village settlement as in any outside organisation.
A recent Ministry of Health report (1932) had pointed
out that a subsidy to a patient in a village settlement
was more economic than allowing the patient and his
family to be supported, entirely unemployed, from
the public assistance funds. He had often wondered
what the country would be saved financially by
acting on a large scale on this dictum.
SURGICAL TUBERCULOSIS
Sir HENRY GAUVAIN said that in the vast proportion
of cases conservative surgical tuberculosis treatment
was the treatment of choice. Occasionally radical
treatment was preferable, as for example in most
cases of tuberculous disease of the knee-joint in
adults, where excision was very often indicated, both
because duration of treatment was thereby shortened
and danger of recurrence largely avoided, and also
because the resulting disability was comparatively
trifling, and indeed was often less than if protracted
conservative treatment were employed. It might also
be desirable for small tuberculous foci which could be
readily and completely removed. In tuberculous
disease of the spine and hip there was much contro-
versy as to when fixation operations should be
undertaken. In his own experience these operations
were not advisable as a rule during active and pro-
_ gressive disease, especially in the presence of deformity,
since deformity could nearly always be reduced or
corrected during treatment. The treatment of
tuberculous glands of the neck varied with the type
of case, but usually a preliminary period of con-
servative treatment was useful, after which if neces-
sary any hard glands remaining which were unlikely
to be absorbed should be carefully excised. In
tuberculosis of the abdominal glands also conservative
treatment was always the method of choice and
operations avoided whenever possible. The Triboulet
test he thought was sometimes a useful guide to the
condition of the large intestine.
EXPERIENCES IN THE DOMINIONS
Dr. R. J. COLLINS (Canadian Tuberculosis Associa-
tion) said that in Canada they had no centralised
—i.e., national—department of health. Each province
built up its own schemes, agreeing in objectives
but differing in methods. In his own province of
New Brunswick special emphasis was being laid on
better housing and diet, the establishment of numerous
clinics, and adequate after-care. Very little con-
structive work had so far been done in respect of
housing; otherwise the advances made paralleled
those in England. The introduction of travelling
clinics had done a great deal. In 1928 survey work
—eroup examinations—had been begun with the
entry classes in the universities, and this had gone
on to other survey groups. These plans were dupli-
cated more or less throughout Canada. They had
an average in Canada of 1} beds per tuberculosis
death. Saskatchewan had 2 beds per death, but
the maritime provinces had less financial means.
With the object of shortening hospitalisation and
rendering the sputum negative there had been a great
increase in artificial pneumothorax treatment and
thoracoplasty, and at the present time some 20 to
THE CARE AND AFTER-CARE OF TUBERCULOSIS
patient in sheltered employment.
[may 15, 1937
50 per cent. of the sanatorium population received
some form of collapse therapy. There were 20 centres
in New Brunswick alone for A.P. refills. The employ-
ment of ex-patients was very valuable. Occupa-
tional therapy the speaker thought rendered little
service towards future employment. Vocational
training could be made more effective if there was more
diversity of subjects, and it should be supplemented
by some scheme for the subsequent placing of the
After-care in
Canada was a problem affecting some 10 per cent.
of the discharged patients. |
Miss GLORIA LANGMAID (Canadian Association of
Occupational Therapy) said that occupational therapy
was now part of the equipment of every up-to-date
sanatorium in Canada. It assisted young patients to
adjust themselves to their new conditions, and
aroused their interest in new directions.
Mr. D. M. DEANE described the work of the
Tubercular Soldiers’ Aid Society, Adelaide.
- Dr. A. J. COLLINS (Commonwealth of Australia)
said that notification of tuberculosis was compulsory
in Australia, but the State was powerless if a man
declared he could not afford to give up his work to
undergo treatment. Unless financial assistance was
available for their dependants, a certain proportion
of tuberculous patients would not avail themselves
of the necessary institutional provision. The public
health officer should be empowered to insist on
adequate treatment in every case.
At a subsequent session the Hon. FRANCIS GABA
(Minister of Health, Tasmania) said that the principal
difficulties in Tasmania lay in organisation, transport,
and public apathy. Sometimes they had to take
their people as far as 200 miles away from their homes
and to put them in the central institution set apart
for special treatment. The patient often rebelled
at being transported so far, with the result that they
had been dealing with a later stage of tuberculosis
than could be found in centres where clinics could be
readily located. The Government was about to
establish a full-time free medical service for people
living in the remoter portions of the State. The
medical officers were to be part of a central medical
scheme run in conjunction with Tasmania’s public
hospitals, and were to be given frequent opportunities
for refresher courses in the hospitals. A central
sanatorium along modern lines was also in process
of development. Where centres of population per-
mitted, it was intended to adopt the British method
of tuberculosis clinics, classification and ambulatory |
treatment generally. More ambulance units were
to be installed to facilitate transport; health talks
by radio were to be given, and elementary instruction
in hygiene provided by the State schools. The
speaker concluded by referring to the fundamental
importance of guaranteeing to the public a pure milk-
supply.
INDIGENOUS RACES
Viscount GOSCHEN took the chair at the fifth
session. He emphasised the importance of a free
exchange of information.
Dr. CHARLES WiLcocks (Tanganyika Territory)
gave the results of a five-year investigation of tuber-
culosis conducted by him in Tanganyika inhabited
by some 5,000,000 natives, mainly of Bantu origin.
For the tuberculin survey the Mantoux technique
was used throughout, supplemented by stethoscopic
examination, collection of sputum if desired, and an
X ray examination of suspected cases. In 9866
such examinations 114 cases of definite tuberculosis
were found, giving a crude rate of 11:5 per 1000.
THE LANCET]
In every place half or more of the adult population
were positive to tuberculin, the rates for children
being lower. Of X ray films of 106 unselected
contacts, 16 per cent. showed definite tuberculous
infiltration of the lungs. In a larger series of contacts
who were tuberculin-tested 83 per cent. of all ages
were positive, of whom some were contacts of non-
pulmonary cases. The results of the survey suggested
that continuous exposure to exogenous reinfection
tended to produce first sensitivity, then hyper-
sensitivity, and finally disease; and if the highly
allergic state was harmful rather than protective,
then the process might be a continuous one. The
dominating factor was contact. The prognosis in
native tuberculosis cases was usually bad. This
might be due to late diagnosis, poor living conditions,
and diet, or possibly to a racial predisposition to the `
disease, perhaps increased by concurrent diseases ;
and with better conditions and treatment an improve-
ment might be looked for. The resistance shown
by the infected natives proved that under most
circumstances they could control their infection.
It might take very little to increase that capacity
for control, so that a repetition of the experience
of the North American Indians might be avoided.
Major-General Sir CUTHBERT SPRAWSON (Indian
Medical Service) said that the Indian population as a
whole was more susceptible to tuberculosis than
the population of Great Britain. There were also
special difficulties inherent in the purdah system and
the early marriage of girls, while another peculiarity of
tuberculosis in India was the large proportion of cases
of primary abdominal tuberculosis. Infection from
the bovine tubercle bacillus, however, was believed
to be rare. The dispensary system of tuberculosis
control in this country presupposed existing hospital
or sanatorium accommodation for all the cases the
dispensary might send, but in India such accommoda-
tion did not exist. There was an urgent need for
increased hospital accommodation, by which the
most essential link in the chain of case disposal would
be achieved. There was, also, room for a tuberculosis
settlement on the lines of Papworth—.e., an institu-
tion receiving cases of all types with its own dispensary,
hospital, sanatorium, and factory. No such settle-
ment had yet been established in India, but if every
Indian city with a population of 100,000 or more
were to start a tuberculosis settlement a few miles
outside municipal limits, with accommodation and
arrangement for expert treatment of patients of all
types, and with separate quarters for the families
of those fit to resume work, the speaker believed that
a need would be met and the public health improved.
Money should be raised mainly by public subscription
rather than by government assistance, and by many
small subscriptions rather than a few large ones.
Dr. P. V. BENJAMIN said that a tuberculin survey
by the Union Mission Sanatorium, South India,
suggested that the infection, even in the villages,
was widespread, the disease usually being of the acute
rapidly developing type. In spite of the widespread
infection and severity of type, there was a surprisingly
small amount of tuberculous disease in the area of the
tuberculin survey. The fact that the type of disease
met with was almost exclusively acute exudative
might be due partly to auto-inoculation, brought
about by undue stress or unfavourable environment
during a period of relative instability in tuberculosis
immunity, and partly to exposure to repeated massive
doses of tubercle bacilli from outside. As many as
40 per cent. of the patients gave a history of direct
contact with tuberculous patients. Dr. Benjamin
urged that further research work should be under-
THE CARE AND AFTER-CARE OF TUBERCULOSIS
[may 15, 1937 1187
taken through surveys in different areas, but coördi-
nated under a single control; also that efforts against
tuberculosis should not be wasted in a general broad-
cast type of propaganda, but should be concentrated
and directed to reach and educate those among whom
the disease is actually found; and finally that efforts
should be made- to detect, treat, and isolate those who
were a serious source of danger to others.
Mr. NORMAN MACLENNAN (Department of Health,
Palestine) said that a tuberculosis survey had been
carried out amongst all sections of the Palestine
population in 1934-35 ; observations were also made
on tuberculin sensitivity rates in school-children
5-13 years of age. It was found that the Palestine
rates were considerably less than half the figures given
for London and for Leeds, and it was likely that the
process of tuberculisation would increase in the
near future. The immigrant adult Jewish population
was, however, probably already tuberculised. Factors
generally admitted to be operative in promoting the
incidence and spread of tuberculosis existed in a large
proportion of the population. These factors were,
uncontrolled infection, poverty, malnutrition, over-
crowding, ignorance, and insanitation. As far as
the nomadic Bedouin in Transjordan were concerned,
both individual and racial resistance appeared low,
and the disease was often of the “ galloping ” variety.
Bovine infection apparently played a negligible rôle
in the production of the disease in Palestine.
Prof. S. LYLE Cummins presided over the last
session of the conference. |
Dr. BERNARD MYERS, speaking on tuberculosis
in New Zealand, said that Maoris contracted tuber-
culosis more easily than the New Zealanders of
European descent and appeared also to have a
lessened resistance to the disease, so that the death-
rate was distinctly higher. The hygienic conditions
under which the Maoris lived and their reluctance
to adopt the necessary European methods made their
treatment very difficult. An advance had, however,
been made by the establishment of tuberculosis
clinics in various parts of the North Island and a
tuberculosis scheme was being organised which was
expected to bear fruit in the near future. Dr. H. B.
Turbott, medical officer of health at Hamilton,
New Zealand, carried out in 1933 a thorough survey
of a typical Maori country population, and the
knowledge gained resulted in the adoption of a care
and after-care scheme over the same area, covering
about 4000 Maori population. The tuberculosis
mortality in the demonstration area dropped to
less than half between the years 1934 and 1936.
And thus after three years’ trial the scheme had proved
sufficiently successful to recommend for adoption
for Maori’s throughout New Zealand.
Dr. J. CAUCHI (Nigeria) dealt with tuberculosis
in West Africa. Explaining that Nigeria had an
approximate population of 20 million over an area
of just under 373,000 square miles, and that outside
the municipal area of Lagos there were almost no
qualified men in private practice—the actual available
strength of the establishment in the country at any
one time amounting to less than 100 medical officers—
he said it was obvious that only a small minority
of those suffering from disease could ever come to
the notice of the medical organisation. It was
therefore unavoidable that their knowledge of the
incidence of tuberculosis in Nigeria should be limited,
although the incidence was known to be high. In
1935, in the returns of Government institutions,
tuberculous infections accounted for over 23 per
cent. of the total of 836 fatal cases of infectious
1188 THE LANCET]
disease. The two main clinical groups of cases seen
in Lagos were: (1) those showing cavitation and
surrounding fibrosis of the lungs, and (2) those showing
multiple lesions of the various organs and tissues.
In both groups the disease’ followed a steadily
progressive course with little or no evidence of
reparation or retrogression. It was thought possible
that these two groups might be correlated to two
different strains of Bacillus tuberculosis. If this
theory was confirmed, it should have a bearing on
practical methods of control. Tuberculosis had been
made notifiable since last year for the whole of
Nigeria, and cases were being reported from many
of the hospitals. Lagos had been undergoing rapid
urbanisation in recent years, and as house building
had lagged behind the increase of population over-
crowding had resulted, with its increased opportunities
for infection. Town-planning and housing improve-
ments which were now being energetically carried
out constituted sound lines of control. There was
also some evidence of tuberculosis among cattle
in widely scattered districts. There was thus ample
material for tuberculosis research by clinician,
laboratory worker, and public health officer as soon
as the country could afford to add to its present
much too limited staff.
The conference concluded with speeches from
Dr. A. D. PRINGLE, representing the Transvaal
Chamber of Mines, and Dr. G. M. C. POWELL, repre-
senting the medical services of Northern Rhodesia.
AN AMBULANCE IN SPAIN
Last November we published a letter from Mr.
K. Sinclair-Loutit describing the work of the Spanish
Medical Aid Committee’s ambulance unit at Grajien
in Aragon. In December most of the personnel
left for an area of greater activity and the following
letter gives a further account of what they are doing.
- “ Here on the Madrid front we lead a very different
sort of life. In the three months we have been here,
we have established five different hospitals and
treated, in round figures, 2000 wounded. Our
function is that of mobile hospital to the XIV Brigade
which means that we lead a very active life, often
being compelled to pack up, transport, and re-establish
the entire hospital in 24 hours. In the beginning we
found this a well-nigh impossible task, but now,
- with proper division of labour and systematised
packing, we are beginning to look upon it as being
all in the day’s work. We are usually housed in
large villas of fascist ownership which, with a little
initiative, can be converted into excellent first-line
hospitals. This is not always so, however, and in
one case the choice lay between a baroque palace,
the walls of which were festooned with cupids and
saints chasing each other round with a fine disregard
for the laws of hagiography, and a sixteenth century
Alcaldia. We chose the latter because the rooms
were larger and there were accessible water and some
elementary sanitation It was built round a most
beautiful courtyard and among its amenities was a
bar which between 4 a.m. and 7 A.M. was converted
into an operating theatre—much to the surprise
of some local inhabitants who dropped in for ‘a
quick one’ at 9 o’clock. The public hall became
our largest ward, every other part of the building
being utilised, so that when we came to leave six
weeks later, the place was wired for electric light,
there was running water on the premises and the
lavatories were up to normal English standards.
«We carry with us a carpenter, an electrician, and
AN AMBULANCE IN SPAIN
[May 15, 1937
a plumber, who in Spain are as essential as any of our
personnel, They also confer a lasting benefit on any
premises we occupy; thus when the line advances,
the civilians reoccupying those houses find their
last state better than their first.
“We usually arrive at the village that has been
chosen for us—some 14 or 15 kilometres behind the
firing-line—in the small hours of the morning. Large
convoys by day are too vulnerable to aerial attack.
Our house, which has already been marked and is
often enough Hobson’s choice, has to be immediately
prepared for the results of the dawn offensive, which
will begin to arrive about 9 a.m. Three things are
our first attention: (a) a working operating theatre ;
(b) a minimum number of beds; (c) a proper water-
supply. This is sufficient for the first rush and the
rest can be completed in the subsequent 24 hours.
“ We attempt to follow the same plan in all our
hospitals. We start with a large reception room
which can hold about 15 stretchers and the same
number of ambulant cases. Here, as the cases arrive,
a rapid sorting is performed by the reception officer
and the wounded are dispatched to major or minor
operating theatres, or, in cases of great shock,
straight to the wards. He, too, is responsible for
evacuations, dispatching those who can stand
further transport farther back from the line. Here,
also, any first-aid treatment is given, the pre-anses-
thetic dopes, antitetanic, and anti-gas gangrenous
sera, morphine, and, with the lighter cases, a very
welcome cup of coffee and a cigarette. Next comes
the operating theatre, or theatres. We have always
found this a great problem: it is difficult to find a
series of suitable and adjacent rooms to give our
operating teams separate theatres. In the last two
hospitals we have had to put all five tables in the
one large room—this has proved an admirable arrange-
ment and an economy in both material and staff.
“The theatre and reception room having been
chosen, the rest of the house goes of necessity to wards,
office, and kitchen. Our small sterilising-room
is in a way the most vital part of the hospital. We
cannot rely on prepared dressings nor can we allow
anyone else to do our sterilising ; and so, for instance,
every bit of gauze is cut and autoclaved on the
premises. Our steriliser, an ex-R.A.M.C. orderly, is
kept hard at it keeping up the ever-diminishng stocks.
“The whole organisation is designed on such @
scale as to deal with about 120 cases daily, with
5 operating tables and 70-80 beds.
“ Having settled the all-important question of the
hospital, the billeting officer has to house and feed
some 50 personnel, Amongst our number are repre-
sentatives of every European country—English
predominating on the medical staff. This does not,
as one might expect, result in a babel, for the war has
produced its own language, a sort of trench-Spanish.
A little difficult for lengthy conversation with a
Spaniard, but quite enough for a Czech and an
Englishman to make each other understand.
‘* As we are so close to the line we cannot rely on
uninterrupted or fixed hours of work. We have
often had to work the 24 hours round and that
under the difficulties entailed by air-raids, failure of
the light supply (here the grid system often works
right up to the front line) and all the other accidents
of war. A Belgian driver has now rigged up a very
effective emergency lighting plant for the theatre
out of salvage from car wrecks and a dynamo from
a bombed garage; so now we can carry on with
something better than flash-lamps and candles.
For the sanitary service there is no rest. When
our brigade is “en repos,’ we, although things are
naturally quieter, have a full day’s routine work with
medical (as opposed to surgical) patients, occasional
civilian road casualties, routine inspections, and
inoculations. Then there is the checking-up of stores
from which arise those urgent appeals you receive
(and we hope attend to at once) sent out by our
London committee. Then the theatre staff are fully
occupied in preparing dressings, manufacturing
plaster bandages, repairing gloves, and cleaning and
adjusting instruments. During these brief rest
periods each arm of the brigade tries to organise an
evening’s entertainment for the remainder of the
service. First, a musical entertainment followed
by a dance—always described as a Gran Bal! As the
women are naturally in the minority there being
only eight English nurses and a few Spanish girls
from the village, there are no wall-flowers and one
sees such couples as a 6-foot Belgian regimental
sergeant-major waltzing around with a 5 ft. 4 in.
Polish dispatch rider. The order to move comes and
back we go to some hard-pressed sector.
“ The contrast between this and our former work
on the Aragon front strikes one from every angle.
At Grafien we were permanently established behind
a stationary defence line: Spain was on the defensive.
That line, at any rate when we arrived there last
August, was manned by discoérdinated militia without
unique command, without concerted plan of action.
All that has passed. And now, eight months later, we
find ourselves behind a determined and disciplined
army engaged in an offensive which stretches from the
borders to the seas against a foreign fascist invasion.
Thus No Pasaran has changed to Nosotros Pasaramos.”
MEDICINE AND THE LAW
A Disputed Will
In 1908 a Lancashire gentleman took to his bed
complaining of influenza and malaise. He had a
slight rise of temperature, but did not appear to be
seriously ill. In a few days, however, his illness
took a serious turn and his doctor was summoned.
The patient obviously had an acute abdominal
emergency, and diagnosis of a perforated typhoid
ulcer was confirmed by a second opinion. He was
given occasional doses of morphia—gr. } hypo-
dermically—to ease his pain. In a day or two he
died, but a few hours before his death he was propped
up in bed and signed a long will which had been
prepared by his solicitor and by which he left his
wife an annuity and the bulk of his fortune to his
sons and their descendants. His daughter, then
only a few months old, received only a small share
of the testator’s inheritance from his father.
various reasons she did not learn of the circumstances
in which the will was executed until 1936. She then
issued a writ against the executors alleging that the
will was not properly executed because the testator,
when he signed it, had not possessed sound mind,
memory, and understanding; that he did not know
and approve of its contents, and was delirious and
comatose the day before and continued in this state
with intervals of consciousness until he died; that
he suffered a great deal of pain and distress and died
two hours after the execution of the will; that he
gave no instructions for the will, that it was not read
over to him, and that he could not appreciate or
understand its meaning, effects, or contents, or form
a rational opinion of his financial position or the claims
of his family on his testamentary dispositions.
The action was heard before Mr. Justice Langton
on April 22nd, 23rd, and 27th. By good fortune
MEDICINE AND THE LAW.—REFORM OF THE CURRICULUM
For
[may 15, 1937 1189
Dr. Walter Rigby, the testator’s medical attendant
and a witness of the will, was able to give evidence
of the circumstances. He said that the dying man’s
mental state was quite clear. There had been nothing
to show that he knew it was his will, but there was
no doubt that he did know. Cross-examined, he
said that perforated typhoid ulcer was very rare but
almost certain to cause death in two or three days;
that delirium was not a common feature of the
illness unless the temperature was high. Typhoid
being a ‘‘ low fever,” this was not usual. The patient,
although not quite normal, was perfectly in possession
of his senses and knew quite well what he was doing.
He could see and was conscious of his surroundings.
He had no persistent agony or pain, nor had he been
delirious or comatose within the doctor’s knowledge.
Other evidence showed that the will had been drafted
on the instructions of the testator. It has been
settled law since the case of Parker v. Felgate 1883,
8 P.D., 171, that if a person has given instructions to
a solicitor to make a will and the solicitor prepares
it in accordance with those instructions, the testator
need only be able to reflect: “I have settled that
business. with my solicitor: I rely upon him as having
embodied it in proper words, and I accept that paper
which is put before me as embodying it.” As the
case was settled, the court had no opportunity of
hearing evidence by Sir William Willcox and Dr.
G. W. B. James on the,probable effect of a perforated
typhoid ulcer on the mind of a testator. The case
is interesting, not only because the cause of the
alleged testamentary incapacity was unusual but
also because, although the events happened nearly
thirty years ago, the evidence of the medical attendant
was available. Its absence would probably have
handicapped the executors considerably, for the
onus was upon them to prove that the will had been
properly executed.
REFORM OF THE CURRICULUM
(FROM OUR EDINBURGH CORRESPONDENT)
A DISCUSSION on medical education was held last week
in Edinburgh under the ægis of the University Union.
Sir FRANCIS FREMANTLE, speaking as a medical
Member of Parliament, said that in establishing the
General Medical Council Parliament had delegated
to the profession itself the duty of maintaining
standards of education and etiquette. The standards
thus attained were high, but the dual factors of
government protection and stereotyped training
had resulted in a rigidity of mind in the profession,
and an undue bias against innovations, as was
exemplified in its tardiness to acknowledge the
principles of homeopathy and osteopathy. Among
changes he would recommend in the medical curri-
culum was more thorough instruction in the history
of medicine, to offer encouragement and to foster the
student’s pride in his profession. Teaching should
be directed rather to the maintenance of perfect
health than to the cure of disease, and a place should
be found for instruction in administration and com-
munal medicine. He accused physicians of faulty
pathology ; the identification of an organism should
not end the investigation of a case; the patient
should be followed to his home or place of work, and
the prime cause, which had enabled that organism
to flourish should be sought and eradicated. Students
should be judged in examinations not only by the
marks then obtained, but also by their previous
record of work, intelligence, and tact.
Dealing with the supervision of medical schools
. 1190 THE LANCET]
by the General Medical Council, Sir Francis main-
tained that the Council’s powers were too restricted ;
further that the Council, as now constituted, with
members who had received their training upwards
of thirty years ago, was not a suitable body to make
the necessary improvements. There was but little
prospect of aid from the Government in reforming the
‘ medical curriculum, and such reform must be initiated
by the individual medical schools, and especially by
the universities. He favoured the appointment of
younger men to the General Medical Council; the
addition of student representatives to boards of
studies ;
on the General Medical Council; and the formation
of a statutory Health Council under the Privy Council,
which would assist the General Medical Council
in the necessary reforms, and be responsible to
Parliament for the coédrdination of health services.
Dr. G. O. BARBER (Cambridge and St. Mary’s
Hospital, London) spoke as a general practitioner.
The student, he said, tended to regard the acquisition
of a medical degree as fully and finally qualifying
him to undertake the care of patients. This view
was encouraged by the general public, which placed
unfaltering faith in those who hold such a degree.
In point of fact the possession of this degree indicated
only that a high standard had been reached in a
large number of disconnected, academic, scientific
subjects. Dr. Barber pleaded for a larger representa-
tion of general practitioners on the General Medical
Council, and amongst the teachers and examiners
of students. Speaking of the teaching of future
general practitioners by specialists under the present
system, he declared: “we are like bricklayers, who
have been taught to mix their mortar by architects
who have never touched a brick.” He wished to
see more thorough grounding in the common ailments,
strict limitation of academic instruction, and a
break-down of the watertight compartments in which
subjects were now taught. The medical course
should involve less memorising ; there should be more
direction of the student’s thinking powers, and less
exhibition of the teachers prowess. Academic
instruction should be reduced to that minimum,
which included only material directly applicable to
practice, and such instruction should be undertaken
in connexion with practical work. Anatomy and
physiology should be more closely correlated, as
should also pathology and bacteriology; and the
connexion of these subjects with clinical medicine
should be more adequately demonstrated. The
anatomy course should be much curtailed. Dr. Barber
pressed the claim for instruction in the common
ailments and social and preventive medicine, whilst
agreeing that this would necessitate the surrender of
some part of the present curriculum. He thought
that, the special subjects, of which only a general
knowledge was needed, might be pruned.
Prof. SYDNEY SMITH defended the curriculum at
Edinburgh as being years in advance of that at any
English school. The claims of preventive medicine
were amply realised, at least in Edinburgh, and this
was exemplified by the chair in child life and health,
by the institution of school medical services, and
by systematic antenatal supervision. Prof. Smith
contended that the premedical subjects—physics,
biology, and chemistry—should be learnt at school.
It was intended at Edinburgh University to institute
a full five years’ course, not including these subjects,
which could then be learnt either at school or at the
University in a course unconnected with medicine.
Other changes shortly to be effected at Edinburgh
were the curtailment of practical anatomy and
THE ROYAL SOCIETY
lay representation of the health services —
[may 15, 1937
lengthening of the course in physiology; a more
generalised instruction in biology ; and a fuller course
in applied physiology and anatomy, to be continued
throughout the five years. The systematic teaching
of medicine and surgery was to be largely transferred.
from the third to a later year, and instruction in these
subjects was to be given in hospital, to ensure that
the theoretical and clinical aspects should be not
divorced. Further clinical instruction was to be
given at the expense of vacations. Under the
system now employed in Edinburgh, pathology and
bacteriology were closely correlated with theoretical
instruction in medicine and surgery, and with clinical
work. Prof. Smith strongly rebutted the suggestion
that the teaching of special subjects should be
curtailed. This instruction was, he asserted, essential
and was general enough to be of interest to the general
practitioner. He approved of the teaching of students
by specialists, who, he asserted, were not unmindful
of the needs of the general practitioner. The practi-
tioner required the first-class training, which the
specialist could offer. While allowing that much
could be said in support of the old system of apprentic-
ing students to practitioners he thought the present
system fitted the student more fully for his manifold
roles, as scientist, artist, and priest. It was true that a
student could not be a competent physician after five
years’ training, but the degree he obtained implied asolid
basis on which he could build for the rest of his life.
After further discussion Dr. CHALMERS WATSON, in
summing up, supported Sir Francis Fremantle’s plea for
a reorganisation of the curriculum, and emphasised
the necessity of instruction in preventive medicine.
THE ROYAL SOCIETY
THE only medical man among the 15 Fellows
elected to the Royal Society on May 6th was Dr.
A. N. Drury, lecturer in pathology in the University
of Cambridge. He is distinguished for researches on
the refractory period of, and conduction in, heart
muscle, for studies of coronary circulation, and of
the physiological action of adenosine. He has recently
` published jointly observations relating to the action
of psychosin sulphate on bacteria, toxins, serum, and
red blood cells. Mr. Percival Hartley, D.Sc., does
valuable work in close relation to medicine as director
of biological standards at the National Institute for
Medical Research, and as member of the British
Pharmacopeeia Commission.
We offer cordial congratulations also to Mr. J. D.
Bernal, lecturer in crystallography, University of
Cambridge; Mr. A. C. Chibnall, assistant professor
of biochemistry, Imperial College of Science and
Technology ; Mr. G. R. Clemo, professor of chemistry,
Armstrong College, University of Durham, Mr. H. M.
Fox, professor of zoology, University of Birmingham ;
Mr. W. E. Garner, professor of physical chemistry,
University of Bristol; Mr. Sydney Goldstein, Ph.D.
lecturer in mathematics, University of Cambridge ;
Mr. H. L. Hawkins, professor of geology, University
of Reading; the Rev. J. E. Holloway, lecturer in
botany, University of Otago; Mr. William Hume-
Rothery, D.Sc., Warren Research Fellow of the
Royal Society ; Mr. T. G. Mason, Sc.D., of the Cotton
Research Station, Trinidad ; Mr. J. R. Moir, archzo-
logist; Mr. M. L. E. Oliphant, Ph.D., assistant
director of research, Cavendish Laboratory, Cam-
bridge; Mr. C. F. A. Pantin, Sc.D., lecturer in
zoology, University of Cambridge; Mr. D. R. Pye,
Sc.D., deputy director of scientific research, Air
Ministry ; and Mr. E. C. Stoner, Ph.D., reader in
physics, University of Leeds.
THE LANCET]
[may 15, 1937 1191
GRAINS AND SCRUPLES
Under this heading appear week by week the unfettered thoughts of doctors in
various occupations.
Each contributor is responsible for the section for a month ;
his name can be seen later in the half-yearly index.
FROM A MEDICAL ECONOMIST
II
WHEN children are ill their toys, the toys they
cannot play with, acquire a new significance. If the
illness is very serious parents will scarcely endure
the sight of these toys. |
If the subject is discussed at all it is usually spoken
of in terms of memory, the idea being that the toys
recall happier days. A dramatist however, who is
accustomed to secure his effects by means of material
things as well as by means of words and gestures
and expressions, challenged this view recently in
my hearing. ‘It is not,’ he said, “that the toys
recall happier days in the past but that they demand
happier days in the future.”
Asked to explain himself, he mentioned the wedding
dress of which so much use is made by Sir James
Barrie in his play, Quality Street. “A glimpse of
that dress towards the end of the play makes many
people weep,” he declared. ‘‘ Indeed the dress
undergoes transmutation, from act to act. At first it
is just a wedding dress; at last it has become an actor
endowed with a personality of its own and playing
the chief part. The effect is tension—the hope that
the wedding dress may yet be worn. Kill that hope
and the dress loses its significance and becomes a
relic.”
I suppose that it can be said that, in the same way,
the toys are unbearable because of the hope of
recovery. If recovery does not take place the toys
will become relics to which no tension will attach.
Indeed, in that sorrowful case, they may, as precious
memories, afford some consolation,
* * *
The point that seems to emerge is the tendency
of all men and women to transform the materials
which surround them into spiritual values. My hat
in the hatter’s shop and my hat upon my head are
two widely different things. In the latter case,
side by side with consumption, there is going on a
process of change whereby what was as obvious
and definite as a brick is becoming endowed with new,
mysterious qualities. Aristotle understood this pro-
cess and detected in all things two kinds of substance—
the accidental and the essential. The accidental
‘substance of my hat happens to be black felt—
it might have been straw or beaver or cloth; its
essential substance is its ‘‘ hattishness.”’
Aristotle devoted long and careful thought to
the nature of essential substance, and it is profitable
still to ask oneself: ‘‘ What is a hat?” ‘‘ What is a
chair ? ” and so on. The question soon convinces
those who ask it that no definition in terms of material
substances, that is of accidental substances, is possible.
Nor will mere description afford a satisfactory
answer. Whether we like it or not we shall find
ourselves compelled to bring in the human element.
Thus, a hat is a covering for a head; a chair is some-
thing upon which to sit. Our definition is therefore
teleological. Further, it expresses a relationship
between the designer and maker of the hat and the
user—a relationship which, if the hat is a good one,
is likely to be of a neighbourly character in the
‘broadest sense of that term.
The hat, in short, embodies an idea of a specific
kind—namely, usefulness. It is upon this idea that
its owner’s mind becomes fixed and it is this idea
which, if the owner lies ill, will occasion tension in
the hearts of those who care for him. No piece of
material unmade into an article of use is capable of
producing such tension.
k * k
Aristotle called his study metaphysics. Another
name was given to the same study by St. Thomas
Aquinas, who recognised in the products of crafts-
manship an expression of the emotional relationship
which exists between all men of good will. Essential
substance for him was love and he saw the material
universe, therefore, as a spiritual universe. Verbum
caro factum est. Thus he recognised the capacity of
material things to become vessels or containers of
spiritual things, nor was he disposed to establish
any sharp differentiation between the vessel and its
contents. . The wood of which the chair was made
was, in fact, the chair. It had been subjected to a
process of trans-substantiation whereby, retaining
the physical properties of wood it had, neverthe-
less, acquired the metaphysical or, as he would have
preferred to say, neighbourly qualities of a chair.
It had acquired also the power to create tension -
in the form of a claim to be used,
St. Thomas supposed that this claim to be used was
characteristic also of living forms and his ideas have
an important bearing to-day upon the attitude of
men who cannot find employment. These men,
as we are all well aware, produce a tension in the
minds of their neighbours which, recently, was one of
the most important elements in thé political and
economic life of the country.
Incidentally the identity of a man with his use
to his fellows, the transmutation of man into crafts-
man, artist, doctor, is, from the individual’s point
of view, a very remarkable psychological process
involving not only a discipline, or if the word be
preferred, a morality, but also an enthusiasm strong
enough to carry the apprentice or student through
the severe restraints of training. Such enthusiasm
may not be self-conscious in the sense that a definite
service is held in view from the beginning, but since
it seeks and finds some particular expression—
making chairs or painting pictures or engaging in
medical research—it is not the less on that account
a surrender of purely selfish aims and so a kind of
rebirth. Not only has the craftsman acquired
power to transmute materials into spiritual values ;
he has himself, also, in the process been transmuted
so that the greater his capacity to create the greater
also is likely to be his contempt of personal considera-
tions or personal safety. His body, an accidental
substance, has thus become identified with the essential
substance of love.
x x *
The fact of this trans-substantiation is always
present consciously or unconsciously to the doctor’s
mind, in which, invariably, it produces tension.
The doctor feels that the body disabled by sickness
challenges him to restore it to its usefulness and
so to secure the future. In responding to that
1192 THE mee
challenge the virtue goes out of him and he experiences,
often, a sense of exhaustion disproportionate,
apparently, to the effort he has made. In fact, his
effort is creative in the true sense of that word,
for the injury he essays to repair is not to flesh
and blood only but also to the power which has
transmuted flesh and blood into spirit.
That power, in the case of materials, lies outside
of the material itself and must be imported into it.
This is so obvious that none for a moment doubt it.
But where flesh and blood are concerned such importa-
tion, being less obvious, is often overlooked. The
body is self-repairing and so we discount the truth
that external influences can be, and always are being,
exerted upon the reparative process. One of these
influences, as has been said, is that virtue which
the doctor feels he has lost; another is the patient’s
own enthusiasm, that is to say the patient’s own
spirit. He who turns his back to the wall will not
recover. It is difficult, in the face of that fact, to
avoid the conclusion that the rebirth which is the
finding of a vocation is the importing into a man’s
body of a new director, spirit, or soul, henceforward
to be the man. Browning had knowledge of that
incarnation when he wrote :
“ Lo, a blade for a Knight’s emprise
“To fill the empty sheath of a man.”
And during many centuries the thought of Europe
was focused upon it. Thus, it was believed that help
given to anyone in distress was help given to the
spirit in possession of the distressed person’s body.
The story of St. Christopher is a case in point; so
,
PARLIAMENTARY INTELLIGENCE
{may 15, 1937
is ‘the story of the crippled child who, on being
rescued, was transmuted miraculously into the form
of Christ. Doctors, on that showing, healed souls
or rather helped souls to heal themselves. The
conception of a secular medicine was almost wholly
unknown.
* * *
It is of interest to note that, until frustration fell
upon the world in the nineteenth century, poets and
artists accepted the idea of immortality as self-
evident. The poets of the frustration period are,
without exception, minor poets. To be condemned
to uselessness in unemployment or to perverted use
in sweat-shops is, apparently, to lose that sense of
the supernatural which is the heritage of all men whose
enthusiasm to serve their fellows has free play. In
a world of frustration and perversion, moreover, the
minds even of the free become darkened. Thus
there would seem to be an interaction between
economic conditions and the intimate texture of
thought. The chairs in a museum, so long as they
remain out of reach, are wood and upholstery; the
men held prisoners of enforced idleness or perpetually
vexed by fear, are so much flesh and blood—in
Mr. Roosevelt’s terrible phrase ‘‘ industrial cannon-
fodder.” Not for them the ecstasy of self-surrender
to love of their fellows, the stern and inexorable
morality inculcated by refractory materials, the growing
sense of identity with powers which are not of this
world, and so of emergence from the dimensions of
space and time which flesh and blood, untransmuted,
impose like a turnkey upon the human spirit.
PARLIAMENTARY INTELLIGENCE
THE FACTORIES BILL IN COMMITTEE
THE Factories Bill was further considered by a
Standing Committee of the House of Commons on
April 27th. Major LLOYD GEORGE was in the chair.
On Clause 68 (General conditions as to hours of
employment of women and young persons),
Mr. SILKIN moved an amendment to provide that
as respected young persons where the hours of
employment included thé hours from half-past eleven
in the morning to half-past two in the afternoon an
interval of not less than three-quarters of an hour
should be allowed between those hours for dinner
if dinner was taken in the factory or in a building
of which the factory formed part, or one hour if
dinner was not taken in the factory or such building.
He said that hon. Members had recently been con-
cerned with malnutrition ; it was almost as important
to secure that meals should be taken at the proper
times as that they should be of the right. quality and
adequate in quantity. As the clause stood young
persons might be employed for considerably longer
than three hours without any guarantee of a proper
meal time between half-past eleven and half-past two. .
The principle of the amendment was accepted as
far back as 1912 and was contained in the Shops
Act of that year. |
Mr. G. Litoyp, Under-Secretary, Home Office,
said that in 1912 there was no limit to the hours for
women and the limit of weekly hours for young
persons was 74. It was therefore imperative to see
that there was sufficient time for lunch in the middle
of the day. The position was very different under
this Bill. It was a question of striking a compromise
in individual cases all over the country.
Mr. BANFIELD said that be knew that even to-day
in thousands of workshops young persons got no
proper meal time.—Mr.,. LEWIS JONES said that
every employer was anxious that proper facilities
should be given for meals, but this amendment
might interfere with the collective agreements which
had been made by trade unions and employers, in
some cases providing for a minimum of one hour for
the midday meal.—Mr. SHorT said that if when
drawing up welfare orders the Home Secretary would
undertake to consider this aspect, particularly in
respect of young persons, and make some conditions
regarding the hours of meals that would meet the
Opposition.
Sir JOHN Simon, Home Secretary, said that he did
not think that their existing powers as regarded welfare
orders covered an actual mandatory direction as to
the length of the interval for meals. The conditions
in different kinds of work varied very considerably
and it was better not to make a stiff rule which had
to be applied indiscriminately. The effect of a
discussion like this however, which would be noticed
outside, was all to the good, because no one desired
to rush people unduly, or to give them indigestion.
The amendment was negatived.
On the question that the clause as amended
stand part of the Bill,
Mr. Ruys Davies said that the Labour Party
would vote against the clause to show their dis-
satisfaction with it. He was a little alarmed that
members of all parties failed to understand that this
country was lagging behind some other industrial
countries in the treatment of young people. He was
ashamed at the way boys and girls were exploited
in hotels —Mr. GRAHAM WHITE said he hoped the
limit of working hours for young people would be
nearer 40 per week than 46.—Sir W. SMILES said
it was unnecessary for young people under 15 to
work in factories or to work 48 hours a week, but some
workers in his constituency seemed to want their
children to go to work at 14 and to work for 48 hours
a week.—Mr. VIANT said that many of the parents
referred to by Sir W. Smiles had small incomes and
that was why they were anxious for their children
to go to work at an early age. When they realised
that it would be for the ultimate benefit of their
children that they should not start work so early
THE LANCET]
their attitude would change.—Mr. G. MANDER urged
that the Committee should consider the limitation
of working hours for young people up to 18 years.—
Mr. G. BUCHANAN said that the clause was shockingly
inadequate.
Sir J. Suwon said that he had undertaken to put
down a new clause modifying the hours of labour
in factories for young persons between 14 and 16.
He was glad that the Committee was going to make
the modification in the hours of work of young people.
He was sure it was right. l
The clause as amended was ordered to stand part
of the Bill by 34 votes to 18.
On Clause 70, which provides that, with limitations,
pressure of work in any factory may be dealt with
by the employment on. overtime of women and
young persons who have attained the age of 16,
Mr. ELLIS SMITH moved an amendment to delete
the reference to “ young persons who have attained
the age of 16.”’—Mr. M. McCorquoDALE supported
the amendment. He said there was a general feeling
in the country that young people ought not to work
overtime.—Mr, VIANT said that they should prohibit
the working of overtime by young people under 18.—
Sir J. TRAIN said that overtime -was not economic,
but it had to be worked in certain circumstances.—
Viscountess ASTOR said that an overwhelming case
had been made out for the amendment. Every
organisation concerned with juveniles was alarmed
at the effect that overtime had on them. The
question had been asked whether industry could
afford not to employ young people overtime, but the
real question was whether the country could afford to
overwork its juveniles.—Sir W. SMILES said that if
overtime for persons up to 16 was prohibited there
should at least be some exceptions, such as apprentices
in the engineering trade.—Mr. WAKEFIELD said that
young persons between the ages of 16 and 18 should
noe allowed to work for more than 48 hours a
week,
After further debate,
Sir J. SIMON said a Factory Bill worthy of the name
must, within limits, make improvements which
would involve a certain measure of reorganisation.
At the same time they must realise the difficulties.
There would be very many cases which would never
come up to the maximum, and which he hoped
increasingly public opinion would urge should be
brought below the maximum. They wanted to know
to what extent the provisions of the Bill would be
an advance on present conditions. He had a list
of some 31 trades. In the woollen and worsted
_ trade, in 45 per cent. of the factories over 100 hours
of overtime per year were being worked by women
and young persons, In 29 per cent. of the cases over
150 hours a year were worked; in 16 per cent.
over 200 hours; and in 3 per cent. over 300 hours.
These were very big figures. They were, of course,
a great deal short of what the present law allowed.—
Mr. GIBBINS: Were those hours worked in addition
to the 48-hour week ?—Sir J. SIMON answered in the
affirmative. He gave figures showing the amount
of overtime worked in various trades at present,
though he did not suggest that the present position
ought either to be authorised by Parliament or made
a standard for the future. But under the existing
law over and above the 48 hours a week it was possible
in a non-textile factory to have in the year 640 hours
of overtime for women and young persons and in
textile factories the figures were somewhere between
300 and 400 hours. At the present time those hours
might not be worked in many factories, but the figures
in a large proportion of cases greatly exceeded that
which this Bill would make permissible. The Bill
would involve much reorganisation in many factories.
In September, 1936, the Ministry of Labour appointed
& Board of Inquiry which after investigation recom-
mended that from Jan. lst, 1937, the number of hours
for all workers employed in the industry should be
48 per week. They recommended that paid overtime
might be permitted in excess of 48 hours and they
also recommended that in the case of women and
PARLIAMENTARY INTELLIGENCE
[may 15, 1937 1193
young persons under 18 overtime should be restricted
to six hours per week and that the total overtime
worked by any individual woman or young person
in any calendar year should not exceed 96 hours.
Those recommendations were subsequently embodied
in a collective agreement between the parties in
the industry and that agreement was now in force.
He would remind the Committee that the Govern-
ment had approved the view that there should not
be any overtime at all for juveniles between 14 and
16. He would give figures to illustrate that change.
The present legal hours for young persons between
the ages of 16 and 18 in a year were 3060 hours,
cutting out one week for a statutory holiday. Under
this Bill they were going to reduce that total to
2550 hours—10 hours a week less in a 51-week year.
That seemed to him substantial. In addition they
were laying down that overtime should be limited to
100 hours and that there was not to be more than 30
weeks in which it could occur; and if it occurred
to the maximum extent permitted in one week
it would not be spread over’ more than 16 weeks.
What more could the Government properly and wisely
do? He did not attach much importance to the
argument that they might have a breakdown, or
that two or three boys might be away through illness.
It was the industries which depended on juvenile
‘labour which mattered and there were something
like 500,000 people between 16 and 18 engaged in
factory work of some kind or another.
It seemed to him that there were two qualifications
which should be made on the proposals of the Bill:
(1) That even this limited amount of overtime ought not
to be allowed in an industry which was injurious to
the health of young people. (2) That if as a result
of inquiry the view was taken that overtime could
be reduced without serious detriment in the industry
the Secretary of State might make regulations to
that effect.
Mr. SHORT said that Sir J. Simon had given them
nothing and had entirely ignored the collective
opinion of the Committee.
The amendment was negatived by 34 votes to 19.
A further amendment to add a provision that
no young person in a factory should work more than
50 hours overtime in any calendar year was also
negatived by 33 votes to 21.
The Committee adjourned.
The discussion of Clause 70 was resumed by the
Committee on April 29th. .. |
Mr. G. MANDER moved an amendment to limit the
overtime to 20 weeks in any calendar year.
Sir J. SMON said he would be prepared to agree
to the figure of 30 being reduced to 25 if that was
thought to be an advantage. They wanted some-
thing in the Bill to show that overtime was not
intended to be the rule.
The amendment was agreed to with the figure
fixed at 25.
Sir J. SIMON moved a new subsection to provide
that if representations were made to the Secretary
of State concerning any class of factories that, having
regard to the particular circumstances, the over-
time allowed under the clause could be reduced
without serious detriment to the industry, he might
direct an inquiry to be held and make regulations for
modifications to secure a reduction of overtime worked
by women and young persons in such factories.
The new subsection was agreed to.
Sir J. SIMON moved a further new ‘subsection
providing that if he was satisfied that the business
in any class of factory involved the overtime employ-
ment of different persons on different occasions to
such an extent that the provisions limiting over-
time would, as respects a substantial number of
factories of that class, be unreasonable or inappro-
priate he might make modifying regulations. Such
regulations would secure that no woman should be
employed overtime in a factory for more than 75 hours,
and no young person for more than 50 hours, in any
calendar year, and that no woman or young person
1194 THE LANCET]
should, except as otherwise provided in the regula-
tions, be employed overtime in the factory for more
than six hours in any week or more than 25 weeks
in any calendar year.
The new subsection was agreed to and Clause 70
as amended was ordered to stand part of the Bill.
The Committee adjourned.
The Factories Bill was further considered by a
Standing Committee of the House of Commons on
May 4th with Major LLOYD GEORGE in the chair.
On Clause 78 (Exceptions as to male young persons
employed in shifts),
Sir JOHN SIMON moved a series of amendments
which he said were designed to meet the wishes of
certain members of the committee. This clause was
directed to industries which required to be carried
on continuously day and night. The present law
did allow exceptional provisions to be made for
night work in processes which required continuous
attention, even in the case of young people under 16.
He had come to the conclusion, especially in view of
what the committee had done earlier in the Bill,
that it would not be right to make any exception at
all as regarded young persons under 16. They might
have to do it in the case of youths between 16 and 18,
but it was not necessary to do it for anybody younger
and he proposed to make that clear in an amendment.
Provision would also be made for an interval of not
less than fourteen hours between shifts. Young
persons over 16 would be periodically examined by
the examining surgeon in the conditions of the work
in order to see if they were fit for employment at night.
Several amendments carrying out the proposals
indicated by the Home Secretary were agreed to.
Mr. A. SHORT moved an amendment to delete the
part of the clause which allows young persons to
work on the four-shift system between 6 A.M. and
10 P.M. on Sundays.—Sir J. SIMON said this was a
system employed in certain trades and undoubtedly
it appealed very much to the workers employed under
it. He thought that they ought to give fair latitude
to a system which had considerable practical advan-
tages. The amendment was negatived.
Ki the question that the clause stand part of the
Mr. DENMAN said that night work for young persons
was so well-accepted in industry that there was no
chance of abolishing it at this stage, but he thought
that it was desirable that it should not go out that
that committee really approved of night work for
young people as a permanent system. Medical
evidence was lacking to show that it was injurious
to the young persons themselves, but the point was
that it was injurious to them as adults. He had had
statements to that effect not only from a doctor
of a London hospital who had experience of the
effects of night work, but a factory inspector told
him (Mr. Denman) that although they could bring
no kind of evidence of ill health among young
persons they could see the result in adults by
whom they were surrounded every working day.
An authoritative statement of the case appeared
in THE LANCET (Feb. 20th, 1937, p. 451) after
the second reading of this Bill. It was a very
interesting editorial article which he wished hon,
Members had read. It pointed out the simple fact
that the evil appeared later in life and it made this
a very interesting point in arguing that it was bio-
logically unsound to subject young persons between
16 and 18 to the strain of night work. He felt sure
that as we rose in civilisation, and as we paid more
attention to the importance of youth in building
the nation, we should raise this age from 16.—
Mr. ViAnT said it might not be possible to produce
medical evidence, but from his own experience he
knew that night work was not good for the health of
anyone. He deplored the fact that the committee
had not seen the wisdom of inserting in this clause
a proviso prohibiting night work for young persons
up to the age of 18 at least. This was the one black
spot on the clause.—Sir E. GRAHAM-LITTLE said that
PARLIAMENTARY INTELLIGENCE
[may 15, 1937
no doubt he was asking for a counsel of perfection,
but that did not deter him from making his protest
against working young persons on night work.
He would give some recent figures from an authorita-
tive book just published by Dr. Vernon, an experienced
research worker, whose conclusions had been accepted
by the whole medical profession. Dr. Vernon
showed that there was an extraordinarily high
mortality-rate in the age-group of males between
15 and 19. He dealt with large figures because the
unit was 40,000. In this age-group the number of
fatal accidents was very high; they constituted
one-fifth of the deaths in that group. The Depart-
mental Committee on the Employment of Young
Persons in their report recommended a general
prohibition of night employment for a period of
eleven hours, including the hours of 10 P.M. to 6 A.M.,
for young persons. The incidence of accidents during
night work was also discussed in Dr. Vernon’s book
in a most judicial way. He said that on the whole
accidents were more frequent during night work
than during day work. In the iron and steel industry
the rate was sometimes 50 per cent. higher. If they
had a combination of what they might call an
accident-prone group, boys between 15 and 19
years of age, and an increased rate of accidents in
steel works, were the committee really comfortable
‘in going forward with the suggestion that these
boys should work at night in steel works ? He thought
there was a strong case for reconsidering this matter.—
Viscountess ASTOR said that Sir E. Graham-Little
had made out a very good case against night work for
young people. If the Home Secretary would raise
the age to 17 he would go a little way to meet the
case. She could not possibly vote for working
children of 16 on night work. The clause was
ordered to stand part of the Bill by 24 votes to 13.
On Clause 89, which provides that the period of
employment of male young persons who have attained
the age of 16 may begin at 5 o’clock in the morning
in that part of a bakehouse in which bread making
is carried on,
Mr. J. W. BANFIELD moved the deletion of the
oa He said that there was no need for it in the
trade.
Mr. G. Lioyp, Under-Secretary, Home Office,
said that the 5 a.m. start fer boys in bakehouses
had almost disappeared in England, but it was not
uncommon in Scotland, where apprenticeship started
at 16 years. The Committee should pass the clause
on the understanding that it might be modified when
the report on the Committee on Night Baking was
available.
The clause was ordered to stand part of the Bill.
On Clause 92 (Certificate of fitness for employment
of young persons),
Sir E, GRAHAM-LITTLE moved the first of a series
of amendments designed to enlarge the scope of the
clause by enlarging the class of young persons who
would be the subject of medical examination before
being engaged in factory work. He said that the
amendments were all attested by medical authorities.
—Mr. GRAHAM WHITE hoped the Home Secretary
would see his way to meet the point put forward in
these amendments. There seemed to be no reason
at all, and in fact every reason to the contrary, why
the present provision in the Bill which limited the
examination to young people under 16 should not be
extended. He was advised that it was particularly
valuable and necessary in the case of female young
persons between 16 and 18. In any case, a single
examination within a few days of the entry into
employment was a very inadequate safeguard.
Those who put forward these amendments urged that
the scope of the clause should be enlarged by making
the examination apply to all those up to the age of
18, and also that the examination should be repeated
as a safeguard from time to time.
Sir J. SIMON said he did not deny that there were
fair arguments for raising the age and the Factory
Department and medical officers of the Home Office
were not in the least disposed to pour cold water
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n
PARLIAMENTARY INTELLIGENCE
[may 15, 1937 1195
on that idea if on balance it was a good one. The
clause required that every young person entering
a factory under the age of 16 should be examined by
the examining surgeon. If there was any doubt as
to fitness for employment the examining surgeon
would re-examine. The advice given to him by the
responsible medical authorities who were connected
with the factory system was that these examinations
were sufficient to secure that any young person under
16 who was suffering from defects would be warned
off that employment and have to find his living
elsewhere. It was intended also to make the examina-
tion a much more satisfactory one than previously.
There was also to be a liaison between the examining
surgeon and the school medical officer. There was a
second point on which his medical advisers felt very
strongly indeed. They were satisfied that there
might be a considerable amount of feeling on the
part of the older juveniles if it was said that because
they chose to come into factory life they would by
law be put under compulsory medical examination
at intervals, They were making improvements
in the medical inspection and it would be a mistake
to go further.
After further debate the amendments were with-
drawn and the clause was ordered to stand part of `
the Bill.
The Committee adjourned.
PANEL DOCTORS’ FEES
In the House of Commons on Thursday, May 6th,
Mr. Rays Davies asked the Minister of Health
whether he was now able to state the terms of
reference and the personnel of the tribunal to inquire
into the fees paid to panel doctors under the national
health insurance scheme,
Sir KINGSLEY Woop replied that the object of the
Court of Inquiry appointed by the Secretary of
State for Scotland and himself was to investigate the
question whether any, and, if so, what alteration
ought to be made in the amount of the doctor’s
capitation fee having regard to any changes since
1924 in the cost of living, the working expenses of
practice, the number and nature of the services
rendered to insured patients, and other relevant
factors. He was glad to say that the services of the
following gentlemen as members of the court had
been secured: the Right Hon. Lord Amulree. C.B.E.,
K.C., LL.D. (chairman); Mr. Thomas Howorth,
A.C.A.; and Mr. D. H. Robertson, M.A. Mr. E. H.
Phillips, O.B.E., of the Ministry of Health, to be
Secretary.
The following are the terms of reference of the
Court of Inquiry :—
To inquire and report to H.M. Government whether any,
and if so what, alteration ought to be made as from
Jan. Ist, 1938, in the amount of the capitation fee (per
insured person per annum) on the basis of which the
Central Practitioners’ Fund under Article 19 of the
National Health Insurance (Medical Benefit) Regulations
1936, and the corresponding Scottish Fund under Article 19
of the National Health Insurance (Medical Benefit)
Consolidated Regulations (Scotland), 1929, is calculated,
having regard to any changes which may have taken
place since 1924 in the cost of living, the working expenses
of practice, the number and nature of the services rendered
by insurance practitioners to their insured patients, and
other relevant factors. The inquiry is to proceed on the
assumption that as from Jan. Ist, 1938, employed persons
under the age of 16 will have become entitled to medical
benefit by virtue of amending legislation, but that the
conditions would not impose any obligation upon the
practitioner to issue medical certificates to these persons.
This capitation fee is not to include any payment in
respect of the. supply of drugs and appliances or any
payment to meet the special conditions of practice in rural
and semi-rural areas. Payments to insurance practitioners ,
in respect of these matters are the subject of separate
arrangements and are outside the scope of the inquiry.
Mr. Rays Davies asked whether the right hon.
gentleman contemplated that the report would be
issued soon enough to admit of the Bill, which he had
promised, being presented to Parliament and passed
into law before the summer recess ?—Sir KINGSLEY
Woop hoped that would be so.—Mr. THORNE asked
: whether the inquiry was not made necessary by the
fact that the right hon. gentleman could not reach
an understanding with the doctors.—Sir KINGSLEY
Woop thought it should rather be regarded as a
friendly arrangement to have this matter dealt with
by independent people. There were discussions
between the British Medical Association and himself
on this matter and this appeared to be the best means
of dealing with it.
DIETARY SURVEYS AND NUTRITION POLICY
In the House of Lords on May 5th Viscount ASTOR
drew attention to the report of the Advisory Com-
mittee on Nutrition to the Ministry of Health, and
in view of the recommendations of that committee
asked (a) whether the Ministry of Labour inquiry
for the purpose of the cost of living index would
include an inquiry into dietary surveys, and, if so,
how many families would be concerned in this inquiry,
and what steps were being taken to ascertain the
family incomes so as to correlate this inquiry with
that proposed to be undertaken by the Registrar-
General and an independent statistician ; (b) whether
steps had been taken by the Registrar-General
to carry out this proposed inquiry into the constitution
of families by age, sex, occupation, and locality, and
into the distribution of family incomes; (c) what
local authority in urban and rural areas. respectively
were conducting dietary surveys in England and
Wales and in Scotland respectively, and about how
many families would be covered in each country.
The noble Lord moved for papers.
Lord Astor said the main cause of the evils of
malnutrition was undoubtedly poverty. By mal-
nutrition he did not mean hunger or starvation, but
a degree of ill health or of subnormality due to mal-
nourishment, and in other cases actual bad physical
development due to malnutrition in early youth.
So that the problem really was one of purchasing
power. Where they had a small income they had a
small expenditure on the essential foods—the health-
giving foods. It was a serious problem, because a
large number of people who showed the effects of
malnutrition could not be put right. It was a
problem which arose very largely because of mal-
nourishment in youth. A certain number of cases
of maternal mortality were due to malformed pelvis.
That was largely due to the malnutrition of the woman
when she was a child. The difficulty was that they
had to get into their minds an entirely new standard.
He had no doubt that at the beginning of last century
medical officers were perfectly satisfied with the
housing conditions in our large industrial centres.
To-day those same medical officers were unanimously
agreed that those hauses must be pulled down as
slums. They had to bear that in mind when they
saw quoted, as they so often did, reports from medical
officers of health to the effect that there was no
problem of malnutrition. Those who made such
reports were out-of-date ; they were not acquainted
with the new knowledge—the new findings of science.
After making all the allowances for exaggeration
and over-statement, one could say without fear of
contradiction that there was a real problem of mal-
nutrition affecting millions of people of this country.
‘In the Advisory Committee’s report reference was
made to methods of clinical assessment. Did the
Ministry contemplate undertaking an investigation
of the clinical aspects in direct correlation with the
‘dietary surveys which it was proposed to make ?
The main function of agriculture, certainly in this
country, should be to see that the right sorts of
food were provided at the right costs for our people.
We should aim at basing our agricultural policy
upon the methods of the farmers who were making
money rather than pay so much attention to the
shouts and protests of the farmers who were not
making money or who were losing money, or who
1196 ‘THE LANCET]
did not want to change their methods in order to
move with the times. The Advisory Committee’s
report had indicated the importance of the nutrition
of milk as an article of consumption and diet. It
was the foundation of good nutrition. This country
was surely a suitable and good country for milk
production and yet after four years of the Milk
Marketing Scheme they found a very low consump-
tion of milk, retail prices the second highest in the
world, and the dairy farmers were all discontented.
There surely must be something fundamentally
wrong with a scheme that had such results. The
first thing wrong with the Milk Scheme was the
structure of the governing body. If they were dealing
with armaments nobody would suggest that they
should go to the armament firms and say: ‘‘ We will
pass an Act of Parliament giving you statutory power
to form a monopoly ring. You can elect your own
governing body, and if any armament manufacturer
dares to cut prices you can put him in prison, and
we will have no Ministry of Munitions to supervise.”
That was being done under the Milk Scheme. The
second thing which was wrong was that the Milk
Board had used its powers in order to develop new
industries in this country. These activities of the
Milk Board had been condemned by the Milk Com-
mission which had recently been sitting and also
by the Milk Council; but the result of all this was
that the price of milk in England to-day was much
too high. |
The Minister of Health, as soon as the Report of the
Advisory Committee was published, circularised all
local authorities drawing their attention to the
recommendations of the report of the Committee and
urging them to make more provision for supplying
milk to mothers and children. Why should the
Minister of Health ask the ratepayers to spend money
in buying milk which had been artificially put up
in price by another colleague in the Cabinet? The
Minister of Health must get his colleagues in the
Cabinet to give the country reasonably cheap milk—
milk produced by an efficient dairy industry—and
then he could justifiably ask the local authorities
to accede to his request. Their aim should be to
reduce the price of milk by 8d. a gallon, which would
bring it down to 2d. a pint, instead of 3d., which was
the present cost. Even after they had done that,
they would still have to have subsidised milk for
large sections of the community. They could reduce
the cost of milk by one-third. First of all they could
save 3d. a gallon by stopping the subsidy and they
ought to be able to save 3d. or 4d. on distribution.
Ulster had a milk scheme which had been eminently
satisfactory because the controlling influence on the
Ulster Milk Board lay with the members nominated
by the Government though the producers were repre-
sented too. Also the milk was compulsorily graded
according to its hygienic quality, and farmers were
paid according to the grade they produced. It
worked automatically and, as a result, in Ulster the
price of milk was very much lower than it was here.
As to distribution he would advocate a bold policy.
He found no reason why the nation should not have
control over the wholesale distribution of milk.
In Scandinavian countries they had what was called
the Oslo breakfast: every child who arrived half an
hour before school opened got a free breakfast of a
glass of milk and bread and butter or margarine with
fruit and also a cereal if possible. He (Lord Astor)
did not necessarily advocate free meals to all children,
or say all children should have to pay for them.
He thought they must contemplate subsidising food,
not only for children of school age but also for the
pre-school child in nursery schools. He was glad to
notice that in his circular to local authorities the
Minister of Health urged local authorities to help
mothers at maternity centres. If they were to
subsidise the consumption of these protective foods
so that mothers, pre-school children, and school-
children had enough of them, in the next generation
the country would have a very much stronger and
healthier race and a much more prosperous agriculture,
PARLIAMENTARY INTELLIGENCE
[may 15, 1937
Lord SNELL said that there was something
incongruous in the fact that at a time when they
were undertaking great national rejoicings they
should have to confess that a large proportion of
our population was actually underfed. The Govern-
ment and people about the country seemed to be
pursuing a false way of approaching the problem, in
that they were putting the question of gymnastic
exercises and of keeping fit before the question of
feeding. It was good to see the grace of young life
in gymnasium and elsewhere, but inflated muscles
did not compensate for weakened hearts, and jerry-
built manhood of that character was not what the
nation required. The proposals made by Lord
Astor should be very seriously considered by the
Government. The right way to begin was first of all
to feed the children and the mothers. There was
no need to haggle as to whether milk should be 3d.
or 6d. per pint, or what the profits should be. It was
the business of the community to feed its children.
What the children required was milk and if it could
not be paid for, the Government should provide that
milk free for children and also for expectant and
nursing mothers.—Lord ELTIsLEyY said that the
Milk Marketing Board and the various committees
connected therewith had prevented a certain collapse
of the milk industry in this country. It had
undoubtedly saved from disaster 135,000 milk
producers.—Lord NoEL Buxton said that. the
experience of such bodies as the Save the Children
Fund confirmed the plea that Lord Astor had made.
He was glad that the Government in dealing with the
problem had not been governed solely by the theory
of parental responsibility, but had ensured a better
start in life for countless children who otherwise
would have suffered. All the evidence showed that
that policy ought to be carried further.—Viscount
BLEDISLOE said that as regarded young children we
in this country might learn a great deal more than
we had yet learned about their care, and particularly
the supply and treatment of milk, from New Zealand,
where the Plunket or Truby King system had been
in use for a great many years and where the vital
statistics showed the enormous advantage to the
infantile population as the result of this system
carried through not only for the benefit of nursing
mothers but for the benefit of both mothers and
children in what were known as the Karitane Homes
which were to be found all over the Dominion.
The Bishop of Norwich said that he thought
they were apt to confuse the nutritive value of milk
with the other side of the milk question. He could
not feel certain that the restrictions now put upon the
quality of milk were really as necessary as medical
men told them they were, and the dairy farmers were
in consequence striving to reach a standard that
after all the medical man might one day pronounce
to be unnecessary. He had never yet seen anything
really convincing to show the relative nutritive value
of plain milk, pasteurised milk, and boiled milk.
Children did not like boiled milk. No one had told
them in a really authoritative way what was meant
by pasteurisation. It was found also that in many
cases those who did drink raw milk without contracting
disease seemed to flourish more on the plain raw milk
than upon milk that had been treated in any way.
He could not persuade himself that our system of
bottling, and so on, was really satisfactory in delivering
pure milk to the child. There were so many oppor-
tunities of lapses. He believed that a great impetus
would be given to dairy farming if the standards
demanded were readily intelligible and easily carried
out, if they became intelligent pupils and not the
slaves of laboratory experiments made on the side of
medicine, and if they were able to take a broader
common-sense view of the whole situation. .
Lord DENMAN said that the Ministry of Health
‘ recently circularised maternity and child welfare
authorities asking them to review arrangements
for the supply of milk to mothersand to young children.
The Minister suggested that ‘‘ scales should be so
framed as not to render it difficult for mothers to
THE LANCET]
PARLIAMENTARY INTELLIGENCE
[may 15, 1937 1197
take advantage of the authorities arrangements.”’
A society which he (Lord Denman) represented
complained that this instruction was too indefinite
and that in some areas mothers and children under
school age could not obtain free milk unless family
income fell within a very low limit. In some cases
the income, after deduction of rent for a family of
five, must be as low as 25s. or even 22s. 6d., before
free milk was granted. He hoped that the Minister
might be able to issue more definite instructions on
that point, or that he might ask his Advisory Com-
mittee to draw up for the guidance of local authorities
a scale based on the present knowledge of food require-
ments. The Minister’s circular, valuable as it might
be in some respects, went only a small way towards
securing increased consumption of milk by mothers
and young children.
Viscount GAGE, replying for the Government, said
the investigations into nutritional problems fell into
three simple categories—namely, what the people
ought to eat, what they did eat, and methods of
improvement. The report of the Advisory Com-
mittee showed that certain foods, especially milk,
dairy products, green vegetables, and fruit were
essential to health. They had protective value
because they stopped certain definite deficiency
diseases and also built up the resistance of the body
to other forms of disease. It seemed difficult to
exaggerate the importance attached by these experts,
with a unanimity rare among experts, to the value
of these protective foods, especially in infancy, and
the Government entirely accepted the conclusions
of the report on that subject. It was satisfactory
to know that the average consumption per head of
most foodstuffs had increased since just before the
war and that with one exception there had been a
general improvement in the quality of the national
diet. It was also satisfactory to know from the
report that the supply of energy-giving foods avail-
able for the nation was more than was considered
adequate by the Committee of the League of Nations.
The Government fully accepted the recommendation
of the Advisory Committee that much more informa-
tion was desirable and they were prepared to collect
it. But such inquiries were not always so easy
as was sometimes imagined. What the Government
had in mind was really a three-fold inquiry. There
was first the Ministry of Labour inquiry in connexion
with the cost of living index figure. For this it was
hoped to procure the weekly budgets of 10,000
families taken over four separate weeks in various
parts of England, Wales, and Scotland. These
families would all come from the classes covered by
the national insurance schemes. Naturally the
inquiry would comprise information besides that
relating to food, but the special information relating
to food would be summarised separately. Family
budgets were made up as a rule in rather a rough-and-
ready way. For certain purposes calculations of
that sort might be quite sufficient, but when they
were trying to find out about the number of calories,
vitamins, carbohydrates, and so forth, that were
consumed they could not afford to be rough-and-
ready. Accordingly they proposed to check these
results by another inquiry called a ‘‘ quantitative
dietary survey ” which would be of a much more
detailed character. It was in fact already in progress
and would eventually embrace 500 families of which
200 would come from Scotland. This might appear
to be a small number, but he would emphasise that
a dietary survey of this kind meant that a qualified
investigator had to spend much time in the homes
of these families, weighing up all the food which
came into the house, and what was left over, estimat-
ing its composition down to the constituents even
of the cakes and puddings, and so forth, and noting
any wastage. He thought they ought to be grateful
to these families for codperating with their inspectors
to the extent that they had done. He (Lord Gage)
could not give the dates by which the whole inquiry
would be completed, but the results of the surveys
which had already taken place at Newcastle-on-
Tyne, affecting 69 families, had been published some
months ago. There was another inquiry affecting
205 families in the West Riding, the results of which
would probably be published by the end of this year.
These were not included in the 500 families which he
had mentioned. An inquiry had already been begun
in the Isle of Ely, Surrey, Glossop, Aberdeen, and
certain industrial towns near Glasgow. It would be
extended to Somerset, Glamorgan, Carmarthen,
Cardigan, Aberdeen County, Banff, Kincardine,
Dumfries, and the Border Counties. The next step
after that would be to take out from the last census
figures a definite proportion, say of one in five hundred,
or one in a thousand, of all the family census schedules,
and this they expected would show roughly, after
certain allowances had been made for altered condi-
tions, the distribution of the population according
to occupation. These statistics would then be
compared with information in the possession of the
Ministry of Labour with regard to wage rates
current in such occupations. It was hoped that on
this basis they would be able to correlate to some
degree all these inquiries and to present a working
analysis of how the incomes of various classes of the
community were divided, with special reference
to food.
He would now return to the third and most con-
troversial question of how they could improve.
He adrhitted that three-quarters of the problem
must turn on the capacity of the people.to buy the
right foods, and that therefore food must be cheap.
It was equally important that the people should have
the wages to pay for the food. ‘During their period
of office the number of those in employment had
increased by about 2,000,000. In one year over
2,350,000 had benefited from an increase of wages
amounting to nearly £190,000 a week, and the
price of essential foodstuffs, in spite of some rather
wild statements to the contrary, had during the last
five years remained fairly steady. Following the
unanimous advice of their experts the Government
had been particularly active in connexion with the
supply of milk on special terms to special classes
of the community, principally. school-children,
expectant mothers and infants and unemployed in
the distressed areas. There were also schemes for
the provision of free and cheap food to similar classes.
The scheme for providing school-children with cheap
milk which started in 1934 had now been made
available to 92 per cent. of all the school-children
in the country and 2,500,000 school-children were
making use of the scheme. Free food might also
be supplied to any child showing signs of requiring
it, though certain safeguards obviously had to be
observed in this connexion. Over 400,000 children
received free milk last year, and 23,000,000 free
meals were consumed by 143,000 children. About.
£700,000 was paid to the local authorities by the
Government in specific grants towards these schemes.
As to the mothers and infants, at all maternity and
child welfare centres and at all antenatal clinics
free food and milk might be supplied under medical
advice to necessitous cases, special attention being
paid to malnutrition, rickets, and so forth. There
had been a large extension of these centres in the last
few years and the attendances had greatly increased.
Two hundred and ninety-seven thousand mothers
now attended the clinics. Last year the equivalent
of about 7,000,000 gallons of milk were distributed
free, or at less than cost price, according to the means
of the applicants. Schemes for cheap milk had been
adopted in the Special Areas, the cost of which was
borne in part by the Commissioner instead of by the
local authorities.
As to the future he could undertake that the Govern-
ment would press forward with all these schemes to
the best of their ability. They had recently issued
a circular inviting all the local authorities to review
their arrangements under the Maternity and Child
Welfare Acts and to improve and increase the diet,
and especially the milk diet, of expectant mothers
and children, They had also laid emphasis on the
1198 THE LANCET]
necessity for securing the purity of the milk. A
publicity campaign was contemplated in the autumn
to make better known the existence of the facilities
available at welfare centres. The Government had
also put another £5,000,000 into the general pool
available under the block grant scheme and by the
reweighting of the formula they felt that the
necessitous local authorities would be placed in a
better position to bear their part of the financial
burden. In conclusion he would like to say one
word of what he might call subdued optimism.
In the seventies of last century there was a death-
rate of 21°4 per 1000. In 1936 the death-rate was
12°1 per 1000. In the nineties the death-rate of
children under one year was over 150 per 1000.
By 1936 this figure had been reduced to 59 per 1000.
The death-rate from tuberculosis was less than half
what it was twenty-five years ago, and from rickets
less than half what it was five years ago. Of the
1,700,000 children inspected by school medical
officers during 1936 the nutrition of 14°6 was said to
be excellent, 74 per cent. were normal, 10°5 per cent.
slightly abnormal, and 0°7 per cent. bad. These
figures, he thought, showed that this country was
making real progress, and were a general encourage-
ment to further effort. The Minister of Health
had shown the profound interest which he took in
the problem of nutrition. Setting aside all questions
of human sympathy, a vast amount of administrative
effort which was now being spent on the cure and
care of disease would obviously be immensely reduced
if illness could be prevented, as the experts claimed
it could be, by better nutrition, The Government
had to assist them bodies of unimpeachable reputation
such as the Medical Research Council and the
Advisory Committee on Nutrition presided over by
Lord Luke. All these factors seemed to indicate
that if prosperity could be maintained progress in
nutrition would also be maintained with increasing:
impetus,
Viscount ASTOR, in congratulating the Government
on what they had done, urged them not to sit back
satisfied, but to realise that there was still a great deal
that required to be done.
The motion for Papers was withdrawn.
CONTRIBUTORY PENSIONS (VOLUNTARY
CONTRIBUTORS) BILL
On the motion for the third reading of the Widows’,
Orphans’, and Old Age Contributory Pensions
(Voluntary Contributors) Bill in the House of
Commons on May 6th, |
Sir KINGSLEY Woop, Minister of Health, said
that this scheme had a very wide popular appeal
and it would fill a definite gap in our existing social
insurance system. So far as the insurance provisions
were concerned, the Bill provided the best and
cheapest and safest policy of the kind in the world.
He hoped that it might soon be possible to introduce
another measure which would fill another gap.
The Government had already announced their inten-
tion to introduce national insurance legislation to
entitle boys and girls to receive medical benefit
immediately on taking up employment after leaving
school instead of having to wait until the age of 16
as at present. The introduction of this measure
had been postponed pending the settlement of the
terms of remuneration of the medical practitioners.
That question was going to be settled, he hoped, quite
amicably and certainly by agreement, between the
medical practitioners and himself by an arbitration
court at an early date. He desired to see a good
many gaps filled, but they had to recognise that the
social protection of the people must be an evolutionary
process. There were in Great Britain to-day more
than 19,000,000 persons insured under the Con-
tributory Pensions Acts, and if their dependents
were taken into account it might be said that 75 per
cent. of the population were protected by this scheme.
Already 4,250,000 persons had participated in the
pensions and allowances, and £350,000,000 had been
PARLIAMENTARY INTELLIGENCE
[may 15, 1937
paid out in benefits to persons under 70, while a
further £170,000,000 had been paid to persons over
70 entitled to pensions by virtue of the Contributory
Pensions Acts. The Exchequer contribution to the
cost of pensions payable to persons under 70 was no
less than £15,000,000 during the financial year
1936-37 alone. These contributions rose by £1,000,000
a year to £21,000,000 in 1942-43, at which figure
they would remain until 1945-46, after which Parlia-
ment was to determine the further subventions
required. The cost to the Exchequer in 1936—37
of pensions to those over 70 payable by virtue of the
Contributory Pensions Acts was approximately
£25,600,000 and the cost of the pensions to people
over 70 payable under the Old Age Pensions Acts
by reference to means was approximately £18,400,000.
To those figures must now be added the considerable
cost of this new scheme. If there were 700,000
entrants—and he would be disappointed if there
were not—then, if they excluded the consideration
of the financial commitments in respect of pensions
for those over the age of 70, the Exchequer liability
would be £43,000,000. They could legitimately
claim that no country made such a financial contribu-
tion as we did or had a wider range of social protection
for its people.
The Bill was read the third time and passed.
NOTES ON CURRENT TOPICS
In the House of Lords on May 6th the Royal Assent
was given to the Local Government (Financial
Provisions) (Scotland) Act; the Maternity Services
(Scotland) Act; and the General Cemetery Act.
Both Houses of Parliament adjourned on May 6th
for the Whitsuntide recess. The House of Lords will
reassemble on May 25th and the House of Commons
on May 24th.
QUESTION TIME
THURSDAY, MAY 6TH
Codéperation between Public and Voluntary
Hospitals
Mr. SorRENSON asked the Minister of Health whether,
in view of the report of the Voluntary Hospitals Com-
mission and of the increasing contributions by public
authorities to voluntary hospitals, he would require that
the finances of voluntary hospitals should be pooled and
that greater codrdination should be effected between
voluntary and public hospitals.—Sir Kincstey Woop
replied : I have noted with interest that the Voluntary
Hospitals Commission, while not recommending the
immediate pooling of hospital finances, suggests the
creation of regional funds, but I have no powers in this
matter, which is one for consideration by the governing
bodies of the hospitals. I may assure the hon. Member
that I shall continue to encourage coöperation between
voluntary and public, hospitals, which, I am glad to say,
is already increasing steadily.
Cleanliness in Handling of Bread
Sir NıcmoLas GratTTaN-DoYLE asked the Minister of
Health whether, after the introduction of the recently
announced legislation to provide that milk for human
consumption should be clean and bacteriologically pure,
he would consider means by which to ensure that bread
for human consumption, whether in course of distribution
or whilst held for sale, should at all times be covered or
wrapped in dust-proof material to reduce uncleanliness
by handling.—Sir KinesLey Woop replied: I appreciate
the advantages from the point of view of cleanliness of the
wrapping of bread, but on the information before me I
am not satisfied that a general requirement on the subject
is necessary.
MATERNITY CLINIC FOR SUNDERLAND.—Sunderland
health committee have approved in principle a scheme
for erecting a maternity clinic in the east end of the
town. An application will be made to the commissioner
of the Special Areas for a grant towards the estimated
cost of £10,000.
THE LANCET] |
[may 15, 1937 1199
PUBLIC HEALTH
Circular on Maternal Mortality Report
In a circular (No. 1622) addressed to maternity
and child welfare authorities on May 7th the Minister
of Health draws attention to the report on maternal
mortality summarised in THE Lancer last week
(p. 1125) especially to the recommendations emphasis-
ing (1) the importance of team-work ; (2) consultant
services; (3) emergency units; (4) maternity
accommodation; (5) antenatal services; (6) post-
natal services ; (7) ancillary services ; (8) the keeping
of records; (9) education. The Minister notes that
recommendation (2) in Section X of the report
contemplates that each local supervising authority
under the Midwives Acts should, in consultation with
the local medical profession, be empowered to take
steps to ensure that the best local obstetric skill is
made available in all cases in which midwives are
required to call in a doctor. An alteration in the
rules of the Central Midwives Board would be required
before effect could be given to this recommendation,
and the Minister has asked the Board to consider
the recommendation. He is also inviting the views
of the associations of local authorities concerned, and
of the British Medical Association, on this recommen-
dation (see below). As to the three subjects recom-
mended in the report for further study, the Minister
is in communication with the Medical Research
Council on the suggestions that further research
should be undertaken (a) with a view to the discovery
of a reliable prophylactic treatment for puerperal
sepsis, and (b) into the possible influence of the
dietary upon childbearing. With regard to the
third . subject recommended for further inquiry,
that of abortion, the Secretary of State for the Home
Department and the Minister are appointing a com-
mittee to inquire into the prevalence of abortion and
to consider the steps necessary to secure the reduction
of maternal mortality and morbidity arising from
this cause. The Minister asks each authority to
give early consideration to the report and to the
suggestions made in the circular, and inform him of
the action they propose to take.
THE VIEWS OF THE BRITISH MEDICAL
ASSOCIATION
The British Medical Association has already, in an
addendum to the annual report of their council
published in the Supplement to the, British Medical
Journal of May 8th, said that the suggested amend-
ment of the rules of the Central Midwives Board is
not one that could be approved or supported by the
Association. The proposal that midwives in the
future would in cases of emergency be able to call for
the services only of certain selected practitioners, and
that local authorities should be advised and encouraged
to make such selective lists, would, in the opinion of
the Association, aggravate the disadvantages of the
present situation. They call attention to three
inconsistencies which might immediately arise:
(1) Many insurance practitioners would be by statute
charged with the duty of attending or accepting respon-
sibility for insured women from the time conception
took place up to the moment that labour pains began,
and again from ten or fourteen days after delivery,
while they would be prohibited, if the mother wished
to take advantage of State provision, from having any-
thing to do with her in the intervening period.
(2) There would be practitioners in some areas freely
available for attendance in the case of midwives’
** emergencies,” while in a neighbouring area they might
be debarred from any such attendance owing to alleged
incompetence or inexperience.
(3) In one area in 3 per cent. of all confinements
the emergency was such as to require the immediate
attendance of a practitioner in order to save the life of
mother or child, so that in many rural areas the midwife
might, by rule, be prohibited from calling in the most
easily available practitioner.
An alternative plan which the council of the Asso-
ciation greatly prefers and would urge upon the
Minister is that each local authority should prepare a
list of local medical practitioners who are willing to
make themselves available to be called in by mid-
‘wives, that such practitioners collectively should at
once be brought into close touch with the consultant
obstetricians recognised for the service in the area,
and should be kept in frequent association with those
consultants with a view to the appreciation of their
several spheres of action, to instruction as to the
proper course of action and the means of securing
appropriate help in cases of difficulty, and to the
mutual and confidential investigations as to the
causes of difficulty or of death. If thought necessary
it might be arranged that, if a practitioner’s name
was to continue on the list beyond a certain period
of years, he should have to undertake a more formal
post-graduate course in obstetrics; and it might be
possible to establish some machinery by which the
name of a practitioner whose work proved unsatis-
factory might be removed from the list. In some
such way as this the council believes that local lists
would be established in a less objectionable and less
difficult way than in any other, and that the lists so
established under these conditions would prove to be
more satisfactory and successful in maintaining an
adequate service. The council suggests that such lists
should be established at the time, or shortly after
the time, at which the Midwives Act comes into
operation.
Supervision of Midwives
With another circular (1620) the Minister encloses,
for the information of local supervising authorities
under the Midwives Acts (England), copies of the
regulations! which he has made, prescribing the
qualifications of persons appointed to exercise super-
vision over the midwives practising in their areas.
The regulations will come into operation on June Ist
next, and apply only to persons appointed as super-
visors of midwives on or after that date. The
object of the regulations is to ensure that persons
appointed in future to supervise midwives shall have
had adequate experience in the practice of midwifery.
In order that an inspector of midwives should be
regarded as the counsellor and friend rather than a
relentless critic, the persons appointed should not
only possess the necessary professional qualifications
but also the essential qualities of sympathy and tact.
The title of ‘inspector of midwives” will be
superseded by that of ‘“‘supervisor of midwives,”
which is that used in the regulations. The regulations
prescribe qualifications for a medical supervisor,
and a non-medical supervisor, and it is within the
discretion of each authority to appoint either one or
the other, or both. In large areas it appears to the
Minister desirable to appoint a medical supervisor,
acting under the direction of the medical officer of
health, to exercise general supervision over the
1 Statutory Rules and Orders, 1937, No. 398. The Midwives
nse of Supervisors) Regulations, 1937, dated April
1200 THE LANCET]
THE SERVICES
[may 15, 1937
midwives practising in the area, and non-medical
supervisors to work under the instructions of the-
medical supervisor and perform the routine duties
of supervision. .
A medical supervisor is defined as a registered
medical practitioner who has had at least three years’
experience in the practice of his profession, and who
(1) is registered as the holder of a diploma in sanitary
science, public health, or State medicine, (2) has held
the appointment of resident medical offcer in a
maternity department for a period of not less than
six months, and (3) within a period of two years
before his first appointment as a medical supervisor
under the provisions of these regulations had had not
less than one year’s continuous experience in some
branch of obstetric work. The Minister may dispense.
with any of the requirements of these regulations in
any case in which it appears to him desirable so to do,
on such terms and conditions as he thinks fit. The
Minister appreciates that at the outset it may be
difficult in some cases to secure medical supervisors
who possess all these qualifications and if necessary
he will be prepared to consider the question of using
his dispensing power. He points out, however,
that the words “some branch of obstetric work ”
have a wide range, and include the conduct of ante-
natal clinics, the duties of administrative officers
in a maternity department, the investigation or
treatment of puerperal fever, obstetric research,
and so forth.
INFECTIOUS DISEASE
IN ENGLAND AND WALES DURING THE WEEK ENDED
MAY IsT, 1937
Notifications —The following cases of infectious
disease were notified during the week: Small-pox, 0 ;
scarlet fever, 1628 ; diphtheria, 1019; enteric fever,
26; pneumonia (primary or influenzal), 856;
puerperal fever, 38 ; puerperal pyrexia, 98; cerebro-
spinal fever, 30; acute poliomyelitis, 2; acute polio-
encephalitis, 1 ; encephalitis lethargica, 5; dysentery,
14; ophthalmia neonatorum, 102. 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 May 7th was 3069 which included: Scarlet
fever, 799; diphtheria, 866; measles, 55; whooping-cough,
505 ; puerperal fever, 16 mothers (plus 11 babies); encephalitis
lethargica, 283; poliomyelitis, 0. At St. Maregaret’s Hospital
there were 21 babies (plus 10 mothers) with ophthalmin
neonatorum.
Deaths.—In 123 great towns, including London,
there was no death from small-pox or from enteric
fever, 18 (0) from measles, 3 (0) from scarlet fever,
18 (4) from whooping-cough, 30 (3) from diphtheria,
48 (12) from diarrhoea and enteritis under two years,
and 33 (3) from influenza. The figures in parentheses
are those for London itself.
Five deaths from diarrhcea and enteritis under two years
were reported from Liverpool, and 3 each from Manchester
and Newcastle-upon-Tyne. Birmingham had 5 deaths from
measles. Sheffield and Bradford each reported 3 fatal cases of
diphtheria,
The number of stillbirths notified during the week
was 284 (corresponding to a rate of 41 per 1000
total births), including 46 in London.
THE SERVICES
ROYAL NAVAL MEDICAL SERVICE
Surg. Capts. J. H. Burdett to Pembroke for R.N. Hosp.,
Chatham; and J. D. Danson to Victory for R.N. Hosp.,
Haslar.
Surg. Lt.-Comdrs. J. B. Patrick to President for course ;
and C. D. D. de Labilliere to Pembroke for R.N.B.
Surg. Lts. G. C. Denny to Excellent; W. B. Taylor to
President for course; J. G. Vincent Smith to Pembroke
for R.M. Infirmary, Chatham; I. C. Macdonald to
Pembroke for R.N.B.; and D. Simpson to Victory for
R.N. Hosp., Haslar.
F. B. Gamblen and J. B. Knight entered as Surg. Lts. (D)
for short service, and appointed to Victory for course of
instruction at R.N. Hosp., Haslar.
The following have been appointed Admiralty Surgeons
and Agents :—
Mr. J. W. Ross (Darlington) for Darlington ; Mr. T. C.
Gipson (Pinhoe, Exeter) for Exeter; and Mr. R. Anderson
(Helensburgh) for Helensburgh.
ROYAL NAVAL VOLUNTEER RESERVE
Surg. Lt.-Comdr. (D) G. P. Monk placed on Retd. List. `
Surg. Sub-Lt. R. F. Hand promoted to Surg. Lt.
ROYAL ARMY MEDICAL CORPS
Capts. A. McMillan and W. G. S. Foster to be Majs.
Lts. C. P. Stevens and J. A. G. M. Lynch to be Capts.
SUPPLEMENTARY RESERVE OF OFFICERS
J. Robertson to be Lt.
ARMY DENTAL CORPS
Capt. A. Brazenor, to be Maj.
Short Service Commission :
(on prob.).
E. A. Moore to be Lt.
MILITIA
Maj. R. D. Goldie relinquishes his commn. and retains
the rank of Maj.
TERRITORIAL ARMY
Capt. E. J. G. Glass to be Maj.
T. Fitt (late Cadet Serjt., Rossall Sch. Contgt., Jun.
Div., O.T.C.) to be Lt.
R. H. Barnes (late Cadet Serjt., Bedford Sch. Contgt.,
Jun. Div., O.T.C.) to be Lt.
J. D. Finlayson (late Ofir. Cadet, Aberdeen Univ.
Contgt. (Med. Unit), Sen. Div., O.T.C) to be Lt.
~ TERRITORIAL ARMY RESERVE OF OFFICERS
Lt. A. Wilson, from T. A. Res. of Off. (5th Bn. Border R.),
to be Lt. (Army Dental Corps).
ROYAL AIR FORCE
Squadron Leaders H. W. Corner to R.A.F. Depét,
Uxbridge, for duty as medical officer; J. Hutchieson
to R.A.F. Station, Dhibban, Iraq, for duty as Senior
Medical Officer; and G. W. Paton to Aircraft Depét,
Hinaidi, Iraq, for duty as Senior Medical Officer.
Flight Lt. R. C. H. Tripp to R.A.F. Station, Upper
Heyford.
Flying Offr. F. L. Whitehead is promoted to the rank
of Flight Lt.
INDIAN MEDICAL SERVICE
Majs. to be Lt.-Cols.: S. N. Makand, S. C. Alagappan,
and B. R. Chaudhri.
Capt. M. P. Conroy to be Maj.
The undermentioned officers have vacated appts. in
India :—
D.D.M.S.: Maj.-Gen. C. W. F. Melville, C.B., K.H.P.,
I.M.S., and retires.
A.D.M.S.: Col. I. M. Macrea, C.I.E., O.B.E., -K.H.P.,
; and Ma)j.-Gen. W. H. Hamilton, C.I.E., C.B.E.,
.. K.H.P., I.M.S.
and P.: Lt.-Col. J. B. de W. Molony, O.B.E.,
oe
ta
On
ny
.D
undermentioned appts. have been made in India :—
S.: Maj.-Gen. W. H. Hamilton and Col. I. M.
Col. A. F. Babonau, C.I.E., O.B.E., I.M.S.
: Maj. H. T. Findlay, R.A.M.C.
COLONIAL MEDICAL SERVICE
The following appointments have been made: Dr. E. N.
Brockway and Dr. C. J. Fournier (M.O., Bermuda) Medical
Officers, West Africa; Miss E. Cardwell, L.R.C.P. and S.,
and Dr. H. J. Bermingham (M.O., Gambia) Medical
Officers, Gold Coast; Dr. R. H. Purnell, Medical Officer,
and Dr. J. A. Acheson (M.O.) Senior Medical Officer,
Northern Rhodesia; Dr. A. A. Cameron, Medical Officer,
Malaya ; and Surg. Lt. S. R. G. Pimm, Medical Radiologist,
Colonial Hospital, Port of Spain, Trinidad. |
.P. : Major J. S. Riddle, I.M.S.
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D.P.
THE LANCET]
(may 15, 1937 1201
OBITUARY
BENNETT MAY, C.B.E., F.R.C.S. Eng.
EMERITUS PROFESSOR OF SURGERY, UNIVERSITY OF BIRMINGHAM
THe death occurred on May 3rd of Mr. Bennett
May, emeritus professor of surgery in the University
of Birmingham and one of the oldest members of the
medical profession, having reached the advanced
age of 92. He died at his house in Edgbaston.
Prof. May was the son of Benjamin May, an official
of the Inland Revenue, and was educated at
Sydenham College, before proceeding to the Uni-
versity of Edinburgh for his medical education. He
graduated as M.B., B.S. Lond. in 1875 and took the
F.R.C.S. Eng. in the following year. He then
became resident surgical officer at the Birmingham
General Hospital, at the termination of which appoint-
ment he became assistant surgeon to the Queen’s
Hospital, Birmingham. His association with the
University of Birmingham, then Mason College,
began as a demonstrator in anatomy, but his surgical
work soon brought him a large consulting practice,
while he was invited to fulfil important appointments
outside Birmingham, such as surgeon to the Small-
wood Hospital, Redditch, the Guest Hospital, Dudley,
and the Tamworth Hospital. He was appointed
demonstrator of operative surgery at Mason College,
and on the establishment of the University of
Birmingham became professor of surgery in the
University. He made now some important clinical
contributions to medical literature, writing in the
British Medical Journal on the ‘ligature of arterial
trunks and to these columns valuable clinical notes,
among others a description of distal ligature of the
common carotid and axillary arteries for aneurysm,
and one for the excision of a tumour of the cerebellum,
In 1897 he delivered the Ingleby lectures on the
operative treatment of cancer of the breast, the
lectures being afterwards published in volume form.
During the war, despite his seniority, he gave out-
standing service at the Rubery Hospital.
Prof. May was a widower and leaves no family.
During the last years of his long life he was invalided
by arthritis.
Sir Gilbert Barling sends the following tribute
to Prof. May’s work and fine personality: ‘‘ Bennett
May commenced his medical studies as long ago as
1864 at the Sydenham College which was attached to
the General Hospital, Birmingham. In 1870 he was
appointed to the valuable post of resident surgical
officer with the supervision of all the surgical beds,
a position which he filled for three years, and which
formed the foundation of all his future success.
He came to the practice of his profession in what
may be called the transitional period when Lister’s
early teaching began to have its influence and at a
time when ‘laudable pus’ was almost regarded as a
compliment to the surgeon, and when all surgical
operations were approached with an anxiety difficult
to appreciate now, for the threat of bad sepsis and .
even hospital gangrene was always present. And
no wonder, when amongst other detrimental con-
ditions the surgeon was generally garbed in an old
coat soiled with blood or even pus. May, unlike his
older predecessors, was guided in his work by Lister’s
teaching, that is he adopted ‘the antiseptic system,’
but hardly the minutis of ‘asepsis. To hi
disappointment he failed to secure a post as assistant
surgeon to the General Hospital but found his
opportunity at the Queen’s Hospital when he was
elected surgeon in 1881, and here he soon showed his
worth. Rather a slow operator, he was most pains-
taking and thorough, his opinions were very reliable,
and he gave confidence to members of the profession
who sought his advice in consultation. He taught
anatomy at Queen’s College and eventually became
professor of surgery in Mason College and the
University of Birmingham, where I was his co-
professor, and I more than ever learnt to appreciate
him as an excellent colleague and a very honourable
man. He was at times a little eccentric in his
mannerisms and students did not fail to exploit
these, but despite peculiarities he acquired the respect,
indeed the affectionate regard, of those he taught.
‘“ During the war I had special reason to be grateful
to him. In 1915 I organised two war hospitals in
Birmingham, and eventually these provided nearly
2000 beds. At that time it was not easy to secure
an adequate surgical staff as nearly all the general
surgeons in Birmingham were either on service abroad
or attached to the lst Southern T. Hospital. May
had entirely given up practice, and was then 70
years of age, but at my request he took charge of a
large section of beds and simply devoted himself to
looking after them. For his services he was given the
C.B.E In his later years he was greatly crippled
by arthritis, indeed he was bedridden during the last
five years; this and his increasing deafness cut him
off from his friends and he became very solitary.
His death came as a real relief from distress; he
will long be remembered with affection.”
SIR GEORGE WASHINGTON BADGEROW,
C.V.O., C.M.G., M.D. Toronto,jF.R.C.S. Edin.
THE sudden death occurred on Sunday last of
Sir George Badgerow, a laryngologist equally well
known in this country and in his native country of
Canada, He was born in 1872, the son of Mr.
Harrington Badgerow of Toronto, and was educated
at Upper Canada College and the University of
Toronto. He received his medical training partly
at the Toronto General Hospital and partly at the
University of Edinburgh, and he was also a student at
the Middlesex and University College Hospitals. He
took the English
double qualification
in 1903 and two
years later.
graduated as M.B.
Toronto with
honours, proceeding
to the M.D. degree
in 1909 and taking
the diploma of
F.R.C.S. Edin. in
1910. He early
decided to specialise
in diseases of the
throat, nose, and
ear, and became
chief clinical assist-
ant in the depart-
ment at University
College Hospital.
He then acted
as Clinical assistant
and registrar at
the Throat Hos-
pital, Golden-square, becoming later resident medical
officer, posts which he held from 1903-08. He made
during this period and later practical contributions
to the literature of his subject, describing in our
(Pholograph by Elliott & Fry
SIR GEORGE BADGEROW
1202 THE LANCET]
columns several ingenious appliances useful in
operative treatment, while he wrote in the Practitioner
and also in The Lancet on the types of pharyngeal
suppuration and on the general relation of diseases
of the throat, nose, and ear to constitutional disease.
He was appointed surgeon to the Golden-square
Hospital and acted also as dean. He did fine service
during the war as lieutenant-colonel in the Canadian
Army Medical Corps, both in the field and in institu-
tional positions. He was mentioned twice in dispatches
and at the conclusion of hostilities received the C.M.G.
He was consulting surgeon to the Ontario Military
Hospital, Orpington, to the Duchess of Connaught
Red Cross Hospital, Cliveden, the King’s Canadian
Hospital, Bushey, and the Officers’ (Daughters
of the Empire) Hospital He was a member of
the Imperial War Graves Commission. In 1928
he was knighted and in 1930 was appointed C.V.O.
CONTINUOUS VENOUS HUM IN CIRRHOSIS OF THE LIVER
[may 15, 1937
Sir George Badgerow was active in many provinces
of his specialty. He was honorary surgeon for the
diseases of the throat, nose, and ear to the Royal
Normal College for the Blind, to the Livingstone
Hospital, Dartford, and to the Warehouse Clerks’ and
Drapers’ Schools, Purley ; he was a member of the
Education Committee, L.C.C., of the Residential
Open-air School in Bushey Park, and consulting
surgeon to the Reedham Orphanage. It will be
readily understood how well known he was in his
profession as well as to all Canadians resident in or
visiting England. He married Maud, daughter of
Mr. Herbert Oxley, who died recently, and leaves a
son anda daughter. His death was tragically sudden ;
he collapsed in a taxi-cab and was found unconscious
at’ Waterloo Station. Conveyed to St. Thomas’s
Hospital he was found to be dead. He was 64 years
of age. : ; l
CORRESPONDENCE
CONTINUOUS VENOUS HUM IN CIRRHOSIS
OF THE LIVER
To the Editor of THE LANCET
Sir,—In your issue of May 8th Dr. J. L. Bates
records an interesting case of continuous venous hum
in cirrhosis of the liver, the exact cause of which
has not yet been confirmed at autopsy.
Some years ago I had under my care at the Sheffield
' Royal Hospital a case of cirrhosis of the liver with a
somewhat similar localised venous hum. In my case
it was possible to correlate the physical signs in life
with the findings at autopsy. The loud and con-
tinuous venous hum in the earlier stages (1916)
extended over the xiphisternum up to the level of
the third costal cartilage with an area of maximum
intensity over the former. Five years later (1921),
when the ascites had all disappeared, the sound was
sharply circumscribed to an area covered by a half-
crown at the right of the sternum opposite about the
sixth chondrosternal junction. At autopsy in 1924
there was a monolobular cirrhosis. The left portal
vein was much dilated and communicated by a
circuitous course through the round and falciform
ligaments with the right internal mammary vein,
which showed marked varicose dilatations. As this
vessel was lying immediately under the place where
the venous bruit was of maximum intensity, it seemed,
on these grounds alone, to be the most likely source
of the sound, and this view was supported by the
sudden variations in diameter of its lumen, from
narrow to wide, thus providing the requisite physical
conditions which Dr. Bates mentions—namely, “the
passage of blood through a constricted lumen into a
relatively dilated channel.”
An almost exactly similar condition was found in a
case of Ogle’s, quoted in Rolleston’s text-book (1912
edition), and apparently others of a somewhat similar
kind to that described in Dr. Bates’s interesting
record have been added in the later edition, to which
I have not had an opportunity of referring. An
account of my case, during life, was published in the
British Medical Journal for April 15th, 1922.
I am, Sir, yours faithfully,
Sheffield, May 7th. ARTHUR J. HALL.
PERNICIOUS ANEMIA IN AN INFANT
To the Editor of THE LANCET
Smr,—Dr. Smallwood’s letter, in which he questions
the correctness of the diagnosis of pernicious anæmia
in the infant whose case was recorded by Langmead
and Doniach in your issue of May lst, does not
mention whether any of his cases of acute or sub-
acute hemolytic anzmia showed achlorhydria follow-
ing injection of histamine. Of the previously recorded
‘cases of pernicious anæmia in infants, few, if any,
have fulfilled all the postulates required in the
diagnosis of this disease. The case recorded by
Langmead and Doniach fulfils all of them. Should
the infant, at a later date, be able to thrive without
liver therapy, it could ‘reasonably be maintained
that the syndrome, had been caused by a temporary
cessation of ability either to elaborate, or else to
absorb the antipernicious ansmia factor. An
analogous situation may arise in celiac disease.}
‘The criteria of the diagnosis of pernicious ansmia,!
quoted by Langmead and Doniach, could have with
advantage suggested achlorhydria following hista-
mine injection.
| I am, Sir, yours faithfully,
London, W.1, May 7th. J. C. HAWKSLEY.
PRURITUS ANI
To the Editor of THE LANCET
Smr,—In recent issues of your paper I read
interesting references to this subject, and it seems
obvious that the treatment of pruritus ani is still
wrapped in obscurity. I wrote to THE LANCET in
1923 (Sept. 29th, 1923, p. 678) recording the treat-
ment which had been successful in my own case many
years before. I then consulted Sir Charles (then Mr.)
Gordon-Watson who held the view that the cause of
this trouble lies in the papilla of Morgagni, which,
situated at the anorectal junction, are absent in the
majority yet present in a considerable proportion of
individuals. They are normally small white glistening
papilla, pyramidal or triangular, with the apices
directed upwards and inwards towards the lumen
of the gut. They vary from one to six, and when
hypertrophied resemble in size and shape the writing
end of an ordinary lead pencil; when much hyper-
trophied they may be felt as small shotty nodules.
In some cases one finds small fibrous branched
papill# as well; and I think it is advisable to destroy
these also as they may possibly be an additional source
of irritation. In my own case, Sir Charles Gordon-
Watson destroyed these hypertrophied papillæ with
the electric cautery. This was done without even
a local analgesic and was not very painful. The
itching, which had become unbearable, disappeared
1 Parsons, L. G., and Hawksley, J. C. (1933) Arch. Dia.
Chiidh. 8,-117. -
THE LANCET]
at once like magic, and I remained absolutely free
for about five years. There was then a slight return
occasionally, but carbolic vaseline kept it in check.
Later on, as the pruritus had again become rather
troublesome, I was examined by a surgeon, having
first told him what he would probably find. He
destroyed five or six papille with instantaneous
results, and has since treated four similar cases with
equally good effects.
is in my case always attended by a return of the
pruritus and discharge of irritating mucus which
rapidly causes the skin to inflame.
I would add now that I have found that repeated
cauterisations of the papilla of Morgagni deprive
one of the sensitive area which gives warning of the
presence of a stool at the anal orifice ; and occasionally
if one had diarrhoea, an “ accident’? was likely to
occur. This is, of course, one of the results which
is apt to follow Whitehead’s operation for piles or
prolapse of the rectum.
I am, Sir, yours faithfully,
F. J. W. PORTER,
Tangier, May 1st. Major, R.A.M.C., retired.
FREE MILK AND CHEAP MILK
To the Editor of THE LANCET
SR,—Following the report of the Advisory Com-
mittee on Nutrition, the Ministry of Health last
month circularised maternity and child welfare
- authorities asking them to review their arrangements
for the supply of milk and other foods to mothers
and young children. May we comment on some of
the issues involved ?
In many areas pregnant or nursing mothers and
children under school age cannot obtain free milk
unless the family income falls beneath a very low
level. We know of authorities where the income
(after deduction of rent) for a family of five must be
as low as 25s. or even 22s. 6d. a week before free
milk is granted. But the circular, in urging that
“scales should be so framed as not to render it
difficult for mothers to take advantage of the
authorities’ arrangements,’ does not itself suggest
any basis on which this should be done. Such a basis
might be found in the British Medical Association’s
estimate of the minimum costs of satisfying food
requirements, as revised to conform with the milk
recommendations of the Advisory Committee on
Nutrition. If, however, the Minister feels that he
cannot. accept these estimates, we suggest that he
should ask the Advisory Committee itself to draw
up, for the guidance of local authorities, a scale based
on the present knowledge of food requirements.
Estimates for necessities other than food, such as
have been used in the various social surveys, could be
added, and the scale adjusted to changes in prices
from time to time and place to place.
The report of the Advisory Committee indicates
that on health grounds milk (or its equivalent in
other protective foods) is necessary for all pregnant
and nursing mothers and young children. However,
under most local authorities, even after a stringent
income test has been satisfied, milk and other foods
are only supplied free if clinical symptoms are dis-
covered showing the need for additional nourishment.
Should not local authorities be asked to provide free
milk wherever the income available for expenditure
on food is insufficient, and thereby anticipate the
dangers of undernourishment before health is actually
impaired ? j
The Minister’s circular which seeks to implement
the report of the Advisory Committee is valuable in
FREE MILK AND OHEAP MILK
The reappearance of a papilla
[may 15, 1937 1203
encouraging local authorities to remove some of their
restrictions: but further measures will undoubtedly
be required if we are to secure that “ largely increased
consumption of safe milk by mothers, children, and
adolescents,” which the Committee states would do
more than anything else to improve the health,
development, and resistance to disease of the rising
generation. 7
The onus, for extending the provision of milk
remains on the local authorities, who will have to
pay the whole cost of such an extension out of the
rates. It is true that the poorer authorities have
benefited by the recent revision of the block grant,
but such relief is required for many purposes, including
‘the reduction of rates raised to unprecedented heights
by years of severe unemployment..
Measures on an extensive scale will be needed if
the hope of the Advisory Committee that a “‘ supply
of safe milk to the amount (we have) recommended
is brought within the purchasing power of the poorest ”
is to be fulfilled. These amounts are 2 pints a day
for expectant and nursing mothers and from 1 to 2
pints a day for each child. With milk at 33d. a.
pint, a family in which there were three children
taking, say, 14 pints a day, and a mother taking
_ 2 pints, would have a bill of 13s. 34d. a week. Such
an expenditure is, as recent surveys show, quite
beyond the means of most working-class families
with. young children.
At present about one-third of the milk produced is
sold for manufacture at an average subsidised price
of 54d. a gallon, whereas it is only available for
liquid consumption at a price which puts a sufficient
quantity for health beyond the reach of many families.
It is understood that the Government are considering
a scheme for extending the provision of cheap milk
to mothers and children under school age. We very
much hope that a result of the report of the Advisory
Committee will be its early initiation.
We are, Sir, yours faithfully,
F. D. ACLAND,
SUSAN LAWRENCE,
ELEANOR F. RATHBONE,
DUNCAN SANDYS.
The Children’s Minimum Council, 72, Horseferry-road,
London, S.W.1, May 7th.
PRISONERS AND CAPTIVES
To the Editor of THE LANCET
Sm,—Despite your mental hospital correspondent,
who so vigorously championed the statutory hospitals
against Taddygaddy in your issue of May Ist, is
there not a subtle difference ? Is it perhaps a matter
of the limelight focused on the “‘ voluntary ” institu-
tions owing to the continual fight for funds? The
public develops an almost parental feeling of responsi-
bility : not only does it support financially, it protects,
cherishes, excuses. Statutory hospitals still contend
against a remnant of suspicion. The tradition of
the locked-door, the inferiority stigma has not yet
vanished. The governing bodies are recruited with
a difference: members of county or borough councils
must be rationed out over the work to be done and
the hospitals committee may perhaps be the Cinderella
that gets the leavings. At any rate there seems to be
less opportunity for detailed intercourse, intimate
knowledge, personal contact: they all have too
much to do. l
At a recent opening of a municipal hospital the
equipment shown was superb but where were the
local doctors and their wives and their friends ?
It was a different crowd: it nearly always is. If
1204 THE LANCET]
Taddygaddy and your correspondent are both
right surely an urgent and immediate task ahead is
to find a way of amalgamating ‘“‘ atmospherics >° or
at least of demonstrating that no real difference
need exist. i
I am, Sir, yours faithfully,
ESTHER CARLING.
Berks and Bucks Joint Sanatorium, Oxon, May 6th.
To the Editor of THE LANCET
Sir,—Taddygaddy fain would raise a storm.
Will there be pennies from Heaven? Authority, in
spite of all the gossips, is not too mean a deity.
There is, of course, much of truth in Taddygaddy,
much to welcome. Nevertheless, whensoever we seek
to preach this freedom, ought we not first to ask with
Nietzsche : “ Freedom for what?” ?
I am, Sir, yours faithfully,
Birmingham, May 10th. H. FREIZE STEPHENS.
INSULIN SHOCK TREATMENT OF
SCHIZOPHRENIA
To the Editor of THE LANCET
Sm,—In the excellent account of insulin shock
in schizophrenia given by James, Freudenberg,
and Cannon in your last issue, the question of depth
of coma arises. Coma is rightly defined as a period
of unconsciousness, but the differentiation of depths
of coma is rather at variance with that set out in
Dr. I. G. H. Wilson’s report and so may lead to
confusion. James and his collaborators define coma
as ‘‘ unconsciousness,” deep coma being characterised
by loss of corneal and plantar reflexes and also by
hypotonus. Dr. Wilson describes “light coma,”
coma with restlessness and all reflexes present ;
coma proper, in which hypo- or hyper-tonus is seen
and in which the corneal reflex is absent; “deep
coma,’ in which the pupillary light reflex is lost.
I feel that this difference should be emphasised, as
any attempt to prolong this latter form of deep
coma for the 1} hours permissible for the deep coma
of James, Freudenberg, and Cannon would
undoubtedly be disastrous.
The “coma” mentioned in the ‘very brief note
on method in my report on cases, being unqualified,
simply means ‘period of unconsciousness.” When
this is 24 hours it is usual to find, with proper dosage
of insulin, that 1 hour is spent in light coma and
14 in coma proper. I cannot agree that hypertonus
in general extension is an imperative indication for
interruption and have frequently seen this and
allowed hypoglycemia to continue for the usual length
of time: some cases have shown this daily.
I am, Sir, yours faithfully,
LEONARD W. RUSSELL.
St. Bernard’s Hospital, Southall, May 10th.
a | eee ee
East HAM MEMORIAL HOSPITAL.—This hospital is
now free from debt for the first time in its history.
In 1935 it had a deficit of £18,000; half of this sum
was given by Lord Bethell, the president, and the
other half by the public. A new children’s ward is required
and Lord Bethell has offered to meet half its cost in
commemoration of the Coronation.
NATIONAL HOSPITAL FOR NERVOUS DISEASES.—
Princess Alice, Countess of Athlone, has laid the foun-
dation-stone of the extensions to this hospital which
have been made possible by a grant from the Rockefeller
Trust. The extensions will be devoted to the work of the
clinical research unit, while facilities for neurosurgical
work and some small wards for paying patients will also
be provided.
CORONATION HONOURS
[may 15, 1937
CORONATION HONOURS
THE list of honours bestowed by the King at his
Coronation contains the following names of members
of the medical profession :—
Baron
The Rt. Hon. Christopher Addison, F.R.C.S.
First Minister of Health (1919-21).
Baronet
Sir Cuthbert Wallace, K.C.M.G., C.B., M.B.
President of the Royal College of Surgeons.
K.C.B.
Edward Mellanby, F.R.C.P., F.R.S.
Secretary of the Medical Research Council.
K.C V.O.
Sir John Atkins, K.C.M.G., F.R.C.S.
Physician-in-Ordinary to the Duke of Connaught.
George Frederic Still, F.R.C.P.
Consulting physician for diseases of children, King’s
College Hospital.
K.B.E. (Military)
Air Vice-Marshal Alfred Wiliam Iredell,
M.R.C.S., K.H.P.
Director of medical. services, Air Ministry.
K.B.E. (Civil)
The Hon. John Richards Harris, M.D.
Minister of Public Health, Victoria.
Knights Bachelor |
Arthur Edwin Horn, C.M.G., M.R.C.P.
Consulting physician to the Colonial Office.
Arthur Frederick Hurst, F.R.C.P.
Senior physician to Guy’s Hospital.
Harold Beckwith Whitehouse, F.R.C.S.
Professor of midwifery, University of Birmingham.
C.B. (Military)
Surgeon Rear-Admiral G. L. Buckeridge, O.B.E.,
M.R.C.S., K.H.S.
Major-General W. H. Hamilton, C.I.E.,C.B.E.,D.S.0.,
F.R.C.S., K.H.P., I.M.S.
D.D.M.S., Northern Command, India.
Major-General Osburne Ievers, D.S.O.,
D.D.M.S., Southern Command.
Major-General H. Marrian Perry, 0.B.E., L.R.C.P.I.,
ee of Royal Army Medical College.
Air Commodore A. V. J. Richardson, O.B.E.,
K.H.S.
C.B.,
M.B., K.H.S.
M.B.,
. (Civil)
John Harry Hebb, C.B.E., M.B.
Director-general of medical services,
Pensions.
C.M.G.
Robert Henry Hogg, O.B.E., M.B.
President of New Zealand branch of B.M.A.
C.I.E.
Lieut.-Colonel Ronald Herbert Candy, M.B., I.M.S.
Civil surgeon, Poona.
Ernest Muir, M.D., F.R.C.S.E.
Secretary, British Empire Leprosy Relief Association.
Ministry of
THE LANCET]
Lieut.-Colonel Clive Newcomb, D.M., F.1.C., I.M.S.
Principal of the Medical College, Madras.
Colonel John Taylor, D.S.0., M.D., V.H.S., I.M.S.
Director of Central Research Institute, Kasauli.
C.B.E. (Military)
Surgeon Captain William Bradbury, D.S.O., M.B.,
R.
Colonel John MHeatly-Spencer, O.B.E., F.R.C.P.,
K.H.P.
Professor of tropical medicine, R.A.M. College.
C.B.E. (Civil)
Edgar Leigh Collis, M.R.C.P., J.P.
Emeritus professor of preventive medicine, University
of Wales.
George Carter Cossar, M.C., L.R.C.P.E.
Founder of Todhills Farm Colony.
Peter Sinclair Hunter, M.B.
Municipal health officer, Singapore.
James Lochhead, O.B.E., F.R.C.S.
Senior medical officer, Gibraltar.
James Perrins Major, M.D.
Hon. secretary of Victorian branch of B.M.A.
`
O.B.E. (Military)
Major David Fettes, F.R.C.S.E., R.A.M.C.
Major Frank Holmes, M.B., R.A.M.C.
Captain Trevor Edward Palmer, M.B., I.M.S.
Late M.O., British Legation guard, Addis Ababa.
Surgeon Captain James Bruce Ronaldson, V.D.,
M.D., R.N.V.R.
Wing-Commander Alan Filmer Rook, M.R.C.P.,
R.A.F.
Surgeon Commander John Wylie, M.B., R.N.
O.B.E. (Civil)
C. R. Cooke-Taylor, M.R.C.S., D.P.M.
Parliamentary candidate for Dulwich.
John Merrill Cruikshank, M.D.
Chief medical officer, Bahamas.
Owen Wynne Griffith, L.R.C.P., J.P.
Eleven times mayor of Pwllheli.
John Daniel Harmer, F.R.C.S.
Surgical specialist, Northern Rhodesia.
David Hynd, M.B,
_Of Bremersdorp, Swaziland.
Major G. M. Moffatt, L.R.C.P.I., I.M.S.
Civil surgeon, Lashio, Burma.
Mrs. Dorothy Mary Roberts, M.B.
Of Bishopsbourne, Straits Settlements.
Lieut.-Colonel John Rodger, M.C., M.B., I.M.S.
Chief medical officer in Baluchistan.
George Waugh Scott, M.D.
Of Sungei Siput, Perak, F.M.S. $
Lieut.-Colonel P. H. S. Smith, M.B., I.M.S.
Superintendent, Central Jail, Haripur, N.W.F.
Imperial Service Order
Herbert Rendell, M.B.
Formerly superintendent of tuberculosis sanatorium,
Newfoundland.
THE LANCET 100 YEARS AGO
[may 15, 1937 1205
7 M.B.E. (Military)
Captain A. G. D. Whyte, M.B., R.A.M.C. >
M.B.E. (Civil)
Percy William Barnden, M.R.C.S.
Medical officer, Sudan United Mission.
Miss Harriett Biffin, M.S.
Of New South Wales.
Thomas Bertram Butcher, M.R.C.S. |
Hon. surgeen superintendent, Cottage Hospital,
Mussoorie, United Provinces.
Major Francis Joseph D’ Rose, I.M.D.
Civil surgeon, Myaungmya, Burma.
Atul Chandra Dutta, L.M.S.
Late medical officer, Malacca, Straits Settlements.
Birendra Nath Ghosh, F.R.F.P.S.
Medical practitioner, Bengal.
‘Barjor Framji Khambatta, M.B.
Port health officer, Karachi.
Kaisar-i-Hind Medal
Jehangir Ardeshir Anklesaria, M.B.
Port health officer, Rangoon.
THE LANCET 100 YEARS AGO
May 20th, 1837, p. 315.
From the report of a paper on malignant diseases
of the skin of the face read by Mr. CÆSAR HAWKINS
at a meeting of the Royal Medical and Chirurgical
Society held on May 9th, 1837.—Dr. BRIGHT, President.
. e e The term “malignant ” disease, however, having
been employed in a very vague and ill-defined manner,
the author commences by stating, that he restricts the
term ‘‘ malignant ”’ to such diseases as essentially possess
a new structure, capable of exerting a poisonous influence
in one or more of these several degrees; Ist, upon the
neighbouring textures, which are converted into a sub-
stance exactly similar, or, at least, analogous, to that
of the new formation; 2ndly. Upon the absorbent
system, so that the neighbouring glands become enlarged
into a tumour, like that originally deposited ; or, 3rdly,
Upon the whole constitution, so that the poisonous secre-
tions of the newly-formed part gain access to the circu-
lating fluids, and tubercles of various forms, but of the
same or an analogous character, become developed in
some distant organs, or textures, which have no direct
communication, except through the blood, with the parts
in which the new structure was first formed.
*,* Our centenary extract this week contains two
historic medical names. Richard Bright, who gave
his name to Bright’s disease, was the first to connect
albumin in the urine with dropsy, no one previously ,
having suspected the kidney to be the organ
implicated.
Cesar Hawkins, an eminent man himself, is often
confused with his grandfather, Sir Ceesar Hawkins.
The name Cesar had come down in the family
from the sixteenth century. Sir Cesar was
sergeant-surgeon to King George II and King
George III and his portrait by Hogarth is in
the Royal College of Surgeons of England.
His grandson, whose name appears above, was,
like Sir Cæsar, on the staff of St. George’s Hospital.
As a student he worked under Everard Home and
Benjamin Brodie; he taught anatomy in association
with Charles Bell in the Windmill-street school;
and he was president of the College of Surgeons of
England in 1852 and again in 1861, being one of
the last presidents to hold office twice, after an
interval.—ED. L.
+
1206 THE LANCET]
[may 15, 1937
MEDICAL NEWS
University of Cambridge
The board of research studies has approved Prof. C. C.
Okell, F.R.C.P., for the degree of doctor of science.
Royal College of Physicians of Edinburgh
A meeting of the college was held on May 4th with
Dr. W. T. Ritchie, the president, in the chair. Dr. Douglas
James Campbell (Grimsby) was introduced and took his
seat asafellow. Dr. George Abeysingha, Weera Wickrama-
suriya (Ceylon) was elected to the fellowship. The
Freeland Barbour fellowship was awarded to Mr. Walter
Tebrich, B.Sc.
Honour for Sir Patrick Laidlaw
The faculty of medicine of the University of Toronto has
awarded the Charles Mickle fellowship to Sir Patrick
Laidlaw, F.R.S., of the National Institute for Medical
Research, London, for his contributions to practical
medical research.
Royal Society cf Arts
On Wednesday, May 26th, at 8.15 p.m., Prof. H. D.
Kay, D.Sc., director of the National Institute for Research
in Dairying of the University of Reading, will address
this society on the biochemistry of milk secretion. Applica-
tions for tickets should be made to the secretary of the
society, John-street, Adelphi, W.C.2.
National Physical Laboratory
Prof. W. L. Bragg, F.R.S., Langworthy professor of
physics in the University of Manchester, has been
appointed director of the National Physical Laboratory.
He will take up his duties in the autumn.
Science and Peace
One of the commissions of this year’s National Peace
Congress, which meets in London from May 28th to 3lst,
is concerned with the contribution of science and medicine
to peace. The chairman is Prof. S. Chapman, F.R.S.,
of the Imperial College of Science, and the introductory
address will be given by Prof. P. M. S. Blackett. Particulars
may be had from the National Peace Council, 39, Victoria-
street, London, S.W.1. —
International Rheumatism Congress
The annual international symposium organised by the
Ligue Francaise contre le Rhumatisme will be held this
year in Paris on Oct. 9th under the presidency of Prof.
Laignel-Lavastine on radiotherapy in rheumatism. In the
morning a clinical meeting will be held at Prof. M. Loeper’s
medical Clinic, Hôpital Saint-Antoine. At 3 P.m. the
congress will meet at the Faculty of Medicine when Coste
(Paris) will discuss radiotherapy, Piéry, Cluzet, and
Milhaud (Lyons), emanotherapy, and Euziére and Castagne
(Montpellier), the radio-active action of thermal waters.
Further information may be had from the offices of the
Journée du Rhumatisme, 23, rue du Cherche-Midi,
Paris, . VI.
Association of Registered Biophysical Assistants
At a meeting of the executive committee on April 15th
it was agreed that this association, which was founded
in 1932, should in future be known as the Society of
Physiotherapists. The change of title is made desirable
by the formation of the National Register of Medical
Auxiliaries, in which the Roll of Biophysical Assistants
is now incorporated. Membership of the Society of Physio-
therapists will be limited to those termed physiotherapists
in the National Register of Medical Auxiliary Services.
The society is not an examining, qualifying, or registering
body ; its principal aim is to represent its members by
making their work known to the medical profession and
the public, thereby promoting the expert administration
of physical methods of treatment and the ultimate elimina-
tion of the unqualified from the field of physiotherapy.
Applications for membership may be addressed to the
hon. secretary at 159, Victoria-street, London, S.W.1.
Lord Horder has been appointed a deputy-lieutenant
for Hampshire.
Glasgow Royal Infirmary
As soon as space is available in the new premises in the
Blind Asylum buildings, a fracture clinic is to be set up.
Accommodation will be provided for both out-patients
and in-patients with ten beds for men and ten for women.
International Leprosy Conference
The fourth International Leprosy Conference will be
held at Cairo beginning on March 21st, 1938. This will be
the first international conference to be arranged by the
International Leprosy Association since its inauguration
in 1931. Previous conferences were held at Berlin in
1897, at Bergen in 1909, and at Strasbourg in 1923. Further
information may be had from the secretary, 131, Baker-
street, London, W.1.
International Union against Tuberculosis
The Italian Fascist National Federation against Tuber-
culosis has placed at the disposal of the Union six scholar-
ships each of the values of 2000 liras with board and
lodging at the Carlo Forlanini Institute in Rome. The
scholarships will be awarded to young physicians who are
already familiar with tuberculosis problems and who wish
to improve their knowledge of this branch of medicine.
The kind of work undertaken at the institute will be
arranged between the director of the institute and the
candidate, and papers on the work must be submitted for
publication in the first instance to the editor of the
Bulletin of the International Union against Tuberculosis.
The scholarships will be awarded at the next session of
the executive committee which will meet in Lisbon in
September. Applications should reach the secretariat
of the Union, 66, Boulevard, St.-Michel, Paris, by July 5th.
Research in Tropical Medicine
The Medical Research Council, advised by their tropical
medical research committee which was appointed after
consultation with the Colonial Office (THe LaNnoer, 1936,
1, 558) have decided to offer three junior fellowships
to qualified medical men who wish to receive training
for research work in tropical medicine. Preference will
be given to candidates who have already had preliminary
experience of methods of research in some branch of medical
science. Subject to satisfactory reports, the fellowships
will be tenable for three years. The first year will be
spent at a school of tropical medicine; the second in
doing research in the same or some other institution at
home; and the third largely in work under direction at
some centre in the tropics. The stipend will be at the
rates ‘of £300, £400, and £500 per annum in the successive
years, with an additional allowance during service abroad
and necessary expenses. In three years’ time, at least
one senior fellowship will be available for candidates
who have held the junior fellowships mentioned above.
This will be awarded for a further period of ‘three years,
carrying stipend at the rate of £600—£750 per annum, with
an additional allowance during service abroad and expenses.
The time will be spent mainly in research work in .the
tropics. The council are also prepared. to consider
immediate applications for senior fellowships from candi-
dates who have had adequate experience in research work,
whether already specially trained in tropical medicine or
not.
The council intend to establish in due course, as suitable
investigators become available as the result of the fellow-
ships scheme, permanent and pensionable appointments
for research work in tropical medicine, including senior
posts. Members of this research staff will work partly in
the tropics, and partly in institutions at home to which
they will be attached. The exact terms of service are
still undecided, but they will be not less favourable than
those which apply to other Government appointments
at home or overseas for men of similar professional stand-
ing. Inquiries may be addressed to the secretary of the
tropical Medical Research Committee, 38, Old Queen-
street, London, 8.W.1, to whom applications should be
sent not later than June 15th.
THE LANCET]
MEDICAL NEWS.—APPOINTMENTS
[may 15, 1937 1207
eee SOUSU
Alexandra Rose Day
Those who are willing to sell roses on Alexandra Day to
benefit hospitals and charities for the sick are asked to
communicate with Mrs. Leslie Morshead, 86, Eccleston-
square, London, S.W.1.
Chadwick Public Lectures
On Wednesday, May 26th, at 5.30 p.m., Prof. J. G-
Fitzgerald, director of the department of hygiene of the
University of Toronto, will give a lecture, entitled Pre-
ventive Medicine—an Avenue of Good Will. The lecture
will be held at Manson House, 26, Portland-place, London,
W., and Sir William Collins will be in the chair. On
Thursday, June 10th, at 5 P.m., at the Chelsea Physic
Garden, Swan-walk, S.W., Mr. H. Gilbert-Carter, director
of the University Botanic Garden at Cambridge, will
speak on plants in health and disease. Further information
may be had from the secretary of the trust, 204, Abbey
House, Westminster.
The Royal Sanitary Institute
_ A sessional meeting will be held at Newcastle-upon-Tyne
on Friday, May 28th, when a discussion on the difficulties
of nutritional assessment will be opened by Dr. H. E.
Magee, medical officer of the Ministry of Health,
Dr. G. C. M. M’Gonigle, medical officer of health for
Stockton-on-Tees, and Dr. J. C. Spence, hon. assistant
physician to the Royal Victoria Infirmary, Newcastle-
upon-Tyne. The meeting will be held in the Connaught
Hall, Y.M.C.A. Buildings, Blackett-street, at 5. P.M.
At 6 p.m. on Saturday, May 29th, in the City Hall, Sir John
Orr, F.R.S., will address a public meeting on the national
problem of food and health.
University of London Medical Graduates’ Society
For the first time in a setting appropriate to its name,
this society, on May 6th, held its annual dinner in the
university’s own home, the new buildings in Bloomsbury.
The dinner, which had been preceded by the annual
meeting, was attended by some 150 members and guests.
After Dr. Dorothy Hare, the president, had drunk wine
with the company and had given the loyal toast, Mr.
H. Lightfoot Eason, vice-chancellor of the University,
proposed her health and that of the society. He said he had
been forbidden by her to give an account of the society,
but he was very glad to see there that eminent gynzco-
logist, Sir StClair Thomson—for had he not been closely
concerned with the society’s birth ? It was fitting that
the profession should be represented by him in the Abbey
at the Coronation Service, for no one more distinguished
and deserving of that privilege could be found. Mr.
Eason said he was glad that the society was created
solely for social reasons and had no political activities.
Just such objects were badly needed in the faculty to-day.
Dr. Hare, responding, said that the occasion was a red-
letter day in the society’s history, for they were sitting in
the University’s own hall, eating its own food. The
dinner, she said, would be the first opportunity many
would have to see the interior of the new building. This
had not been erected to solve a housing problem, It was
“ just a big idea ” for the furtherance of education in the
metropolis, and the City Corporation had itself con-
tributed a large sum towards its cost. Hitherto there
had been as little corporate form among the faculties as
there was in an amæœba; the chief objects of their society
were adhesion to the university and cohesion between the
medical graduates. The personal interest of every one
of these was more necessary to the university than the
tangible bricks and mortar, lectures and professors. She
would mention at that time especially the work of Mr.
McAdam Eccles in drawing into membership numerous
overseas medical graduates. The chief event of the past
year had been the official recognition of the society by
the University, which Sir Edwin Deller, the late principal,
had himself obtained a fortnight before his tragic death.
They were very grateful to the University for the dignity
and status its recognition had given the society. Sir
Charlton Briscoe, president elect, proposed The Guests.
He divided them into three groups. To those who were
not graduates of the University—by their presence there
-a rule had been broken—he would say, ‘‘ Although you
can never be like us, be as like us as you're able to be.”
Others who, though they were graduates, had not joined
the society, would not be blackmailed to join but would
be offered every inducement. Thirdly, he welcomed the
authorities in the persons of the vice-chancellor and Mr.
W. Girling Ball, the dean of the faculty. The latter,
responding, said that he himself was not a graduate, but
he had always worked very hard to achieve closer codpera-
tion between the various medical bodies in London. The
president had agreed with him that one matter, for example,
that needed looking into was the status of women medical
students and why the three largest hospitals and medical
schools in London should not admit them. He also
thought that the rivalry between the twelve teaching
hospitals of the city would disappear with the formation
of a real university, and it had at last reached a stage
when it could at least be seen. The society, he was
sure, was soon to have a great. part to play in the
furtherance of that end. During the dinner Mr. Harry
Brunning entertained the company, and to conclude the
evening they were invited to inspect the parts of the
University already completed, which included the senate
room, some of the administrative offices, and the kitchens.
Appointments
Derrcn, H. I., M.S. Lond., F.R.C.S. Eng., has been appointed
Medical Superintendent at the Halifax General Hospital.
OVENS, G. H. C., M.B. Lond., F.R.C.S. Eng., Surgical Registrar
at St. Mary’s Hospital, London.
Rackow, A. M., M.B. Lond., D.M.R.E., Senior Assistant
Radiologist to King’s College Hospital.
THompson, B. G., M.D. Edin., D.M.R.E., Junior Assistant
Radiologist to King’s College Hospital.
London County Council Hospital Staff. —The following appoint-
ments, promotion, and transfers are announced. A.M.O. (I)
or (II) = Assistant Medical Officer, Grades I or II., D.M.O. =
District Medical Officer; Temp.=temporary.
BRUCE, R. D., M.B., A.M.O. (I), Hackney ;
MACKENZIE, IAN, M.B., A.M.O. (I), St. Giles’ ;
Epwarps, L. M., M.B., A.M.O. (I), St. Mary Abbots :
Roseg, Isaac, M.B., A.M.O. (I), St. Olave’s ;
JAMES, ELIZABETH M., M.B., A.M.O. (II), Fulham ;
BROWNE, OLIVE M., M.B., A.M.O. (II), Hackney ;
WoLrson, L. J., M.R.C.S., A.M.O. (II), Highgate ;
BOUCHER, C. A., B.M., A.M.O. (II), New End;
Ramsay, J. D., M.B., A.M.O. (II), New End ;
Hoce, G. C. H., M.B., F.R.C.S., A.M.O. (II), St. James’:
Lrerrrr, W. N., M.R.C.S., A.M.O. (II), St. Olave’s ;
FoORGIE, JANE R., M House Physician, Downs ;
WALTER, JOSEPH, B.M., House Physician, Dulwich ;
Munn, J. E. T., L.M.S.S.A., House Surgeon, Mile End ;
THOMPSON, N. J. W., M.B., House Surgeon, Paddington ;
HALES, SAMUEL, M.R.C.S., House Physician, St. Alfege’s ;
MAGUIRE, W. T., M.D. (Toronto), House Surgeon, St. Alfege’s ;
BOOKHALTER, SOPHIE, M.D., House Physician, St. Andrew’s ;
BRETT, E. St. M., L.R.C.P., House Physician, St. Andrew’s ;
STOCKINGS, G. T., M.B., House Physician, St. Giles’ ;
ADAMS, J. C., M.R.C.S., House Physician, St. James’ ;
Scotr, J. S. H., M.R.C.S., House Physician, St. James’;
CORMIOK, JANET F., M.B., House Physician, St. Luke’s,
Chelsea ;
BARRACLOUGH, RONALD, M.B., House Surgeon, St, Mary
Abbots ;
MACKENZIE, A. M., M.B., House Surgeon, St. Mary Abbots ;
NEWCOMBE, A. R., M.B., Clinical Assistant, St. Mary Abbots ;
THOMPSON, A. W., M.B., House Surgeon, St. Mary Abbots ;
Bayne: Max, M.R.C.S., House Physician, St. Mary
ots ;
CoBLEY, J. F. C. C., M.B., House Physician, St. Olave’s ;
DILL-RUSSELL, P. W., M.R.C.S., House Physician, St. Olave’s ;
HAYMAN, A. A.,L.R.C.P., Temp. D.M.O., City of Westminster ;
WALSHAM, E. J., M.R.C.S., Temp. D.M.O., Balham ;
IRIZELLE, G. M., M.D., Senior A.M.O. (II), St. Nicholas’;
HARDING, KATHLEEN M. D., M.D., M.C.O.G., Senior
A.M.O. (II),, St. Pancras ;
MATHESON, I. W., M.B., F.R.C.S., A.M.O. (I), Mile End;
MAYEUR, MARY H., M.D., A.M.O. (I), St. James’ ;
GAULD, W. R., M.B., A.M.O. (II), Hackney ;
May, TENE I. E., M.R.C.S., A.M.O. (II) St. Charles’;
an
ALLAN, D. Y., M.D., A.M.O. (I), St. Mary, Islington.
‘ Certifying Surgeons under the Factory and Workshop Acts:
Dr. HENDERSON Gow (Newbury District, Berks).
Medical Referee under the Workmen’s Compensation Act,
1925: Dr. S. S. RENDALL, of Boston, Lincs., for the Boston,
Holbeach, Sleaford, Spalding, Spilsby, and Skegness
County Court Districts (Circuit No. 17).
1208 THE LANCET]
VACANCIES.—BIRTHS, MARRIAGES, AND DEATHS
(may 15, 1937
V acancies
For further information refer to the advertisement columns
Altrincham General Hosp.—Sen. and Jun. H.S.’s, at rate of
£150 and £120 respectively.
Aylesbury Isolation Hosp.—Deputy Matron. Also Night Charge
Nurse, £90 and £70 respectively.
Barnsley, St. Helen Municipal General Hosp.—M.O., £650.
Bedford County Hosp.—Second H.S., at rate of £150.
Belfast Royal Maternity Hosn.—Res. H.S., at rate of £100.
Birmingham and Midland Hosp. for Women.—H.S., at rate of l
£100.
Blackburn Royal Infirmary.—Res. H.S., £175.
Bradford Children’s Hosp.—H.S., £100.
Brighton, Royal Sussex County Hosp.—H.P., £150.
Cardiff, King Edward VII Welsh National Memorial Association.
Three Area Asst. Tuber. Physicians, each £500. Res.
M.O.,£350. Asst. Res. M.O., £200. Also Asst. Res. M.O.
for Glan Ely Tuber. Hosp., £200. -
Chelsea Hosp. for Women, Arthur-strect, S.W.—Jun. H.S., at
_, rate of £100.
City of London Hosp. for Diseases of the Heart, &c., Victoria
Park, E.—H.P., at rate of £100.
Connaught Hosp., Walthamstow, E.—Sen. Res. M.O., at rate of
£175. Also H.P., H.S., and Cas. O., each at rate of £110.
Coventry and Warwickshire Hosp.—Hon. Asst. Surgeon. Also
Res. H.S., Cas. O., and Res. H.S. for Aural and Ophth.
Depts., each £125.
rou con Montal Hosp., Upper Warlingham, Surrey.—Asst. M.O.,
Dartford, Kent, City of London Mental Hosp.—Jun. Asst. M.O.,
Dewsbury and District General Infirmary.—Sen. H.S., £200.
Also Second H.S., £150.
Own Ra Tok, Down County Mental Hosp.—Jun. Asst. M.O.,
East Ham_ Memorial Hosp., Shrewsbury-road, E.—H.S. to
_ Spec. Depts., and Cas. O., at rate of £120.
Elizabeth Garrett Anderson Hosp., Euston-road, N.W.—Temp.
Hon. Asst. Surgeon. Also Temp. Hon. Jun. Obstet. Surgeon.
pens Petia for Sick Children, Southwark, S.E.—H.P., at rate
o :
Exeter, Royal Devon and Exeter Hosp.—H.S. to Ear, Nose,
and Throat Dept., at rate of £150.
Farnborough Public Assistance Hosp—Res. Asst. M.O., £250.
Gloucestershire Royal Infirmary, &c.—H.P., at rate of £150.
Gordon Hosp. for Rectal Diseases, Vauxhall Bridge-road, S.W.—
Res. H.S., at rate of £150.
Goswell Women’s Welfare Centre, 39, Spencer-street, E.C.—M.O.
Hastings, Royal East Sussex Hosp.—Jun. H.S., at rate of £150.
Hertford County Hosp.—H.S., at rate of £180.
Henney, East Sussex County Mental Hosp.—Sen. Asst. M.O.,
Hosp. for Epilepsy and Paralysis, 4, Maida Vale, W.—Hon.
Anesthetist. '
Hosp. for Sick Children, Great Ormond-street, W.C.—Res. H.P.
and Res. H.S., each at rate of £100.
Hosp. of St. John and St. Elizabeth, 60, Grove End-road, N.W.—
Ophth. Surgeon.
Hosp. for Tropical Diseases, 25, Gordon-street, W.C.—H.P., at
rate of £120,
POD Jor Women, Soho-square, W.C.—Res. M.O., at rate of
Huddersfield County Borough.—Asst. School M.O.. £500.
Hull Royal Infirmary.—H.S. to Ophth. and Ear, Nose, and Throat
Depts. Also Second Cas. O., each at rate of £150.
Ilford Borough.—Res. M.O. for Maternity Home, £400.
Infants Hosp., Vincent-square, Westminster.—Hon. Clin. Assts.
to Out-patients. Also H.P., at rate of £100.
Isleworth, West Middlesex and County fHosp.—Cas. M.O., at
rate of £350.
Kensington Royal Borough.—Deputy M.O.H., £900.
Keitering and District General Hosp.—Res. M.O. and Second
_ Res. M.O., at rate of £160 and £140 respectively.
King’s College, Strand, W.C.—Two Demonstratorships in Dept.
_ Of Anatomy, each £100 per term,
Liverpool Heart Hosp.—Hon. Asst. Physician.
London County Council.—Coroner for County of London, £1700.
Also Part-time M.O., at rate of £40.
London Lock Hosp., 283, Harrow-road, W.—Res. M.O. to Male
Dept., at rate of £175.
London University.— University Readership in Obstetrics and
Gynecology for British Postgraduate Med. School, £800.
Manchester, Ancoats Hosp.—Hon. Reg. for Kar, Nose, and
poar ROPE: Res. Surg. O., £200. Also Orthopædic
eg., £50.
Manchester, Park Hosp., Davyhulme.—Second Res. M.O., at
rate of £225.
Manchester Royal Infirmary.—Med. Chief Asst., £300.
Manchester and Salford Hosp. for Skin Diseascs.—Two Asst.
Also Asst.
Dental O., £500.
Newcastle-upon-Tyne, Royal Victoria Infirmary.—Hon. Asst.
M.O.’s, £100,
Aane er, Withington Hosp.—Res, Asst. _M.O., at rate of
Middlesex County Council.—Asst. M.O., £600.
Miller General Hosp., Greenwich-road, S.E.—Two H.P.’s. Also
H.S., each at rate of £100.
Surgeon. Hon. Asst. to Throat and Ear Dept. Also Jun.
Surg. Reg., £150.
Ne Mon., Loyal Gwent Hosp.—Two H.S.'s, each at rate of `
Nottingham General Hosp.—Two Res, Cas. O.’s. Also H.S.
for Kar, Nose, and Throat Dept., each at rate of £150.
va pie Hosp., Walton-street.—H.S. to Ophthalmic Dept.,
Plymouth, Prince of Wales’s Hosp.—Res. Surg. O., at rate of
£225. Jun. H.S., at rate of £120. Also Hon. Physician,
Hon. Physician with charge of Out-patients, and Hon.
Ophth. Surg.
Plymouth Royal Eye Infirmary.—Hon. Phys.
Princess Elizabeth of York Hosp. for Children, Shadwell, E.—
H.P., H.S., and Cas. O., each at rate of £125. Ta
Princess Louise Kensington Hosp. for Children, St. Quintin-
avenue, W.—H.S., at rate of £120-£150.
Queen Mary’s Hosp. for the East End, Stratford, E.—Res. M.O.,
Two Cas. and Out-patients O.’s; each at rate of £150.
Also Two H.S.’s, H.P., Obstet. H.S., and Res. Ansesthetist
and H.P., each at rate of £120.
Reading, Royal Berkshire Hosp.—Cas. O. Also H.S. to Spec.
Depts., each at rate of £150.
Rochester, St. Bartholomew’s Hosp.—H.P. Also Cas. O. with
PO erp of erunopdic Bet eck at rate of £150.
erham Hosp. as. H.S., `
Royal Free Hosp., Gray’s Inn-road, W.C.—1st H.P., Sen.
ma EY Aron aieo Hee D O., at rate of £150.
Royal Nava ervice.—M.0O.’s.
Royal Waterloo Hosp. for Children and Women, Waterloo-road,
soni oye lots Eeh, 252
ord Royal Hosp.—Psychiatrist, ;
Salisbury General Infirmary.—Res. M.O., £250. Also H.P.,
at rate of £125.
St. Bartholomew’s Hosp., E.C.—Asst. Physician and Asst.
Director to Med. Professorship Unit.
Shrewsbury, Royal Salop Infirmary.—Res. H.P., at rate of £160.
Southampton, Royal South Hanis and Southampton Hosp.—
Locum Tenens Radium Officer, 12 guineas per week.
Southend-on-Sea General Hosp.—Surg. Reg., £275. Also Cas. O.,
at rate of £100.
Staffordshire County Council.—Res. Asst. M.O. for Wordsley
blic Assistance Institution, at rate of £300.
Stoke-on-Trent, Burslem, Haywood, and Tunstall War Memorial
Hosp.—Res. H.S., at rate of £175.
Stoke-on-Trent, North Staffs. Royal Infirmary.—H.S. for Aural
and Ophth. Dept., at rate of £150.
Stroud General Hosp.—Res. M.O., at rate of £160.
Sunderland Royal Infirmary.—Two H.S.’s and H.P., each £120.
Surrey County Council.—Asst. M.O., £600. Also Jun. Asst. M.O.
for County Sanatorium, at rate of £350.
Taunton and Somerset Hosp.—H.P., at rate of £100.
hac Hosp. for Children, Tite-street, S.W.—Physio-therapist,
50.
Weir Hosp., Grove-road, Balham, S.W.—Jun. Res. M.O., £150. °
Mes iam Com Borough end Asst. Res. M.O. for Central
ome, Leytonstone, ;
West London Hosp., Hammersmith-road, W.—Jun. Asst. M.O.
OE Dept., £350. Also H.P. and Two H.S.’s, each at rate
o 100.
Wickford, Runwell Hosp.—Asst. Res. Physician, £350.
Willesden aire Hosni e CHEB TOIET ORE, N.W.—Hon. Clin.
ssts. to Out-patient Dept.
Wolverhampton, New Cross Hosp.—Res. Asst. M.O., £200.
Te oon oN and aa E ne 2 emorial Hosp., Shooters-hiil, S.E.—
Three Hon. sesthetists.
Worksop, Victoria Hosp.—Sen. and Jun. Resident, £150 and £120
respectively, l
Births,- Marriages, and Deaths
BIRTHS
BaDo.—On May 3rd, at Plymouth, the wife of Major A. J. Bado,
R.A.M.C., of a son.
CooPER.—On May 3rd, at Milford Lodge, near Stafford, the wife
of Dr. T. V. Cooper, of a son.
Dawes.—On May 3rd, at Wotton-under-Edge, Gloucestershire,
the wife of Dr. W. A. Dawes, of a daughter.
JaAucH.—On May 4th, at Grantham, the wife of F. Joselin
Jauch, F.R.C.S. Eng., of a daughter.
TENNENT.—On May 4th, at Sutherland-avenue, W., the wife of
Thos. Tennent, M.D. Glasg., of a son.
WARNER.—On May lst, at Devonshire-place, W., the wife of
E. C. Warner, F.R.C.P. Lond., of a daughter. .
DEATHS
BADGEROW.—On May 9th, in London, Sir George Washington
Badgerow, C.M.G., C.V.O., M.D. Toronto, F.R.C.S. Edin.
BENSTED.—On May 5th, at Brookmans Park, Herts, Lewin
Bensted, M.R.C.S. Eng., late of Muswell-hill, aged 65.
GoLDIE.—On May 4th, Walter Leigh Mackinnon Goldie, O.B.E.,
F.R.C.S. Eng., of Leamington Spa.
Kerr.—On May 7th, at Dundee, Charles Kerr, O.B.E.,
M.B. Edin.
May.—On May 3rd, at Edgbaston, Birmingham, Bennett
May, C.B.B., F.R.C.S. Eng., late Emeritus Professor of
Surgery at the Birmingham University, aged 92.
SANGER.—On May ith, in London, Frederick Sanger, M.D.
Camb., of Tanworth-in-Arden, near Birmingham,
Scotr MacGREGOR.—On May 4th, George Scott MacGregor, M.D.
Edin., of Glasgow.
STURGES-JONES.—On May 10th, at Herne-hill, S.E.24, Wilfrid
Edward Sturges-Jones, M.R.C.S. Eng., late of Chichester,
and H.M. Vice-Consul, Interior Peru, in his 73rd year.
N.B.—A fee of 7s. 6d. is charged for the insertion of Notices of
Births. Marriages, and Deaths.
THE LANCET]
NOTES, COMMENTS, AND
[May 15, 1937 1209
ABSTRACTS
A COMMERCIAL ART CENTRE
‘A MEETING for the inauguration of a commercial
art centre was held recently at the Royal Society of
Arts, and some of our readers may be interested ©
in the project. The intention is to establish in London
a centre where specimens of the work of practising
commercial artists can be displayed. Those behind
the scheme find that manufacturers, advertisers,
and their agents find a difficulty in choosing the
right artist for the advancement of a publicity scheme ;
it is difficult both to obtain a sufficient range of a
particular artist’s work at short notice, and to dis-
cover new talent. The artist who is not working to a
particular commission experiences difficulty in keeping
touch with the general market, and only a few artists
Possess sO many specimens of their work that they are
able to keep possible buyers adequately informed.
The establishment of a centre where an up-to-date
range of the work of available artists could be inspected
would solve the difficulties. The proposed commercial
art centre would be situate in London and supported
by the Society of Industrial Artists and the Incor-
porated Society of Artists in Commerce. It is not
intended that the centre should act as an agency
for the sale of work; its effect would be to place
buyers in direct touch with artists or their agents.
The scheme has been worked out in some detail both
financially and otherwise, and has received promises of
support from responsible sources. Those interested in
the movement should communicate with the secretary
of the organising committee, Commercial Art Centre,
4, Bedford-square, London, W.C.
A DOYEN OF MICROCHEMISTRY
THE celebration by Prof. Hans Molisch of his
eightieth birthday has been made the occasion for
the issue of a special commemoration number of the
journal Mikrochemie ' in view of the valuable contribu-
tions which Prof. Molisch has made to micro-
chemistry. The number contains 47 papers by 45
different authors, many of whom have been his
pupils. The contributions cover a very wide range
of topics and vary considerably in size, one of the
longest being by Prof. H. Fischer on the constitution
of chlorophyll, which covers some 30 odd pages,
The subjects dealt with are by no means exclusively
botanical and cover all branches of inorganic and
organic analysis as‘ applied to foodstuffs, drugs,
pharmaceutical products, and the detection of
traces of carotene in blood.
THE ‘‘MAXAID”? HEARING-AID
Two so-called ‘‘ pocket-model’’ hearing-aids with
valve-amplification have recently been produced
by the Peto-Scott Company, of 62, High Holborn,
London, W.C.1. In both the apparatus is. incor-
porated in a small unusually flat case measuring
64 by 53 by 1# in. A small self-fitting ear-piece may
be used, or the more usual disc-shaped one held by
a light spring-band. The low-tension current is
supplied by two dry cells with a normal life of 25 to
30 working hours, or an accumulator may be substi-
tuted at an extra cost of 7s. 6d.; the high-tension
current is provided by a small dry battery stated to
give several months’ service.
cell are of well-known makes, easily obtainable,
the high-tension one costing 3s. 9d., and the low-
tension 33d. each, so that upkeep is inexpensive.
A volume-control is provided, and also a tone-
control adjusted by means of a set-screw inside the
case. The latter is intended to be set to suit the
wearer’s individual , hearing and then to be left
undisturbed ; it is a useful feature which enables the
instrument to be adapted to cases with loss of either
1 Mikrochemie: Festschrift zum 80 Geburtstag von Hofrat
Prof. Dr. Hans Molisch. Vienna: Emil Haim and Co, 1936,
Pp. 454. M.28.
Both forms of dry —
high or low tones. Model 52 P.L. employs two stages
of amplification and costs 14 guineas, while model
52 P.L.C., costing 19 guineas, has three stages and,
in addition, a crystal microphone. This latter
model, which we have examined, is very sensitive
and at the same time free from background noise.
The makers suggest that the instrument may be kept
in a man’s pocket during use, but this is hardly to be
recommended, Althouglr small, it is rather too
large for the ordinary pocket, the microphone is not
then in the best position for receiving sounds, and
friction against the clothes sets up disturbing noises ;
better results are obtained with the instrument on
the table or on the knee.
It is a very neat and efficient
apparatus, ,
PROPAGANDA AGAINST VENEREAL DISEASE
A VALIANT attempt to dispel the fog of ignorance
and misconception still surrounding the subject of
venereal disease in the public mind Has been made
by Mr. Carl Warren ! who urges that these diseases if
jointly attacked by doctors, public health authorities,
and the public could be virtually prevented or cured.
Without intelligent coöperation from the patient the
medical profession is hopelessly handicapped ; hence
the importance of teaching the public the facts and
fallacies concerning syphilis and gonorrhoea and the
value of such a book as this. The Scandinavian
countries have already achieved a large measure of
success in reducing the incidence of venereal disease
and there seems no reason why America and this
country should not follow suit provided public
enlightenment kept pace with medical knowledge
and organisation. The book is written simply and
_ accurately. The author obviously has no very high
opinion of the existing standard of sexual ethics
in America. Although the statistics are drawn
almost entirely from American sources the book could
be read with profit by young persons, and particularly
by those concerned with education, in any country.
A HOSPITAL DIARY
Messrs. Fredk. Aldridge, 34, Paternoster-row,
E.C.4, issue annually a diary particularly directed
to the needs of the hospital world. The issue for 1937
is edited by Mr. F. P. Carroll. The diary contains,
in addition, informative articles on law and engineering
which should prove particularly helpful to the efficient
management of a hospital, Ample space is left for
entries in the body of the diary, and a thumb-index
facilitates reference. A comprehensive buyers’ guide
arranged alphabetically under the names of the
articles is included in the diary. The price of the diary
is 5s. 6d.
CONTRACEPTION : PRINCIPLES AND
TECHNIQUE
PROBABLY nurses, health visitors, and midwives
receive more inquiries about contraceptive principles
and methods than any other member of the com-
munity, and a book? written essentially for their
instruction deserves attention. Dr. Griffith writes
well if somewhat dogmatically. He discusses the
advantages both to the individual and the State
of the proper spacing of families and emphasises the
urgent need to check dysgenic breeding. He relates
the various devices, both past and present, used for
limiting families, including abortion, infanticide,
coitus interruptus, and sexual abstinence, and draws
the conclusion that the soundest method is scientific
birth control. As a member of the medical sub-
committee of the National Birth Control Association
he can speak with some authority on methods of
1On Your Guard! By Carl Warren, B.A., B.S., M.S.J.
Foreword by M. J. Exner, M.D. New York: Emerson Books,
Inc. 1937. Pp. 160. $1.
2 Voluntary Parenthood. By Edward F. Griffith, Fe R.O.S.,
L.R.C.P. London: Heinemann. 1937. Pp. 141. 5s.
1210 THE LANCET]
MEDICAL DIARY ¢
-
{way 15, 1937
contraception and he describes briefly those which
have best stood the test of clinical and laboratory
investigation. Sexual education and ethics, the
meaning of marriage, and the importance of family
stability are given considerable space, but the
chapters on genetics, the biology of cell division, and
_ the internal secretions are somewhat sketchy. A
few unfortunate inaccuracies have creptin: on p. 103,
for example, the author speaks of the ovarian
follicular hormone (or folliculin) when he obviously
means the corpus luteum ‚hormone (progestip or
progesterone ) An index, a list of voluntary and
municipal clinics giving birth control advice, the
Ministry of Health’s memoranda on birth control,
and a short bibliography are appended.
THE ‘‘ BREVIS ”? IONIZER
AT the present time zinc ionisation is being largely
used in the treatment of hay-fever and similar nasal
affections, The Victoria Electric Plant Company,
of Spenser-street, Westminster, have produced a
convenient instrument for supplying the necessary
electric current. It consists of a polished wood
case measuring about 18 by 74 by 7 in., containing
an ‘‘ Ever Ready ” dry battery delivering a current
of 30 volts, together with an instrument-board on
which is mounted a voltmeter actuated by a push
switch for checking the output from the battery,
and a milliammeter with a red line at the 3 milli-
ampere mark, The rheostat to regulate the strength
of current is controlled by two rotating knobs giving
a fine and very even adjustment. There is also a
space for storing the necessary leads and terminals.
The price is 10 guineas, and a somewhat smaller
model without a cover to the instrument panel is
supplied at 8 guineas. It is a well-made and portable
machine for the application of ionisation for any
purpose.
CoRRIGENDUM.—Insulin Shock Treatment of Schizo-
phrenia. In the article by James, Freudenberg, and
Cannon, published in our last issue, the word subcu-
taneous in the second line on p. 1102 under the
cross heading Phases of the Treatment should read
intramuscular. l
Medical Diary
SOCIETIES
ROYAL SOCIETY OF MEDICINE, 1, Wimpole-street, W.
WEDNESDAY, May 19th.
Surgery : Subsection of Proctology. 5P.M. annual general
meeting. Sir Edmund Spriggs: A Review of Disorders
and Diseases of the Colon, Founded on the Examination
of the Alimentary Canal in 5800 Cases.
THURSDAY.
Dermatology. 5 P.M. (Cases at 4 P.M.), annual general
meeting. Dr. S. M. Whitteridge (introduced by Dr.
- W. Barber): 1. Benign Lymphogranuloma.
Dr. H. MacCormac: 2, Molluscum Sebaceum. Dr,
A. D. K. Peters: 3. Granulosis Rubra Nasi. Dr.
A. D. K. Peters and Dr. A. N. Macbeth: 4. Partial
Resolution of Leucoplakia Vulvie under (Céstrin
Therapy. Dr. F. Jacobsohn: 5. Case for Diagnosis:
? Tuberculoid Leprosy. Dr. R. T. Brain: 6. Case for
Diagnosis. Dr. R. E. A. Price and Mr. Pask (introduced
o a0 W. O’Donovan): Infantile Prurigo. (With
m.
Neurology. 8 P.M., annual general meeting. Prof. M.
Kroll (Moscow) : Remote Symptoms in Nervous
Diseases,
FRIDAY.
Radiology. 7 P.M., annual general mecting.
ROYAL SOCIETY OF TROPICAL MEDICINE AND
HYGIENE, Manson House, 26, Portland-place, W.
THURSDAY, May 20th.—8.15 P.M., Dr. Elis H. Hudson:
Bejel, the Endemic Syphilis of the Euphrates Arab.
ROYAL MEDICO-PSYCHOLOGICAL ASSOCIATION.
THURSDAY, May 20th.—2.30 P.M. (County Rooms, Hotel-
street, Leicester), Dr. Ross Ashby: The Incidence
of Mental Disorders and Allied Conditions in a large
Group of the General Population. Dr. C. J. C. Earl
and Dr. McKail: The Present Requirements for the
Diploma in Psychological Medicine. (Mental Deficiency
Committee.)
FRIDAY.—2.30 P.M. (Leicestershire and Rutland Mental
Hospital, Narborough), Dr. K. K. Drury and Mr.
C. E&E. J. Freer: Suicide of a Voluntary Patient:
an Abortive Case of Negligence. Dr. D. Prentice:
Syphilis in Mental Hospital Practice. Dr. I. J. Davies;
Schizophrenia.
SOCIETY OF MEDICAL OFFICERS OF HEALTH, 1, Thorn-
haugh-street, W.C.
FRIDAY, May 21st.—5 P.M., Dr. W.. G. Savage and Dr.
E. H. T. Nash: The Future of Obstetrical Practice.
TUBERCULOSIS ASSOCIATION. :
FRIDAY, May 21st.—5.15 P.M. (Manson House, 26, Portland-
place), Dr. A. Stanley Griffith: Bovine Tuberculosis
in Man. 8.30 P.M., Dr. James Watt and Dr. Burton
Wood : Radiological Classification of Pulmonary
Tuberculosis.
SOCIETY OF RADIOTHERAPISTS OF GREAT BRITAIN
AND IRELAND.
FRIDAY, May 21st.—5 P.M. (11, Chandos-street, W.), Mr.
G. Gordon-Taylor, Dr. J. H. D. Webster, Dr. H.
Burrows, Dr. R.T. Payne, Mr. R. F. Phillips: Malignant
Tumours of the Testis. i
MEDICAL SOCIETY OF INDIVIDUAL PSYCHOLOGY.
THURSDAY, May 20th.—8.30 P.M. (11, Chandos-street, W.),
Dr. Elsie Warren : The Psychology of Minor Ailments.
Dr. C. W. J. Brasher: The Present Position of Medical
Peychology.
NORIH ee ONDON MEDICAL AND CHIRURGICAL
THURSDAY, May 20th.—9.15 P.M. (oyal Northern Hospital,
Holloway-road, N.), Dr. er Wilson : Epilepsy
and other Fits.
SOUTH-WEST LONDON MEDICAL SOCIETY. l
WEDNESDAY, May 19th.—9 P.M. (Bolingbroke ria Op
Wandsworth-common), Dr. Wilfrid Sheldon : bdo-
minal Distension in Children.
LECTURES, ADDRESSES, DEMONSTRATIONS, &c.
UNIVERSITY OF LONDON.
TUESDAY, May 18th.—5.30 P.M. (University College, Gower-
street, W.C.), Mr. E. S. Russell, D.Sc: Ancient
Biological Conceptions.
THURSDAY and FRIDAY.—5.30 P.M., Prof. Charles Singer :
Emergence of Modern Physiological Doctrines to the
end of the Eighteenth Century, with Special Reference
to the Growth of Views on the Circulation of the
Blood.
UNIVERSITY OF BIRMINGHAM.
TUESDAY, May 18th.—4 P.M. (Medical Lecture Theatre),
Prof. Arvid Wallgren: Erythema Nodosum.
THURSDAY.—4 P.M., Prof. Wallgren: Childhood Infection
and Adult Type of Pulmonary Tuberculosis. (Ingleby
lectures. )
ST. MARY’S HOSPITAL, W.
TUESDAY, May 18th.—5 P.M. (Institute of anolo and
Research), Mr. W. R. Thompson, D.Sc., F.R.S.:
The Biological Control of Insect and Plant Pests.
BITIST POSTGRADUATE MEDICAL SCHOOL, Ducane-
road, W.
WEDNESDAY, May 19tb.—Noon, clinical and pathological
conference (medical). 2 P.M., Dr. J. Gray: Peptic
Ulcer and Gastric Carcinoma. 3 P.M., clinical and
pathological conference (surgical).
THURSDAY.—2.15 P.M., Dr. Duncan White: Radiological
Demonstration. 3.30 P.M., Mr. A. K. Henry: Demon-
strations of the Cadaver of Surgical Exposures,
FRIDAY.—2 P.M., operative obstetrics. 2.30 P.M., Mr. Russell
Howard: Diseases of the Breast. 3 P.M., clinical and
pathological conlerence (obstetrics and gynecology).
Daily, 10 A.M. to 4 P.M., medical clinics, surgical clinics and
operations, obstetrical and gynrecological clinics and
operations.
WEST LONDON HOSPITAL POST-GRADUATE COLLEGE,
Hammersmith, W.
TUESDAY, May 18th.—10 A.M., medical wards. 11 A.M.,
surgical wards. 2 P.M., operations, medical, surgical,
and throat clinics. .
WEDNESDAY.—-10 A.M., children’s ward and clinic. 11 A.M.,
medical wards. 2 P.M., gyneecological operations,
medical, surgical, and eye clinics.
THURSDAY.—10 A.M., neurological and gynrecological clinics.
Noon, fracture clinic. 2 P.M., operations, medical,
surgical, genito-urinary, and eye clinics.
Fripay.—10 A.M., medical wards, skin clinic, Noon. lecture
on treatment. 2 P.M., Operations medical, surgical,
and throat clinics.
SATURDAY.—10 A.M., children’s and surgical clinics. 11 A.M.,
medical wards.
FELLOWSHIP OF MEDICINE AND POST-GRADUATE
MEDICAL ASSOCIATION, 1, Wimpole-street, W.
MONDAY, May 17th, to SATURDAY, May 22nd.—StT. JOHN
CLINIC AND INSTITUTE OF PHYSICAL MEDIOINE,
Ranelagh-road, S.W., Sat. and Sun., course in physica]
medicine.—ST. JOHN’S HOSPITAL, 5, Lisle-street,
W.C., afternoon course in dermatology.—MAUDSLEY
HOSPITAL, Deninark-hill, S.E., afternoon course in
psychological medicine.
B FOR SICK CHILDREN, Great Ormend-street,
THURSDAY, May 20th.—2 P.M., Dr. B. E. Schlesinger:
Periodic Vomiting, Headache, Pyrexia. 3 P.M., Mr.
H. C. Apperly : The Care or the Child’s Teeth.
Out-patient clinic at 10 A.M. and ward visits at 2 P.M.
URETAN SCHOOL OF DERMATOLOGY, 5, Lisle-street,
TUESDAY, May 18th.—5 P.M., Dr. J. E. M. Wigley: Napkin
Area Eruptinns.
WEDNESDAY.—5 P.M., Dr. I. Muende: Pathological
Demonstration.
rempo P.M., Dr. W. J. O'Donovan: Tuberculosis of
Ne SKIN.
GLASGOW POST-GRADUATE MEDICAL ASSOCIATION.
WEDNESDAY, May 19th:—4.15 P.M. (Royal Infirmary),
Mr. Arthur Jacobs: Urological Cases, ` `
e
THE LANCET]
ADDRESSES AND ORIGINAL ARTICLES
[may 22, 1937
—
THE B.I.P.P. METHOD OF TREATMENT
OF ACUTE OSTEITIS*
By James H. Saint, M.D. Durh., F.R.C.S. Eng.,
F.A.C.S.
CONSULTING SURGEON TO THE THOMAS KNIGHT MEMORIAL
HOSPITAL, BLYTH, AND SENIOR SURGICAL REGISTRAR AT THE
ROYAL VICTORIA INFIRMARY, NEWOASTLE-ON-TYNE
ALTHOUGH acute osteitis may be said to be relatively
infrequent in comparison with the more common
acute surgical conditions, its seriousness must neces-
sarily render this disease one of great importance.
Wakeley (1932) quoted figures from hospitals in the
British Isles to show that there was a gradual lowering
of its incidence in the last decade as compared with
that of the first decade of the century. However,
the latest figures from the Registrar-General’s office
show that whereas in 1931 there were 403 deaths
from this disease,t in 1935 the number was 447.
Other figures from the same source indicate that the
death-rate was a little higher in 1926-30 than it was
during 1921-25, but that since 1930 there has been
no significant change. Thus it seems that the last
15 years have not brought forth evidence to support
the comforting belief in a continued, though gradual,
disappearance of this disease.
Some idea of how serious acute osteitis is may be
had from Table I, which shows the fatality-rates in
recently published series of cases.
TABLE I
Fatality-rates in Acute Osteitis
Percentage
Author. of deaths.
Eric Lloyd Ceo b 32°5
Pyrah and Pain (1932) 27°1
John Fraser (1934) .. 23°2
Ogilvie (1928 Sue 21°0
Gwynne Williams (1932) 19°9
Alex. Mitchell (1928) 14°3
Holman (1934) we 9°7
It is seen that in some instances one patient out of
every three or four died, a fact which cannot be
regarded with complacency. Mortality alone, how-
ever, is not the only feature of acute osteitis that
makes it a disease of serious import, for amongst
those who recover may be seen deformity and inter-
ference with function of greater or less degree, and
these patients often suffer from recurrent attacks,
either in the bone first affected or in others, at
intervals during a long life. Thus acute osteitis
often leaves in its wake sequelæ that may cause, if
not actual chronic invalidism, at least impairment of
capacity for work and of enjoyment of life. Any
method of treatment, therefore, that holds out hope
of reducing its mortality and decreasing its morbidity
deserves consideration, and it is the belief that the
B.I.P.P. (bismuth-iodoform-paraffin paste) method of
treatment may accomplish these objects that is largely
responsible for this contribution.
The term “ osteitis ”?” is used throughout as meaning
the inflammation of any or all of the constituent
parts of bone which are so intimately connected with
* Based on a Hunterian lecture delivered at the Royal College
of Surgeons of England on Feb. 5th.
t The varieties of disease or description of disease included in
this group by the Registrar-General are as follows: acute
osteomyelitis, epiphysitis, osteoperiostitis or necrosis of bone ;
infective osteomyelitis, periostitis or necrosis of bone; septic
or suppurative osteitis or osteomyelitis or epiphysitis and
Brodie’s abscess if found after inquiry to be a description of
ee of he foregoing diseases.
9
one another—namely, the periosteum, osteum, and
medulla, In view of this nomenclature such terms as
periostitis, indicating inflammation of the periosteum,
and osteomyelitis (or myelitis), intended usually to
infer inflammation of the marrow-containing medullary
cavity, become superfluous apart from possessing the
disadvantage of tending to denote that they represent
separate diseases.
The present article will consider only the typical
form of acute osteitis found in young people where
the blood stream is the channel of infection. No
reference will be made to the more uncommon type
due to the direct introduction of organisms into the
bone as, for example, in a compound fracture.
Pathological and Clinical Aspects
Success in combating any acute infective disease
depends upon two factors: first, correct diagnosis of
the condition in its earliest stages—i.e., before com-
plications, due to spread of the infection, have
developed ; and secondly, the institution of a rational
form of treatment based upon a proper conception of -
the pathology present. Acute osteitis is no exception
to these general rules, and attention is drawn to certain
of its pathological and clinical features which have
an important bearing on these points.
PATHOGENESIS
Acute osteitis begins as a small, delimited focus of
infection in the cancellous tissue of the metaphysis of
‘one of the long bones, usually at the more actively
growing end. The importance of realising this fact
cannot be over-emphasised, for at this stage the focus
can be completely removed, this procedure constituting
the rational treatment. From this focus, the infection.
if not checked will spread to involve the periosteum,
the surrounding soft tissues (giving rise to an acute
cellulitis), and the medullary cavity. Thus it is seen
that “acute periostitis’’ and “ acute osteomyelitis ”
are not separate diseases but are only complications
due to the spread of infection from the initial bony
focus, the infection still being confined to the bone
itself. Starrs hypothesis (1922) that the spread
of infection commonly takes place towards the
periphery, resulting in early involvement of the
periosteum, and that infection of the medullary
cavity occurs relatively late by way of the Haversian
canals secondarily to involvement of the periosteum,
receives support in. my own clinical experience, for
in my series of cases a subperiosteal abscess was often
present while the medullary cavity was not yet
involved. :
A further feature of the pathology of acute osteitis
is the relationship between the general and local
infections. It is often stated that acute osteitis is
“a local manifestation of a systemic disease,” but
this appears to be an incomplete representation of
the true facts. It is accepted that the organisms
reach the bone by way of the blood stream, this path
of infection presupposing a septicemia to be present
before the bone becomes affected. Since this is so,
it must be admitted that this septicemia must be a
mild type since it gives rise to no symptoms, the
general symptoms which point to an infection of
the blood stream only obtruding themselves upon the
clinical picture after the development of the bony
focus. Thus it seems reasonable to assume that these
symptoms are caused by a reinfection of the blood
stream from this focus. It is suggested, therefore,
that the sequence of events is as follows: (1) a mild
x
1212 THE LANCET ]
form of septicemia with slight or no symptoms
(consequent upon some septic focus in the skin or
mucous membrane) ; (2) a focus of infection develop-
ing in the metaphysis of one of the long bones (the
condition then becoming one of acute osteitis) ;
(3) severe blood-stream infection (toxemia or septi-
cemia in the early stages or pyæmia later) due to
absorption of toxins or organisms from the bony
focus. Hence to regard acute osteitis as “a local
manifestation of a systemic disease” is to consider
only the relationship between the bony focus of
infection and the primary mild septicemia and to
omit to take into account the all-important fact that
the serious systemic infection seen in acute osteitis
occurs after the development of the bony focus and
is consequent upon it. This view of the pathological
sequence of events is one that calls for removal of
the bony focus at the earliest possible moment.
SYMPTOMS AND SIGNS
From what was said about success in combating
an acute infective disease, it follows that the important
clinical features to know about acute osteitis are
those that will help to establish the diagnosis of this
` condition in its earliest stage. The clinical picture,
only too easily diagnosed, of high temperature,
delirium, and a red, hot, swollen limb, almost literally
a bag of pus, indicative of the spread of infection to
such an extent as to make it almost impossible
to save life, should be regarded as a relic of the past
when the early symptomatology and pathology were
but little understood. It is true that the disease
occurs in young subjects before the epiphyses have
united, that the patient is usually of the hospital
class, often undernourished, with evidence of some
recent infection of skin or mucous membrane and
with a history of a blow or fall, but with the exception
of the first-mentioned all these features may be absent
in a given case. It is therefore important to bear in
mind that, as in other acute surgical conditions, the
history may not be typical and that an, atypical one
must not be allowed to cast doubts upon the diagnosis.
What, then, are the special features in the
symptomatology which can be said to point unequi-
vocally to the diagnosis of acute osteitis in its earliest
stage ? They may be considered under general and
local and are as follows :—
GENERAL
Inflammatory fever.—Often starts with a rigor, especially
_in severe cases, with a temperature of 100°-105° F. and of
a continuous type.
Polymorphonuclear leucocytosis.—This is always present
except in cases where the virulence of the infection is so
great as to overwhelm the resistance of the patient; it
is important because it indicates the presence of a pyogenic
infection.
LOCAL
Pain of sudden onset and intense, over the end of a
long bone; it is worse at night and usually prevents the
patient from sleeping for more than minutes at a time.
Tenderness.—Where the pain is complained of, palpation
will reveal a spot of exquisite tenderness.
This triad of elevated temperature with pain and
tenderness over the end of a long bone found on
clinical examination, associated with a leucocytosts,
definitely establishes the diagnosis and should be
impressed upon the minds of medical students and
practitioners, so that no doubt will remain about the
significance of these findings and so that any patient
found suffering from them will be regarded as a
surgical emergency.
Since the diagnosis appears simple, why is it that
so many cases of acute osteitis are not seen by a
MR. J. H. SAINT: B.I.P.P. IN ACUTE OSTHITIS
[may 22, 1937
surgeon for several days after the onset of their
illness ? There is no doubt that the most prevalent
cause of delay is the provisional diagnosis of acute
rheumatic arthritis accompanied by the decision to
await the result of giving salicylates. What are the
reasons. for this frequent error of diagnosis? They
are to be found in the swelling (the so-called “ sympa-
thetic effusion’) and apparently painful movements
of the adjacent joint, leading to inadequate examina-
tion. Insufficient attention is paid to other symptoms
and signs which are present—namely, that the pain
is not in the joint but only near it, that careful
palpation will reveal an adjacent metaphysis to be
exquisitely tender, and that a definite degree of
passive movement of the joint is obtainable without
pain such as would never be the case were the joint
the seat of an acute rheumatic arthritis. Absent
also will be the involvement of other joints and the
peculiar sweating of the rheumatic patient. Two
other conditions which may be mistaken for acute
osteitis are acute infective arthritis and acute cellu-
litis, but these have the advantage of being such
that a surgical opinion will be sought at once, so that
no time will be lost. In the former, any attempt
to obtain passive movement causes excruciating
pain and such pain may be caused even by an atten-
dant walking across the floor or by touching the
bed, much less the affected extremity. Acute cellu-
litis near the ends of the long bones is so uncommon
in the absence of underlying bone infection that it
was made the subject of one of Rutherford Morison’s
many pertinent aphorisms, ‘“ Cellulitis in a young limb
means osteitis.” However, it should be remembered
that cellulitis is a complication of osteitis and indicates
that the infection has already spread through the
periosteum into the surrounding soft tissues. There
is one further observation that is of great use in the
diagnosis of acute osteitis, and that is the absence
of involvement of the lymph glands draining the
area superficial to that where pain and tenderness
are present; these are always the seat of a lymph-
adenitis in cases where the infection has begun in the
soft tissues.
Actions of B.I.P.P.
Bismuth-iodoform-parafin paste (Bipp) consists
of bismuth subnitrate 1 part, and iodoform 2 parts,
mixed with liquid paraffin in sufficient quantity to
form a paste. The presence of the bismuth salt
recalls the paste used by Emil Beck, but the addition
of the iodoform results in a chemical action which
gives Bipp its valuable properties. In the Pharma-
ceutical Codex the formula of Bipp is given as bismuth
subnitrate 25 per cent., iodoform 50 per cent.,
and liquid paraffin 25 per cent. One interesting
feature of this formula lies in the fact that whereas
iodoform is used ordinarily in strengths of 5-10
per cent., its incorporation into Bipp enables it to
be used in a strength of no less than 50 per cent.
The origin of Bipp dates back to the late war when,
at the Northumberland War Hospital, Prof. Ruther-
ford Morison (1918) was experimenting, with the
help of Mr. W. W. Hunter, to find an ideal antiseptic
—that is, one of such a strength as to inhibit the
growth of organisms without doing tissue cell damage.
At this time many of the men sent to this hospital
had foul, discharging wounds necessitating frequent
dressings, to the exhaustion of the nursing staff and
to the agony of the patients themselves. After
the institution of the Bipp method of treatment
the scene changed dramatically, for these wounds
ceased to be painful, dressings were only necessary at
weekly or less frequent intervals, and the wards ‘‘ were
THE LANCET]
full of cheerful men, whose chief anxiety seemed to
be to know when they could get up” (Morison 1922).
This method of treatment was adopted widely for
wounds and compound ‘fractures, both clean and
infected, by the British Army authorities at home `
and abroad and was the means whereby thousands
of limbs and lives were saved, to say nothing of the
relief from suffering which was achieved.
The chemical and bacteriological actions of Bipp
were demonstrated by the work of Anderson, Chambers,
and Goldsmith (1917) as a result of extensive experi-
ments. They consider that the chief chemical reaction
that takes place consists in the oxidation of the
iodoform by oxygen derived from the air or from
arterial blood and by the nitric acid formed by the
hydrolysis of the bismuth salt. The result of this
reaction is the continued liberation of small quantities
of free iodine. They found that although organisms
were still present in wounds treated by Bipp yet
they were unable to proliferate freely and that
the wounds healed as though they were surgically
clean. It seems that the introduction of Bipp into
a wound results in the liberation of nascent iodine,
this forming a mild, continuously acting antiseptic
‘which acts as a deterrent to the growth of organisms
but does no harm to the tissues. As illustrating
this continuous chemical action of Bipp, it is of
interest that after the application of the paste to
a wound, iodine has been recovered daily in the
urine for as long as three weeks.
At this juncture it might be well to draw attention
to the fact that Bipp can act as a poison, a dis-
advantage from which it was found to suffer in the
early days of its use,if large quantities were left
in wounds. It is also dangerous to use it in the
serous cavities on account of possible absorption of
the iodoform. Except for occasional idiosyncrasy,
examples of which must be very rare and have never
occurred in my extensive experience of Bipp, there
need be no fear of poisoning provided that the paste
is used sparingly in the manner to be detailed later.
Should poisoning occur, it may be due to either the
iodoform or the bismuth salt. JIodoform poisoning
is usually’ seen within 24 hours of operation, the
symptoms being a high temperature—often 103°
to 105° F.—a rapid pulse, dilatation of the pupils,
a red tongue, and sometimes the appearance of a bright
scarlet rash. There may be no complaint from the
patient.
and the patient may die delirious and of heart failure,
Bismuth poisoning is a later manifestation, the
symptoms usually not appearing until four or five
days after operation. The patient complains first
of a sore mouth and on examination the breath is
foul, the gums are spongy and show a black line
round the teeth due to the deposition of bismuth
sulphide. In severe cases much salivation is present,
the black deposit may be seen on the tongue and
cheeks as well as on the gums, and ulceration is
likely to occur, the breath meanwhile becoming
more and more foul; diarrhoea may ensue, the
temperature becomes raised, a secondary anæmia
develops, and the patient’s condition rapidly deterio-
rates. In either case the only hope lies in the immediate
evacuation of the Bipp and while this may lead to
relief in a case of bismuth poisoning, patients with
serious symptoms of iodoform poisoning often die
in spite of this measure and any others that may be
taken,
Method of Treatment
The principles which govern this method of treat-
ment of acute osteitis may be outlined briefly as
MR. J. H. SAINT: B.I.P.P. IN ACUTE OSTEITIS
The pulse becomes more feeble and rapid .
(may 22, 1937 1213
consisting of (1) the complete removal of the infected
bony focus, (2) the disinfection of the resulting wound
by Bipp in the manner to be described, and (3) immo-
bilisation of the affected part. It is considered that
these measures will arrest the spread of infection
if they have been carried out efficiently. With
this object in view, it is clearly important to realise
that the disease begins as a small bony focus, for this
can be completely removed, and that delay in diag-
nosis, through leading to spread of the infection,
will render the operative treatment more prolonged
and more extensive and may decrease materially
the likelihood of complete removal of the infected
tissue, thereby leading to further complications
perhaps with a fatal issue.
THE OPERATION
Rather than describe the technique of this method
of treatment in general terms, it may be better
understood by describing it in a typical case as,
for example, one in which the upper end of the tibia
is the seat of acute osteitis, when the operation would
be conducted as follows :—
General anesthesia.—Provided that this is well admini-
stered, there need be no special preference given to one
type over another.
Preparation.—A tourniquet applied to the thigh should
be considered essential for without it the patient may
lose a considerable amount of blood, and children, who
form the majority, do not withstand hemorrhage well.
The skin of the whole leg distal to the tourniquet should
be cleansed with 1 in 20 carbolic or other antiseptic.
A sandbag is placed so that the leg will rest upon it and the
sterile towels arranged in position,
Incision.—A free vertical incision is made down to the
bone with its centre over the focus, indicated previously
by the most tender spot that is found over the antero-
internal surface of the tibia. The periosteum will usually be
seen to be cedematous, indicating underlying mischief,
while in some cases an actual subperiosteal abscess will be
encountered when the pus is evacuated and the abscess
wall cleaned gently by mopping it. The incision in the
periosteum should be long enough to give a satisfactory
exposure of the underlying bony surface.
Removal of the bony focus.—The focus is sought for in
the suspected area by drilling, which is stopped as soon
as pus is seen to emerge from a drill-hole. The bone is now
opened up with a gouge and every visible trace of inflamed
cancellous tissue removed, the opening being enlarged
only as far, but no further, than is necessary for this
purpose. The medullary cavity must not be opened
unless the infection has spread into it, and such an opening
is regarded as necessary for the efficient removal of
purulent contents. It may be difficult to know when
one has come to the margin of the diseased area but
ordinarily this is not so, for the yellowish-white purulent
focus contrasts greatly with the normal reddish cancellous
- tissue. The absence of pus on drilling—a rare occurrence
—should not affect the decision to open up the bone, for
a purulent focus may be discovered only when this is
done. In early cases no pus may be found at all, but there
will be a focus consisting of tissue that is softer in con-
sistence and more hyperemic than normal cancellous
tissue. Occasionally pus may exude from a drill-hole and
yet on opening up the bone no more may be found, what
little there was having escaped through the hole; in such
a case, however, a definite focus of soft and hyperemic
tissue will be found. From the foregoing description
it will be seen that a “gutter ’’ operation has been per-
formed with the specific purpose of removing the focus of
infection in the bone, but it is emphasised that the amount
of guttering done must only be commensurate with
_ efficient removal of the infected tissue and that unneces-
sary opening up of healthy tissue is to be strongly depre-
cated. This type of operation has the added advantage
that, in the event of some of the infected tissue being
left behind, the opening in the bone is large enough to
provide adequate drainage.
1214 THE LANCET]
“MR. J. H, SAINT: B.I.P.P. IN ACUTE OSTEITIS
[may 22, 1937
Disinfection of the wound.—The whole of the wound
cavity is thoroughly mopped out with methylated spirit
and then dried. The spirit is not only an efficient cleansing
agent but, by its dehydrating action, leaves behind a dry
surface to which the Bipp can adhere.
put on a dry gauze and rubbed into every part of the bone
cavity and wound surface and all excess is removed, there
being left_behind only a thin covering of the paste over
the exposed tissues.
Closure of the wound.—The bone cavity is now packed
with a Bipped gauze and the wound closed with inter-
rupted sutures of thick Bipped silk except for the gauze
exit, which leaves a passage for discharge. The packing
of the cavity is advantageous since the gauze acts as a
preventive against the hæmorrhage which would otherwise
take place on removal of the tourniquet, and if some-
infected tissue has been left behind the organisms would
find an ideal pabulum in the blood which would fill the
cavity in the absence of the gauze. It is found that sutures
of thick silk tend to cut through the skin much less than
those of silkworm.
Dressing.—Sterile boric powder is sprinkled liberally
over and around the wound and a dressing put on con-
sisting of dry gauze and abundant wool. The limb is
then immobilised by fixing it on a back splint with Gooch
side splints or plaster-of-Paris may be used for this purpose
if preferred. The tourniquet is removed and the limb
elevated.
AFTER-TREATMENT:
Should hemorrhage appear on the bandage—a
rare occurrence—methylated spirit is poured over the
stains and after this has been done the hæmorrhage
will usually cease. Unless the patient should feel
that the dressing is uncomfortable or there is much
discharge—also rare—it is not touched for 10-14
days, when a general anesthetic is given, the dressings
and the sutures removed, the wound opened, and
the gauze taken out. It will be seen that all the wound
cavity is clean and lined by healthy granulation
tissue.
The treatment of the cavity now comes under
consideration. Should it be small no further treat-
ment is necessary, and the wound, after being cleaned
afresh with methylated spirit and a thin layer of
Bipp applied ‘to its surface, is closed again with
interrupted sutures of thick Bipped silk. Following
this there is usually little or no discharge and at the
end of another 10—14 days the wound may be found
to have healed entirely. Should there be any dis-
charging area at this time, two or three weeks will
usually suffice for its cessation.
When dealing with larger cavities it is advisable
to resort to some means of attempting obliteration
and the best method of doing this lies undoubtedly
in the use of the pedicled muscle graft. In the
situation under review—namely, the upper end
of the tibia—such a graft is easily obtainable, it
being possible to use either the tibialis anticus or the
soleus, although the former is preferable as the
operation is likely to be more easily accomplished.
The cavity will have to be enlarged by removing
the adjacent part of the crest of the tibia as the base
of the graft must not lie over a ridge of bone, since
the blood-supply to the distal portion of the graft
would probably be seriously jeopardised. The graft
is cut with its base proximal to ensure the blood-
supply necessary for its survival, Bipped and laid
in the cavity. The wound is then closed, as before,
without drainage. While such a wound may heal
by first intention, there may be a small amount of
discharge which only calls for infrequent dressing and `
will probably cease in a week or two. The result of
this method of dealing with the cavity is that a
scar is formed consisting o: the full thickness of the
skin.
Some Bipp is .
Mention of the use of free fat grafts should not
be omitted when considering the obliteration of a
bone cavity, for it is often successful. The grafts
are usually easily obtainable from the thigh, gluteal
region, or the abdominal wall, and this method
is particularly valuable in situations where it is
impossible to obtain a pedicled muscle graft such
as the lower end of the tibia. On the whole, however,
the muscle graft is to be preferred.
=
Ñ
Š
N
Q
l2 i4 16 (8 20 22 24 26 28 30
AUG.
FIGS. 1 and 2.—Temperature charts in two fatal cases.
Unless the gutter made in one of the long bones
of the inferior extremity is exceptionally large, it is
safe to allow weight-bearing some two Montas after
the institution of treatment.
COMMENTS
There are several observations on this method
of treatment which might well be made here. On
the day following operation the temperature usually
begins to descend and in some cases drops to normal
in a dramatic manner, to remain afebrile. The
absence of post-operative pain is remarkable and
gratifying, for the intense pain experienced before
operation will be found to have disappeared when
the effects of the anzsthetic have worn off. In
my earlier cases even large cavities were packed
and allowed to heal by granulation, but this method
of procedure has the disadvantage of taking three
or four months before healing is complete, and it
results, when a subcutaneous bone such as the tibia
is involved, in a thin scar adherent to bone, although
it is only fair to state that it is by no means necessary
to wait until such a cavity has healed completely
before getting the patient up and allowing him to
walk or attend school, for a weekly dressing is all
the care that is required. However, it is obvious
that this is a poor method of dealing with a bone
cavity when compared with the quick and efficient
closure of such a cavity as described above.
It will have been noticed that, in the description
of the Bipp method of treatment, no mention was
made of the formation of sequestra, the apparently
common result and bugbear of other forms of treat-
ment of acute osteitis. The truth is that apart from
the flaky variety that are discharged naturally
without any trouble to the patient, sequestra do not
form and that secondary operations for their removal
are therefore not necessary. It is interesting to
consider the reasons for this remarkable absence
of sequestrum formation. At operation it is usually
impossible to tell what amount, if any, of the dense
bone is either already dead or likely to die, but there
seems no doubt that by the guttering over the focus
of infection much of the dense bone which has
necrosed, and which would later separate as a
sequestrum, is removed, Also, the provision of such
adequate drainage combats the risk of further
necrosis due to tension which might occur as a result
of the inability of the products of inflammation
to escape sufficiently quickly if, by any chance, they
were not completely removed at operation. Further-
more, from what has been said about the bacterio-
logical action of Bipp, the absorption of the iodine
seems to control the infection even when it has
spread into the tissues around the excised area,
this control leading to diminution of inflammation
and therefore of tension, and so helping to avoid
the formation of sequestra. These reasons appear
to explain satisfactorily the absence of sequestration
following the treatment of acute osteitis by the
Bipp method.
Lastly, it will have been realised that the technique
of this method is relatively simple, this in itself
being a commendation for its employment.
TABLE II
Bones Affected in 21 Cases of Acute Osteitis
Femur (lower end) ar << 7
Tibia (upper end) ae š 3 | 11
,, (lower end) 1
Humerus (upper end) 3
Fibula (ower end te ri 2
Radius (lower end) 10
Clavicle (inner end)
Os pubis l leach .. 5
Os calcis
Fifth metatarsal us
Total zi Sa ès 21
Résumé of Personal Cases
The series reported here numbered 21 patients,
all of whom were operated upon during the past
six years at the Royal Victoria Infirmary, Newcastle-
on-Tyne, and the Thomas Knight Memorial Hos-
pital, Blyth. This number, though not large in itself,
has provided sufficient personal experience to sub-
stantiate
certain
claims that
=
N will be
S made for
x this method
of treat-
ment.
In 15 cases
there was a
definite
history of
injury, and
27 29 31 2 4 a Dn
MAY JUNE waicnh a
bacterio-
FIG. 3.—Temperature chart of a typical case lo ical
of acute osteitis treated with Bipp, indicating 8 g
length of stay in hospital. examina-
tion of
infected tissue was made, a growth of Staphylococcus
‘aureus was obtained in 18, no organism being grown
from the remaining one. The ages varied between
3 and 17, 11 of the patients being under 12 and
the remaining 10 over that age. As regards sex
and the bones affected, this series agrees very much
with others which have been reported. There were
14 males and 7 females, a proportion of two to one
in favour of the former. Table II shows the bones
affected. From this table it will be seen that the
femur was the bone accounting for a third of the
cases and that the femur and tibia combined comprise
just over a half of the total number. It is also of
interest to recall that the lower ends of the femur,
MR. J. H. SAINT: B.I.P.P. IN ACUTE OSTEITIS
1215
fibula, and radius and the upper ends of the tibia and
humerus are the more actively growing ends of these
bones.
In general terms, the aims of treatment of acute
osteitis may be said to be first, the preservation of
life, and second, the preservation of growth and
function, and the results given below indicate the
degree to :
which
they have
been
achieved
by the
Bip p
method of
treatment
in the pre-
sent series
of cases.
[May 22, 1937
IMME-
DIATE
RESULTS
These are
considered =e 48
under the i HAES IA I A
following = D SSA
headings :
(1) fatal-
ity, with
discussion
of fatal cases; (2) complications which arose before
discharge from hospital; (3) length of stay in
hospital.
Fatality, with discussion of fatal cases.—There
were 2 deaths in this series, a fatality-rate of 9-5 per
cent., a rate much lower than most of those shown in
Table I. While it is realised that it is manifestly
unfair to judge any method of treatment on fatality
alone because of those patients who are so ill when
first seen by the surgeon that their fate is not decided
by operative treatment, yet human nature is such that
a method which has been shown to be associated with
a low mortality will always be regarded with more
enthusiasm than one that has resulted in a larger
percentage of deaths.
The first fatal case was that of a boy, aged 16, who
was admitted to hospital with great pain in the much
swollen region of the left shoulder. The patient had
been delirious while at home and on admission he was
obviously very ill, having a temperature of over 104°F.,
a rapid and weak pulse, sordes on the lips, and sunken
eyes. At operation a large subperiosteal abscess was
found and nearly all the cancellous tissue of the upper end '
of the humerus was purulent, but the infection had not
involved the medullary cavity of the bone. Between
the time of his operation and his death four days after-
wards, he developed a left-sided parotitis and an effusion
into the left knee-joint. His temperature, shown in Fig. 1,
came down to normal on the day following his operation
but then rose again to over 104°F. just before he died.
A post-mortem examination was not obtained.
FIG. 4.—Late result in a case of acute osteitis of
the right femur treated with Bipp. There was
no deformity or shortening. Knee-joint shown
in full flexion.
Most surgeons with experience of acute osteitis
have met cases which, when first seen by them, were .
obviously suffering from an overwhelming blood-
stream infection of the nature of a septicemia or
septico-pyemia. About such cases there appears
to be general agreement that the condition is due
to the virulence of the organism, to the lack of
resistance of the patient, or to a combination of them,
and that no treatment, either conservative or radical,
is likely to be of any avail, the patient’s doom being
already sealed. I believe this to have been such
1216 THE LANCET]
MR. J. H. SAINT: B.I.P.P. IN ACUTE OSTEITIS
[may 22, 1937
a case, It is reasonable to assume, however, that
some of these cases, if not a fair proportion of them,
have passed through a stage of the disease when
surgical treatment would have saved their lives. The
boy mentioned above had been ill at home for almost
two weeks before admission to hospital, and it is
probable that recovery would have followed more
timely surgery. At the pre-
sent time, when apparently
it is not unusual for one of
every four or five patients
to die, it would seem that
the necessity for early diag-
nosis is one upon which
sufficient emphasis has not
been laid. Just as we
stress the importance of
the removal of an acutely
inflamed appendix before
the onset of complications
resulting from the spread
of infection, in like manner
should we emphasise the
importance of removing
the acute - inflammatory
: focus in a bone at the
Toir Aa earliest possible moment.
FIG. 5.—Late result in a This M a only be
case of acute osteitis of achieved by early diagnosis
upper end of left tibia i
a e Don Ab: and this cannot be expected
sence of deformity or unless more attention is
Bhorcvening ; extension 1 initi `
S OTening s ZuM ote tha given to the initial signs and
symptoms of the disease.
It should therefore be in-
sisted that in childhood or
adolescence, any individual
who complains of intense
pain of sudden onset in the region of the end of one
of the long bones, who has a point of exquisite tender-
ness in the same region, and who has an elevated
temperature must be regarded as a potential case
a oe osteitis and surgical opinion sought without
elay.
The second case was that of a girl, aged 3, with acute
osteitis of the lower end of the fibula. At operation only
a small purulent focus was found and removed. After
operation she appeared to be well for five days when
her temperature rose to over 102° F. (Fig. 2) and signs of
a broncho-pneumonia developed, but with no pain sugges-
tive of pyæmic infarction of the lung. Her temperature
fell again but then remained elevated for several days before
she died nearly three weeks after operation. During this
time the wound itself appeared to progress favourably,
there being no clinical evidence suggestive of local spread
of infection.
It certainly could not be said that this patient came
under the category of having an overwhelming
infection at the time of her admission to hospital,
for there was then no apparent reason why recovery
should not take place and consequently the final
outcome was an unexpected disappointment. Unfor-
tunately an autopsy was not allowed.
broad adherent scar, the
result of healing of the
- bone cavity by granula-
tion, and compare with
Fig. 10.
Complications occurred in 6 of the 19 surviving
cases but in 4 of these they were of little consequence,
consisting as they did of superficial pyemic abscesses
that healed in less than two weeks after being opened
and drained. In 3 of the 4 cases only one abscess
formed while in the remaining 1 there were two.
Of the 2 cases in which more severe complications
occurred, the first was one of acute osteitis of the
lower end of the femur. At operation there was found
a large subperiosteal abscess and involvement of the
bone to such an extent that a gutter about 6 in.
long was required to reach the upper limit of the
purulent focus. Unfortunately an accidental fracture
occurred. Turbid fluid aspirated from the adjacent
swollen knee-joint at the time of operation yielded,
like the pus from the bone, a growth of S. aureus.
Since the patient complained of no further pain after
operation and the swelling of the knee-joint gradually
subsided, no further treatment of this mild septic
arthritis appeared to be indicated and none was
undertaken. Further reference to this case will be
made when considering restoration of function and
sequestrum formation.
In the second case the tibia was the bone involved,
there being a large subperiosteal abscess and spread
of the infection into the med cavity. The
operative treatment proved a failure as both the knee-
and ankle-joint became involved and eventually the
leg was amputated through the thigh as a life-saving
measure, After this the patient quickly recovered.
There seems no doubt that the failure of the treat-
ment was due to the leaving behind of infected tissue
at the first operation.
Each of these patients had been ill for nearly
two weeks before coming to operation and illustrate
well how delay in diagnosis may militate against
success of treatment by permitting of the spread of
infection, this not only undermining the general condi-
tion of the patient but also increasing the risk of
operative accidents or errors in technique which
ordinarily are readily avoided.
Length of stay in hospital.—Very little is mentioned
in the literature of the length of time patients suffering
from acute osteitis are kept in hospital. Ogilvie
(1928), reporting a series of 51 cases from Guy’s:
Hospital, found that the average length of stay im
hospital was 2 months 12 days—i.e., approximately
72 days—omitting fatal cases and two others who-
were in for a longer period. These figures indicate
how the disease may be of such a protracted nature
as to impose severely upon the bed accommodation
of any hospital, and sight should not be lost of the
important fact that the longer the duration of the
illness the worse is the functional result likely to be.
It is therefore of interest to contrast these figures
of Ogilvie’s with those in the present series. Of the
19 surviving cases, 14 were in hospital under 28 days
and 2 others under 35 days. The remaining 3 were
in hospital for longer periods, 2 of them being the
complicated cases mentioned above and the third
one of acute osteitis of the lower end of the femur
where the wound was packed and allowed to heal by
granulation, the home conditions of this patient
being such that it was considered advisable to keep
him in hospital until the wound had healed completely.
The length of stay in hospital of these cases was
59, 95, and 75 days respectively. Fig. 3 is a tempera-
ture chart of a typical case of acute osteitis
treated by the Bipp method and indicates the short
duration of their stay in hospital.
LATE RESULTS
These may be considered conveniently under the.
following three sections: (l) growth and function ;
(2) sequestrum formation ; (3) recurrence of infection.
Growth and funcitton.—There is an unfortunate
lack of information on the late results of acute.
osteitis concerning growth and function in spite of
the fact that, in endeavouring to assess the value
of any particular method of treatment, this aspect
of the disease must always form an important.
consideration. Most articles on the subject, while-
giving prominence to the method of treatment.
THE LANCET]
employed by the author and the mortality associated
with it, often omit altogether to mention the effects
of the disease on those who were fortunate enough
to recover. In no case of this series has the growth
of the involved bone been other than normal, there
being neither shortening, such as might be caused
by extensive damage to the epiphyseal cartilage,
nor any irregularity of growth with resulting deformity,
such as might occur with its partial destruction.
The function of the adjacent joint has only suffered
in one case, where an acute osteitis of the lower
end of the femur was complicated by a septic arthritis
of the adjacent knee-joint, there being now only
about 10° of movement present.
Figs. 4 and 5 are photographs of two typical
cases taken to show the absence of shortening or
deformity and the preservation of function of the
adjacent joint.
Sequestrum formation.—In published reports the
formation of sequestra following acute osteitis appears
to be the rule rather than the exception, although
here again the information given is often vague. `
In the present series the remarkable absence of this
feature, which is the chief cause of persistent dis-
charge and which often renders further operation
necessary, is therefore noteworthy. In 3 cases tiny,
flaky sequestra formed and were discharged naturally
without any trouble to the patients. In only one
case did a sequestrum form which was large enough
to need a second operation for its removal ; the femur
was accidentally fractured and this was apparently
responsible for interference with the blood-supply
to a portion of the bone and for the consequent
necrosis. In view of the absence of sequestration
in other cases in this series where large gutters were
made, there is reason to believe that, had the fracture
not occurred, in this case also there would have been
no sequestrum formation. Mention has already been
made of the suggested reasons for this absence of
sequestrum formation after using Bipp.
Recurrence of infectton.—From some months to
six year$ have passed since the cases in this series
were operated upon and while this short post-
operative history is long enough to provide accurate
information about the effects of the disease on growth,
function, and sequestrum formation, it is not long
enough to establish with anything like the same
certainty the degree of liability to recurring infec-
tion, which is one of the well-recognised characteristics
of acute osteitis. It may be either in the same or
another bone, though usually in a less acute form,
it being not uncommon for this to take place as long
as 30 years or more after the initial attack. Con-
sequently, the absence of recurrence in this series of
cases except in one instance is recorded to complete
the investigation of the late results and not as an
attempted proof that recurrence is less likely to take
place following the Bipp method of treatment than
after any other, for many years must still elapse
before accurate information can be obtamed on this
point.
The case in which recurrence took place was one where
the bone originally involved was the left tibia. Three
years later the boy was brought complaining of a gradually
increasing swelling above the right knee, with a dull,
boring pain in the same region. The pain and swelling
had been noticed first about three months before the boy
was brought for examination, the condition thus being
very chronic in contrast to his former acute illness. During
this three months the boy had remained in good general
health. At operation a purulent focus about 1 cm. in
diameter was found in the lower end of the femur, requiring
a limited operative procedure for its removal. The Bipp
DR. D. LEYS: DIAGNOSIS OF GASTRIC AND DUODENAL ULCER [May 22, 1937 1217
method of treatment was again carried out and the patient
had an uninterrupted convalescence. Bacteriological
examination showed the presence in the focus of the
S. aureus, the same organism as that found on the first
occasion.
(To be concluded)
- DIAGNOSIS AND TREATMENT OF
GASTRIC AND DUODENAL ULCER
By Duncan Leys, D.M. Oxon., M.R.C.P. Lond.
PHYSICIAN TO THE SELLY OAK HOSPITAL, BIRMINGHAM
RADIOLOGY has revolutionised diagnosis, prognosis,
treatment, even the classification of disease processes
in many parts of the body, and it is no longer per-
missible to leave any patient in whom symptoms of
indigestion have persisted or recurred for some weeks
or months without X ray examination. None of
the older methods available for the diagnosis of
ulcers, whether benign or malignant, are entirely
reliable. A few will certainly escape X ray diagnosis
also ; but if a chronic ulcer is present skilful radiology
will disclose it on the first or second examination.
An ulcer may give rise to no pain, vomiting, or
alteration of appetite; no tenderness may be found
when the patient receives the ordinary clinical
examination. - The test-meal may show a normal
or low percentage of acid, or free acid may be entirely
absent. The benzidine test may show no trace of
blood in either test-meal or stool.
The apparent incidence of ulcer amongst a group of
patients with persistent or intermittent dyspepsia
may increase by 100 per cent. or more when the X ray
diagnosis is made by an experienced, interested, and
careful radiologist, until it becomes a matter for
surprise when clinical expectations are denied by the
Röntgen rays. The degree of discomfort to the patient
and his readiness to submit to repeated investigation
bear also a simple relation to the skill of the
radiologist.
. The fluoroscopic examination is obviously of the
first importance, but it is a preliminary to the per-
manent record of the site of the ulcer, and it is unneces-
sary for physicians who have neither time nor training
enough to make their own X ray diagnosis to be
content with merely a verbal report. I made a clinical
diagnosis of ulcer in 58 patients attending my clinic
at Selly Oak Hospital in 1936; Dr. B. T. Hooper,
radiologist to the hospital, was unable to make a
permanent record in only 3 of these cases. The
reliability of skilled radiography does not of course
excuse the omission of any of the older methods of
diagnosis ; the physician has in any case to make the
preliminary diagnosis, and must have in mind all the
possibilities if serious cases are not to be missed nor
the time of biochemist and radiologist wasted.
DIFFERENTIAL DIAGNOSIS OF CARCINOMA
Although it is possible to lay down a number of
clinical criteria by which carcinoma of the stomach
may be differentiated from simple ulcer, it may be said
that in individuals of appropriate age nothing except
satisfactory Réngten ray examination is sufficient
to exclude it: there are rare cases in which only
histology can do so. Nevertheless, given adequate
radiological help, there should be no difficulty in
promptly distinguishing the majority of cases of
carcinoma of the stomach as soon as the patient
seeks advice, and mercifully it is a relatively uncommon
1218 THE LANCET]
disease. (It is, however, not encouraging to realise
that in nearly six years of busy hospital practice,
I have not seen a single patient with carcinoma
of the stomach whose life has been usefully prolonged
by surgery.)
SILENT BLEEDING
Gastric ulcer is an important cause of hypochromic
anemia. It is true that most patients with ulcer
have pain, and that the presence of an ulcer is there-
fore not likely to be overlooked; it is also true that.
if gastric analysis shows a complete achlorhydria
in patients whose only symptoms are those of anæmia,
iron deficiency is the likely cause. But it is safest to
assume, until proof to the contrary is forthcoming,
that (1) a patient with achlorhydria and long-standing
indigestion, whatever the age, and (2) a symptomless
patient who has anæmia with free hydrochloric
acid in the stomach, both have gastric or duodenal
ulceration. It is in any case a serious mistake to treat
any patient for anæmia without both blood count
and gastric analysis, and even the absence of a
positive benzidine reaction in the stools does not
warrant the assumption, in either of the two eventu-
alities cited, that no ulcer is present. I have seen
cases misdiagnosed for months as Banti’s disease
or Witts’s anemia, and even the label of petit mal
attached to a man who had had several attacks of
fainting from periodic loss of blood from an ulcer which
- had not caused other symptoms severe enough
for him to complain of them. Experience also, and
not imagination, prompts the warning that ‘‘ hemor-
rhagic diathesis”’ and ‘“ gastrostaxis’’ are probably
the result of a bleeding-point in the base of a chronic
ulcer. Diffuse oozing of blood from the gastric mucous
membrane has been seen both at operation and post-
mortem; thrombosis of the splenic vein can cause it.
But a clinical assumption that gastric hemorrhage
has originated in this way is scarcely justifiable.
In general, local tenderness, as ordinarily tested,
is an extremely unreliable sign of ulcer. The radio-
logist may elicit tenderness when the clinician does
not, since the ward examination is made in bed,
without knowledge as to the site of the ulcer, whereas
the radiologist has his patient standing, with the
stomach more accessible, and can direct his finger to
the exact point where he sees the barium clinging
to the ulcer base: under such conditions the presence
or absence of tenderness can be, especially on repeated
examination, a good indication as of the state of
healing. '
GASTRIC ANALYSIS
The fractional test-meal rarely if ever makes a
diagnosis, but it can provide useful confirmatory
evidence. In gastric ulcer the highest value for free
acid in the fractional test-meal scarcely ever exceeds
0-2 per cent., and it may be completely absent from
all specimens (2 cases in a series of 39 proved cases
of gastric ulcer). It is frequently over 0:3 per cent.
when duodenal ulcer is present, and I have never
seen complete achlorhydria with duodenal ulcer,
although several specimens, and not necessarily
the early ones, may show no acid.
The presence of blood is very significant, and it is
never safe to assume, unless repeated examination
later shows a complete absence of blood, that hæmor-
rhage, even in minute amount, is traumatic. Similarly,
a positive benzidine reaction in the stools should
always be taken as evidence of bleeding: in my
experience it is unnecessary to get the subject of the
test to abstain from meat, fish, or vegetables in order
to avoid ‘“‘false positives”; I have on several
occasions tested the point by asking a normal person
DR. D. LEYS: DIAGNOSIS OF GASTRIC AND DUODENAL ULCER -
[may 22, 1937
to take a milk diet, successively adding greens, fish,
and meat to the diet, and have never found the test
become positive. | |
HEALING
The rapidity with which the X ray shadow of an
ulcer crater may disappear, under favourable con-
ditions, is astonishing. Ulcers known to have been
present at the same site for ten years will disappear
in half that number of weeks. It has been questioned
(see, for example, Rehfuss, 1927) whether the dis-
appearance of X ray crater shadows can be accepted
as conclusive evidence of healing, but even if one ©
discounts the initial rapid diminution in size as due
merely to the disappearance of local muscle spasm,
there can still be followed the narrowing of the
residual pit to a V-shaped depression, and its ultimate
disappearance, coincident with the disappearance of
blood from the stools and tenderness on deep palpa-
tion. There seems no reason to doubt that the ulcer
has healed; whether or no it remains so is not so
obvious.
The accompanying tracings of ulcer craters taken
from the radiograms of some of these cases are records of
the actual time taken for chronic ulcers to disappear ;
they are drawn from films taken by the same radio-
logist, with the same technique, and give largest
dimensions of the ulcer as it appeared in the films.
Neither age nor sex appeared, in this small series,
to be factors of importance for healing except in so
far as older patients tended to have larger and more
chronic ulcers (there were, however, two patients
whose first symptoms appeared after the age of 70).
Of very great interest are those cases, fortunately
rare, in which, while treatment is still being applied,
an initial rapid healing is followed by some retro-
gression, as in Cases 9 and 23 figured below. In the
latter case, recurrence of symptoms coincided with
retrogressive changes in the radiogram and both
with an attack of acute rheumatism. While more
spectacular pictures of healing are obtained with
gastric than with duodenal ulcers, on account of
their greater size, and while the general tendency is
certainly for more rapid progress to be made in the
gastric cases, some remarkably quick cures have
been seen in patients with duodenal ulcer. Rehfuss
regards residual duodenal deformity as evidence
of incomplete healing, but post-mortem and surgical
experience show that the scar of a chronic healed
ulcer can produce it, and clinical evidence seems to
point to the same conclusion.
Absence of pain, of discomfort, of nausea and
vomiting, of local tenderness, of blood from the
stools: none of these things can be taken as evidence
of complete healing. Six cases in this group had no
blood in the stools when repeatedly examined,
during the whole period of observation in hospital,
and it is a common experience to find X ray evidence
of an ulcer still present after the benzidine reaction
has changed from positive to negative. From the
observations of Faber (1935) it is certain that the
gastric wall is permanently diseased in many cases
before ulcer develops, and it is the obvious duty of
clinicians to discover what are the factors which
predispose to the breaking down of the mucous
membrane and what to its healing. One set of factors
may quite possibly be the reverse of the other.
THE SITE OF THE ULCER
Although the opinions expressed in this paper have
been formed over a period of many years, the cases
actually under review number only 58, and represent
rather less than a single year’s experience from
THE LANCET]
the wards under my care at Selly Oak, a year during
which X ray coöperation has been exceptionally
good. Gastric ulcers were almost twice as common
as duodenal, a finding which is contrary to the usually
accepted incidence, stated by various authors to be
D.U. : G.U.=8 or 4: 1 (Osler and Macrae, 4: 1;
Rehfuss, 3: 1 or 4:1; Shelton Horsley, at least 4:1;
Crohn, ‘several’? duodenal ulcers to every gastric
ulcer). I wish to call attention to this discrepancy,
since, although the number of cases reviewed is not
large, it is as large as the number of cases upon
which most of these estimates were based, and the
probability of finding fortuitously, in my unselected
Wd 5 RELAPSE
| CASES
OCT.36 7. 1236 131.37
REMISSION
CASE 23 REMISSION wA
20.232 24.7.33" 14.5.34 . 14.2.36 5.12.36 10.1.36
oo j J.
CASE 45
CASE 54
9.7. 36
20. 10.36 9.12.36 16.10.36 8, 12.35
CASE 34
24.2.36 16.6.36 7.7.37
CASE 17
26.1.37,
Tracings from X ray films of healing gastric ulcers.
series, twice as many gastric as duodenal ulcers,
if the true incidence in the general population is
D.U. : G.U. = 4 : 1, is one in many hundred thousands.
The probability is still exceedingly small if the
incidence is taken as D.U. : G.U.=1: 1.
For myself, I think the explanation is that while
careful radiography gives the site incidence in an
unselected group of cases, standard text-book estimates
are founded on surgical experience, and perforation,
the common indication for interference, is much
more common in duodenal than in gastric ulcer
(D.U. : G.U.= 9 :: 1, according to Maingot’s “‘ Post-
graduate Surgery ”). The incidence found in my
series of cases can hardly be due to the easier recog-
nition of gastric than duodenal ulcer by radiography,
since out of 58 clinically suggestive cases, only 3
were left undetermined by X rays. Before surgical
intervention was common, gastric ulcer was reckoned
to be frequent, and the occurrence of duodenal ulcer
DR. D. LEYS: DIAGNOSIS OF GASTRIC AND DUODENAL ULCER [MAY 22, 1937
1219
barely recognised. It is possible that some patients
who attended my clinic or were admitted to my
wards during the period under review were suffering
-from ulcer, but have not appeared in this review
owing to lack of evidence on which to base a diagnosis,
but the risk of their numbers being large enough
to upset conclusions, based on the belief that all
cases of ulcer seen are included, is small. By the
nature of the symptoms it is improbable that chronic
ulcers were missed, and acute ulcers, being all the
more likely to be the site of hzemorrhage, would be
brought to notice when the stools were examined.
This is not a mere academic point. Several facts
suggest that the site of the ulcer may have some
bearing on xtiology: duodenal ulcer occurs at an
. earlier age, is More common among men than women,
and seems to be immune from carcinomatous change ;
duodenal ulcer occurs with equal frequency among
poor and rich, but gastric ulcer is twice as common
among the poor.
TREATMENT
Certain facts must be kept in mind in attempting to
assay any special line of treatment or in drawing
conclusions as to ætiology from its apparent success :
(1) Healing undoubtedly takes place quite often in
a gastric ulcer without the patient having been either
put to bed or ordered any special treatment beyond
advice as to diet. (This latter may, of course, be an all-
important point, but it is not the obvious factor, since
healed cases may have been given very different diets;
there is, however, one factor in common in almost all
systems of gastric ulcer dieting—i.c., milk.)
(2) Healing usually takes place more quickly in hospital
than at home, even if good conditions, including rest in
bed, are employed at home.
(3) Pain from gastric ulcer disappears almost immediately
if the patient goes to bed, no matter what diet is taken
(excluding, however, gross indiscretions).
(4) Cases frequently occur in which healing does not
take place, or in which healing occurs, but is followed by
recurrence of ulceration, notwithstanding prolonged rest
in bed and milk diet.
(5) Alkalis and bismuth, while appearing to relieve the
pain of duodenal ulcer, are powerless per se to effect a
cure, and have no effect either on the symptoms or the
size of the lesion in gastric ulcer.
If these facts are remembered, there is at present
no evidence that any special line of treatment,
such as injections of histidine, has any influence
upon the course of the disease, nor has there yet
appeared any account of the conditions under which
ulcer develops, which can pretend to implicate any
special set of circumstances.
Gastric ulcer is known to be common among all
classes, and a study of the type of work performed
by the men in the present series yields no information
of apparent significance: the work ranged from the
purely sedentary to navvying. It is possible that
hurry, stress, and anxiety all play a part, but no
close association has as yet been described as existing
between, e.g., ulcer and anxiety states.
The nature of the diet seems, on the face of it,
a very promising line of inquiry. It is already known
that mere trauma can continue for a lifetime without
causing ulceration; what other factors can be
involved ? McCarrison is quoted by Rehfuss (1927)
as having suggested the possibility of vitamin
deficiency, and there are many things to make diet
deficiency plausible as a working hypothesis. Thus
a long period of unemployment has preceded symp-
toms in several of my cases, the onset of symptoms
coinciding with a return to work. It might account
for the class difference in mortality from gastric
x2
1220 THE LANCET]
ulcer shown in the Registrar-General’s Decennial
Supplement. The one factor common to every type of
treatment employed is a diet which includes a high
proportion of milk, butter, and fish. Gastric ulcer is |
notoriously a disease of remissions and relapses
such as are characteristic of several deficiency diseases.
It has at all events seemed to me wise to give
all patients with ulcer of stomach or duodenum large
doses of vitamin A because of the evidence of its great
importance in the life and growth of epithelial tissues,
and because we are ignorant as to the optimum
intake. Patients have been rested and have taken a
simple diet with a high proportion of first-class
protein, but no other treatment has been given beyond
paraffin as required for constipation and if requested
by the patient, and iron when there is anemia.
It is under these conditions that very rapid healing
of ulcers has taken place. That unwise therapeutic
limitation of diet may be a cause of delay in healing
is very likely: it is already known to have given rise
to iron-deficiency anæmia, and one patient in this
series, who, when he was admitted to hospital, was
known to have had an ulcer for ten years, was proud of
the fact that he had, according to his doctor’s reputed
instructions, lived during the whole of that time
without fresh fruit, vegetables, or meat. I have seen
another case in which a severe polyneuritis leading
to permanent .disability developed after a very
prolonged abstinence from meat and fish.
Specific factors apart, all patients with ulcer who
have anything less than the full 100 per cent. of
hemoglobin require a supply of iron in addition to
their diet: neglect of this factor in treatment may
delay cure of anemia for many weeks, although all
hemorrhage may have ceased. Provided adequate
precautions are observed, there can be no question that
the risks to a partially exsanguinated patient, even
on those rare occasions og which it is possible to be
certain that all bleeding has stopped, of death from
infection in an open hospital ward, or from exhaustion
or further loss of blood, are much greater than the
possible ill effects of blood transfusion. Personal
experience has made me very sceptical of the theory
that transfusions of 20 ounces of blood are prone to
provoke further hemorrhage, or to harm the patient
in any way. Pygott (1937) points out that in reported
cases of death following blood transfusion when
blood incompatibility has been excluded, there is
reason to believe that the heart or vessels have always
been diseased, and that no death has been reported
as following the immense numbers of transfusions
carried out for hemorrhage.
SURGERY
My experience of surgical remedies for gastric and
duodenal ulcer has been uniformly unfavourable.
Particularly does one dread the patient with an ulcer,
whether gastric or duodenal, for which any form of
short-circuit operation has been performed. Even
symptomatic improvement is very difficult to obtain ©
in such cases once symptoms have recurred, and
one is strongly inclined to attribute initial improve-
ment and subsequent freedom from symptoms,
following gastro-enterostomy, to factors other than
the surgical operation. Although greater caution is
now exercised by surgeons in their selection of cases,
and the fashion for wholesale short-circuit and
excision operations is mercifully on the wane, it-
is still common enough for a surgeon to consider
himself entitled or even obliged to interfere when the
diagnosis of chronic ulcer is “made. Shelton Horsley,
for ‘example, states, ‘‘an operation on a gastric ulcer
should not long be delayed.”
DR. D. LEYS: DIAGNOSIS OF GASTRIC AND DUODENAL ULCER
[may 22, 1937
In view of the obvious ease with which cure can
almost ‘always be obtained by perfectly safe means,
operation for exctston of ulcers is, in my opinion,
entirely unjustifiable. Initial mortality is great, and
the evidence for subsequent freedom from symptoms
unsatisfactory, unless, as is sometimes the case,
real attention is paid for years to “‘ medical ” treatment
after operation. The removal of such a bulk of tissue,
often including that part of the stomach concerned
in the manufacture of the hæmatinic principle,
is an added danger to the patient.
One is not even entirely convinced that the appre-
ciable mortality, even in expert hands and with
local “ splanchnic anesthesia,” warrants operations
for hour-glass deformities and pyloric stenosis unless
they are so gross as to exclude the possibility of safe
remedies making a tolerable life possible. My
impression is that every case in which X rays disclose
such deformity should be given several months of
“ medical” treatment—i.e., rest, physiological diet,
and possibly stomach lavage—before operation is
considered. The whole of the deformity seen at the
first examination is not necessarily permanent.
If one excludes (as recent controversy and personal
experience surely entitles one to do) gastrectomy for
hematemesis as being anything more than a last
resort after repeated transfusions have failed to keep
pace with bleeding, perforation remains the sole
ordinary indication for surgical interference in gastric
or duodenal ulceration, and, with the knowledge
available, this complication should already be less
frequent than it is.
SUMMARY
1. X ray examination of 58 consecutive cases,
clinically diagnosed as peptic ulcer, demonstrated the
ulcer crater in 55.
2. Gastric ulcer in this series was twice as common
as duodenal (a reversal of the commonly accepted
proportional incidence). Reasons are given for thinking
that the older estimates of incidence were based on a
surgical selection of cases.
3. Ulcers known to have been present for at least
ten years have been shown to heal in a few weeks
under certain conditions, the significance of which,
as regards ætiology and treatment, is discussed.
REFERENCES
Crohn, B. B. (1927) Affections of the Stomach. Philadelphia.
Faber, K. (1935) Gastritis and its Consequences. London.
Horie = (1933) Surgery of the Stomach and Duodenum.
t. Louis.
Maingot, R. (1936) Postgraduate Surgery. London. l
Osler, W., and McCrae, T. (1935) Principles and Practice of
Medicine. 12th ed. London.
Pygott, F. (1937) Brit. med. J. 1, 496.
Rehfuss, M. E. (1927) Diagnosis and Treatment of Discases of
the Stomach. Philadelphia.
Stewart, R. J. (1923) Brits med. J. 2, 955.
Wanton, A; J. (1937) Nelson’s Loose-leaf Surgery. New York.
>
St. BARTHOLOMEW’S HOSPITAL, LONDON. — The
governors of this hospital have under consideration a
scheme for the erection on a site adjoining the hospital
of a special ward block financially independent of the
hospital but which would be able to call upon the special
services of a large general hospital: This block would
be open to persons with incomes of between £250 and
£500 whom the hospital by its charter is at present debarred
from helping. It is anticipated that the new block would
be ultimately self-supporting but a capital sum of about
£120,000 would have to be found for the building and
equipment. No appeal is at present being made to the
public but those interested may obtain further informa-
tion from Sir Gordon Campbell at the hospital.
THE LANCET]
TUBERCULOSIS IN WILD VOLES
By A: Q. WELLS, D.M. Oxon.*
PATHOLOGIST TO THE BUREAU OF ANIMAL POPULATION IN THE
UNIVERSITY OF OXFORD
(From the Sir William Dunn School of Pathology)
Griffith (1930) states that tuberculosis in warm-
blooded animals living wholly in the wild state is
unknown. The object of this paper is briefly to report
@ widespread occurrence of tuberculosis in voles
—Microtus agrestis. These animals are subject to a
cycle of population, increasing over a period of
three to four years and then decreasing suddenly
to a low figure in one or two months (Elton et al.
1935, Findlay and Middleton 1934, Elton et al.
MS. (in preparation)).
The possibility of this sudden decrease being due
to epidemic disease has been the subject of my
investigation, of which this is a preliminary report.
For the past twelve months the field service of
the Bureau of Animal Population in the University
of Oxford has enabled me to examine voles, both
dead and alive, from areas in Scotland, Wales, and
England which are uncultivated and fenced off from
domestic animals. The Bureau, after much experi-
ment, has established a system of live trapping and
transport of the voles to the laboratory, where they
have been kept in isolated cages.
On Jan. 29th, 1937, a vole died which had been in
the laboratory for a little over one month. The post-
mortem examination showed caseous areas throughout the
subcutaneous tissues of the body, involving the glands
of the neck, axille, inguinal region, and back, with ulcera-
tion of the skin round the right pinna; both lungs con-
tained caseous areas with sharply defined edges; the
mediastinal and mesenteric glands were much enlarged
and caseous; the spleen was enlarged. The caseous
material in the subcutaneous tissues contained a very
large number of acid-fast bacilli, which have the mor-
phology of Mycobacterium tuberculosis. The caseous areas
in the lungs similarly contained a great number of acid-
fast bacilli, but there was in section very little cellular
reaction. Cultures made from the caseous material yielded
no growth on nutrient agar, but growth was visible after
six weeks on Dorset’s egg and Petrofi’s medium. The
nature of the growth and the morphology of the organism
were similar to that of Mycobacterium tuberculosis.
An emulsion of caseous material from several voles
similarly infected has been injected, either sub-
cutaneously or intraperitoneally, into laboratory
bred voles, guinea-pigs, and rabbits. The disease has
been reproduced in the voles with death of the
animals; three guinea-pigs have died with. wide-
spread disease of the organs, in which acid-fast
bacilli are present ; large local lesions have occurred
in the rabbits, without so far causing death. All the
guinea-pigs and rabbits have become reactors to
tuberculin in about one month after inoculation.
Since February, 1937, 134 voles have been found
with macroscopic tuberculous lesions, in which acid-
fast bacilli have been demonstrated. These have been
sent from seven different stations in the British Isles.
Ninety-two of these infected voles have arrived dead
or have been killed on arrival. There is, therefore,
no doubt that the infection has occurred in the field
and not in the laboratory.
Although some facts about the bacterium in
question are not yet known, it seems highly probable
that it is Mycobactertum tuberculosis. If it proves to
be so several points of interest arise. The existence of
* Working with a part-time grant from the Medical Research
Council.
e
DR. A. Q. WELLS: TUBERCULOSIS IN WILD VOLES
{may 22, 1937 1221
tuberculosis in wild animals may have some import-
ance in the spread of the disease to man and domestic
animals; the use in the laboratory of an animal
which naturally contracts the disease may be preferable
to the use of the animals, used hitherto, which are
not known to have the disease in nature; and the
fact that a small animal, easily maintained and
bred in captivity here, is available for epidemiological
study may throw some fresh light on tuberculosis.
The organism is being typed by Dr. A. Stanley
Grifith of ‘the Field Laboratories, University of
Cambridge. I am indebted to him for his advice,
SUMMARY
The presence of disease, presumed to be tubercu-
losis, in wild voles is reported. The fact that the
disease is widespread in the British Isles suggests
that this is not a chance infection.
REFERENCES
Elton, C., Davis, D. H. D and Chitty, D. H. (in préparation):
and Findlay, G . M. (1935) J. Anim. Ecol. 4, 277.
Findlay, G. M., and Middleton, A. D. (1934) Ibid. 3, 150.
PERTO A. Stanley (1930) A System of Bacteriology, London,
vol. V, ‘
AUTOSEROTHERAPY FOR DRUG
ADDICTION
By MARGARET VIVIAN, L.S.A.
Druc addicts have long been the bétes noires of
the medical profession, and it is common knowledge
that a long-standing case is an almost hopeless
proposition when treated by the ordinary methods
of gradual withdrawal or sudden deprivation. In
the past I have tried to help many of these unhappy
people. Many of them insisted on leaving the
nursing-home while still needing small doses of
morphia, and of those that endured to the end,
the majority sooner or later relapsed because they
found themselves unable to cope with their daily
work without their accustomed stimulant. These
patients are usually the victims of circumstance, and
I am glad to be able now to record greater success
in their treatment.
The method used (autoserotherapy) consists in
the hypodermic injection of fluid obtained from
blisters raised by applying irritant plaster to the
patient’s skin, the amount injected being usually
5-10 c.cm. at a time. In the treatment of drug
addiction this method was first described, I believe,
by Modinos of Alexandria in 1929, but I did not
see his paper until some years later. He records
that he was treating some arthritic patients by
autoserotherapy and that one of them, who chanced
to be a cocaine addict, lost his craving after the first
two injections—an event that led Modinos to try
the same procedure in cases of morphine and heroin
addiction. I have now used it in 8 cases and will
give brief accounts of all of them.
THE CASES
Case 1.—Dr. A. had been taking 3—4 grains of morphia
a day for two years. He had tried the gradual with-
drawal method and had laboriously got down to a little
under gr. 2 a day, but had failed to reduce the dose any
further. He was very anxious to be cured and came to
me for treatment in June, 1934. After the second blister-
fluid injection three days later, he felt no further desire
for the drug, and he went home at the end of a fortnight,
although I begged him to stay another week. This was
my first case, and I was as astonished as the patient at
the remarkable result. He has never relapsed.
1222 THE LANCET]
CasE 2.—Dr. B. had been taking 4—5 grains of morphia
daily for about five years. He had three blister-fluid
injections and needed no morphia after the second. The
only difficulty in this case was insomnia, but at the end
of three weeks he was sleeping naturally and felt no desire
for morphia. I have lost sight of this case and do not
know whether he has relapsed.
CasE 3.—Dr. C. had been taking morphia on and off for
the last twenty years, and had taken as much as 20 grains
a day. Had been “cured” several times, but always
relapsed because he felt ill and depressed after the gradual
withdrawal. He needed no morphia after the second
blister-fluid injection, but had so strong a desire for a
hypodermic injection that I gave him Dionin gr. } t.d.s.,
filling up the bottle each time with the equivalent amount
of water. When I told him that he had had no morphia
for ten days, he ceased to ask for the injections, and left
the home after being there three weeks. I have not heard
from him since.
CasE 4.—Dr. D. had bas taking 3—4 grains of morphia
a day for eight years, having started it after an operation
for gall-stones. Later he developed attacks of pseudo-
angina, but his supplies of Dangerous Drugs Act drugs were
stopped by the Home Office, and he was obliged to seek
help in order to be set free from his addiction. He was
a difficult patient, threatening to commit suicide unless
he could be assured of a supply of morphia for the rest
of his life. He had four blister-fluid injections, and
insomnia was the only difficulty. Finally he left at the
end of four weeks, sleeping fairly well with an occasional
tablet of Dial at night. I saw him six months later,
when he was in good health, had no desire for morphia,
and slept well without any sedative. His anginal attacks
had ceased. Recently a Home Office official, when
writing about another patient, volunteered the information
that Dr. D. is now in excellent health and free of any
drug addiction. It is eighteen months since he left the
home. |
CasE 5.—Dr. E. was a medical missionary who considered
it very wrong to take drugs and had tried very hard to
cure himself, but without success. He had been taking
about 3 grains of morphia by the mouth daily for seven
or eight years, and suffered from persistent constipation.
After the second blister-fluid injection he had no further
desire for morphia. Dionin tided him over the first few
nights, when he had difficulty in getting to sleep, and at the
end of eighteen days he left the home, sleeping and eating
normally. I heard from him three months later, and he
assured me that he had no desire for drugs.
CasE 6.—Dr. F. had been addicted to drugs for about
fifteen years. His daily dose when he came to me was
20-30 grains of morphia, 10 grains of cocaine, and a bottle
and a half of whisky. Like most addicts, he had fortified
himself with enormous doses the day he arrived, and his
first request was for a tumblerful of neat whisky. It
seemed a hopeless kind of case, especially in view of the
fact that he had been treated a year earlier at a home for
inebriates, where it took three months to get him entirely
free of drugs. On leaving the home he had remained
free for six months although in practice and dispensing
his own medicines. . What was in his favour was that he
seemed genuinely anxious to be cured. After the first
10 c.cm. of blister fluid Dr, F. slept and ate well and made
no complaint on a daily dose of morphia gr, 2 during
the first three days. No whisky was given or desired
after the first day, and no cocaine was given at any time.
Three days later a further 10 c.cm. of fluid was injected.
For a few days he still wanted hypodermic injections, and ©
asked for them at the usual times, but after the second
blister-fluid injection, dionin gr. + was substituted for the
morphia without his knowledge. He made no complaint
of needing morphia, but had very little sleep the first
two nights, even after heavy doses of one or other of the
barbiturates. The next night he still seemed excited and
sleepless, and so I asked Dr. H. J. A. Simmons to give
him an intravenous injection of Sodium Evipan to ensure
a good night’s rest. He injected the solution very slowly,
giving 20 c.cm. in all, and while Dr. F. was in the early
stage of anesthesia we gave him strong and repeated
suggestions that he should in future sleep without the aid
of drugs or spirits. He had about six hours’ sleep, and
DR. MARGARET VIVIAN: AUTOSEROTHERAPY FOR DRUG ADDICTION
-he be tempted to relapse.
[may 22, 1937
the sodium evipan in decreasing doses was repeated
for a further two nights. Thereafter Dr. F. slept 63-8
hours every night without sedative. A third blister-
fluid injection was given on the tenth day, and from this
time onwards the patient declared that he had no need
or desire for drugs or spirits. At first he was easily
tired and felt disinclined for any exertion, mental or
physical, but this symptom disappeared rapidly, and when
he left the home at the end of the third week he looked
and felt a perfectly fit man.
In view of his past history with the long addiction and
heavy dosage, the patient’s relatives and I begged him
not to return immediately to his work. But nothing
that we could say would stop him. He declared that he
felt perfectly safe and that under no circumstances would
His wife, however, tells me
that he is now taking the same heavy doses as before.
Case 7.—Mr. G. had become addicted about two years
previously through being given hypodermic injections of
morphia when suffering from renal colic. He had had
various methods of treatment but had always relapsed.
He professed a great desire to be set free from his addiction
because of the increasing difficulty in obtaining supplies.
The result of three blister-fluid injections was similar to
that observed in the other cases. He had no withdrawal
symptoms, and had three nights’ excellent sleep after
the morphia had been discontinued. He ate well and
was in excellent health when disaster supervened. One
Sunday morning he asked if he might go out alone, saying
that he felt that a walk would do him good. Feeling
reasonably sure that as a non-medical man he would
find it impossible to obtain supplies of morphia in the
town, I agreed. I learned later in the day that he had
gone straight to a hotel where he had booked a room and
summoned a doctor, to whom he simulated renal colic
so successfully as to get an injection of a quarter of a grain
of morphia. The procedure was repeated with another
medical man, who was similarly deceived, but on hearing
from the landlord that a doctor had already been called
in, he became suspicious and rang up the first doctor, who
in turn communicated with me. When Mr. G. returned
- late in the evening, tired but pleased with his cleverness,
I taxed him with having obtained morphia by false
pretences. At first he denied it, but when he saw that
I knew what had happened, he took the next train home.
He is, I fear, one of the cases that are quite hopeless, for
he admitted that he was in no need of the drug when he
took all this trouble to obtain it. It is impossible to
change a man’s character, and the relapse does not alter the
fact that he was cured of all physical need for morphia
within a fortnight.
CasE 8.—Dr. H. had taken a daily dose of 2 grains of
morphia for the past nine years. Recently he had
substituted heroin for the morphia and was anxious to
be free of his addiction because of an increasing fatigu-
ability, and also because he found it difficult to obtain
supplies without arousing the suspicion of his chemist.
He feared that sooner or later he might get into trouble
with the authorities. I immediately replaced the heroin
by morphia, as J have found that heroin is far more
difficult to withdraw by the ordinary methods than is
morphia. Dr. H.’s recovery was uninterrupted and
uneventful. After the second blister-fluid injection he
no longer needed morphia, and a few doses of dionin
tided him over the customary period of insomnia. He
left the home at the end of three weeks in perfect health,
and he was wise enough to take my advice and promised
to keep away from medical practice until he had been
away for six months’ holiday. Since then a fortnight
has elapsed and he has written saying that he is steadily
improving in health and has no desire for any drug.
COMMENT
I ‘hope that these brief notes may induce some of
my colleagues to try autoserotherapy in similar
cases. It does not perform miracles, but it obviates
the usual distressing withdrawal symptoms, such as
diarrhea, restlessness, anorexia, and sneezing, and
removes the physical need for the drug within two
or three weeks. Naturally, if the patient elects to
THE LANCET]
DR. S. G. JAMES: EPILOIA WITH TUMOURS OF THE NAIL-BEDS [MAY 22, 1937 1223
return to his addiction after he has been freed from
the physical need, nothing will prevent him from
doing so.
In obtaining the fluid I find two, or even three or
four, small blisters—e.g., 14 in. square— preferable to
one large one, because they heal more readily. The
fluid is withdrawn before the plaster is removed and
reinjected immediately, causing no pain or reaction
of any kind.
REFERENCE
Modinos, P. (1929) Bull. Acad. Méd. Paris, 102, 283.
EPILOIA WITH ASSOCIATED TUMOURS
OF THE NAIL-BEDS
By STANLEY G. James, M.B. Sydney,
M.R.C.P. Lond., D.P.M.
DEPUTY MEDICAL SUPERINTENDENT TO THE RAMPTON
STATE INSTITUTION, RETFORD
Ermora is the name given by Sherlock (1911)
to a clinical syndrome which consists of mental
deficiency, epilepsy, and a condition of the skin
known as adenoma sebaceum. Associated with this
syndrome is the condition of nodular or tuberose
sclerosis of the brain. According to Tredgold (1929)
and others, these four conditions, mental deficiency,
epilepsy, adenoma sebaceum, and tuberose sclerosis,
occur independently of each other and without
anything else, but the presence of the first three
together implies the existence of the fourth, and
the whole warrants wider recognition as a clinical and
pathological entity.
CLINICAL PICTURE
Elliott (1936) has recently described a case of
Pringle’s disease (adenoma sebaceum) with associated
tumours of the nail-beds of the toes, and from a
subsequent discussion it appeared that this associa-
tion, although exceedingly rare, is not unknown.
The case which is here recorded is one of epiloia
in which the adenoma sebaceum is associated with
tumours of the nail-beds of the toes as in Elliott’s
case, and also of the fingers. The epiloia is also
unusual in that there is mental deficiency with
dangerous and violent propensities.
Epiloia is a relatively rare condition. Brushfield
and Wyatt (1926) found it in 0-66 per cent. of
admissions of mentally defective children to the
Fountain Hospital. It is present from birth. A
neuropathic heredity can usually be made out and
blood-relations with atypical nevi and hyperkeratosis
have been described. The mental deficiency is
usually pronounced, the lower grades, imbecility
and idiocy, being most commonly encountered. The
epileptic fits begin at a very early age and are usually
of the major variety. Most of the patients die before
reaching adult age, but this also applies to low grade
defectives in general..
| THE BRAIN LESION
Sclerosis of the brain associated with mental
deficiency occurs in two forms, the diffuse, which
may be hypertrophic or atrophic, and the nodular
or tuberose. The former may be accompanied by
epileptic fits, but does not enter into the syndrome
of epiloia. Tuberose sclerosis was first described
by Bourneville (1880) and a number of cases have
since been recorded. The following are some of the
authors: Sailer (1898), Tredgold (1903), Dobson
(1906), Vogt (1908), Fowler and Carnegie Dickson
(1910), Bonfilia (1910), Weygandt (1921), Kufs (1913),
Brushfield and Wyatt (1926), and Critchley and
Earl (1932). These forms of sclerosis are disorders
of development which are present at birth and there
are various theories as to their cause. Some writers
favour a vascular origin, some an inflammatory, and
others a neoplastic process, but the majority go no
further than developmental anomaly. The sclerosis con-
sists of a neuroglial proliferation which forms tumour
masses. In the diffuse form the masses involve the grey
and the white matter, but in the tuberose form they are
circumscribed tumours
and are confined to
the grey matter of the
cerebral cortex, the
basal ganglia, and the
retina. In the last
situation, the tumour,
known as a phakoma,
affords direct clinical
evidence of the con-
dition of the brain, eae
but unfortunately it is be a
extremely rare. The oa
brain tumours are
found in the cortex
and projecting into
the lateral ventricles,
usually in large numbers. They are pale, rounded
bodies, varying in size from a pin’s head to a walnut.
The consistency is firm even to stony hardness, and
in the cortical situation the pia strips more readily
from the tumour than from the normal tissue. Central
umbilication may occur, and cystic degeneration and
calcification. Microscopically, the masses are seen
to be composed of glial fibres and large abnormal
glial cells, with degenerating glial and nerve-cells
and myelinated fibres intermingled. There may be
thickening of the meninges in the neighbourhood of
the tumours. .
FIG. 1.—Photograph showing
the white eyebrow on the
right side, and the adenoma
sebaceum.
THE SKIN LESION
Adenoma sebaceum is a papular eruption of the
skin. Sequeira (1927) refers to three types: in the
first the tumours are pale (Balzer), in the second
they are pink (Pringle 1890), and in the third the skin
is warty (Hallopeau and Leredde). The eruption
consists of neoplasms of the sebaceous glands, the
pink colour of the second type being due to over-
growth of the capillary vessels, and the third variety
resulting from the addition of hyperkeratosis. The
tumours are present at birth, and at puberty there is
either an increase or a diminution in their growth.
They are closely set and vary in size from a pin’s head
to a pea. Alt three types'may be present in the same
case. The commonest site is the face, beginning
in the naso-labial folds and spreading to the nose and
cheeks in a butterfly pattern. The pink variety is
usually confined to this situation but the others may
be found on the forehead, chin, neck, trunk, and limbs.
Additional lesions of the skin may also occur and
particular mention has been made of cutaneous
horns, vascular nevi, vitiligo, white hair in the
eyebrows, pigmented and hairy moles, and patches
of fibromata on the trunk, but there is little reference
to papillomata of the nail-beds.
Apart from these skin conditions tuberose sclerosis
may be accompanied by tumours in the kidneys, heart,
liver, duodenum, spleen, thyroid, thymus, stomach,
and uterus, in that order of frequency. For the most
part they are myomata, and are not recognisable
during life.
CLINICAL REPORT
The patient was a single woman aged 33. ‘The records
state that she suffered from epilepsy, the fits beginning
when she was a baby and continuing until the age of 8.
1224 THE LANCET]
She left school while in Standard III. She stole her
mother’s jewellery, sold it, and sent the money in a plain
envelope to a friend abroad. The police arrested her as
being a person found without visible means of support
and she was certified as mentally defective and sent to an
institution at the age of 17. She remained continuously
in institutions from that time until, at the age of 28,
she was sent to Rampton State Institution in 1931. Her
propensities as noted in the other institutions were that
she was suspicious, unstable, difficult to manage, hostile,
violent, influenced others to their detriment, and finally -
2.—Filiform papillomata and chronic paronychia around
the finger-nails. 7
FIG.
made a violent assault on another patient. She says
that she has had warts on her face, body, fingers, and toes
as long as she can remember.
FIRST ADMISSION (1931)
Physical state.—Height 5 ft. 84 in., weight 12 st. 4 lb.
Eyes grey, hair auburn. The right eyebrow and the
inner half of the right upper eyelashes are white. Palate
high and arched. There was generalised adenoma
sebaceum with typical ‘‘ butterfly’? distribution on the
face, and patches on the trunk and limbs. Numerous
warts were present also and there was keratinisation
of the finger and toe-nails. Apart from some facial
asymmetry the other systems were normal.
Mental state.—Feeble-minded. She was childish in
manner, with limited reasoning power and defective
mental capacity. Her mental age was below the average
for her age. She stated that she had a bad temper which
she did not try to control. She was said to be difficult
to manage and to be violent and dangerous.
Subsequent progress.—A few days after admission she
was noted to be hostile in manner and attitude, and she
stated that she would knock out the first person who
interfered with her. She worked in the laundry in a
careless fashion and was usually somewhat depressed.
She resented her removal to Rampton and did not realise
that she had done anything wrong in the previous institu-
tion. She gave no particular trouble except that on one
occasion she tore up her bedclothes. Her explanation of
this was that she was unsettled because the other girls
had made remarks about her personal appearance.
Fifteen months after her admission she was sent back to
the certified institution, but failed to maintain her progress
and was again admitted to Rampton three months later.
SECOND ADMISSION (1933)
Physical state——The previous findings were confirmed,
the warts being more fully described as filiform papillomata
at the roots of the nails of the fingers and toes. Her
general health and condition were moderate.
Mental state.—Unaltered.
Further progress.—She developed an isolated personality,
more solitary and silent than before, objecting quietly to
ordinary routine. Six months later she became irritable,
insolent, and troublesome and needed to be secluded.
She attacked the staff when reproved for making a noise.
There has been nothing further of note beyond the
occurrence of an undoubted epileptic fit, ten months ago.
PRESENT CONDITION
The hair.—A considerable number of white hairs are
present on the scalp, contrasting sharply with the general
auburn hue. The hairs of the right eyebrow and the
DR. S. G. JAMES: EPILOIA WITH TUMOURS OF THE NAIL-BEDS
[may 22, 1937
inner half of the upper eyelashes on the right side are
quite white and contrast with the remainder (Fig. 1).
The filiform papillomata.—These have given rise to
some pain and discomfort and the larger ones have become
abraded with secondary infection and hemorrhage. This
condition has been treated from time to time by various
means, including silver nitrate and tinct. benzoin co.,
with the result that the appearance of the papillomata is
now modified. Those surrounding the finger-nails have
practically disappeared and there is a condition of chronic
paronychia in their place (Fig. 2). On the toes they have
mostly lost their filiform shape and are more rounded
(Fig. 3). Patches of small fibromata are also present on
the axillary folds and on the neck.
Adenoma sebaceum.—The appearance on the face is
tvpical of the Pringle type (Fig. 1). The tumours are
distributed on the cheelss on either side of the nose in
butterfly fashion, some being situated on the nose as well,
and a few scattered on the lips and chin. They are
numerous and their size is variable, the largest being 7 mm.
across.‘ The greater part of their bulk is projected above
the surface of the skin, their surfaces are smooth and their
colour either pink or red. In the other situations, on the
neck, trunk, and limbs, the appearance of the adenomata
is quite different. They are much larger, up to 2 cm.
across, and somewhat resemble the shrivelled skins of
white grapes. They hardly project above the surface and
may be felt more easily than seen. Their colour does
not differ much from that of the surrounding skin.
The other systems show no abnormality. The ocular
fundi are normal and the urine contains no red blood-
corpuscles. The mental state is unchanged.
COMMENTARY
The outstanding point of interest in the case is
the occurrence of fibromata of the nail-beds. Fibro-
mata in other parts are common in epiloia, as also
are the patches of white hair. Emphasis may be laid
on the “ grape-skin”’ type of adenomata occurring
on the trunk and limbs. These tumours are liable
to be mistaken for
scars following burns
or other injuries, but
careful palpation
reveals their true
nature. I have seen
a case of mental
deficiency with epi-
lepsy not recognised
as epiloia, in which
there were several
“ srape-skin ” adeno-
mata in the skin over
the scapulæ, but no tumours on the face. The
patient died in status epilepticus and a post-mortem
examination revealed the presence of tuberose
sclerosis of the brain.
It is to be noted that epiloia does occur with high
grades as well as with low grades of mental deficiency.
The defect of intelligence is not necessarily obvious
and may be overlooked unless attention is paid
to the point. Further, the epilepsy may be unknown
to the patient or even deliberately concealed. In
the case here reported, the history of fits up to the
age of eight is rather vague and the diagnosis could
not be made with certainty until the typical seizure
was observed.
No treatment is known to be of avail in epiloia
but the diagnosis of the condition is important in
that the expectation of life is thereby considerably
reduced.
FIG. 3.—Papillomata on toes.
REFERENCES
Bonfilia (1910) Mschr. Psychiat. Neurol. 27.
Bourneville (1880) Arch. Neurol., Paris, 1, 69
Brushfield and Wyatt (1926) Brit J. Child pie 23, 178, 254.
Critchley, M., and Earl, C. . (1932) Brain, 55, 311.
Connued at Dae of opposite page)
THE LANCET]
NUTRITIONAL RETROBULBAR
NEURITIS
FOLLOWED BY PARTIAL OPTIC ATROPHY
By D. FITZGERALD Moore, M.R.C.S. Eng.
SENIOR MEDICAL OFFICER, WEST AFRICAN MEDICAL
SERVICE, NIGERIA
In 1934 I published a report, which included
a summary of earlier findings, on retrobulbar neuritis `
followed by partial atrophy due to avitaminosis.
The essential symptoms were shown to be defective
vision associated with active symptoms or a past
history of a sore tongue and sore mouth, a scaly,
itching scrotum, and mental and other nervous
manifestations.
CLINICAL PICTURE
The history of these patients is quite definite.
' Vision that has been perfectly normal becomes
suddenly misty and there is much difficulty or
inability in seeing clearly at a distance and in reading
print. There is photophobia in bright light. The
patient invariably has or has had one or more attacks
of sore tongue, white patches at the edges of the
lips, and dry, scaly itchy scrotum. These skin lesions
vary in intensity; usually the tongue looks raw,
and the edges of the lips are only slightly cracked,
the genital skin being smooth and dry. In worse
cases these lesions are intense as shown in the Figures.
Additionally linear skin lesions may appear on the
skin in front of the arms and at the back of the
knees. In school-children these lesions are frequently
passed unnoticed and their cause is not recognised,
particularly as they tend to improve in holiday
time—that is, on return to natural home conditions.
Examination of the eyes reveals no changes
externally. In early cases there are few or no fundus
changes, but very definite changes appear later,
usually about two months after the first onset. After
the first onset of symptoms there is a definite pallor
of the disc, more extreme on the temporal side;
in severer and more advanced cases the disc appears
typically that of a primary optic atrophy, almost
dead white with thin vessels and greyish retin.
Some very bad cases may also show a true optic
neuritis with post-neuritic changes. The effect on
vision is profound and, if untreated, lasting, even up
to an inability to see hand movements. I have
met boys at school who listen to their teachers because
they can no longer see to read. All the evidence,
however, goes to prove that total blindness does not
occur, though the patient may be rendered totally
unemployable by virtue of his defect.
The optic nerve changes appear to be a direct result
of an acute involvement at the onset of the syndrome,
and its severity is demonstrable in time by the
resultant optic nerve changes. The optic nerve
condition is therefore a partial post-optic atrophy
following retrobulbar neuritis.
(Continued from previous page)
Popren: ar (1906) Lancet, 2, 1583.
Elliott M. (1936) Proc. R. Soc. Med. (S. Dermat.) 30,
Fowler, kad Carnegie Dickson, W. E. (1910) Quart. J. Med 2 4.3,
Kufs. H. (1913) Z. ges. Neurol. he i 18, 291.
Pringle, J. J. (1890) Brit. J. Derm. 2, 1.
Sailer, J. A: J. nerv. ment. Dis. 25, 402.
Sequeira, mUD Diseases of the Skin, ED.4, London, p. 44.
Sherlock, . (1911) The Feeble- Minded London.
redgold, A (1903) Arch. Neurol., Lond. 2
(1 29) Mental Deficiency, ED.5 Kondon, T 5330.
Vogt, H. (1908) Zbl. Nervenheiik., Berl. 1
Weygandt (1921) Arch. Derm. Syph., Wien, "52, 466, 473.
DR. D. F. MOORE: NUTRITIONAL RETROBULBAR NEURITIS
[may 22, 1937 1225
The mouth and other skin lesions are not neces-
sarily seen unless the patient is in an early or recurrent
stage of the disease, probably because he returns home
—to good food—on account of his illness. These
skin lesions are, however, always a precursor to or
concurrent with the first eye symptoms.
Stannus (1911) observed similar skin conditions on the
Gold -Coast and has always maintained that these were
, pellagrinous. Scott (1918) described an acute, mostly
fatal, epidemic in Jamaica among the coolie workers in
the cane plantations. Sore mouth and tongue, defective
vision, and severe nervous involvement were the main
features. Recovered cases showed “ residual eye symptoms,
high steppage gait, &c.’’ There is reason to believe this
acute condition has definite points in common with the
syndrome I describe, though a fatal termination here
is unknown. More recently Meagher (1936) appears to
have described a similar acute epidemic in the Solomon
Islands termed “‘ epidemic stomatitis.” In 1926 Wright
described in Sierra Leone a disease which he later
(1930) termed the A and B avitaminosis of Sierra Leone.
The symptomatology is identical with this’ syndrome.
St. John (1936) finds an identical condition in the
Barbados. He agrees in detail with the cause of defective
vision being due to a retrobulbar neuritis followed by
partial optic atrophy. Landor and Pallister (1935)
reported cases of identical type in Malaya, and believe
the condition to be a world-wide one. In reference to
myself they state ‘“‘ he came to the conclusion the disease
was due to lack of vitamin B, and we think this syndrome
must be very near identical with ours.... In a recent
paper however he blames particular foods also, such as
kassava, especially for the defective vision.” They agree
the ophthalmic defect is a retrobulbar neuritis followed
by partial optic atrophy. Recently attention has been
drawn to a similar condition in Jamaica by Clark (1937)
by a pamphlet on malnutrition as a cause of retrobulbar
neuritis in children; and by Dickenson (1937) optic
atrophy in children ; ‘also in Gold Coast by Purcell (1937).
Nicholls (1935) describes a syndrome in Ceylon which is
identical in some respects, but in which there seems also
to be xerophthalmia. ‘‘Tongue sprue in natives”
(Manson-Bahr 1915), similar in definition, appeared to
have a dietetic cause. :
ZTIOLOGY
The disease itself is curable with Marmite alone or
with yeast alone, the skin lesions by autoclaved
products, and the eye lesions probably so. Landor
and Pallister have proved that liver, marmite, and
both autoclaved marmite and yeast are all successful.
Their experiments definitely established that the skin
and mouth conditions were dramatically amenable
to vitamin-B, therapy. The visual symptoms were
shown to respond in the course of time to liver,
marmite, and yeast; on the other hand cod-liver
oil and fruit juice as controls had no effect on any
lesion. .
In 1934 cases were quoted in my report showing
satisfactory results of treatment. This was given
in a combined form—marmite, a teaspoonful three
times daily, with cod-liver oil, half an ounce daily,
a standard iron tonic, and native palm wine. It was
shown that ophthalmological response was excellent
in early cases and up to six months, quite dramatic
end-results being obtained. Usually response began
three weeks after treatment and improvement
was Maintained up to a vision of a smaller
Snellen line in a fortnight in the most favourable
cases, even if they had gross loss of acuity of
vision; on the other hand patients with longer
history, usually over a year, responded less and less
according to the time since the onset of the disease.
This was largely in keeping with clinical find-
ings, though there were surprising exceptions in
some apparently bad cases. I believe, however,
1226 THE LANCET] DR. D. F. MOORE:
that absolute cure is not possible;
cases seeing only hand movements may
improve to 6/6 vision, but there is
difficulty in sustained reading of small
print, the pupil also appearing to react
slowly to light, and photophobia to a
slight degree in bright light remains.
This combined treatment was not
enough to establish directly the specific
cause, and at this stage I believed that
it lay between pellagra itself and
vitamin-B, deficiency, plus the probable
addition of a toxic factor. During 1935
and 1936 I have carried out as far as
local circumstances permitted selective
therapy as suggested by Landor and
Pallister. Response to marmite, yeast,
or autoclaved dried yeast agree fully
with their findings. Over 200 selected
patients were treated for a period up
to 10 months with yeast or marmite
alone—the majority with marmite owing
to its more stable properties. All skin conditions
cleared up rapidly, and the visual response was
entirely in keeping with results formerly obtained.
Unfortunately I was only able, owing to local
difficulties, to use autoclaved dried yeast in
8 cases, which I specially selected for their skin
lesions, and treated for a very short time; results
here were dramatic. Thus it has not been possible
yet for me to prove therapeutically that ophthalmo-
logical response is due to vitamin-B treatment
exclusively, but other general evidence is so strong
that I believe this certainly to be only awaiting
' confirmation in this respect.
To demonstrate the ophthalmological response to
marmite I quote a fairly severe and typical case
from my records.
A young negro, aged about 19, was seen in July, 1935.
Vision was then 4/60 : 4/60; he was unable to read.
Discs showed well-marked atrophic changes. He had a
history of one year of sore tongue and mouth, an itching,
scaly scrotum, and defective vision. When seen he still
had active skin lesions; he had had to leave school because
of his defective vision, and latterly had become quite
unemployable in any capacity owing to this increasing
defect. He was given marmite 3 oz. daily for a period
of nearly 10 months. His vision had improved in six
months to 6/18 : 6/12 part, and remained so till I went
on leave in November, 1936. The skin condition had
cleared up entirely within a fortnight. The whole out-
look of this boy is now changed; he is employable, bright,
and active mentally, whereas when first seen he was
dull and morose.
FIG. 2.—The same patient after ten days’ treatment.
NUTRITIONAL RETROBULBAR NEURITIS
[May 22, 1937
ig
ee ied
> *
x
`
ge.
F
P =
<
-
E Pe ~
+35 wy ees
FIG. 1.—Photographs showing the condition of the face and of the skin of
scrotum and buttocks.
The second case illustrates the dramatic effect
of marmite on the skin lesions.
A Mende boy from Sierra Leone was brought off an
‘Italian ship by one of the officers who had noted his
peculiar gait and appearance. It was possible to keep
him only ten days as the ship was leaving port. He was
treated by my colleague G. E. Dodds whose notes are
as follows. Patient a Mende, aged 30, normal stature,
striking facial appearance. Skin dull and rough with
symmetrical patches of epithelium round eyes and angles
of mouth (Fig. 1). Tongue smooth, thickened, pale,
slightly denuded of epithelium. Scrotum dry, rugose, and
desquamating. Mentally he is slow but able to give
his history. Skin condition was present three years,
hands and feet ‘‘humbugging’”’ him for some months.
Defective vision three years, getting worse, 4/60 : 5/60.
Illiterate. Severe optic neuritis and post-atrophic changes
in discs. Knee-jerks absent, very ataxic. Kahn test
negative. Given marmite ł oz, daily.
Figs. 1 and 2 show the remarkable effect in ten
days on the skin lesions.
The syndrome is also prevented by adequate pro-
teins of higher biological value. This is demonstrable
in prisons in Southern Nigeria, since a carefully con-
trolled and adequately balanced dietary is insisted
upon and this syndrome is relatively unknown.
On the other hand in institutions where food may
not be balanced, particularly in essential proteins,
a rate of 10 per cent. and over has been opeerved,
quite frequently.
Perhaps this point is best illustrated at a certain
school specially visited by me on account of many
cases. of defective vision, a number of
girls having had to leave school. The
school was in an isolated area and
consisted of 80 pupils about half of
whom were boys. All the girls showed
well-marked evidence of this syndrome
but not one of the boys, whose bright
shiny faces showed their good health.
All food was brought by canoe twice
weekly and distributed equally to both
sexes. It was seriously deficient in
proteins. Further inquiry showed that
the boys augmented their diet daily by
the simple expedient of catching and
roasting the land crabs that existed in
countless numbers in the vicinity.
This was not permissible to the girls,
who were kept in strict seclusion.
Xerophthalmia, the classical accepted
clinical result of vitamin-A deficiency,
THE LANCET]
has not been observed once in all the cases I have
seen, now amounting to some thousands. This is
not surprising since palm oil, shown by Prof. J. C.
Drummond to be rich in vitamin A, is a basic food
of these people.
INCIDENCE
There are thousands of these cases, some mild,
many severe. I have seen patients with histories
dating back many years who are permanently defective
in vision. Some of these patients are now quite
old and their history traceable to their old school
days, the passage of time showing they have got
neither better nor worse. I have seen many others
whose vision has made them quite unemployable.
Some of these are young adolescents and literates
and their condition is a tragedy. The onus of defective
vision is greater on the literate classes and has thus
been specially noticeable in schools. Even so all
classes are affected, including pregnant women and
even very young children.
RELATION TO DIET fe
The dietary of the Southern Nigerian peoples
consists of palm oil, kassava, yams, rice, green leaves
of various kinds, local or imported dried fish, salt,
pepper, and maize, and various fruits in season. Eggs
though plentiful are not eaten. There are practically
no cattle, and milk is not available in the South
owing to the prevalence of tsetse fly. Meat is expensive
and a rare luxury to the poor. Tinned milk is popular
when it can be afforded. The sea coasts abound in fish
but all such indigenous trade is controlled by Africans.
There seems little doubt protein foodstuffs afford the
missing protective link in this country and their
gradual introduction by educational propaganda
offers the solution to the prevention of this syndrome.
It would be useless to discourage suspect basic foods,
such as manioc, which have been in use for so many
generations.
In Barbados St. John reports that rice, corn-
flower, sweet potatoes, locally made biscuit, salt
pork dried or with butter for flavouring, are usually
eaten, Eggs and green vegetables they sell rather than
eat. Kassava they also eat though not as much as
formerly. In Scott’s polyneuritis cases the diet was
almost entirely sugar cane.
TOXIC FACTORS
Clark, who also spent 18 months in Nigeria and saw
many of these cases with me, believes that cyanogen-
bearing foodstuffs, such as sugar cane, manioc
(kassava), guinea corn, rice, millet, and maize, are by
virtue of that content responsible for pellagra in the
absence of adequate protective proteins. He believes
the essential sulphur of the proteins is eliminated by
the cyanogens to form cyanates and that sulphur
therefore plays an important part in pellagra. There
is much clinically to support the presence of a toxic
element, plus a deficiency as shown by co-relationship
to other diseases. There are wide variations in both
from true pellagra itself. It is not without interest
that Clark informs me from Egypt that he sees many
of these pellagrinous cases identical in nature to this
syndrome side by side with classical true pellagrins.
I have to thank Sir Walter Johnson, late director of
medical services, Nigeria, and Dr. A. Selwyn Clark, deputy
director health services, for their interest and encourage-
ment. I am also indebted to Dr. A. Clark, who showed
such keen interest in this work during his visit to Nigeria,
to Mr. E. Arthur for the preparation of autoclaved dried
CLINICAL AND LABQRATORY NOTES
[may 22, 1937 1227
yeast, and to Mr. G. Duckworth and Mr. P. Phillips
for the photographs.
REFERENCES
Clark, a eon Trans. R. Soc. trop. Med. Hyg. 26, 301. .
936) Certain Aspects of Poisoning by Food Plants in
Nigeria, er (privately printed).
Clark, art oe (19 35-36) Trans. Brit. med. Ass. (Jamaica branch),
p.
Dickenson, W. N. (1935-36) a ae
Landor, J. V., and Pallister, R. A. (1935) Trans. R. Soc. trop.
Med. Hyg. 29, 121
Manson-Bahr, P. H. (1915) A report on Researches on Sprue
in Cey ylon 1912-14, pp. 21-22, 46-47. Plate I, PET 15-17.
Meagher e0 ) Tr rans. R. Soc. trop. Med. Hyg. 30, 251.
Moore, D. F. 930a) School-children. Partial PAA of Central
uity of Vinton for Reading and Distance. Association
Sh Food Deficiency. Report to 1 hina Medical
__ and Sanitary Services, Nigeria, No. 171.
(1930b) Partial Loss of Central Acuity for Reading and
~ Distance in School-children and its Possible Association
with Food Deficiency, IF. Afr. med. J. 3, 46
— (1932) Retrobulbar Neuritis, Ibid, 5, 28.
— EN ) Avitaminosis, Ibid, 6, 65.
ue 34a) Manioc (Kassava) as a Native Food in Nigeria,
97.
34b) Ann. trop. Med. Parasit. 28, 295.
wicnoug T (1933) Indian med. Gaz. 68, 681.
(1934) Ibid, 69, 241.
Purcell, F. ao 1937) Private communication.
St. John, (1936) Malnutrition in Patients Attending the
Eye a N, of
_ (privately printed).
1936) eae communication.
Scott, H. H. (1918) An Investigation into an Acute Outbreak
“ Central Neuritis,” Ann. trop. Med. ee 12, 109.
Stannus, H. (1911) Trans. R. Soc. trop. Med. H
Wright, E. J. (1926) Report in the Sierra Locus cern Med. and
San. Report.
— (1930) The A and B Avitaminosis of Sierra Leone
(privately printed).
the Barbados General Hospital
Clinical and Laboratory Notes
UNUSUAL CASE OF CHOKING
By S. SHARMAN, M.B. Glasg.
ASSISTANT MEDICAL OFFICER, MAPPERLEY HOSPITAL,
TTINGHAM
A WOMAN of 37, a certified patient with dementia
preecox, was breakfasting’ with other patients.
At 8.15 a.m. she suddenly jumped-up and hurried to
the lavatory (followed by the nurse-in-chargo), where she
tried to cough and vomit, but merely brought up a little
saliva. She then walked to the door leading to the ward-
garden (about 30 yards) and said to the nurse “let me
out, I want air.” A few minutes later she began to turn
bluish, her respirations became gasping ; the nurse passed
a probang and then brought her back into the ward,
the patient walking with support. The patient was
helped on to a bed, where after a few moments she
collapsed. Seen by me a few minutes later, she was ashen-
grey, pulseless, and appeared to be dying from syncope
rather than from asphyxia. Her respirations continued
(5 per minute) but gradually, despite cardiac stimulants
which did not bring back the pulse, they ceased, and she
died at 8.45 a.m.
Post-mortem examination showed none of the usual
signs of death from asphyxia except that there were a
few crumbs of the pudding in the trachea and a slight
congestion of that organ. There was some congestion
of the lower lobes of the lungs, but the upper lobes were
normal. The heart was enlarged, the myocardium flabby
and pale, and there were signs of fatty degeneration in
both ventricles. There was marked atheroma of the
aorta, affecting the mouth of the coronary arteries. The
whole length of the cesophagus was filled with black
pudding, and a piece of the skin of that food pressed
against the posterior aspect of the larynx, though it
did not obstruct the airway.
In death from choking “the heart beats continue
a minute or two longer after the respiratory move-
ments have stopped ” (Peterson, Haines, and Webster
1903).—In the present case, the entry of air into the
1228 THE LANCET]
lungs could be clearly heard for some time after the
heart sounds were gone.
« Where death is due to cardiac inhibition, the usual
post-mortem findings do not obtain, but these cases
are usually characterised by death occurring with
extreme rapidity °” (Peterson and others, Mann
1922).—In this case death occurred thirty minutes
after the first onset of the choking, during which
time the patient walked about and spoke a few words.
“The impaction of a bolus in the cesophagus
caused death from asphyxia by pressure on the trachea
in two of my cases”
certainly had a large bolus of food in the esophagus,
which may have pressed upon the trachea, but the
post-mortem findings were more consistent with
syncope than asphyxia.
“ Foreign bodies may by irritation induce a reflex
spasm of the vocal cords leading to closure; or the
mere presence of such an irritation may reflexly
cause syncope, irrespective of the size or character
of the substance ” (Peterson and others).
In this case it appears that the patient had an
attack of choking but managed to free the airway
sufficiently to enable her to walk some distance and
to speak; that a second obstruction occurred (part
of the black-pudding skin acting as a valve at that
time, or by a reflex closure of glottis due to pressure
from the filled csophagus?); that this also was
dislodged or overcome; and then, while air was
entering the lungs, that the diseased heart went into
syncope, reflexly initiated. At the inquest a verdict
was returned that the patient died from syncope
due to shock caused by choking.
I am indebted to Dr. G. L.' Brunton, medical superin-
tendent, for permission to publish this case.
REFERENCES
Mann, J. D. (1922) Forensic Medicine and Toxicology (edited
by Brend, W. A.). Philadelphia and London.
Peterson, F., Haines, W. S., and Webster, R. W. (1903) Legal
Medicine and Toxicology. Philadelphia and London.
Smith, S. (1931) Forensic Medicine. London.
EXTRA-UTERINE PREGNANCY
AN UNUSUAL CASE
By R. R. D. KaRrxı-Panuwa, M.B. St. And.,
L.M. Rotunda
Ld
A woman, aged 41, was admitted to the
Lady Emerson Seth Chaturbhuj Maternity Home,
Amritsar, on Feb. 21st, 1937, with a very large
abdominal tumour which was diagnosed as ovarian
cyst. For confirmation she was twice sent to the
Civil Hospital, Amritsar, for radiography, but
unfortunately the plant there was out of order and
no skiagram could be taken.
She had had amenorrhea since December, 1935, with
usual signs of pregnancy such as morning-sickness. In
the middle of February, 1936, she had slight vaginal
bleeding which stopped after two days. In March she
had acute pain in her left abdomen lasting an hour.
Constipation was severe throughout and her abdomen
eventually became so big that she could not get up from
bed. In November, 1936, she had another attack of
bleeding lasting one day for which she was treated by a
hakim. At this time she also felt shght movements in
her abdomen on the left side. When she came to the
hospital she had had amenorrhea for 14} months. Three
years before the present illness she had had one normal
pregnancy and labour.
On admission there was a very large abdominal tumour
full of fluid, giving a thrill. No foetal parts could be felt,
but there was a hard fixed lump on the right side of
CLINICAL AND BABORATORY NOTES
(Smith 1931)—My patient —_
[MAY 22, 1937
abdomen just to the right of symphysis pubis. Foetal
heart sounds could not be heard. On March 9th I opened
her abdomen under chloroform. A sac with very thin
walls and full of fluid came in view; it was adherent to
the peritoneum all round, and while I was separating it
from the surrounding tissues it burst and 14 pints of
blood-stained chocolate-coloured fluid came out. Then
a hand was seen on the right side just above the umbilicus,
and I realised that I was dealing with a case of extra-
FILE PEM Stas Ue. Ee IIe
punas
The fœtus and placenta.
uterine pregnancy that had gone beyond full term. All
the parts of the foetus were seen, one after the other, and
the placenta was found to be adherent to the intestines
and to the peritoneum covering the bladder. The fœtus
was removed and the placenta was very carefully separated.
The abdomen was closed, a drainage-tube was inserted,
and the patient was put in the Fowler’s position as soon
as possible.
The foetus weighed 12 lb. and was 24 in. long; it
appeared that it had been dead for some time. The
placenta weighed 2 lb. and the cord was 17 in. long. The
foetus was very well formed (see Figure).
Radiography would probably have led me to make
the correct diagnosis, but unfortunately that help
was not available. The age of the woman accounted
for her amenorrhea, and therefore the condition was
diagnosed as ovarian cyst. The acute pain which
she had felt on the left side of her abdomen in March,
1936, was evidently the rupture of her left Fallopian
tube, after which the fœtus planted itself on the
intestines. I may add that recovery was uninterrupted
and uncomplicated despite the fact that there were
signs of chronic peritonitis when the abdomen was
opened.
Dehradun, United Provinces, India.
ACTION OF TRYPSIN ON DIPHTHERIA
TOXIN
By A. C. BRANDWIJK, M.D.
AND
A. TasMAN, Chem. D.
THE question of the preparation of protein-free
antigens has come very much to the fore of late.
After the successful attempts of Avery and Goebel !
there soon appeared several communications from
Topley and his co-workers ? in which the preparation
of almost protein-free antigen fractions from various
strains of typhus bacteria was described. These
latter antigens, which also possessed the property of
stimulating the production of antibodies in animals,
THE LANCET]
appeared to be stable towards treatment with trypsin.
An attempt by Stamp and Hendry? to apply a
similar treatment to the antigen of hemolytic strepto-
cocci was unsuccessful. The antigenic properties
were lost during digestion with trypsin.
It appeared to us of interest to investigate whether
or not diphtheria toxin would be stable towards the
action of trypsin.
The trypsin preparation was prepared as described by
Cole* from finely ground ox-pancreas. The alcoholic
extract was freed from solid constituents by filtration
and had a titre of 1: 5005 with centrifuged milk. This
trypsin extract contained about 25 per cent. of alcohol.
The diphtheria toxin had an Lf=1/13, while the minimum
lethal dose (M.L.D.) was 0-003 c.cm. 7:5 e.cm. of the
trypsin solution was added to 150 c.cm. of toxin and the
mixture protected against infection by the addition of a
little toluene. As a control, 7-5 c.cm. of 25 per cent.
alcohol were added to 150 c.cm. of the same toxin and
this liquid also covered with a layer of toluene.
After being thoroughly shaken, both liquids were kept
at room temperature in the dark for five days. After this
period the Lf of the control toxin had diminished from
1/13 to 1/11-5, while the M.L.D. remained unchanged.
The toxin treated with trypsin showed absolutely
no flocculation with antidiphtheria serum. Deter-
REVIEWS AND NOTICES OF BOOKS
[may 22, 1937 1229
minations of the M.L.D. with the product treated
with trypsin were carried out as follows :
Each of three guinea-pigs were treated subcutaneously
with 0-01, 0-10, and 1-00 c.cm. respectively in 4 c.cm.
of saline solution. The first two animals showed no
reaction whatever after the injection, while the third
showed only a slight transient infiltration. This slight
reaction may probably be ascribed to non-specific con-
stituents present in the toxin. The preaun treated with
trypsin was no longer toxic.
Thus diphtheria toxin is destroyed on treatment
with trypsin. This strongly supports the hypothesis
already made by many others, that diphtheria toxin
is a protein, although the possibility of the toxin
itself not being a protein at all, but a substance
very intimately attached to protein, cannot of course
be entirely excluded.
REFERENCES
and Goebel, W. EU T Med. 58, 731.
2. Raistrick, E., and Topley, W. W. C. (19 34) Brit. J. exp. Path.
al : ’ Delafield, E. (1934) Ibid, 1; 130; Martin,
15, 137; M,C » Shanin Rais-
i Wilson, J by Stacey, M allinor, S. W., and
R
3. Stamp, T. C., and Hendry,
W. (1936) Practical (Diy dioloical Chemistry.
1. Avery, O. T,
bridge
5. Douglas, C. G. (1922) Brit. J. exp. Path. 3, 263.
Utrecht. ,
REVIEWS AND NOTICES OF BOOKS
History of the Acute Exanthemata
By J. D. Rotrteston, M.A., M.D., F.R.C.P.,
F.S.A., Medical Superintendent, Western Fever
Hospital, London. London: William Heinemann
(Medical Books). 1937. Pp.114. 7s. 6d.
Dr. J. D. Rolleston’s work not only fulfils one
of the terms of the Trust that the FitzPatrick lectures
must, after delivery before the Royal College of
Physicians of London, be published as a separate
book, but, as he himself notes, serves to some
extent as a companion volume to his “Acute
Infectious Diseases”? (2nd ed., 1929). The author
hopes that his book will appeal to the increasing
number of readers interested in the history of
medicine. Few are better able than he is to
judge the extent of this increase which, it is to be
hoped, includes some proportion of those still unquali-
fied. The history of medicine for the qualified provides
a study the appeal of which is unfailing; for the
unqualified it should provide this and something more
—a sense of perspective. A course of Trousseau and
Murchison may still be recommended to the student
of the acute infections in particular as a liberal
education in the art of clinical observation Dr.
Rolleston tells of the history of small-pox, chicken-pox,
scarlet fever, measles, and German measles ; enteric and
typhus fevers, he thinks, are more suitably ranked
in the class of continued fevers—an obvious oppor-
tunity for a second volume of which we trust the
author will avail himself at some future time.
As might be expected, Dr. Rolleston gives a
scholarly and most interesting historical account of
the diseases he has selected, dwelling perhaps more
on the clinical than on the epidemiological aspects.
The retention of the term “German measles” as a
lecture-title,-like the old spelling ‘‘ Rétheln’’ where
this is chronologically correct, is to be regarded as
logical in an historical account. From its complete
omission, Dr. Rolleston evidently regards the Filatow-
Dukes or “Fourth disease” as the Mrs. Harris
of the acute infections, and this is now the general
opinion among those qualified to express one. The
cosmopolitan list of references appended to each
lecture is valuable and exceptionally complete.
So far as the major acute exanthemata are con-
cerned, study of this book and the relevant refer-
ences should tend to diminish the unwitting re-
discoveries of clinical facts already observed and
recorded by our medical ancestors.
Einführung in die Allgemeine Biochemie
By Prof. CARL OPPENHEIMER, Dr. Phil. et Med.
Berlin, Leiden: A. W. Sijthoff’s Uitgevers-
maatschappij. N.V. 1936. Pp. 227.
THE author. explains in a foreword that the book
is an attempt to assist biochemistry to its rightful
place by developing a general biochemistry, ‘that is,
to teach those fundamentals which are not subject
to the limitations of division according to the three
“ Kingdoms of the World of Knowledge,” but are
free from any special physiological consideration.
He has divided his work into sections under headings
such as living matter as a chemical system, the
building substances of living matter, synthesis and
degradation of foodstuffs and cell matter, the chemical
mechanisms of cell processes, and the thermodynamics
of living matter; and he deals largely in broad
generalisations.
Whether this praiseworthy effort is a success
depends on at least two things: first, whether experi-
mental biochemistry is yet advanced enough to
allow of such a wealth of generalisations; and
secondly, whether there exist many readers to whose
taste this sort of reading is likely to appeal. We
ourselves hold biochemistry to be a laborious science
in which the thinkers should not be allowed to out-
strip the workers, a principle which applies mainly
to the biological sciences. Prof. Oppenheimer tends
to evade rather than face and overcome difficulties.
For instance, when he comes to a dangerous topic,
such as that of carbohydrate oxidation, he says
at first: “ We can give here only quite a superficial
picture, for the debated details are interesting only
to the expert ” ; but later sums up a situation which
1230 THE LANCET]
he has not really defined in the facile phrase “In
principle, therefore, the vast central problem .. . is
to be regarded as solved.”
The student is scarcely in a position to appreciate
the generalisations, whilst the lack of references
would be irritating to the advanced worker who
would no doubt prefer the same author’s ‘‘ Chemische
Grundlagen der Lebensvorginge.”’
The Common Neuroses—Their Treatment by
Psychotherapy
Second edition. By T. A. Ross, M.D., F.R.C.P.,
formerly Medical Director, Cassel Hospital for
Functional Nervous Disorders. London: Edward
Arnold and Co. 1937. Pp. 236. 10s. 6d.
Tars book has already proved its value to the
practitioner who seeks guidance in the labyrinth of
symptoms which neurotic disorders present at every
turn, Dr. Ross makes it clear that he could not
hope to help the student to knowledge in a subject
beset by theories if he were to concentrate on the
difficult issues raised by these theories. The book
. therefore is a practical guide to the everyday
problems of neurotic illness rather than a text-book
on mental dynamics. Unlike other departments of
medicine in which pathology, etiology, and treatment
can be clearly marked off, psychopathology and
psychotherapy are closely interwoven. It has been
wisely said that diagnosis in this, department of
medicine is only arrived at in the course of treatment
when investigation runs concurrently. It is for this
reason that books of this kind appear to be
unsystematic. Dr. Ross is no ideologist, as his book
makes clear, but he is concrete on every page and
never abandons his patient to pursue a theory. There
remain many matters in this volume which will not
satisfy the psychopathologist with an eye for
systematic study of mental dynamics. While Dr.
Ross admits his debt to Freud, he does not pay 20s.
in the pound. The reader will be grateful to him
for a very valuable handbook to the psychopathology
of everyday practice. ;
EP ES
Medical Urology
By Irvin Kort, B.S., M.D., F.A.C.8., Attending
Urologist, Michael Reese Hospital, Chicago.
London: Henry Kimpton. 1937. Pp. 431. 21s.
Tue title of this work is misleading. By the
term ‘‘ medical urology ” most of us understand those
diseases of the urinary system that come under the
care of the physician rather than of the surgeon,
‘that is to say, such conditions as nephritis. Dr. Koll,
however, uses the term to imply the urology of
the general medical practitioner rather than of the
specialist. His book is designed to be useful to the
general physician and to the medical student. It
provides a general survey of the subject, and is
intended to supply just that knowledge that a prac-
titioner requires without intruding on the province
of the specialist. Only those methods of examination
are given which the practitioner is capable of making
and only those forms of treatment described that come
within his range of therapeutics. For those who
want more details a bibliography is supplied.
Dr. Koll writes clearly, gives the results of his
own experience, and avoids confusing his readers
with rival theories. His book is well arranged and is
illustrated by means of excellent diagrams and
plates. The omission in a book describing methods
of treatment that come within the therapeutics
of the general practitioner of such subjects as the
treatment of urinary infections by means of the
REVIEWS AND NOTICES OF BOOKS
[may 22, 1937
ketogenic diet or of mandelic acid is unfortunate.
Our impression is that the work will prove of greater
use to medical students wishing to revise rapidly
their knowledge of urology than to practitioners.
Rasse und Krankheit
By Various Authors. Edited by Dr. med, JOHANNES
SCHOTTKY, Abteilungsleiter im Stabsamt des Reichs-
bauernfiihrers. Munich: J. F. Lehmann, 1937,
Pp. 468. Price outside Germany M.16.20.
A TREATISE on race and disease edited by a German
official is likely to excite the apprehensions of a
foreign reader; he may expect the virtues of
‘“‘ aryans’”’ and the vices of ‘‘ non-aryans’’ to figure
prominently and rhetorically through the 468 pages.
He will be agreeably disappointed. The word aryan
is not to be found in the index and, with the possible
exception of the concluding article by H. Wilker on
racial mixture and disease, there is little if anything
in the treatise which suggests political prepossessions.
J. Schottky is responsible for a general introduction
and the sections on race and mental disease and
feeble-mindedness. O. Fléssner deals with racial
physiology, W. Unverricht with race and internal
diseases, B. de Rudder with race and infectious
diseases, G. Olpp with tropical diseases, M. Schubert
with dermatology, B. Kihn with neurology, K.
Beringer with metalues, F. Hartel with surgery,
G. Frommolt with gynecology and obstetrics, W.
Clausen and R. Grimm with ophthalmology, H. Barth
with diseases of the ear, nose, and throat, F. W.
Proell with odontology, and H. Auler with cancer.
From the introduction onwards the difficulties
of defining race, of distinguishing between racial
and environmental influences, and, above all, of secur-
ing precise information are emphasised, perhaps even
over-emphasised. de Rudder says firmly that we
have no evidence at all of any fundamental differences
in the reactions of different races to infectious diseases.
Kihn says “it is a melancholy fact that all statistical
data respecting diseases are thoroughly untrust-
worthy.” Some of the writers make as brave a show
as they can with statistical comparisons sometimes
of nationalities, as when the marching paces per
minute of armies are compared, sometimes of alleged
races, the Nordic, the Mediterranean and so on.
But practically all of them are oppressed by the
cloud of doubtfulness in which things are enveloped,
even if all are not so gloomy as Beringer who begins
his summary with the words “and so ends our
journey through the tangle of attempted solutions
which overlies an apparently so simple question.”
Some of the writers, for instance Olpp in his article on
race and tropical diseases, side-track most of the specu-
lative questions and give a straightforward account
of what used to be called geographical pathology.
The book is very well illustrated and as a text-book
of geographical pathology has merits. The style
of most of the writers is not unduly ponderous and,
although a great majority of the references are to
German writings, the authors are distinctly aware
of the existence of other nations. Of course the
general problem, like the particular problem which
vexed Beringer, ts overlaid with difficulties. At
first it seems so simple; one does not need to be
an anthropologist to be confident that, whatever
may be the definition of race, we, the Chinese, the
African negroes, and the Red Indians, certainly
do not belong to the same race. How easy it should be
to compare their reactions to disease." Then we
perceive that far from being easy it is very difficult,
because, among other things, we have real control
THE LANCET].
REVIEWS AND NOTICES OF BOOKS
[may 22, 1937 1231
experiments only on a few simple reactions. This
is so when we compare what the man in the street
would call racial extremes. When we seek to compare
Germans, and Frenchmen, and Englishmen, the
business becomes almost fantastic. Perhaps one day
some genius will show how the problem may be
solved ; he is not yet here.
Inhalation Anzsthesia
By ARTHUR E. GUEDEL, M.D., Assistant Clinical
Professor of Surgery (Anesthesia), University of
Southern California School of Medicine, London :
Macmillan and Co. 1937. Pp. 172. 10s. 6d.
Dr. Guedel says in a short preface that his little
book is intended to “guide the anesthetist up to
and through his first few general anszsthesias.”’
This slightly ambiguous sentence indicates pretty
well the nature of the book. It deals with fundamental
principles and makes no attempt to supply that
detailed practical information which can really be
satisfactorily given only direct from teacher to
pupil at the operation table. Nor is the text cumbered
with descriptions of apparatus. The book is in fact
most interesting to read and unlike the usual small
handbook in its constantly scientific outlook and
endeavour to establish practice on logical scientific
lines. It is more a doctrinal application of
physiology to the anesthetist’s aims and activities
than a text-book and it illustrates the principles which
its author has found effective in the education
of students. The chart of stages and planes of anæs-
thesia which Guedel devised and reproduces in the
book was made familiar to many British anesthetists
by Dr. R. M. Waters on his last visit to this country.
In the chapter headed Mechanism of Anesthetic
Requirements the author gives the best account we
have come across of the relation between a patient’s .
metabolic rate and the effect which an inhaled anæs-
thetic will have upon him. He supplies a logical
and sensible explanation of phenomena which appear
to the uninitiated peculiar and surprising. The
second part of the book deals with anesthetic accidents
and here again the strictly scientific analysis of the
problems presented is admirable. Throughout there
are illustrative cases which are related with a dramatic
intensity which is well calculated to enforce the
lesson which they teach. We have but one grudge
against the author, his almost inexhaustible relish in
the split infinitive; many of his pages supply two
or three striking examples.
Emanotherapy
By F. Howarp Humpuris, M.D. Brux., F.R.C.P.
Edin., D.M.R.E. Camb., Honorary Consulting
Radiologist to, and Member of, the Medical
Advisory Board of St. John Clinic and Institute
of Physical Medicine; and LEONARD WILLIAMS,
M.D. Glasg., late Physician to the French Hospital.
London : Bailliére, Tindall and Cox. 1937.
Pp. 188. 7s. 6d. l o
THE authors of this book are concerned at the
confusion in the mind of the public between the
use of radium and its salts as a destructive agent
and the exposure of patients to what they regard
as the beneficial and innocuous influence. of radium
emanation in small dosage. In order to mark the
distinction and to dispel fears they favour the term
emanotherapy for what has been called “mild
radium therapy” or “radon therapy.” They claim
that its value, though little appreciated in this
country, has been recognised by a formidable array
of distinguished clinicians abroad, the list including
such internationally famous names as Hiselsberg,
Lorenz, Novak, Wenckebach, Sauerbruch, and
Doederlein. The conditions in which emanotherapy
is said to be specially indicated are gout, ‘‘ goutiness,”’
pelvic pain, salpingitis, sterility in women, psoriasis,
and chronic catarrh of the respiratory organs;
and the widespread uses, here cited, to which this
treatment has been put by enthusiasts include mental
disease, post-operative adhesions, high blood pressure,
neurasthenia, tabes dorsalis, enlarged prostate, and
spinal arthritis. Most of the readers of this book will
remain unconvinced by the argument that the
doubtless excellent results obtained by the authors
and others in such various conditions depend primarily
on radium emanation, whether administered by
ingestion, inhalation, subcutaneous injection, insuffla-
tion, irrigation, or pulverisation. Those who want to
acquaint themselves with the methods used by
emanotherapists will find them set out in detail
and will also be referred to many more specialised
publications on the subject. The book is well produced
and printed and the diagrams of apparatus including
the inhalation tube partly devised by one of the
authors are easy to follow.
Synopsis of Ano-Rectal Diseases
By Louis J. Hmscuman, M.D., F.A.C.8., Professor
of Proctology, Wayne University; Extra-Mural
Lecturer on Proctology, Post-graduate School,
Michigan. London: Henry Kimpton. 1937.
Pp. 288. 15s. |
THIs is a simple practical guide in the treatment of
those minor diseases of the rectum and anus that do
not require major surgical operation. Almost all the
procedures described can be carried out in a well-
equipped consulting-room, and for most of them the
patient need not be kept in bed. None of the
apparatus described is complicated or expensive,
and although notes on the diagnosis of the more
severe affections of the rectum and sigmoid colon are
included, their treatment is not discussed. The most
valuable point about the book is that the description
of each form of treatment is so detailed that the
reader can picture himself doing the operation.
Methods of anesthesia are particularly well described.
The author himself favours caudal anesthesia, but
also advocates spinal, sacral, and infiltration methods.
Inhalation anesthesia is held to have no place in
these minor operations. Some surgeons would prefer
gas to infiltration anesthesia in opening ischiorectal
abscesses, but Prof, Hirschman does not mention it
in this connexion. The accounts of the operations
for fissure-in-ano and for the removal of piles rob
them of much of their terror for the inexperienced
operator. The author’s special modification of the
ligature treatment of piles seems to be particularly
valuable in cases where hemorrhage has so exhausted
the patient that the primary consideration is to stop it
with as little interference as possible, Prof. Hirschman
seems to find his ligature operation more satisfactory
than injection.
Preparation of the patient for rectal operations
and post-operative care of the bowels are described, not
in a separate chapter but as part of each procedure.
Although this involves some repetition, it has a
practical advantage in emphasising the importance of
these stages of the treatment. The chapter on
pruritus ani contains many useful prescriptions. The
volume is profusely illustrated with photographs and
line drawings. The author vouches for the success of
all the methods of treatment included, and he deserves
praise for his clear and practical exposition,
1232 THE LANCET]
(may 22, 1937
NEW INVENTIONS
A MODIFIED BRONCHOSCOPE
THe value of direct inspection of the bronchi
for diagnosis or therapeusis is increasingly recognised
and measures affording improved illumination and an
adequate working lumen in a bronchoscope are
useful because they minimise difficulties and dangers.
The modifications about to be described are mostly
those of other writers, but they have been assembled
and combined into one instrument with the generous
advice and help of Mr. Perey G. Phelps, of Messrs.
Mayer and Phelps Ltd.
Fig. 1 shows the: modified bronchoscope, which
can be made in various lengths and
calibres. It has been found that for
inspection of the main bronchi a
bronchoscope of 39-5 em. by 10 mm.
inside diameter is most useful;
for the secondary bronchi an instru-
ment 44:5 cm. by 8 mm. permits
of an easy and well-illuminated view; whilst a tube
48 cm. by 7 mm. is used for the more distal bronchi.
The tube is similar to the Jackson model save that
the proximal inch is widened in the vertical axis, 80
that the inlet of the tube is oval; this facilitates
the introduction of endoscopic instruments.
Originally the instrument was equipped solely
with the dual projected lighting system as used in the
Negus laryngoscopes and cesophagoscopes, and I
am indebted to the patentee (Mr. R. Schranz of the
Genito-Urinary Manufacturing Co., Ltd.) for per-
mission to incorporate this system of lighting. Later
FIG. 2.
it was suggested by Mr. R. Doyle, F.R.C.S., resident
surgical officer at the Royal Southern Hospital,
Liverpool, that the value of the bronchoscope would
be enhanced if distal lighting were added; for not
only would this increase the illumination for direct
inspection of the bronchus, but it would also permit
of the use of the Pinchin-Morlock telescopes } through
the instrument. Fig. 2 depicts the special holder
for use with these telescopes. The dual lighting
system is removed and the telescope-holder is then
fitted into the sockets usually occupied by the dual
lighting system. Fig. 3 illustrates a telemagnifier
as devised by Dr. Israel? in the United States.
The telemagnifier gives a magnification of
3} diameters, is light in weight, causes no
respiratory obstruction, and can be focused to
different distances for use with tubes of various
lengths. It is mounted on two rods which are
hinged at A near the points where they plug
1 Pinchin, A. J. S., and Morlock, H. V. (1932) Lancet,
"2 Israel, S. (1935) Ann. Olol., £c., St. Louis, 44, 285.
into the sockets B. These sockets
are situated laterally to those for the!
dual lighting system at the proximal
end of the bronchoscope. By means!
of the hinges the telemagnifier can be'
tilted instantly out of the field so that
instrumentation through the tube can
be carried out with the telemagnifier
either in position or tilted up as
desired.
Fig. 4 shows a special upper-lobe
bronchoscope which is lighted as
FIG. 1.
described above and which can be used with the
telemagnifier. It is designed after the model of
Dr. Vistreich® of New, York. The dimensions
of the bronchoscope are 36 cm. by 10 mm. and
its distal end is cut to form a double V. At the
apices of the V is hinged a small stainless-steel mirror
-which is sufficiently large to reflect the
entire image of the orifice and proximal
portion of the upper lobe bronchus.
The angle of the mirror is controlled
by a screw mechanism at the proximal
FIG. 3.
end of the instrument which can be operated easily
by the thumb. It is necessary to point out that
the interpretation of the mirror image thus obtained
requires some practice, but once this technique is
acquired the information procured is of great interest
and value.
The instruments briefly described above give excel-
lent illumination, they possess a good working lumen,
and they can be used either with distal or proximal mag-
nification. They have been in use regularly for two
years in a bronchoscopic clinic and have given satis-
faction. They are made by Messrs. Mayer and Phelps
Ltd., of New Cavendish-street, London, W.1.
J. E. G. MCGIBBON,
M.B. Lond., D.L.O.
Hon. Aurist and Laryngologist, Royal
Southern Hospital, Liverpool.
P * Vistreich, F. (1935) Arch, Otolaryng.
22, 634.
FIG. 4.
THE LANCET]
THE - LANCET
LONDON: SATURDAY, MAY 22, 1937
t
THE LONDON BUS DISPUTE
Ir is regrettable that the comfort and con-
venience of Londoners and their visitors should
have been disturbed during the Coronation festi-
vities by the cessation of their most important
means of surface transport, but it would be wrong
to take the short view that a strike of busmen.
was a sudden manceuvre designed to take a mean
advantage of a great national event. It was the
culmination of years of argument during which
there had been constant complaint of stress and
ill health due to speeding-up of the services as
well as frequent “lightning strikes ” at different
` garages—always against the advice of the men’s
union and often for apparently trivial causes.
General discontent was obvious, and equally
obvious was the need, in the public interest,
for that discontent to be remedied.
But here comes in a new consideration. If
mechanical defects had become troublesome,
expert assistance would have been sought and
laboratory specialists might have advised upon
metallurgy or the physics and chemistry of oils,
just as, we believe, experts in acoustics were
called upon to deal with excessive noise in tube
trains ; but when the human part of the equipment
showed signs of stress there seemed to be no
awareness of the existence of knowledge that might
be applied to the study and alleviation of that
difficulty. Ever since the late war forced upon our
authorities the need for study of the health and
hours of munition workers, there has been carried
on under the Industrial Health Research Board
extensive investigation of these very problems of
industrial stress and the methods of meeting it
by rest-pauses, rearrangement of work, or other-
wise. The results are to be found in the reports
of the Board, and in addition the National Institute
of Industrial Psychology, a non-official body, is
at the service of employers and employed, for
consultation on such matters. Yet evidence at
the recent court of inquiry revealed that such
questions as whether a certain trip should occupy
108 or 109 minutes, whether the extra minute should
come off the men’s stand-off time, and whether
this was in accordance with the Board’s agreement
with the union, had been a matter of haggling
between the drivers’ representatives and those of
the Transport Board and a cause of exasperation
to the men in the district. The logical rights and
wrongs of the points concerned are immaterial ;
that the human machinery was in danger of being
thrown out of gear was what mattered to the public.
The recommendation of the court that an inquiry
should be carried out as to the conditions of work
and their effect upon the men is welcome, but
THE LONDON BUS DISPUTE
{may 22, 1937 1233
the need for the recommendation arouses thought.
A recommendation that similar i inquiry should be
made into financial or engineering difficulties, by
which the convenience of the public had suffered,
can scarcely be imagined, for the public rightly
assumes that such matters are in the hands of
experts whose business it is to deal with them ;
the same public has nevertheless accepted, without
surprise, that a strike is necessary in order to
force attention to the human part of the working
equipment. We trust that the inquiry will be
held, for to leave the matter to the issue of a
strike is to sow the seeds of further trouble.
Industrial psychology is a technical subject,
and when the claim arose that the men suffered
stress, physical or mental, from driving a modern
bus at modern speeds through London streets,
that claim called for study and, perhaps, planned
experiment ; certainly not for a process of bargain-
ing carried out under the threat of a strike. If
the general principle involved should come to be
recognised, as a result of the present conflict,
we may be saved from worse trouble in the future.
TUBERCULOSIS AMONG WILD FIELD-VOLES
Many of the most spectacular advances in
modern knowledge have taken place when specialists
have been forced to look at their own subject from
the standpoint of the discipline and technique of
some other body’s science. This fertile outcome of
the interaction of the “unlike ” in science is well
illustrated by the announcement by Dr. A. Q.
WELLS on another page of his discovery of a
tuberculous-like disease among English voles. In
the foot-and-mouth disease investigation a distin-
guished animal ecologist, Mr. CHARLES ELTON, has
recently been called upon to help in pathological
research ; the codperation of a pathologist has
now been enlisted for the study of some of the
special problems of animal ecology being under-
taken at the Bureau of Animal Population at
Oxford. The early outcome of this codpera-
tion will give satisfaction to both ecologists and
pathologists and is a happy augury of a fruitful
partnership in the future.
The field- or meadow-vole (Microtus agrestis),
' widely known as the short-tailed field-mouse or
grass-mouse (though it is no mouse), is, it will be
remembered, a little rodent with a reddish-brown
back and a greyish belly, about 4 inches long
without its tail and possessed of a blunt head and a
short disproportionate tail which looks as if it had
been subjected to some untoward accident. The
curious little interlacing alley-ways or “runs”’ it
makes beneath the meadow grass must be familiar
to all who know the countryside. For many years
it has been known that this little mammal is
subject to remarkable fluctuations in population.
Even under average conditions it is very numerous
in our meadows, though its caution and shyness
may give the casual observer a false impression
of rareness. From time to time the numbers of
these animals decline rapidly and on certain
occasions and in certain localities voles may almost
disappear. They are staple articles of diet for
1234 THE LANCET]
MIDDLE-EAR DISEASE IN INFANCY
[may 22, 1937
owls, rooks, and other predatory birds as well as
for weasels, and vast numbers are known to be
consumed by these enemies, but it has been con-
sidered probable that the marked and rapid waning
of numbers is due to an epidemic disease and to
this condition the name “vole plague ” has been
given. It is presumably while investigating this
cause of mortality among voles, of the nature of
which we are quite ignorant, that Dr. WELLS has
been rewarded by his unexpected and interesting
discovery. _
The investigations are still at a very early
stage, but since February in this year 134 voles
have been found with the lesions of tuberculosis
and in these lesions acid-fast bacilli were present
resembling Mycobacterium tuberculosis. In at least
one strain the organism has proved virulent to
rabbits and guinea-pigs though it is as yet impos-
sible to say whether the prevailing strains are to
be referred to the human or to the bovine type of
the bacillus. When it is considered that the
field-vole is extremely common in our pastures
and that many of them with open lesions must be
scattering infection, the medical and hygienic
possibilities of Dr. WELLS’S discovery become
obvious. Whether the bacilli he has found in
voles are pathogenic to other animals or to
man remains to be seen, but it is noteworthy
that they were fatal to guinea-pigs. Obviously
the contamination of areas of water-supply or of
pasture used for feeding dairy herds from this
source is a possibility that must at least be con-
sidered. In the meantime ecologists, pathologists,
and epidemiologists will be equally impatient
for further information. j
The British voles present exceptional interest in
respect to ecology and distribution. Not only
does the field-vole suffer from “ plagues ” but at
times, by sudden increases in its population, it
becomes itself a plague to agriculture and horti-
culture. Ups and downs in its population are
reflected by the ups and downs of owls and other
predatory species; the ecologist will have to
broaden his stage to make room for such a redoubt-
able protagonist as the tubercle bacillus and many
new problems are bound to arise. Interesting
possibilities open in the study of susceptibility
among a number of more or less closely allied
members of the vole family. Thus there are various
sub-species of Microtus agrestis which occur upon
the heights of the Highland mountains and in the
different Hebridean islands and there are at least
five different sub-species of the field-vole’s larger
cousin, the Orkney vole, which are peculiar to the
different islands of the Orkneys. It will be
interesting to study the incidence of the disease
and the experimental susceptibility to tuberculosis
of these varieties. It may be mentioned that it is
generally thought that the Orkney voles (Microtus
orcadensis) keep their numbers very steady and
are not subject to the plagues which affect their
relations on the mainland. Not the least instruc-
tive of the lessons of this new discovery is that the
study of the parasitology of wild life, which has
given up so much treasure in the past, is still an
unexhausted vein.
MIDDLE-EAR DISEASE IN INFANCY
SPECIALISTS in paediatrics and in otorhinology
have during the past few years become increas-
ingly aware of the widespread ravages of otitis
media among very young children, but it is doubtful
whether practitioners as a whole have yet grasped
the implications of recent observations. The
various contributions made to a discussion by
the section of otology of the Royal Society of
Medicine reported in our last issue bring out clearly
the gravity of the situation. Otitis media is
evidently extremely common in children under
five years old; and the younger the child the
more obscure are the symptoms and the more
likely is the condition to be overlooked. When
suppurative otitis is looked for at post-mortems
on children it is very often found and the fre-
quency of its detection in the dead body has very
little relationship to the diagnosis of disease made
during life. Dr. J. H. EBBS in an analysis of
autopsies on 880 children mostly under two years
old found post-mortem evidence of suppurative
otitis in 52-8 per cent. and this incidence would be
endorsed by most pathologists with wide experi-
ence of autopsies on children. It is clear that the
clinical diagnosis of the disease in the young
is far from satisfactory. Often there appear to
have been no symptoms pointing to the ear as a
seat of the trouble. Pediatricians have called
attention to the fact that the outstanding symp-
toms in many children are gastro-intestinal and
that a label of “D. and V.” or “ dysentery ”’
may be given to cases which are subsequently,
sometimes too late, found to have suppurative
otitis as their main lesion. According to Dr.
T. Ritcnre Ropcer, nearly half the cases are
bilateral. And the fact that in very young children
the tympanic cavity and the mastoid antrum
are in such intimate anatomical relationship
means that otitis almost necessarily implies
mastoiditis.
An exact estimate of the contribution of purulent
otitis to infant mortality has yet to be made but
it is evidently a factor of considerable importance.
Much more information is desirable on the bacterio-
logy of the condition. The general opinion is that
hemolytic streptococci play a major part, but
other organisms such as the pneumococci, and even
intestinal bacilli, may be implicated. The rôle of the
tubercle bacillus under normal conditions is small
but significant ; tuberculous otitis may on occasions
become what amounts to an epidemic disease.
Dr. R. B. LuMspEn for example spoke of an incidence
of tuberculous otitis reaching nearly 40 per cent.
in a hospital near Edinburgh. In the light of this
information a grave responsibility is placed upon
all branches of the medical profession who are
concerned with the health and welfare of children.
Otorhinologist, pediatrician, epidemiologist, patho-
logist, and bacteriologist must pool their experience
and collect and correlate more data. In the mean-
while the practitioner must be on the alert to
make an early diagnosis; an examination of the
ears should be part of the routine examination
of every sick child and those who are doubtful of
a
THE LANCET]
their ability to interpret what they find should,
failing expert help, err on the side of action.
Early incision of the ear-drum, it is agreed, is
a first principle of treatment; and this may have
to be followed later by a more radical operation.
It is, however, on the preventive side that
constructive action is most urgently needed.
From a consideration of general principles comes
every hope that this disastrous and crippling
disease of infancy is preventable ; and the problem
of the prevention of otitis media and its complica-
tions has been and still is largely neglected. The
observations of OKELL and ELxiott’ on the spread
of streptococcal infection in ear, nose, and throat
wards have made it abundantly clear that infection
from patient to patient is a very real thing and is
responsible for widespread and as yet probably
only partly realised disasters. The investigations
of W. A. Brown and V. D. ALLison, recorded
in the current issue of the Journal of Hygiene,
on cross-infection in scarlet fever wards tell the
same story. The first and most pressing duty
of the practitioner is to realise that otitis media,
particularly when due to hemolytic streptococci,
is not only an infective but also an infectious
condition and that it should be treated with the
same precaution as any other highly contagious
disease. The main difficulty of following this
precept is, of course, that the source of contagion
may masquerade in various clinical forms. But
in cases of established local infection any careless-
ness or indifference that leads to its spread is
a reproach to the whole profession. The limelight
has now been turned on a dark corner of everyday
medicine and it may be hoped that the report
of the recent discussion will serve as a signal for
attack from every side on this outstanding problem
of child health and welfare.
CLIMATES LARGE AND SMALL
THE medical science of climate still rests on
experience rather than experiment. The fashion
lately has been to decry the experience, to say
that all air is the same, and any locality as good
as another. It is true that man can live at the
Equator and (more or less) at the Poles ; but the
fact remains that a journey from one to the other
requires physiological adjustments, and some
people are sensitive enough to notice a difference
even in travelling from a Yorkshire moor to a
Cornish valley: Nor is this really surprising, since
life, as HERBERT SPENCER put it, “‘is the con-
tinuous adjustment of internal relations to external
relations ” and even the comparatively crude data
of the meteorologist and geographer teach us that
our atmospheric environment varies. It varies
in time, from hour to hour, according to pressure,
temperature, wind, light, humidity, precipitation,
_and electric potential, not to mention the obscurer
influences of atmospheric ionisation or cosmic rays. .
It varies in place, according to elevation, soil,
shelter, aspect, and vegetation. Some may hold
that man, provided he has an umbrella, is too
hardy to bother about such trifles : he can operate
1 Okell, C. O., and Elliott, S. D. (1936) Lancet, 2, 836.
CLIMATES LARGE AND SMALL
than its heat.”
1235
a typewriter or loom equally fast in Bayswater,
Brighton, and Bombay. But can he? And does
it make no difference to his output whether his
office or factory is at 50° F. with an open window
or at 70° F. with central heating ? And even if
climatology, local and general, has nothing to offer
the healthy, can we doubt that it has something
to offer the sick, whose powers of adaptation,
whose sensibility to influences good and bad, are
notoriously deranged ?
As a matter of fact, even those most sceptical
about climatology already accept much of its
teaching. None will deny for example that the
activity of micro-organisms and the growth and
fruiting of plants are nicely adapted to known
conditions of temperature and humidity. From
this it is but a step to consider, as ELSwWORTH
Huntineton did, what is the optimum for the
human species. His conclusion (which in a way
supports the sceptics) was that there is not so
much an optimum as an optimal range; since
variation rather than stability is favourable to life,
and “the uniformity of a climate is more deadly
For the development of a high
civilisation HUNTINGTON demanded a mean tem-
perature of 64° F., a relative humidity of 80 per
cent., and—equally important—frequent but not
excessive changes. Wind and storms are helpful,
and in this respect the British Isles are fortunate,
being situated between three great pressure and
weather systems—the high pressures of the Azores,
the Icelandic low pressures, and the continental
pressures, high in summer and low in winter.
But the variation must not be overdone. The
unduly stimulant climate has been compared to a
bad driver who exhausts his horses; whereas the
ideal is a rhythmical urging and checking, preferring
the voice to the whip. How much daily variation
should there be in the climate of the factory ?
How much can be borne by the young adult
with rheumatoid arthritis and what are the means
round which it should vary ?
In our own country the British Health Resorts
Association continues its attempt to define the
essential features of various localities, and its
latest handbook,! which should be useful to every
practitioner, takes another step towards scientific
accuracy by providing ingenious tables summarising
in a few lines the “ invalid’s winter ” to be expected
at various resorts. It is right to press for more
informative meteorological records of this kind |
but it is even more important to assess their
significance in terms of the human body. Medical
climatology—if that is to be its name—must assess
the powers of adaptation of the body to climatic
influences in youth and old age, in health and in
illness. Thus conceived it becomes an aspect of
medicine which must interest all who seek the
efficiency of man, and advance is possible in it
from many directions. The industrial physio-
logist, with his ‘‘ micro-climates’”’ of laboratory
_ [May 22, 1937
1 British Health Resorts: Spa, Seaside, Inland; including
Australia, Canada, Cyprus, New Zealand, South Africa, and
British West Indies. Official Handbook of British Health
Resorts Association. Edited by R. Fortescue Fox, M.D.,
: London: J. and A. Churchill. 1937. Pp. 178.
28. Gd
1236 THE LANCET]
and workshop, approaches it from one angle; the
pediatrician from another, for as BAUDOUIN ê
remarks, the faulty adaptation shown by many
children should throw light on the means of
defence against external stimuli and the way they
can best be utilised. For many morbid states
there is a “climate” which we should seek to
promote, and it is almost ridiculous, for example,
that at this time of day we should still be uncertain
whether children with pneumonia should not after
all be nursed out of doors. Dr. GEoraE Day 4
lately mentioned that he was trying to discover
the effect of certain types of weather on tuber-
culous patients and had reached the tentative
opinion that they do best when it is positively
2 Baudouin, G. (1936) Rev. Physiothér. 12, 370.
3 See, for example, Wallace, H. L. (1937) Brit. med. J.
March 27th, p. 657.
‘J. State Med. March, 1937, p. 157.
MALARIA AND SYPHILIS
[xay 22, 1937
vile. Much information on such subjects has been
gathered by W. F. PETERSEN in the United States
and published in his “The Patient and the
Weather.” Hitherto it has been customary mostly
to rely on impressions; but better even than
the best impressions are measurements, and the
systematic studies made during the last twenty
years on non-tuberculous children in the island of
Föhr > near Heligoland are an example of serious
effort to introduce precision where it is badly
needed. We may be unable to guess whether the
“ climate ” we recommend—be it at the seaside or
in a bedroom with closed windows—will benefit
our patient, but we should at least try to find out
what effect, if any, it has upon his bodily functions
and the course of his illness. This is a part
of clinical science where we want facts. :
* Kestner, O. (1937) Brit. med. J. March 13th, p. 555.
ANNOTATIONS
MALARIA AND SYPHILIS
THOSE responsible for the mental hospitals of the.
London County Council are anxious that the
opportunities afforded at Horton for the treatment of
neurosyphilis and general paralysis should be better
known. A special unit for the treatment of syphilis
of the nervous system was established there in 1925
by the L.C.C. and Ministry of Health jointly and some
800 cases have been treated. The unit has served
a second purpose, because the malariotherapy given
has allowed of valuable studies of induced malaria.
The methods developed by the Institute for breeding
and infecting mosquitoes have been copied in other
parts of Europe: Wagner-Jauregg’s clinic in Vienna
has adopted the Horton technique for examining
blood films, and the plans of the insectarium have
been reproduced in Germany, Roumania, and Holland.
The research on malaria, which has attracted visitors
and investigators from all parts of the world, has been
made possible only by team-work. The cases have
had medical care from one of the medical officers of
Horton Hospital; the laboratory is in charge of
Mr. P. G. Shute with two assistants; the Ministry
of Health, besides giving clerical aid, have allowed
Colonel S. P. James, F.R.S., to direct the malaria
work and establish a research centre. Since Colonel
James’s recent retirement, Horton has formed a
liaison with the London School of Hygiene and
Tropical Medicine, and Prof. J. G. Thomson is carrying
onthe work. A whole-time investigator, Colonel J. A.
Sinton, I.M.S., with a malaria research fellowship
. from the Royal Society, is now at the hospital, and
we are glad to learn that another whole-time worker,
Dr. E. L. Hutton, with a clerical assistant, is under-
taking work from the neurosyphilitic aspect, under
supervision from Dr. W. D. Nicol, the medical
superintendent, who last November visited Wagner-
Jauregeg’s clinic as well as hospitals and institutions
in Germany. The records of cases already treated
will furnish much good material; the incidence
of syphilis in families of general paralytics is now
being inquired into. The hospital is also keen to
treat more and earlier cases, particularly as it is
hoped that advantage will be taken of the facilities
for treating patients on a voluntary basis at a stage
long before the necessity for certification. In this
type of case very favourable results are to be
anticipated, and the duration of the patients’ stay
in hospital should be considerably curtailed, being
in suitable cases as short as 3-4 weeks. It is hoped
that the opportunities for studying neurosyphilis
will attract to Horton as many inquirers as the
opportunities for studying malaria have attracted
during the past ten years.
SILICOSIS
OBSERVATIONS on the chemistry of some dan-
gerous dusts made by a group of workers at the —
Imperial College under the leadership of Prof.
H. V. A. Briscoe and summarised in two letters in
Nature (May lst, 1937, p. 753) may throw useful
light on some of the perplexities of human silicosis.
Briefly their discovery is that freshly made dust
may be quite different chemically and mineralogically
from the rock from which it has been derived: it
quickly takes up water from damp air and readily
yields alkali and soluble silica on extraction with
water, much in excess of the solubility of natural
quartz. The same dust when it has lain some time in
contact with air is much less reactive, and this
accumulated dust has often been used for experi-
ments on animals whereas in actual practice men are
of course exposed to dust immediately it has been
made by rock-drilling or blasting. A natural inorganic
particle is so arranged molecularly that, rather like
an animal, it is coated with a relatively inert skin,
and when it is mechanically broken its molecules are
disarranged and it may become by comparison an
active chemical agent. It has also been discovered
that the solubility of silica from quartz dust is much
reduced by mixing with finely divided charcoal,
anthracite, ordinary coal, or lime, from which various
possibilities in the way of prevention arise as well
as some explanation of the difficulties about silicosis
in some coal-miners.
MUSICOGENIC EPILEPSY
It has long been known that auditory stimuli
may bring on epileptic attacks, the commonest form
of stimulus being a loud and unexpected noise.
- Music may, rarely, be a determining cause of fits,
and Dr. Macdonald Critchley 1 has collected notes
of 20 cases illustrating this sequence of events.
Of these, 4 were under his own care, 7 were reported
to him by colleagues, while the remaining 9 are
1 Brain, 1937, 60, 13.
THE LANCET]
THE OLD ASHMOLEAN MUSEUM
[may 22, 1937 1237
extracted from the literature, mostly, be it noted,
of Russian origin. The clinical histories show little
in common, though it is worth noting that in 11
out of the 16 cases in which it is recorded the age of
onset of the epilepsy was over twenty-five years.
Dr. Critchley is satisfied that the fits showed the
usually accepted characteristics of epilepsy, and
could in no case be classed as hysterical. Often
the determining factor could be exactly specified.
Thus in one the music must be classical and jazz
tunes were ineffective; in another it must be sad
or reminiscent in quality ; in another only the deep
notes of a wind instrument in a brass band -would
cause the seizure; in another one tune only would
be effective; in another only a tune that was
unfamiliar ; and soon. Perhaps the most interesting
part of the paper is an account by a Russian man
of letters, who was a sufferer from musicogenic
epilepsy, of his own sensations and experiences
when listening to music. In some of the cases the
stimulus was specific ; fits always occurred in response
to the music, and never in the absence of music ;
but other cases lacked this specificity. In discussing
the pathogenesis Dr. Critchley comes to no definite
conclusions. He doubts if hyperventilation or varia-
tions in cerebral blood-supply are of much importance.
He is inclined also to reject the proposition that the
phenomenon is a conditioned reflex in the Pavlovian
sense, but it is not clear that he has sufficient grounds
for doing so. It is recognised that certain emotional
states—notably fear or. anxiety—may determine
fits in one who is already epileptic, and surely music
may induce a variety of emotional response in those
who listen to it. It might be near the truth to
regard musicogenic epilepsy as epilepsy in which
the fits are a response to one form of emotional
stimulus. Consideration of this uncommon but
fascinating sequence opens up wide issues.
PERNICIOUS ANAEMIA AND LIVER THERAPY
Various attempts have been made to deduce
from the recorded mortality-rates from pernicious
anzmia the degree of success that has been attained
with treatment by liver in various forms—success,
that is, in the community as a whole rather than
in the individual case. It is generally agreed that
with an adequate use of liver a fatal termination
may be indefinitely postponed in most instances.
How far is that objective being attained ? Following
the introduction of liver therapy in 1926 the mortality-
rate in England and Wales declined abruptly and has
remained at a relatively low level, though in late
years there has been some tendency for a rise to occur.
P. Stocks has computed ! that since 1926 there has been
an average lengthening of life of all affected persons
of about three to three and a half years. The
decline in mortality has been noted in other countries
—notably in New Zealand, the United States,
Norway, and Canada. In Canada and ‘particularly
in Ontario the registered mortality has invariably
been high, higher according to Hardisty Sellers?
than in any other country in the world. This excess
cannot, he thinks, be attributed in any large degree
to differences in diagnostic acuity or to medical.
teaching and its influence on the certifying practice
of doctors. Here too, however, there has been a
dramatic reduction in mortality. In 1934 the
mortality-rates of both males and females were less
than half those prevailing in 1921-26. The deaths
actually recorded in 1934 numbered 268, whereas if
1 Brit. med. J. 1935, 1, 1013.
2 Amer. J. Hyg. March, 1937, p. 259.
the death-rates at ages in 1921-26 had continued
to prevail as many as 562 would have occurred.
At ages 30-49 years the mortality in 1934 was only
22 per cent. of the rate in 1921-26, at 50-69 it was
36 per cent., but at ages over 70 years the mortality
has changed relatively little, being 89 per cent. of
the previous rate. This picture is best explained,
as Sellers suggests, by the prolongation of life of
persons affected, particularly those at the younger
ages. In fact, the average age at death of persons
certified as dying of pernicious anzmia was 62-1 years
in 1926 and 67-7 in 1934. Allowing for the general
ageing of the population the average lengthening
of life since 1926 is about 5 years. This result, it
must be noted, relates to all cases, treated, adequately
or inadequately, and untreated. Sellers notes that
it may be regarded as a “‘ conservative estimate of the
objective efficacy of modern therapy in this disease.”
It is some measure of the advantage reaped by the ~
community ; if treated cases alone were considered
much greater improvement would doubtless be
apparent,
THE OLD ASHMOLEAN MUSEUM
WE add to a recent suggestion in these columns
that the present position of the Old Ashmolean is
one calling for a sympathy that should take practical.
form in money. The fine Jacobean building was
probably designed by Sir Christopher Wren, though
it was built by one of those working masons who
took a pride in their work. It faces Broad Street, is
next to the new buildings of Exeter College, and is
only separated by a pathway from the Sheldonian
Theatre. Few know its history, fewer still of late
years have entered its noble portico and finely lighted
rooms. It was built at the cost of the University
between 1679 and 1682 to house the collection which
Elias Ashmole had obtained from John Tradescant.
Ashmole was a man of many parts, solicitor, excise-
man, freemason, astrologer, botanist, chemist, anato-
mist, physician, herald, and author of ‘‘ The History
of the Garter.” John Tradescant, traveller and
botanist, had a garden in South Lambeth, where his
name is still perpetuated in Tradescant Street just
off the South Lambeth Road. He collected curiosities
in many countries, and Ashmole thinking them
worthy of preservation added his own coins, medals,
paintings, and the library of Lilly, the astrologer.
He presented them to a grateful university which
caused the house to be built for their reception.
The museum was housed in the top floor; the middle
floor was used as a school of natural history where
lectures were given on chemistry, and the basement
was occupied by a laboratory with furnaces and a
library of books treating of chemistry. Changes
took place in course of time. The books went to
the Bodleian ; natural history specimens were trans-
ferred to the new museums in the parks; some of the
curios to the Bodleian galleries, others to the Taylorian
and university galleries; chemistry was abandoned
by the university and was taken care of by the
colleges. The Arundelian marbles, which had long
rested against the wall of the Ashmolean, found a
more suitable home at the British Museum. The
old Ashmolean had practically ceased to exist as
a museum, and was used as a mere adjunct or
store for the Bodleian and as a scriptorium for those
who were preparing successive volumes of the New
English Dictionary.
Then came upon the scene Mr. R. T. Gunther, LL.D.,
an energetic fellow of Magdalen College, who began to
write on the history of science in Oxford. He soon
‘
1238 THE LANCET]
found that many scientific instruments, often dating
from quite early times, were stored away in the various
colleges, and there was enough to form a first-rate
collection to which generous donors might be invited
to add. The idea has already borne good fruit and
the Old Ashmolean has taken on new life as a Museum
of the History of Science. Its rooms are already
filled with instruments, but more space and money are
needed. A part of the building is occupied as a
scriptorium and some little-used books belonging
to the Bodleian are stored in the basement. Money
is wanted to buy instruments of historic interest
which can still be obtained at reasonable prices ;
to provide cases in which to show them and for
many other purposes. Dr. Gunther issues an appeal
therefore that the Old Ashmolean and its requirements
may not be overlooked when the needs of the univer-
sity are considered in connexion with “ The Oxford
University Appeal” which is now being circulated.
We wish him success very heartily, for at present.
there is no museum recording the history of science
worthy of the name in this country and Oxford is
the place where it might well be established and made
permanent.
ESTIMATION OF MALE FERTILITY
THE errors incidental to testing male fertility by
the examination of condom specimens have long been
known. It was these errors that led Dr. Max Huhner
of New York to urge that examination of the condom
contents should be controlled by subsequently
investigating specimens taken from the cervical canal
after coitus. Returning to this plea,! he says that
supposed necrospermia has often been due to killing
of the spermatozoa by some chemical used in the
manufacture of the rubber sheath. In other cases
the patient, wishing to keep the specimen warm
until its arrival at the laboratory, has placed the
container in hot water or in front of a radiator, and
the spermatozoa have thus been overheated. Huhner
reports cases in which the examination of many
condom specimens, with all precautions, has shown
that the spermatozoa have died as early as twenty
minutes after coitus. Nevertheless in the same cases
spermatozoa removed from the female genitalia
remained active for several hours under the micro-
scope. He therefore concludes that spermatozoa may
preserve their vitality longer in the female genital
secretions than in the semen itself.
MENTAL ABILITY IN A RURAL COMMUNITY
AN interesting survey of mental ability in a rural
community is reported by the research department
of the Royal Eastern Counties Institution, Colchester.?
The district selected contained a population of about
1500 and included a small country town. The
number of children tested, whose homes were in
the district at the time of examination, was 187,
but a few were missed because of illness. Of these
187 children 122, or about two-thirds of the total,
belonged to one “clan,” all of whose members were
related by consanguinity or by marriage or by both.
The children were divided into pairs according to
whether they were related, connected, or unrelated,
and the degree of likeness of scores between any two
related individuals was compared with that degree
which subsisted between any two unrelated indi-
viduals. There were altogether 276 pairs of sibs,
and the correlation coefficient for them with respect
1 J. Obstet. Gynec. April, 1937, p. 334.
a Nintthews, M. V., Newlyn, A., and Penrose, L. S.,
Sociological Rev. January, 1937, p. 1.
MENTAL ABILITY IN A RURAL COMMUNITY
is `
[may 22, 1937
to intelligence measurement was +0:30 -+0-05.
This figure, the authors point out, is rather lower
than that obtained for physical measurement of
sibs by Pearson. If, in a random population, mental
ability were entirely determined by hereditary
factors, the correlation coefficient should lie between
0:41 and 0-50. It is inferred from the relatively low
value of 0:30 that other factors besides heredity
play a part in the ability to score marks in intelligence
tests such as were used; at the same time the corre-
lation is regarded as strongly significant and the
investigators have little doubt that in their group
brothers and sisters are more like each other than
two children taken at random.
The distribution of intelligence was analysed
according to paternal occupation. Four groups were
distinguished under the general headings of pro-
fessional men, traders, artisans, and labourers.
In the intelligence of the children, there was found to
be a steady gradation down these four groups. The
children of unskilled labourers were found to have a
mean intelligence nearly a third of the standard
deviation lower than the general level. It is perhaps
to be regretted that the authors did not examine
the sizes of the sibships to which the children in
these four groups belonged. A survey of the incidence
of mental defect was also made. It included not only
children but persons of all ages. A high incidence,
1-6 per cent. of the total population, was found.
Commenting on the magnitude of this figure when it is
compared with the corresponding figures for rural
areas given in official surveys, the writers suggest
that, if strict canons are observed in these investiga-
tions, a larger proportion of ‘individuals in rural
communities might be counted as defective than has
been officially recognised. Mental defect and disorder
were also found to occur with greater frequency in the
interrelated ‘‘ clan ” than in the rest of the population.
pec ee OF ARTIFICIAL PNEUMOTHORAX
REFILLS
Franklin and his colleagues! are dissatisfied with
the “ average’’ practice of starting a pneumothorax
with two or three daily injections and rapidly increas-
ing the interval until air is only given twice or even
once a week. This routine method is open to the
theoretical objection that during the interval the
lung usually expands again, and the pressure to which
it is subjected is thus by no means uniform. With
this in mind refills were given much more frequently
than usual in a series of 65 patients (4 bilateral
A.P.) treated between July, 1935, and January,
1936. In some cases air was given daily for several
weeks, and the average time before satisfactory
collapse of the pulmonary lesion was only 10-4 weeks
compared with a previous average of 22. This meant,
of course, that the patient’s period of disability was
much shortened. Two possible objections to the new
scheme are mentioned: the first is the additional
cost to the patient when the refills are not done in
an institution where such treatment is included in the
terms quoted ; the second is the possibility that the
repeated slight trauma to the pleura caused by the
passage of the needle may encourage pleural effusions.
Effusions developed in 16 (30 per cent.) of the 53
cases in which it was possible to induce a pneumo-
thorax, but this figure seems no higher than that
found in series treated with less frequent refills.
The present paper is published only as a preliminary
report and it cannot be decided whether the method
1 Franklin, R. M., Zavod, W. A. and Percy, H. E., Amer.
Rev. Tuberc. April, 1937, p. 513.
THE LANCET]
described really represents an advance, It does
appear, however, that frequent refills give more
rapid collapse of the lung and the experience so
far gained does not suggest that they bring more
complications.
LIPOID PNEUMONIA
It has often been said that Nature contrives new
diseases to take the place of those that medical science
has controlled. It would seem, however, that Nature
and science manage sometimes to work hand in hand.
Thus the new disease known as lipoid pneumonia is
as a rule directly attributable to the injudicious
use of oily solutions injected into the nose of young
infants, or to the aspiration of cod-liver oil or cream b
those that are feeble or rebellious. A considerable
number of deaths from this cause have been reported
in America since 1925, and these probably represent
only a small proportion of the whole. So serious is
the condition considered that a brochure about it
has been issued to the medical and nursing personnel
of the department of health of the city of New York.
In this Dr. C. F. Bolduan points out that lipoid pneu-
monia is seen principally in debilitated infants under
two years of age, and in those with difliculty in
breathing or swallowing. In fatal cases the repeated
instillation of nasal drops has commonly been followed
by repeated- coughing or asthmatic attacks and the
signs and symptoms of a low-grade pneumonia.
Where cod-liver oil is the responsible agent, the
pneumonia has usually been more acute. Although
complete recovery appears possible, the pneumonia
often progresses and the infant dies from inter-
current infection. Post mortem the lungs may show
the presence of large amounts of oil, and changes
due to reaction to a foreign body. Dr. Bolduan
quotes a number of eminent pediatricians on the
inadvisability of giving oily nasal drops to young
infants. Although the condition is apparently less
common in this country than in America, the warning
is useful.
THE BILBAO CHILDREN
THE Home Office has given permission for the
landing in England of 4000 refugee children from the
Basque town of Bilbao. It was stipulated that there
should be 1800 boys and 2200 girls, all between five
and fifteen years of age, and that they should be
accompanied by 200 adult women teachers and
attendants and 30 priests. The National Joint Com-
mittee for Spanish Relief, which has made the
arrangements, sent two doctors and two nurses to
Bilbao. The doctors were to examine the children
before they went abroad to ensure that no infectious
diseases that might involve lengthy quarantine periods
were among them. They took medical supplies with
them, since these are very scarce in Bilbao. The
nurses both speak Spanish and have a supply of
medical cards which will furnish a medical record for
each child; they are travelling back on the ship,
the Basque steamer Habana, which has already carried
thousands of children to France. The doctors and
nurses reported that they had to work very hard
under considerable difficulties. Air-raids frequently
interrupted the work and they were forced to do
it from 8 to 12 at night, at which time there have
so far been no air-raids. The Habana is expected at
Southampton at the end of this week and the children
are in the first place being put in a large camp which
will serve as a clearing-station and as a quarantine
camp if necessary. This has been erected at North
Stoneham, near Southampton, and is in charge of an
administrator with long experience of such camps.
THE BILBAO CHILDREN
[may 22, 1937 1239
Dame Janet Campbell, M.D., has been assisting with
the arrangements in Southampton and is an active
member of the committee dealing with this problem.
Already 2000 of the children have homes waiting
for them, the Salvation Army having offered to take
400 and the Roman Catholic Schools and Homes
1200. The remainder will be accommodated in
groups in homes and colonies organised by the
National Joint Committee for Spanish Relief. Those
who are familiar with the situation of Bilbao will
hope that the committee may soon get enough
support and offers of help to justify the rescue of
more of the children congregated in the town. The
address is 35, Marsham-street, London, S.W.1.
OPIUM ADDICTION
ADDICTION to opium or its derivatives is rare in
this country, but unfortunately shows a selective
incidence on the medical profession, sinco of 630
kncwn addicts in 1935 about 110 were doctors.! One
of the main difficulties encountered in its treatment
is the depressiqn, insomnia, and other distressing
symptoms that accompany withdrawal, and especially
rapid withdrawal, of the drug. Various means of
reducing these symptoms have been tried,? and on
p. 1221 will be fcund an account of the use of the
patient’s own serum, reinjected, for this purpose.
Introduced by Modinos in 1929, the method has been
gaining popularity in the Orient, and Woo ? is able
tô report on no less than 1000 cases thus treated by `.
him and his colleagues at Hong-Kong in 1936. Of
these, 872 smoked opium, 46 swallowed opium pills,
11 took opium plus opium wine, 38 took opium and
heroin pills, and 33 took heroin pills. He treated his
cases as out-patients and no restrictions were put
upon them—a severe test for any method. He gave
on the average seven injections of blister fluid on
alternate days with a total dosage of 18:5 c.cm. per
patient. He says that after the first dose most of the
patients found that they needed only half their usual
dose and that the drug became definitely. distasteful
to them after the second or third injection. His
criterion of cure was complete abstinence from the
drug for a month with improvement in weight and
general health, and he reports 16 per cent. of cures,
while a further 18 per cent. were able to reduce
their dose by nine-tenths. Only 24 per cent. showed
little or no improvement. Various unpleasant
symptoms appeared during treatment, the commonest
being constipation, insomnia, and ‘‘ spermatorrhea,”’
Black,‘ writing from Manchuria, says that doses as
large as 10 c.cm. sometimes cause reaction and dis-
comfort, and he therefore prefers 5 or 6 c.cm., while
even 1 c.cm. has an appreciable effect. Schroeder,
in 1933, had trouble with burst blisters, and was
led to try boiled milk as an alternative to serum.
In assessing the value of these and other remedies
for drug addiction we are faced with the familiar
difficulty of separating the effect of suggestion from
that of the actual method employed: the brilliant
results of enthusiastic users of some form of therapy
—especially where, as here, there is an element of
the dramatic—are often followed by the comparative
failure of more sceptical workers using the same
method, Dr. Vivian’s cases, which were treated in a
nursing-home under strict supervision, showed better
1 The Traffic in Opium and Other Dangerous Drugs. Report
to the League of Nations by H.M. Government in 1935.
2 A review of Some Recent Literature of Drug Addiction,
by Dr. E. W. Adams, appears in the Bulletin of Hygiene for
April, 1937. ;
3 Woo, A. W. (1937) Chin. med. J. 51, 85.
‘Black, D. M. (1936) Canad. med. Ass. J. 35, 177.
5 Schroeder, H. (1936) J. Amer. med. Ass. 107, 2150.
1240
results than did Dr. Woo’s out-patients, and it seems
probable that some at least of her success was due
to the belief she has acquired in the method and the
steady transference of this belief. She wisely points
out that “ autoserotherapy ” cannot cure the tendency
towards drug addiction, but it will nevertheless be
very useful if it enables the patient, without much
discomfort, to get rid of his physical craving. Dr.
Adams’s conclusion! about it is that apparently it
is ‘“‘ simple and reasonably successful in the case of
moderate opium-smokers and eaters and does assist
withdrawal considerably. It has however its
limitations, It is rather painful, it may fail in severe
cases and is not very successful where the drug is
injected. Also, relapse seems to be as common as
with any of the more usual methods.”’
THE LANCET]
MEDICINE AND PEACE
Many feel that if the medical profession, as such,
is to help in promoting peace it will do so best by |
demonstrating the emotional disorders that give
rise to war and the means by which nations and
individuals may be contented. The Medical Peace
Campaign (whose activities are described in our
correspondence columns) now has a psychological
section, and its bulletin for April contains many
suggestions about the kind of action that doctors
may fittingly take to expose “false stimulation of
the instinct of self-preservation.”’ Those who would
_ prefer to read a straightforward statement of ore
medical man’s opinion on the present menacing
situation will find it in a pamphlet by Dr. J. Burnett
Rae.1 He writes for the layman, and he writes at
the request of a particular body, the Industrial
Christian Fellowship ; but many of his professional
colleagues and many outside the Church will be
thankful to see their scattered opinions so well
expressed. Dr. Rae believes that we shall never
prevent war by dwelling on its horrors or by pointing
to its senselessness, War is comparable to insanity
but in a psychosis even the most absurd delusion
has a meaning; the symptoms are a blundering
attempt at cure and adaptation. Unfortunately the
nations to-day are too busy attending to their
weapons, or watching those of others, to give more
than academic attention to the fundamental causes
of war. Dr. Rae counters the argument that
primitive human communities are necessarily aggres-
sive, and contends that the future is not with those
who use their power to trample upon the weak but
with those who have a care for them. If we cannot
change our nature we can at least change our
behaviour. The real solution is not extermination
of other people’s point of view but understanding of
it. At the same time we must be loyal to our own
ideals and make them as attractive as possible to
the other type of mind. The kind of peace called
“ non-war ” is not an end in itself: the peace we seek
must be positive.
THE COLONIAL SERVICE
UNTIL recent years, in spite of some abortive
attempts at unification, the colonial services consisted
of a series of independent and unrelated public
services attached separately to each dependency,
although under the general coérdinating control of
the Colonial Office. In 1930 what is known as the
Warren Fisher Committee made strong recommenda-
1 Psychology and the Problem of War. By J. Burnett Rae,
.B., hon. physician for psychological medicine, Croydon
General Hospital. Published by the Industrial Christian
La aca 4, The Sanctuary, Westminster, London, S.W.1.
p. < . .
MEDICINE AND PEACE
[may 22, 1937
tions in favour of unification and these recommenda-
tions were approved by the Colonial Conference
of that year and by the then Colonial Secretary,
Lord Passfield. The history of the further develop-
ments of this policy is set out in a pamphlet (No. 475)
entitled “The Colonial Service” issued by the director
of recruitment at the Colonial Office. In 1932 a start
was made by the creation of a unified Colonial
Administrative Service with a definite membership,
a common method of entry, a general system of train-
ing, and a schedule of posts to any of which a member
might be appointed. Development has since pro-
ceeded by the setting up of other unified branches
on a similar plan, a legal service being inaugurated
in 1933, a medical service in 1934, and forest, agri-
cultural, and veterinary services subsequently. The
introduction of equivalent terms of service in all
dependencies is a matter of great difficulty, as
allowances must be made for the very considerable
differences which exist in climate, cost of living, and
the financial circumstances of the various Govern-
ments. Considerable progress has, however, been
made in a number of colonies towards uniformity in
regard to salary scales, pensions, provision for widows
and orphans, and the granting of leave and free
passages.
The medical service, which at present has some
600 members, including women, offers a wide pro-
fessional scope. The majority of posts are in tropical
Africa and Malaya, so recruits are usually sent for
a course at one of the schools of tropical medicine
before going out. Later they may concentrate on
public health and preventive medicine, departmental
administration, a specialty, or research, or on clinical
medicine. The appointments are intended to be
whole-time and members of the service must not
count on being able to augment their salaries by
private practice, though this is permitted in some
stations. There can be no doubt, however, that in its
present form the service is one which deserves the
serious consideration of medical men at the beginning
of their career.
On May 25th and 27th and June Ist at 5 P.M.
Dr. Edwin Bramwell will deliver the Croonian
lectures of the Royal College of Physicians of London.
His title will be Clinical Reflections upon Muscles,
Movements, and the Motor Path.
To celebrate the fiftieth anniversary of the Bassini
operation, the University of Padua is publishing
two volumes of ‘“ Writings on the Surgery of Hernia ”
containing the original papers of Bassini and contri-
butions to the study of hernia by surgeons in various
parts of the world. The Italian Surgical Society has
called for June 6th in Padua a special meeting, in
the course of which, after two reports on the surgery
of inguinal hernia (S. Spangaro) and on the surgery
of crural hernia (A. Austoni) the various problems of
hernia surgery will come under discussion. British
surgeons wishing to attend are asked to write to the
Clinica Chirurgica della R. Universita di Padova,
which will send detailed information.
GLASGOW POST-GRADUATE MEDICAL ASSOCIATION.—
A general medical and surgical course will be held by
this association from August 16th to Sept. 10th at the
Western Infirmary, the Royal Infirmary, and the special
hospitals of the city. A number of clinical assistantships
will also be available to graduates who wish to make a .
detailed study of one of the specialties. Further informa-
tion may be had from the secretary of the association,
Dr. James Carslaw, 9, Woodside-terrace, Glasgow, C.3. _
THE LANCET]
[may 22, 1987 1241
SPECIAL ARTICLES
THE INFLUENCE OF
ANIMAL HORMONES ON PLANTS
A REVIEW OF EXPERIMENTAL WORK
By E. DOROTHY BRAIN, F.L.S.
THE comparatively recent discovery and isolation
of plant hormones has raised the question of the
relationship between plants and animal hormones
and the possibility of animal hormones influencing
plant growth and development and. vice versa.
A number of investigations along these lines have
been performed.
EXPERIMENTS WITH OVARIAN FOLLICULAR HORMONES
In 1933 Schoeller stated that certain plants when
treated with follicular hormone (æœstrin), both in the
form of Progynon and (3-folliculin, showed accelerated
and increased production of flowers after weekly
doses of 200-300 mouse units. These experiments
have since been repeated by other workers with the
same species of plants in much greater numbers and
their results do not seem to substantiate Schoeller’s
conclusions.
Harder and Stérmer (1934), who repeated Schoeller’s
work, used 1300 bulbs of hyacinth, crocus, narcissus,
and lily-of-the-valley, branches of prunus, forsythia,
cornus mas, and plants of maize and arum lily.
These plants were treated with pure crystalline
a-folliculin and technical progynon (a preparation of
Schering-Kahlbaum A.G., Berlin) in doses of 100,
200, and. 300 mouse units. The hormones were
administered to the roots of the bulbs in water and
earth culture and to the base of cut shoots in water,
agar, and lanolin paste. In spite of careful selection
of samples they found great variation in the rate of
opening of flowers in both treated and control plants.
In arum lilies second blooms were produced in 38
per cent. of the treated plants and 58 per cent. of
the controls. An acceleration of 14 days in flowering,
and slight increased growth, was noted for maize,
as compared to an advance of 14 days found by
Schoeller.
Schoeller and Goebel (1934) repeated their experi-
ments with hyacinths, using an alkaline salt of
folliculin which appeared to be more effectual in
stimulating flowering than the acidic form of the
hormone. Chouard (1934) treated plants of Aster
sinensis with weekly doses of 250 international
units of dihydrofolliculin crystals in solution in
water. The first effects were toxic but after recovering
their condition the treated plants produced more
flowers than controls and flowered 8 days earlier.
The treated plants were slightly shorter than controls
and the inflorescences which were produced on short
branches from the base of the stem were 80 per cent.
more numerous.
Janot (1934 and 1935) experimented with hyacinths
and lily-of-the-valley in soil and water culture.
He used the hormone in the form of folliculin and
dihydrofolliculin, theelol, equilene, and equilenine.
All stimulated vegetative growth except theelol which
was toxic. He also used solutions of hormone, made
alkaline with sodium hydroxide and found them more
effective. His conclusions, based on experiments with
several hundred bulbs, were that inflorescence buds
appeared earlier in treated plants because of increased
vegetative growth but flowers did not open sooner
after treatment with the hormone,
Tincker (1935) tested crystalline ketohydroxy-
cstrin in alcoholic alkaline solution, and theelol in
water, by injection into the stem, administration
through cut petioles, presentation to the roots in
soil and water and culture solution, and to cuttings
in solution. His experiments with Bryophyllum
calycinum, arum lily, and species of grass, Berberts
neubertii, tulip, lily-of-the-valley, lettuce, and hyacinth
produced no evidence that growth was accelerated by
the treatment ; in fact theelol retarded foliar develop-
ment. Tincker also found no effect on the growth
of hyacinth treated with an alkaline solution of
auxin extracted from yeast. He admits the possibility
that the dosage given did not reach the threshold
of reaction level, but he criticises the claim of Schoeller
and Goebel that flowering is stimulated by follicular
hormone since, in their experimental plants, flower
primordia would be laid down before the treatment
began. Schoeller’s results were therefore due to
elongation of the flower stems, which suggests an
action of follicular hormone similar to that produced
by plant hormones or auxins. Janot (1935) and
Harder and Stérmer (1934) also held this view of the
action of follicular hormone and it seems possible
that Chouard’s results for aster may be due to
elongation of branches from buds which remain
dormant normally and not to the formation of extra
branches bearing flowers, as it may superficially
appear. Harrow and Sherwin (1934) state: ‘‘ The
female hormone on the market, the commercial
product, has an auxin-like effect; this is due not
to theelin but to an impurity (auxin ?) which, like
auxin is soluble in bi-carbonate solution. Crystalline
(and therefore pure) theelin has no auxin-like effect.”
HUMAN URINE AS A SOURCE OF PLANT HORMONES
“ Auxin ” is the term used for the growth substances
which are found in actively growing parts of plants
and have been shown to govern cell extension which
is the principal basis of the increase in volume shown
in higher plants. Prof. Kögl (1933) of Utrecht, who
has studied the chemistry of the auxins, has dis-
covered that the most favourable source of “‘ auxin-a”’
is human urine. Kögl states that adults excrete about
2 milligrammes of auxin-a per day, independently
of age or sex. Urine excreted a few hours after a meal
has the highest auxin content. Having tested various
diets it was found that no increase occurred after
glucose, starch, or egg-white but after feeding with
salad-oil or butter increase in the auxiu-a excreted
follows. Kögl has shown that auxin-a is a monocyclic -
trihydroxycarboxylic acid with the structural formula
CH3 CHa CHs
Lal’ “bod
CH3 .CH:—C aa" CH—0OH—CH:3 . CH3
H
E oP le
H” OH oH ‘OH
Kögl and his collaborators have prepared another
growth substance from urine which they term hetero-
auxin. It is §-indole acetic acid with the structural
formula
H
rè)
a” e E E sagan
wn A d
H H
1242 THE LANCET]
It is also prepared from yeast, aspergillus, and
rhizopus and is approximately half as effective
physiologically as auxin-a. The total growth sub-
stance content of urine is about 80 per cent. auxin-a
and 20 per cent. hetero-auxin. So far it has not been
determined if animals make use of these auxins.
PLANT EXTRACTIONS WHICH ACT LIKE ANIMAL
HORMONES
Cases have been cited by Walker and Janney
(1930) in which extractions of male and female
catkins, sprouted oats, rhubarb leaves, and yeast
produced cestrus in castrated mice. Also Skarzynski
(1933) has isolated an cestrogenic substance from
female willow catkins, which possessed properties
identical with those of trihydroxyestrin prepared
from female urine, for solubility, absorption spectrum
in the ultra-violet light, and melting-point of the
acetyl derivative.
active physiologically, containing 1000 mouse units
per mg. as compared with 4000 mouse units per mg.
of the animal hormone. Butenandt and Jacobi
(1933) have also isolated a substance, ‘‘ tokokinin,”’
from palm-nut oil which is chemically identical with
«-folliculin, C,,H,.0., gives the same rotation
for absorption spectrum in the ultra-violet light
and the same physiological action. Other examples
are “ glukokinin,” which reduces the concentration
of blood-sugar in a way which is comparable to the
action of insulin, and has been* prepared by Collip
(1933) from yeast, green leaves, and roots; and
ephedrine, which is chemically related to adrenaline
and behaves similarly physiologically.
OH
Nn i Cia
AH ai xe
c= C——CH;3 CH—CH,—NH—CHs;
OH NHCHs OH |
-= Ephedrine. Adrenaline.
It is obtained from Ephedra vulgaris, a Chinese
plant, the stems of which have been used medicinally
by the Chinese for five thousand years (Harrow
and Sherwin (p. 123) 1934).
It therefore appears that plants produce sub-
stances which are analogous to animal hormones and
that animal excretions can be used as a source of
plant hormones, but it seems doubtful whether the
animal body makes use of the auxins which are
available in vegetable foods.
EXPERIMENTS WITH OTHER ANIMAL HORMONES
Corresponding botanical investigations on the
possible influence of various other animal hormones on
plants have been carried out in recent years. Havas
and Caldwell (1935) treated tomato plants and
hyacinths with Richter’s orchitic extract, Richter’s
Glandobulin (prolan A), Richter’s Glanduatin (extract
of the anterior lobe of the hypophysis) and Cortigen
(extract of the suprarenal cortex), adrenaline and
thyroid extract without showing any marked effect
on the growth or flowering of the plants. Glandobulin
had a toxic effect on tomatoes. Other workers on
the effect of extract of the antertor lobe of the hypo-
physis are Hykes (1933) who found that opening of
leaf buds on dormant branches of certain trees was
inhibited by concentrated solution and stimulated
by dilute solution of the extract, and that roots
of willow and poplar cuttings were longer in the
dilute solution; and di Pascal (1936) who found
addition of the extract accelerated germination
of seeds and that an alkaline extract solution added
THE INFLUENCE OF ANIMAL HORMONES ON PLANTS
The plant substance was less —
[may 22, 1937
to nutrient solutions accelerated growth in some
species and had no influence in others. Large doses
caused damage to roots and inhibited growth.
For insulin and adrenaline Wasicky (1934) claims an
intensification of starch-formation from d-glucose
in plant cells, and Hykes (1933) found an increase in
quantity and size of leaves produced on branches
placed in insulin solution, which was greater in
dilute solutions. He found that adrenaline in dilute
solution accelerated opening of leaf buds and stimu-
lated root growth in willow and poplar, but that
concentrated solutions had an inhibitory effect.
Experiments with extract of swprarenal cortex have
been performed by three Italian workers—de Gaetini
(1929), Occhipinti (1930), and Agostini (1930)—who
found that “ cortical ” stimulated vegetative growth
and accelerated reproduction in the water plants,
Lemna minor, Azolla coriolana, and marsilia.
Thyroid hormone has been tested on bulbs of
hyacinth, narcissus, and allium, various species of
seedlings, Lemna minor, plants of Aster sinesis, and
branches of various trees. Budington (1925) noted
greatly decreased length and increased thickness in
roots on narcissus bulbs grown in solution of thyroid
extract in water. Microscopic examination showed
that the specialised tissues of the root extended nearer
the tip in treated roots than controls and he suggested
that the precocious development of this tissue was
comparable to the precocious development produced
in larval amphibia on treatment with thyroid, since
new tissues in roots and larve both originate from
unspecialised masses of tissue, the differentiation of
which is stimulated by thyroid. Scaglia (1929) noted
decreased mass and more rapid development of
inflorescences in hyacinths treated with thyroid.
Agostini (1930) found little difference in growth of
Lemna minor or Azolla cortolana. Hykes (1933)
showed that leaf buds opened earlier when dormant
branches were placed in thyroid solution and roots
developed earlier on willow and poplar branches
than on controls. Chouard (1934) found that branches
grew to be 25 per cent. longer than controls on plants
of Aster stnests treated with thyroxine in solution
in water, but no influence was noted on rate of
flowering. Davis (1934) treated Pistum sativum
seedlings with sodium salt of thyroxine in water and
culture solutions resulting in shorter, slightly thicker,
less branched roots in treated plants but no difference
in the green parts. Narcissus and allium bulbs injected
with thyroxine flowered earlier but produced shorter
roots and foliage. Florentin and Ehrenfeld (1935)
have made microscopic examination of roots of Allium
cepa grown in thyroxine. Less rapid growth was
evident at the beginning of treatment which was
accompanied by 43 per cent. more mitoses in the
root cells of the treated plants, than those of controls.
This is a similar effect to that described by Budington
in narcissus roots, Experiments performed by me
(1937) showed that Phaseolus multiflorus seedlings
transferred from distilled water to solutions of thyroid
extract containing 0-1 c.cm. per 100 c.cm. distilled
water responded by marked decrease in growth in
length of root. It was not considered that shoot
growth was influenced. Oats and radish seedlings
treated with solutions of different concentrations
indicated a stimulatory effect to growth of roots and
leaves in dilute solutions and an inhibitory effect
in greater concentration. When using thyroid
extract, in spite of careful sterilisation of vessels
used, after several days solutions became con
taminated with bacterial slimes and moulds. This
condition was also noted by Davis for thyroxine and
by Tincker for ketohydroxyeestrin.
THE LANCET]
MEDICINE AND THE LAW
[may 22, 1937 1243
Parathyroid hormone was used by me (1937) on
oat seedlings. Doses of 2-8 Collip units resulted in
shorter length and slightly thicker roots but had no
effect on growth of coleoptiles and leaves.
A summary
of the experiments is given in the accompanying
Table.
TABLE SHOWING RESULTS SUMMARISED
Hormone
preparation.
Ovarian—
Progynon..
a-folliculin
8-folliculin
Alkaline salt
of folliculin
Dihydro-
folliculin
Ketohydroxy-
cestrin
Equiline
Equilenine ..
Theelol ete q
J
f
\
Orchitic
Anterior Anterior lobe)
of Re
physis
a9
Prolan A
(glando-
Adrenaline ..
J
-d
am
Insulin ..{
{
{
{
Suprarenal
cortex—
“ cortigen ”
** cortical ” {
Thyroid...
” 4
Thyroid ate l
Thyroxine
Na salt j
Thyroxine
Na salt
Thyroxine .. {
Parathyroid {
Experimental
plants.
Hyacinths; _ lilies,
bulbs ; seedlings :
flowering plants ;
branches.
Hyacinths.
Hvacinths ; lily-of-
the-valley ; ; Aster
sinensis.
Bulbs; seedlings ;
cuttings.
Hyacinths and lily-
of-the-valley.
Hyacinth.
Dormant branches
of trees.
Seedlings.
Tomatoes and hya-
cinths.
Hyacinths.
Branches of trees.
Tomatoes.
Hyacinths.
Branches of trees.
Tomatoes.
Water plants.
Hyacinth ;
l cissus ;
nar-
allium.
Branches of trees.
a
Seedlings.
Narcissus.
Aster sinensis.
Seedlings.
Results.
Contradictory— possibly
flowering accelerated ;
stimulated growth.
Flowering accelerated.
Stimulated growth;
stimulated flowering.
None ; toxic.
Stimulated growth ; :
greater effect in
alkaline solution.
None.
Dilute solution opening
of buds and growth
in roots stimulated.
Stimulated germination
and growth in some
species.
Toxic.
Intensified starch for-
mation from d-glucose.
Increased quantity and
size of leaves.
None.
Intensified starch for-
mation.
Accclerated opening of
buds.
None.
Stimulated growth and
reproduction.
Inhibited growth in
roots; stimulated
mitosis in cells.
Leaf buds opened
earlier.
Inhibited growth in
roots.
Accelerated flowering.
Increased growth of
stems.
Inhibited growth in
roots.
Note.—In several cases dilute solutions stimulated growth
and more concentrated solutions inhibited growth.
Consideration of the results claimed for the influence
of animal hormones on plant growth and development
shows that some reaction certainly occurs when plants
are subjected to treatment. Whether this can be
ascribed to definite response by the plant to the
hormone in a similar way to the animal’s response
to that hormone is another matter. The results for
the follicular hormone are very conflicting, but the
balance of evidence seems to favour an auxin-like
response of increased vegetative growth. The
increased growth after treatment with the pure
crystalline substance does not entirely support the
theory that the auxin-like effect is due to impurity
in the preparation, but the evidence for the presence
of auxins in animal urine and female hormones in
plant tissue makes it seem quite credible that the
behaviour of both could be similar physiologically.
There are insufficient data to give definite conclusions
on most of the hormones, but it certainly seems as
if the uniformly found effects of thyroid extract can
be considered as an indication that it affects plant
tissues in ‘a way similar to animal tissues by the
stimulation of cell growth by division. This is of
particular interest from the botanist’s point of view
since there is very little definite knowledge of the
influence of auxins ‘and other substances upon cell
division.
Though much work remains to be done there is
already sufficient evidence that the subject is one of
importance to medicine, veterinary science, and
botany. In particular the possibility that the raw
materials of some animal hormones may be derived
from plants may have to be taken into account in
interpreting the symptoms of deficiency diseases.
REFERENCES
Agostini, A. (1930) Scritti Biol. 5, 333. .
Brain, E. D. (1937) Ann. Bot. Lond., in the press.
Budington, K A 1925) Biol. Bull. Wood's Hole, 48, 83.
Butenandt, À., T coL H. (1933) Hoppe-Seyl. Z. "218, 104.
onara, B. (1934) C. R. Soc. Biol. Paris, 117, 1180.
' B. (1923) J. i, Chem. 56, 513.
Dover . E. (1934) Plant ee 9, O17
Florentin, Fenn Ehrenfeld, . (1935) `C. R. Soc. Biol. Paris,
Gaetini, L . de (1929) Seritti Biol. 4, 243.
Harder, R., and Störmer, I. ( (1934) Jb. uʻiss. Bot. 80,
Harrow, B., and Seah ec . (1934) The eai of the
Hormones, Baltimor
Havas, L „and Caldwell, J . (1935) Ann. Bot. 41, 729.
Hykes, O V. (1933) ee R. Soe. Biol. Paris, 113, 629.
Janot, M. M. (1934) C Acad. Sci. Paris, 198, 1175.
(1935) Ibid, 200, “138°
Kögl, F. a Rep. Brit. Ass. p. va
Pascal E. 0° (1930) Seritti Biol. 303.
Pasca C. di (1936) Physiol. Aisir. 20, 520.
Scaglia, G a 929) Scritti Biol. 4 0
Schoeller, W. (1933) Lancet, 1, 38.
and Goebel, H. (1934) Biochem. Z. 272, 215.
Skarzynski, B. (1933) Nature, Lond. 131, 766.
Tincker, M. A. H. (1935) am appl. Biol. 22, 619.
Walker, B.S.,and Janney, J.C. (1930) Endocrinology, 14, 389.
Wasicky, ne, Brandner, D., and Hanke, C. (1934) Biol. Abstr.
» 1655.
MEDICINE AND THE LAW
Epilepsy and Workmen’s Compensation
Martin v. Finch, in the Court of Appeal last month,
was a workmen’s compensation case in which the
workman suffered from epileptic fits to the knowledge
of his employer. His wife said he had fits fortnightly
and sometimes weekly. He worked as a land drainer.
His usual hours ended at 5.30 P.M., but on the day of
his death he had been ordered to leave his work
at 5 P.M. and take his tools to the field where he would
be working next day. A quarter of an hour later
he was found dead by the side of his bicycle near the
field. The county court judge found as a fact that
the workman had fallen from his bicycle in a fit.
The deceased had often been attended by a doctor for
injuries due to falls from his bicycle which he had to
ride every day from his home about four miles away.
He had been warned not to bicycle, but he had no
other way of reaching his work.
The Court of Appeal agreed with the court below
that the accident happened “in the course of” his
employment since, at the time of his death, he was
taking his tools under his master’s orders to his new
place of work. But the accident, to justify the award
of statutory compensation, must have arisen “ out
°
1244 THE LANCET]
PARIS.—VIENNA
{may 22, 1937
of” as well as “in the course of” the employment,
In 1933, in Lander v. British United Shoe Co., the
Court of Appeal disallowed the claim where an
epileptic workman fell on a floor which was not found
to be dangerous. There had been a different result
in 1905 in Wicks v. Dowell, where a workman’s duty
obliged him to work close to an open hatchway.
He fell into the hold below during an epileptic seizure,
and there was an illuminating judgment by Lord
Justice Cozens Hardy. The employers had argued that
the consequences were too remote to make them
liable. The truer view, said the Lord Justice, is that
everybody brings with him some disability. It may
be disability arising from age or some other draw-
back. An old man is inherently more likely to meet
with an accident than a young man; but an employer
could not excuse himself on that ground. The
same consideration applies to a tendency to illness
or fits. If a man with such a tendency is told to go
to work in a dangerous position and there meets
with an accident, the accident none the less arises
“out of ” his employment because its remote cause
is to be found in his own physical condition. Applying
these views of Cozens Hardy, L.J., to the recent
case in the Court of Appeal, the Court took account
of the facts that the workman had been carrying
his tools when he fell off his bicycle and that the
employer, knowing of the epilepsy, had let him go
off on the bicycle. The Court concluded that it was not
epilepsy alone which caused the accident, but a combina-
tion of the epileptic tendency with the fact that the dead
man was placed in an unstable and dangerous position.
And so the widow is held entitled to compensation.
PARIS
(FROM OUR OWN CORRESPONDENT)
A DOCTOR DE FACTO
THE age of miracles having returned, René Hecker
entered the French army as an accountant and
left it as a doctor. After the war he settled in Flavy-
le-Martel where for some 17 years he devoted himself
to the care, often gratuitous and always devoted,
of the sick. Prosperity, the respect and affection
of the community from the mayor downwards, and
a wife and family—all these things were added
unto him. Then the Nast law came into effect with
its requirement that all French medical diplomas
must be registered in one central office. Hecker
was invited to conform to this law but could not.
His credentials, such as they were, proved to be
provisional—stop-gap army permits to carry on
as a surgeon what time he sought original documents
lost, stolen, or strayed. This spring at Saint-Quentin
Hecker was prosecuted for the illegal practice of
medicine, and for several days he made headline news.
He was game to the last in spite of a facetious judge
and an inquisitive prosecution. But the surgeons
and physicians he cited as his mentors at Strasbourg
in his student days lacked the flesh and blood required
of a witness in a court of law; whereas the witnesses
for the prosecution who testified to having known
him as an accountant were disconcertingly real.
To create a diversion, he rang the curtain up on his
therapeutic achievements. Let but his colleagues see
him operating or otherwise caring for his patients, —
and how could they doubt the genuineness of his
claims ? To which the judge retorted that the question
at issue was not his therapeutic prowess but his legal
rights to the title of doctor. Nothing daunted, Hecker
paraded one grateful patient after another, all
snatched from the jaws of death, more or less. They
e
were all very pathetic but not quite convincing.
And in due course judgment was given against the
defendant who was fined 1000 francs for the illegal
practice of medicine and ordered to pay 5000 francs
in damages to the local medical syndicate which had
prosecuted him. Still refusing defeat, he has appealed
against this judgment.
VIENNA
(FROM OUR OWN CORRESPONDENT)
KLEIN, ERDHEIM, AND HALBAN
THe medical faculty of the University has lost
within ten days three of its most eminent members.
Prof. Solomon Klein, the Nestor among Vienna’s
medical men, died at the age of 92 while on a visit
to Budapest. He was well known as one of the best
ophthalmic surgeons of his time and as the originator
of many new methods of diagnosis and treatment of
diseases of the eye. He will be remembered with
regret by many of the doctors from abroad who
visited the ophthalmological department of the
- Vienna Poliklinik while he was in charge.
Prof. Jacob Erdheim, the famous pathologist,
died suddenly at the age of 63. He was a pupil
of Weichselbaum, who early recognised the out-
standing qualities of his assistant and gave him every
help in his career. Erdheim soon became interested
in the branchiogenous structures. He discovered
the relation between calcium metabolism, rickets,
and the development of the teeth. He later began
to study the pituitary gland (“ Erdheim tumours ” ;
adenomata of the pituitary; the hypophysis in
pregnancy), and he was also an authority on the
histopathology of bones and on the pathology of the
blood-vessels. During the war he studied problems
of bacteriology and hygiene. His classes were among
the best attended in the University and his pupils
came from all over the world, attracted by the lucid
presentation of his subjects.
Prof. Josef Halban came from an old Vienntse
family well known in public life and he himself was
intimately associated with the city all his life. He
studied there, acted as assistant to Prof. Schauta,
and in 1909 was appointed professor of gynecology.
In 1910 he became the director of the gynecological
and obstetrical department of the second biggest
hospital in Vienna (Wiedener Krankenhaus) and he
held this post until his death. A few years ago he
was nearly appointed professor ordinarius of the
University Clinic but at the last moment his nomina-
tion was disallowed because, like Klein and Erdheim,
he was of Jewish birth. Halban was an original
thinker and as long as thirty years ago he had realised
the importance of the endocrine glands and had
recognised the placenta as an internal secretory
organ. Indeed, his intuitive and imaginative grasp
of the function of the glands was the foundation of the
modern conception of hormones. He collaborated
with Prof. Tandler in several well-known text-books
on gynecology and obstetrics. A brilliant but
cautious surgeon, he had an enormous private practice,
perhaps the largest in central Europe. He was a
lover of art and music and he married Selma Kurz,
the singer.
THE SUPRARENALS AND ANGINA PECTORIS
At a recent meeting of the Vienna Gesellschaft
der Aerzte Dr. Roab reported on a new treatment
he has used in cases of angina pectoris. Noting
the similarity between the symptoms of this condition
and those produced by an out-pouring of adrenaline
into the system, Roab thought it possible that the
THE LANCET]
IRELAND .—THE LANCET 100 YEARS AGO
[May 22, 1987 1245 —
‘ attacks are usually attributable to the action of
adrenaline, secreted in large quantities, on a cardiac
muscle which has been injured by coronary sclerosis.
(This does not of course apply to attacks of coronary
thrombosis.) Accordingly he attempted to diminish
artificially the output of the secretion of adrenaline,
and especially its excessive secretion by fits and
starts. A suitable means of inhibition was found in
irradiation of the suprarenal region with X rays.
A surface of 8 by 10 cm. on the right and the left
side was exposed to 200 r on three consecutive
days, 600 r being thus applied over each adrenal
gland. (In some cases only one side was exposed
daily so that the course lasted six days instead of
three.) This very moderate dose nearly always
sufficed, and the suggestion is made that sufferers
from angina pectoris may have adrenal tissue which
is abnormally sensitive to X rays, just as the thyroid
gland may be hypersensitive in hyperthyroidism.
Of the 17 patients carefully observed only 2 showed
no improvement after the irradiation, and Roab
thinks the treatment is worth trial wherever there is
no contra-indication. In the ensuing discussion,
Prof. Schiff pointed out that it would be really worth
while to find out whether Roab’s assumption—
viz., that diminution of the adrenal output is
responsible for the improvement—is correct. This
can be done, he said, without resorting to X rays,
simply by administering ergotamine which inhibits
adrenal function. Dr. Scherf said he had been
working on similar lines, but so far his results had not
been absolutely convincing. Dr. Zimmermann was
struck by the fact that only 2 of Roab’s 17 patients
had hypertonus, whereas as a rule half or three-
quarters of angina pectoris patients have high blood
pressure.
IRELAND
(FROM OUR OWN CORRESPONDENT)
RESIDENCE BAR TO MEDICAL APPOINTMENT
Ir was pointed out in this column on May 8th
that the regulation of the Ministry of Home Affairs
of Northern Ireland rendering residence in the United
Kingdom for five years a necessary qualification for
appointment as a dispensary medical officer might
result in the exclusion of a citizen of Northern Ireland
who had obtained his medical education elsewhere
than in Northern Ireland or Great Britain. This
has now happened. Last month the Omagh board of
guardians by a considerable majority appointed Dr.
Percival G. Patton as medical officer of the Omagh
No. 2 dispensary district, the appointment being
subject to the approval of the Minister for Home
Affairs. Dr. Patton is a native of Northern Ireland
who received his medical education at the University
of Dublin, and as a consequence has been resident
in Dublin for the past five years. The Minister has
refused to approve the appointment on the ground
that by the regulation of 1935 Dr. Patton was not
qualified, and the board of guardians has been com-
pelled to proceed to a fresh election. The several
qualifying bodies in the Irish Free State have, it is
stated, drawn the attention of the Northern Govern-
ment to the unfair discriminations imposed by the
regulation against their graduates and licentiates,
and pointed out that the degrees and licences granted
in the Irish Free State are entitled to registration in
the General Register and are recognised by the
authorities of the various branches of His Majesty’s
Service—the Royal Navy, the Army, the Royal Air
Force, and the Colonial Services. It may be added
that many natives of Northern Ireland educated
therein occupy important positions in the public
medical and other services in the Irish Free State,
and as candidates for public appointments in the
Irish Free State natives of Northern Ireland compete
on equal terms with their southern colleagues.
THE LANCET 100 YEARS AGO
May 27th, 1837, p. 345.
From a communication entitled—
GENERAL REGISTER,
We, the undersigned President of the Royal College of
Physicians, President of the Royal College of Surgeons,
and Master of the Worshipful Society of Apothecaries,
having authority from the several bodies whom we repre-
sent, do resolve to fulfil the intentions of the Legislature
n procuring a better registration of the causes of death,
being convinced that such an improved registration cannot
fail to lead to a more accurate statistical account of the
prevalence of particular diseases from time to time.
We pledge ourselves, therefore, to give in every instance
which may fall under our care, an authentic name of the
fatal disease.
And we entreat all authorized practitioners throughout
the country to follow our example, and adopt the same
practice, and so assist in establishing a better registration
in future throughout England; for which purpose we
invite them to attend to the subjoined explanatory state-
ment, in which they will set forth the provisions of the
recent statute, and the means whereby the important
object we have recommended may most effectually be
airerned: Henry HALFORD,
President of the Royal College of Physicians.
ASTLEY COOPER,
President of the Royal College of Surgeons.
J. HINGESTON,
Master of the Society of Apothecaries.
From an explanatory statement which follows the letter.
. . . It is also desirable that such statement should
exhibit the popular or common name of the disease, in
preference to such as is known only to medical men,
whenever the popular name will denote the cause of
death with sufficient precisidn.
From a leading article (p. 349).
. The advice here given, is, in our opinion, calculated
to detract, very extensively, from the value of the remarks
by which it is preceded . . . if medical practitioners fall
into the loose habit of recording the vulgar names of
diseases, to the exclusion of their correct, scientific,
appellations, in accordance with nosological nomenclature,
we shall only obtain from the Registrars a heap of rubbish
which cannot be rendered available for any single useful
object. Besides, it should be borne in mind that the
vulgar name of a disease which is of frequent occurrence
in one county, is unknown to the inhabitants of an adjoin-
ing county, and terms which are perfectly well understood
by inhabitants of the north of England, are unknown to
the population of the south and the west. Again, in the
same county, when the body wastes or decays under the
operation of some internal chronic malady, whether it
be of the heart, the lungs, the stomach, the liver, or the
mesenteric glands, the disease, when mentioned, is generally
included under the single designation of ‘‘ consumption ”’
or ‘‘decline.” What, therefore,’ we would earnestly
recommend, is this—that the scientific name should never
be omitted, when the nature of the disease is actuallv
ascertained, and that, in addition, in all cases, when the
complaint is known by an unlearned appellation, the
vulgar name should be added to the scientific term,
Unless the Presidents of the Colleges issue a further notice
on this subject, containing an additional recommenda-
tion, of the tendency which we have here intimated, we
anticipate that the paper which they have put forth will
be productive of very serious and almost irremediable
disadvantages.
1246 THE LANCET]
[may 22, 1937
GRAINS AND SCRUPLES
Under this heading appear week by week the unfettered thoughts of doctors in
various occupations.
Each contributor is responsible for the section for a month ;
his name can be seen later in the half-yearly index.
BY A MEDICAL ECONOMIST
IV
Most of us have heard economics described as
‘‘ the dismal science.” This is certainly a mistake.
Economics, to-day, is the most exciting science in
the world.
Excitement and science, one has been warned
often enough, make bad bedfellows. I do not
believe it. The gentleman who sprang out of his
bath shouting that he had “ found it” was certainly
excited and so was Pasteur when he hugged the
porter in the university quadrangle and imparted to
that astonished man the news that he knew at last
why tartaric acid crystals might be either dextro-
or levo-rotatory. Ronald Ross, again, was so
excited when he found the malarial parasite in the
body of a female anopheline mosquito that he sat
down and wrote a poem in celebration of the event,
and the late James Mackenzie assured me that
he experienced a similar feeling when he obtained
his first tracings of the auricular wave in the jugular
pulse.
These men were excited because, in Mackenzie’s
phrase, they ‘‘ knew that they were getting at the
truth.” Truth must be exciting since, in immemorial
promise, ‘‘the truth shall make you free.” Did not
Bunyan’s pilgrim shout and dance when the burden
rolled from his back? As G. K. Chesterton said
on one occasion, England used to be full of the songs
and shoutings of happy folk who could not work
without rejoicing nor meet one another without
making a feast of it. Shouting and singing are
heard no longer in English workshops.
Excitement remains, though, in the laboratories
where work that is really considerable is being done.
And excitement would be spreading from the labora-
tories to the workshops and factories and the homes
of the people if only we knew how to make use of
all the good things which science has bestowed,
without at the same time snatching work, and the
livelihood which depends upon work, from men and
women. “ Science,’ laments the good fellow in the
street, “has failed. Science can give us only
unemployment or poison gas.”
It is a monstrous libel; but who shall blame the
good fellow ? If you invent a method of doing some- .
thing which can be used by one man instead of by
the twenty men now employed on the job, you are
taking the bread, surely, out of the mouths of nineteen
families ? That stands to reason and arithmetic.
Again if you go on doing that sort of thing often
enough there will be trouble, national and inter-
national. Poison gas is likely to be wanted.
In other words science is a curse—the greatest man
has ever known. Back to the plough, the spade,
the bare hands of naked savages grubbing for roots
in virgin forests. Away with steam, petrol, electricity,
antisepsis, vaccination, inoculation, antitoxins—all
the apparatus of modern civilisation and modern
medicine, What? Would you preserve life in order
that the ranks of the desperate may be swelled ?
Every child is potential cannon fodder, industrial or
military. A baby lost is a living saved.
What balderdash it all is—and what blasphemy
into the bargain. Can any science which is probing
this mystery—or rather this black magic—be called
dismal while a chance remains that the truth may
be found? “The truth shall make you free.”
It is all a question of money and not one man in
a thousand knows anything about money. Indeed
for every person who thinks that money is important
in this respect there are ten thousand who think that
the real enemy is land or “ capital.” Land can be
seen and capital can be counted. “ Would you
dispossess the landlords or take my money away
from me? Bolshevist !”
* * æ
The point about land, of course, is that it can
be turned into a monopoly. They grasped this
fact clearly and steadily in the Middle Ages and
invented a system whereby nobody could acquire
an absolute title to land. Kings, not Bolshevists,
instituted this system. It was called the feudal
system. From the beginning, noblemen detested it
and fought against it, so that they might acquire their
land in full possession and thus become monopolists
not only of broad acres but also of the folk living
upon them. The noblemen of England scored their
first great victory over the kings at Runnymede
and we therefore celebrate Magna Charta as the
foundation-stone of our liberty. A second and greater
victory was secured when the head of Charles Stuart
fell in Whitehall and perpetual alliance of landowner
and money-lender was sworn over the dismembered
body. Charles had refused to borrow from the City
of London; he had dared to try to obtain money
from the landowners and thus had challenged their
absolute titles. It was the feudal system which he
had been trying to re-introduce; thank God he did
not succeed, for otherwise Englishmen would have
not have enjoyed the loss of their common lands nor
those great measures of liberation which snatched
their acres from the small farmers and transmuted
the whole of the yeomen of this land into hired
labourers condemned, in the hungry forties, to eat
black bread and die of vitamin-D starvation.
The destruction of the feudal system was the
essential prerequisite of the introduction of the
monetary system which is called to-day ‘‘ the credit
system.” It will surprise many people to learn how
this system was discovered.
x * $
There was a man who, long ago, kept a strong-
room where, for a small fee, you might deposit your
gold and silver. He gave you a receipt for the money
you entrusted to him. And you, being a child of
Adam and lazy, never went back for your gold or
silver. These paper receipts, these IOU’s, were
so much more convenient.
The man who kept the strong-room duly noted
this fact. Legend says that he was married and that
his wife had a quick wit. At any rate, she is reputed
to have called her husband’s attention to the fact
that his receipts were circulating in the town just
as if they had been minted coin. The lady drew the
correct inferences and gave ear to the serpent. She
is reputed thus to have addressed her lord: ‘‘ They
are using your receipts instead of money. They
come here for real money only when they are going
7
THE LANCET]
on journeys out of the town because, in other towns,
your name is not known. Do you realise that if a
man has deposited £100 here he will draw out only
about £10 in any year?” The lady’s husband had
realised that quite well. He had observed that
about 90 per cent. of his stock of gold and silver
remained, year after year, idle upon his shelves.
The lady continued: ‘‘ You can therefore issue and
lend receipts for ten times the quantity of gold and
silver in your keeping without danger of being found
out.” And it was so. But note that, from now
onwards, the keeper of the strong-room was never
solvent. Nine-tenths of his receipts, in fact, were
receipts for nothing. Day and night the dread
lay upon him that all his customers might appear
in a body at the same moment to demand their real
money. It follows that he did not dare to go into
the market himself and buy anything with his receipts.
Suppose he had bought a house for £1000. One
thousand pounds worth of receipts would now have
been in the hands of the buyer, who might conceiv-
ably present them and ask for his money. Suppose,
further, that, on that evil day, the value of the house
had fallen to £500. It would not be possible, in such
an emergency, to sell the house and so recover from
the open market enough minted coin to satisfy the
demand.
No, there must be no buying, only lending. Then,
when the borrower brought his house as security
for the loan (of receipts for nothing) one could say :
“ This house is worth £1000; I will lend you £500
so that, if prices should fall, I shall still be amply
covered.” But one thing the keeper of the strong-
room might safely buy outright since its price was
fixed and could not change—namely, gold. He
proceeded to do so; and soon he and his friends had
bought all the gold in the world with nothing more
substantial than their signatures upon receipts for
nothing. Gold was money—the only money. They
had made a corner in gold. They had secured a
monopoly of money. Nothing has ever been bought
so cheaply since the world began.
Now the whole world must come and borrow from
them seeing that there was no other source of money.
The world would be told that security must be given
against every loan. Land, in absolute title, is the
best security. The keeper of the strong-room and his
friends acquired most of the land—also for nothing.
The monopoly of money had bestowed monopoly of
land and so of all that grows upon or is dug out of the
land and of all that is builded upon it. Reason
staggers in the face of this terrific fact—for fact it is.
The immense benefits accruing to all of us through
the destruction of the feudal system and the ruin
PANEL AND CONTRACT PRACTICE
4
[may 22, 1937 1247
of the kings, who were its guarantors, can now be
understood. Had the feudal system continued
land could not have been pledged as security for
debt and consequently the monopoly of money must
have remained more or less insecure, owing to the
strength which the feudal system gave to kings
and peoples. (There, incidentally, is the explanation
of the fact that the Middle Ages left no debt but
many beautiful buildings, including the guildhalls
and cathedrals, whereas our age is likely to leave
£8,000,000,000 of debt and much fewer beautiful
buildings.) The money-lenders had helped the noble-
men to destroy the kings so that the noblemen might
be free to pledge their land to the money-lenders.
' When the nineteenth century began all money was
a debt to the keepers of the strong-rooms, who
preferred now to be known as bankers. In other
words all money consisted of their receipts. You
could cash any given receipt for minted gold, but
had you tried to cash all the receipts'on the same
day the thing happened on several occasions. The
government always came to the rescue with a
moratorium.
Now it is obvious that if all money is debt, repay-
ment of all debt would be equivalent to the dis-
appearance of all money. Debt is constantly being
repaid to the lenders; it is necessary therefore to
secure a constant stream of fresh borrowers—if
the truth is not to be made manifest. Men borrow.
when prices are rising and they hope to make a
profit; they borrow also when prices have fallen
and they have made a loss. Consequently the system
requires an unending succession of booms and slumps.
It requires, further, a solid mass of poverty, seeing
that people who are well off do not make use of the
instalment system and other forms of borrowing.
It is the booms and slumps which sterilise all the
efforts of science to produce a better world. With
a slump in sight the manufacturer will avail himself
of every kind of labour-saving device—in order to
“gave ” labour.
But the system has its Achilles heel. If prices,
or rather the level or average of prices, could be held
‘stable borrowing would necessarily cease and the
system would come to an end. Thanks to the
study of economics undertaken by the President of
the United States that is exactly what is now happen-
ing. The American level of prices and, with it, all
the other price levels of the world, is in process of
being stabilised. What is going to happen? Will
there ever be another slump ?
At least we can say, with full assurance, that the
dismal science is, at this moment, by far the most
exciting science in the world.
PANEL AND CONTRACT PRACTICE
Prescribing for Hospital Patients
THE Somerset insurance committee have been
exercised at having to surcharge two insurance
practitioners in respect of surgical appliances supplied
to patients before leaving hospital. A medical
member, protesting against the surcharges, said that
in one case a patient suffering from a disease of the
spine underwent an operation in hospital, and when
treatment there was finished the patient could not
be moved without a proper spinal support, which was
supplied on the instructions of her insurance practi-
tioner. In the second case it was thought that a
man’s back was broken, and the surgeon said that he
must have a support before being moved out of the
hospital. |
At first sight it would appear to be illogical that
a patient who can manage to get home can be supplied
with a spinal jacket on the order of his insurance
practitioner provided it is required for treatment of
a fracture, dislocation, or disease of the spine ; while
a fellow sufferer who cannot be removed from hospital
without the appliance may not be so supplied. But
it must be remembered that insurance practitioners
are not responsible for the treatment of insured persons
in hospitals or similar institutions which are not
open to medical practitioners generally: for the treat-
ment of their patients, and in fact they exercise no
control over the treatment of their patients in hospital.
This applies especially in surgical cases whose treat-
ment hardly falls within the definition of services
other than those involving the application of special
=
1248 THE LANCET]
skill and experience of a degree or kind which general
practitioners as a class cannot reasonably be expected
to possess. The principle affecting these spinal
jackets is surely the same as that applying to drugs ;
it would not be seriously contended that an insurance
practitioner should prescribe drugs for his insured
patients in hospital.
In 1931 the J.A.C. issued a statement as an inter-
pretation of the position of hospitals in the matter of
treatment of insured persons, with particular reference
to the supply of drugs and appliances to such persons.
The following extract puts the position succinctly :—
If a hospital has a restricted medical staff no insured
person is entitled to any treatment at the hospital qua
insured person, nor is any member of such staff, who is
also an insurance practitioner, entitled to treat. at
the hospital any’ patient qua insured person. It
follows, therefore, that the occasion never arises when
such a hospital is called upon to dispense, nor any insurance —
practitioner upon the staff entitled to prescribe qua
member of the staff of the hospital, medicines or appliances
at the cost of the national health insurance funds.
PARLIAMENTARY INTELLIGENCE
[may 22, 1937
The insurance committee decided to refer the
matter to the National Association of Insurance
Committees,
Cremation Certificates
An insurance practitioner issued an ordinary death
certificate without charge and was then asked for the
special certificate required before cremation could
take place, for which he rendered an account for a
guinea. The relatives raised the question of payment
with the local insurance committee, and an inquiry
was addressed by them to the Ministry of Health
as to whether it was open to the practitioner to
submit an account for a certificate required purely
in connexion with the cremation. Rule I of the
medical certification rules is quite explicit ; certificates
are required to be given only if they are necessary
for the purposes of national health insurance, and
the department gave the obvious answer that there
is nothing in the rules to preclude a practitioner from
claiming a fee for giving a medical certificate in the
circumstances indicated. <i
PARLIAMENTARY INTELLIGENCE
THE FACTORIES BILL IN COMMITTEE
THE Factories Bill was further considered by a
Standing Committee of the House of Commons on
May th.
Examining Surgeons
On Clause 119 (Appointment and duties of examin-
ing surgeons),
Major NEVEN-SPENCE moved to leave out the
proviso that the Secretary of State might authorise
a medical practitioner who was employed by the
occupier of the factory in connexion with the medical
supervision of persons employed in the factory, but
was not otherwise interested in the factory, to act as
examining surgeon for that factory for such purposes
as the Secretary of State might direct. He said the
more he looked at that provision the less he liked it.
Factory examining surgeons were specialists in regard
to knowledge, experience, and qualifications and
were, or ought to be, whole-time men at the job.
A medical practitioner in charge of welfare work in a.
factory had not necessarily any of the qualifications
which he should have as an examining surgeon.
If under Clause 67 (which deals with the duty of an
examining surgeon to investigate and report in certain
cases) the Home Secretary required an investigation
and report in the case of death or injury due to
exposure to fumes, or in the case of any disease, that
duty should not be carried out by someone who was
a paid employee of the occupier of the factory.
Mr. WHITE said he hoped the Under-Secretary
would give favourable consideration to this amend-
ment. A great deal of anxiety had been felt in some
quarters because it seemed to introduce an undesirable
principle in doing something which might tend to
put the medical practitioner employed in a factory in
an undesirable position. Nobody held the medical
profession in higher esteem than he (Mr. White)
did, but people should not be placed in a statutory
position where their public duty might conflict
with their private interests. Under this clause
they might have the position where a man in receipt
of a salary of £1000 a year from the occupier of a
factory could be appointed, but another who held
five shares at a shilling each in that factory would be
disqualified from serving. If the Under-Secretary
was unable to accept this amendment perhaps he
would give special permission for the surgeon employed
by the factory to report for certain extra duties.
EMPLOYMENT IN TWO CAPACITIES
Sir J. HASLAM said he hoped that the amendment
would not be accepted. He had had experience of
factories in which a very high standard had been
developed in regard to the after-care of young people
who worked in mills where there was a complete
system of medical inspection, nurses, and rest-rooms.
In their discretion the owners asked the certifying
surgeon to act as their medical adviser in this matter,
and who could do it better? The ordinary family
doctor had to know something about everything, but
the factory inspector became a specialist in his own
business in knowing the law, understanding
adolescence, and so on. It was a very wise move
indeed for those progressive firms who had rationalised
their business and set an example to the whole of the
country in looking after the health and welfare of
their workers, to call in the factory surgeon as their
medical adviser not only in regard to certifying
but in every other respect of their line. It was
a slur on these medical men that they should be
excluded by statute from occupying this position and
the Home Office would be ill-advised to exclude them
from carrying on welfare work in the factories in
addition to their ordinary certifying business.
Mr. Rays DAVIEs said that he had come in close
contact with this problem, because the factory
surgeons had come to see him personally, so that he
had heard the case put both ways. He had decided
definitely in favour of the deletion of this proviso.
Take the case of a young man direct from a university,
having passed his examinations as a doctor, who was
now employed full time by an industrial firm, and
after a year or so applied to become an examining
surgeon under the Home Office. In his (Mr. Davies’s)
view it was against public policy, and certainly
incongruous, that such a medical gentleman, employed
full time and receiving a salary from his employer,
should be asked to do a public duty in respect of his
own employment. Municipal authorities had decided
that once a man was appointed as a full-time medica]
officer he should not do private medical practitioner’s
work. He did not wish to say anything in criticism -
of the doctors, who were doing a very noble service,
but it was contrary to human nature to expect them
to do a public service on the one hand and to do their
job for their employers at the same time. )
Mr. Lioyp, Under-Secretary, Home Office, said
it was not easy to make up one’s mind on this point.
When he first saw this proviso his attitude was that
of Mr. Rhys Davies, and he was inclined to take the
view that it was not right to put any man in a position
in which there might be a conflict of duties or interests.
Since then, however, he had heard the other side of
the question and he was bound to say that it had
impressed him. He would remind the Committee
that this was only an authorisation to enable the
Home Secretary to allow this procedure in certain
ka
THE LANCET]
cases, and for certain purposes, and therefore it could
be closely controlled by the Home Office. Most of
these factory doctors were very keen on their job.
It was in relatively progressive industries that the
employers had been sufficiently public spirited to
go to the trouble and expense of having a ‘special
doctor for this purpose. That was a development
which the Home Office would like to encourage.
It would seem that it was not necessarily right
always to forbid definitely a works doctor, who
knew so much about the conditions in the factory,
from performing some of this work under the Factories
Bill, such as, for instance, the certification of the
fitness of young persons. Other people might
take a different view, but he thought that under the
safeguards provided in the Bill the Home Secretary
might have power to authorise this. He agreed that
if it were authorised improperly it might be liable
to abuse, but on balance he thought it was wise to
retain this proviso in the Bill.
Mr. Rays DAviges asked what was the process
whereby an examining surgeon might be removed
from the list if it was found that in the public interest
he should not continue with his work.—Mr. LLOYD :
I am taking. a little advice on that matter.
POSSIBLE CONFLICT OF INTERESTS
Mr. SILVERMAN said an examining surgeon was
called upon to act in a quasi-judicial capacity and
to do things in which there might be a conflict of
interests, not between the doctor and the public
but between the employer and the employee. Under
Subsection (4) of the clause under discussion it was
provided that the examining surgeon of any factory
should have power at all reasonable times to inspect
the general register of the factory. In Subsection (6)
of the clause it was provided that an examining
surgeon should, if so directed by the Secretary of
State, make special inquiry and examination of
employed persons as might be directed. Frequently
a special inquiry would be required where there was
a suggestion that something improper had occurred,
or where there had been a breach of the regulations. |
In such a case a doctor who was an employee of the
factory would take part in something of the nature
of a que inquiry. Subsection (9) of the clause
stated :—
“ References in the Workmen’s Compensation Act,
1925, to a certifying surgeon shall be construed as references
to an examining surgeon appointed under this section,
and references to the certifying surgeon for the district
in which the workman is employed shall, in a case where a
workman is employed in a district for which no examining
surgeon is appointed, be construed as references to the
medical practitioner (if any) appointed by the Secretary
of State to have the powers and duties of a certifying
surgeon under Part II of the Workmen’s Compensation
Act, 1925.”
There the dyties were almost absolutely judicial.
There were many cases of industrial disease where
it was the business of the certifying surgeon to
certify what disease had been contracted and whether
it had arisen out of the employment. In many cases
the certifying surgeon’s certificate was conclusive,
or almost conclusive, as to the right to workmen’s
compensation. If a certifying surgeon was given
powers to decide people’s rights as between employer
and employee it was not proper that he should be a
person employed by the employer against whom the
rights were being determined. He was not suggesting
that doctors in that position would act improperly,
but the policy of the law had always been not to place
in positions of judicial office, or quasi-judicial office,
persons who were in any way bound to either side
in the matter which was being litigated. He did not
say that the Secretary of State would often appoint
persons where Subsection (9) would have to be
operated, but surely it was much safer on the whole
not to have this proviso in the Bill at all.
Mr. SHORT said that he found, as many members
of the Committee did, some difficulty in reconciling
PARLIAMENTA RY INTELLIGENCE
[may 22, 1937 1249
this proviso with the provisions of Clause 67 of the
Bill. He suggested that the Home Secretary might
insert some words by which, while it would be possible
for a paid medical officer of a particular factory to
be an examining surgeon, he would not be permitted
to investigate the cause of death or of some disease
reported by the inspector which occurred in his own
factory, but some other examining surgeon would be
called in to do that class of work.
A HOME OFFICE AMENDMENT
Sir JoHn Simon, Home Secretary, said he rather
liked that suggestion. There were undoubtedly
cases in which according to general notions of what
was fair and right it would not be proper for the
medical officer of a factory to act as between possibly
contesting parties. On the other hand, as a matter
of common-sense and progressive administration it
would be a pity if a factory medical officer, appointed
by a progressive factory owner to look after his work-
people’s health, were debarred from certifying who.
was fitand who was not fit, because that work depended
on a man’s knowledge of the people and their work.
He (Sir J. Simon) would be prepared to amend the
proviso so that it would run something like this:
‘“ Provided the Secretary of State may authorise
a medical practitioner ... to act as examining surgeon
for that factory,” and instead of saying: ‘‘ for such
purpgses as the Secretary of State may direct,”
it might be sufficient to say: ‘‘ for the purpose of
examining and certifying the fitness of young persons.”’
Mr. WHITE: There is also the matter of certificates
of employment.—Sir J. SIMON : Yes; it arises under
Clause 92. Continuing, the right hon. gentleman said
that if he might put the words he had suggested into
the Bill provisionally he was willing to do so. .
Major Neven-Spence withdrew his amendment
and moved an amendment in the form suggested by
Sir J. Simon, which was agreed to.
Mr. RHys DAVIES moved an amendment providing
that subject to the consent of the employed person
concerned the examining surgeon should have the
right to inspect the medical records of the medical
practitioner employed by the occupier of the factory. —
Mr, LLOYD said the Home Office would like to go
into this matter further and see whether the proposed
amendment was desirable.
The amendment was withdrawn.
THE QUESTION OF SCHOOL MEDICAL DOSSIERS
Mr. ELLIS SMITH said that there had been gradually
growing up an ideal system of medical supervision
of school-children up to 15 and 16 years of age.
The medical men and women who were administering
the Education Acts had scientific knowledge of the
development of the children, kept records of their
health and capabilities in the classes, and were in
constant touch with the children themselves. Up
to the age of 18 the future of young people was very
uncertain. In these times of repetition work in
large factories it was common for young people to
be discharged at 16, 17, or 18 years of age, and the
progressive education authorities were of the opinion
that the medical officers who administered the
Education Acts ought to have jurisdiction also over
the children until they reached the age of 18. He
understood that the medical officers were already
responsible for children up to 16 so far as the
elementary schools were concerned, and in the case
of the secondary schools they were responsible for
them until the age of 18. He asked the Home
Secretary before the Report stage of this Bill to
reconsider the whole of this clause in order that this
gradually developing scientific method of handling -
children up to the age of 16 might be continued
until they were 18.
Mr. LLOYD said of course the views of educationists
on a matter of this kind, which was not directly
within their purview, were not the final word; there
was another side. There were also the points of
view of the industrialists and the doctors to be taken
into account, and they were not quite the same thing.
1250 THE LANCET]
Everyone knew that doctors attached great importance
to a proper medical history of a case, and they were
really at a loss if they had not got it. If it were
necessary to change the provisions of the Bill in order
to make sure that these medical histories would be
available, and if they could not be made available
in any other way, the case would be very strong,
but even then there would be considerable objections.
He believed that quite a large number of school-
children—many more than one was inclined to think
at first sight; indeed he had heard it estimated
at 50 per cent., though that could not be true.in all
cases—went to work in areas different from those
in which they had grown up as school-children and
that would make the working of this scheme, if it
was still to be based on the educational medical
system, rather difficult. In any case, however, he
thought they must realise that these medical histories
could be made available. There were elaborate
provisions in Subsection (9) of Clause 92 for making
available those medical histories which were really
important. Therefore he did not think that the case
was so strong as was suggested, and he did not think
OBSTETRICS IN GENERAL PRACTICE
[may 22, 1937
that they ought to take the view that the doctors
under the education system were more likely to do
the work better than the examining surgeons were
doing it to-day. They were practical doctors who
had had considerable experience of industry, and he
thought that the Committee would be ill-advised
to make such a change as had been suggested. —
The clause was ordered to stand part of the Bill.
FEES OF EXAMINING SURGEONS
On Clause 120, Mr. VIANT moved to provide that
the Home Office should be charged with the expendi-
ture in connexion with this part of ‘the Act.—Mr.
LLOYD said he thought it was a reasonable view to
take that these medical examinations were on a
similar basis to the other precautionary measures
which occupiers were required to take, and of which
they had to bear the expense, and he saw no reason
why they should be relieved of this particular expense.
The amendment was withdrawn and the clause was
ordered to stand part of the Bill.
_. The Committee adjourned until May 25th.
CORRESPONDENCE
OBSTETRICS IN GENERAL PRACTICE
To the Editor of THE LANCET
Str,—I am in agreement with your leading article
of May 8th that the proposals contained in the
recent report by the Ministry of Health on maternal
mortality and morbidity are revolutionary. You
leave one doubting, however, whether you approve
or disapprove of the revolution. On balance, I
conclude that you approve, as I do. For many years
I have advocated the recommendations contained
in the report. To put it very simply, operative
obstetrics should be placed on a plane with surgery
and the surgical specialties—only experts should
deal with it. By experts I include not only pure
obstetric specialists but those general practitioners who,
by post-graduate training and the interest they
take in obstetrics, have qualified to practise this
special branch of medicine and surgery.
My criticism of the report is that it does not define
and detail how the obstetric service is to be organised.
I did so in 1931 and included my scheme in ‘‘ Maternal
Mortality and Morbidity : a Study of their Problems ”’
published by E. and S. Livingstone in 1933. :
We are now going to have expert municipal mid-
wives. Their work should be directly associated with
the antenatal clinics of jlocal authorities ; this would
give those centres very definite supervision of their
work and lessen the number of “inspectors,” or
‘‘ supervisors ” as the Minister of Health prefers to
designate them, necessary for the service. :
The medical staff of the antenatal clinics should
be well-trained and experienced obstetricians and
they should act as consultants to the municipal
midwives when they require advice or assistance,
Further, the obstetricians of the antenatal clinics
should be on the staff of the local maternity hospitals
and act as assistants to the medical director or
directors of the hospitals. At present in many ante-
natal clinics of local authorities the medical staffing
is unsatisfactory, because the individuals doing the
work are engaged only in the antenatal care of
pregnant women—they have nothing to do with
the supervision of women in parturition or during
the puerperium.
In many large cities, and certainly in all in which
there is a teaching school, pure obstetric specialists
are 10 hand. In some these would have to be intro-
duced, as has been done in a few instances. In small
cities and towns specially well-trained family prac-
titioners should be enlisted into the service. It is
unfortunate in some respects that obstetrics in
common with so many other departments of medicine
has to be removed from the province of the family
practitioner. But as you point out ‘“ occasional
obstetrics is even more dangerous than’ occasional
motoring’’; possibly “may be” should be sub-
stituted for ‘‘ is.”
One word more. I think it would be preferable if
in the further developments of the service con-
struction were made from the centre or the institu-
tion rather than the periphery. It is impossible to
predict to what extent institutional treatment may
extend. As a simple example—a number of us think
that all primigravide should receive institutional
treatment in their first confinement.
I an, Sir, yours faithfully,
Canterbury, May 13th. J. M. Munro KERR.
MEDICAL PEACE CAMPAIGN
To the Editor of THe LANCET
Sm,—The death early in April of Dr. Cecile
Booysen, the secretary of the Medical Peace Campaign,
has been a great loss to her colleagues. It was chiefly
through her inspiration and energy that the work
of such a campaign was conceived and initiated.
As we, who were closely associated with her, interpret .
her thought, it was that our profession has a duty
to strive for the prevention of all human suffering
and pain by penetrating to their causes and removing
them. If war came to be outside the medical purview,
one of the main sources of such suffering would be
eliminated. “A calm, scientific approach is needed
and the profession as a whole should be urged con-
stantly to debate the problems associated with war
and its causation much as it debates the stiology and
prevention of disease.
It is in this spirit that her work will be carried
forward. We do not anticipate spectacular results,
for the point of view will require discussion among
our colleagues before it is likely to receive full accept-
ance, But primarily it is this discussion that we wish
to initiate and foster.
An account of the activities of the Campaign
up to date will be found in the three bulletins that
have so far been issued ; but we feel that our activities
i aÁ o a a
THE LANCET]
THE METHYLATED SPIRITS (SCOTLAND) BILL
[may 22, 1937 1251
are only beginning. We hope soon to issue a short
book on the causes and characteristics of war as
considered from a strictly medical point of view.
Suggestions on possible research will be welcome, as
will any other proposals for furthering the objects
of the Campaign.
Finally we express our hope that all members of
our profession, who are convinced of the urgency
of action, will place themselves in some relation
with the existing Peace organisations, such as the
Peace Councils and the branches of the League of
Nations Union. |
On behalf of the Committee of the Medical Peace
Campaign, I an, Sir, yours faithfully,
May 15th. JOHN A. RYLE.
THE METHYLATED SPIRITS (SCOTLAND) BILL
To the Editor of THE LANCET
Sır, —It must be assumed that the taste for that
noisome fluid methylated spirit is sufficiently
prevalent north of the Tweed to require an Act of
Parliament to check its indulgence; otherwise it
is inconceivable that the Methylated Spirits (Scotland)
Bill, which is down for second reading in the House
of Lords on June Ist, should have passed through
all its stages in the Commons. Is this crank legislation
orisitnot? The Bill as introduced into the House of
Commons sought to control the sale in Scotland
of methylated spirits by requiring that all purchasers
of it should sign an entry in a book kept by the vendor
for the special purpose of tracing the buyer who
purchases the spirit in quantities less than four
gallons. In other words a Scotsman might still
buy 32 pints without disclosing his identity but
if his requirements were for the modest quantity
of say half a pint, whether to take the spots off his
Sunday clothes or to boil water to add to a piece of
lemon and something really worth while, he would,
unless he signed the book,.make the man who sold
him the spirit “ guilty of an offence and liable on
summary conviction to a fine not exceeding ten
pounds or to imprisonment for a period not exceed-
ing sixty days.” For some reason or other surgical
spirit was co-partnered with the other evil spirit in
the course of the passage of the Bill through
the Commons. Should this measure eventually
receive the King’s sanction all persons in Scotland
who are ordered by their medical advisers to procure
a supply of surgical spirit so that the patient in the
house may be treated for bed-sores will have to
go about the purchase of it in much the same way as
they have to follow if they wish to purchase a deadly
poison. This is not a Bill which should be hurried
through Parliament. Its motive is good but the
aim should be to stop the four gallon “ beano,”
to introduce a very vulgar word, rather than to
place the slightest hindrance in the way of invalids
suffering from bed-sores.
I am, Sir, yours faithfully,
London, May 15th. F. C. GOODALL.
PRURITUS ANI
To the Editor of THE LANCET
Sır, —In your issue of May 8th Dr. J. T. Ingram
attacks my views on pruritus ani in no uncertain
manner, and I will concede at once that I would have
been wiser to leave out the word “ destructive”
in mentioning the possible effect of X rays on the
vessels, His other thrusts are more easily parried.
He denies that itching is more apt to occur at
body orifices than elsewhere, but in any public
gathering it is commoner to see people scratching
or rubbing the eyes, nares, corners of the mouth,
and ears than other parts, not excepting the healthy
scalp. In children in whom social inhibitions are not
yet developed the same applies to the vulva and anus ;
and the first symptom of acute urethritis is frequently
irritation at the meatus. This matter, however,
was merely referred to in an introductory manner,
I do not think the term “‘ prepruritic stage ” merits
his sarcasm, as it is merely another way of saying
that the threshold to irritation is lowered, and the
variability of thresholds is an accepted physiological
fact. I am well aware, as I indicated in my article, that
the cedema is generally regarded as due to scratching
and rubbing; but it does not follow that this view
is correct. In fact I think it has been the greatest
stumbling-block to a proper conception of the disease.
Dr. Ingram states that æœædema of the skin is readily
provoked in the skin of the genitalia, but in many
cases of severe scabies in soldiers, involving the
scrotum and penis and exhibiting numerous scratch
marks in that area, I never saw any lesion even
remotely resembling that of pruritus ani.
The constructive part of his letter is not quite
clear to me, but I may be allowed to refer to it.
He says the indulgence in the pleasure of anal itching
often creates the habit which is so difficult to break.
Does he mean that the patient creates itching by
auto-suggestion and that the sensation arises in the
sensorium ? As scratching is used to relieve itching
why does the patient scratch to get rid of a sensation
which he likes? Why is pruritus ani a disease of
middle age, though habits are most easily acquired
in childhood and youth ? Dr. Ingram complains that
I dismiss the psychological side of the problem ;
but psychology, though a good servant, is a bad
master.
Major Porter in your last issue is, I think, unwise
in the generalisation that pruritus ani is due to
abnormal anal papillæ. Papillæ which are enlarged,
inflamed, or partially detached are often seen in the
absence of pruritus, but they overlie veins passing
down to the external hemorrhoidal area, and these
veins can hardly fail to be damaged when the papillæ
are cauterised. I am, Sir, yours faithfully,
J. W. Rippoca,
Edgbaston, Birmingham, May 17th.
INSULIN SHOCK TREATMENT OF
SCHIZOPHRENIA
To the Editor of THE LANCET
Str,—Before subjecting patients suffering from
schizophrenia to the train of events incidental to
the depletion of glucose from the body fluids and
tissues (referred to as ‘‘ hypoglycemic shock’’), it
is to be presumed that consideration will be given to
the possibility that such a train of events may be
due to colloidal precipitation. Having in view the
cellular pathology of true schizophrenia the adoption
of such a procedure would appear to entail especially
serious risks. I am, Sir, yours faithfully,
Stafford, May 15th. B. H. SHAW.
To the Editor of THE LANCET |
Sir,—I read Dr. Russell’s letter in your last issue,
and having recently had the advantage of studying
the latest modification of this treatment at Vienna
and Münsingen I think it may serve a useful purpose
to record the methods now adopted by these experi-
enced workers in assessing the various depths of coma
which we follow in our treatment at this hospital.
In Vienna and Münsingen the degrees of uncon-
sciousness during hypoglycemia are expressed as
1252 THE LANCET]
light coma, deep coma, and very deep coma. The
onset of “light coma ” is noted as soon as the patient
is unable to respond to external stimuli, such as
calling his name or touching his body. He may be
quiet or restless. His reflexes are present. The onset
of ‘‘ deep coma ” is carefully noted and is characterised
by loss of the corneal reflex. A sign I have seen
frequently used is gentle blowing on the eyelids ;
in “deep coma ” there is no flinching. ‘“‘ Deep coma”
is considered essential in treating excited and paranoid
schizophrenics. It is never allowed to exceed one to
one and a half hours. The patient is in a “very
deep coma” when the pupils do not react to light.
As long as the pulse and respirations are satisfactory
this condition may be allowed to last for a short
time, but the doctor keeps close to the patient and
ready to interrupt the hypoglycæmia.
From personal experience in this hospital I find that
frequent examinations of the conjunctival reflex
delay the onset of deep coma and therefore I consider
the absence of response to gentle blowing on the
eyelids as a useful guide. When deep coma has lasted
for several minutes a more thorough examination
can be made with less likelihood of the patient
returning into light coma (release of adrenaline).
I am, Sir, yours faithfully,
L. A. FINIEFS.
Three Counties Hospital, Arlesey, Beds, May 18th.
A DISPUTED WILL
To the Editor of THE LANCET
Sir,—In THE LANCET of July 2nd, 1904, you were
kind enough to publish an address I had recently
delivered before the Hunterian Society on the subject
of perforating typhoid ulcer. In it I drew attention
to the fact that between the first symptoms of
perforation and those indicative of the consequent
fatal peritonitis, a remission of symptoms may occur
to such an extent that the diagnosis of perforation
may be abandoned, and I illustrated my remarks
with details of cases. One of these is very pertinent
to the case referred to in your last issue, for the
patient, a man of 56, actually within a few hours of
his death gave certain directions as to the disposition
of his property. He was quite compos mentis, and
I should have been prepared to testify that he had
been so in any court of law had it been necessary, as
I was present at the time.
I am, Sir, yours faithfully,
E. W. GOODALL.
Hemingford Abbots, Hunts, May 16th.
SPAIN OR INDIA?
To the Editor of THE LANCET
SIR, —A letter in your issue of March 13th, under the
heading A Spanish Ambulance, reminds one again
of that peculiar characteristic of the British people
which impels them to lavish their time, energy, money,
and even their life-blood for the relief of the foreigner
in distress, whilst they will turn a completely blind
eye on the needs of their fellow-countrymen. Let a
war break out, or some major national disaster occur
in Spain or Abyssinia, or indeed in any country
other than one belonging to the British Common-
wealth, and at once appeals appear over distinguished
names calling for money, doctors, nurses, and all
the paraphernalia for equipping and dispatching
medical units to the distressed area, and such appeals,
apparently, meet a ready response.
Does it ever occur, I wonder, to those who promote
and respond so generously to these appeals that there
is surely room for their philanthropic efforts in our vast
SPAIN OR INDIA ?
[May 22, 1937
Empire, and indeed even in our own small island ?
Do they realise, for example, that here, in India, there
are vast areas where sickness, disease, and starvation
are rife and where perhaps the only person to whom
the people can look for the relief of their distress—
if indeed there is anyone at all—is one underpaid and
overworked missionary doctor ?
I am not a missionary doctor; I hold no particular
brief for missions, nor is this letter an appeal in aid
of the medical missions; it is merely intended to
indicate one channel into which I consider the charity
of my fellow-countrymen might more profitably be
directed. However much one may feel for the unfor-
tunate victims of the Spanish civil war, I think we
should remember where charity ought to begin, and
I personally would not give one farthing to aid a
distressed Spaniard or Abyssinian so long as one
fellow-member of our Empire is in need of assistance
and it is within my power to help him.
. I am, Sir, yours faithfully,
Assam, India, April 20th. CIVANEC.
EXPLANATION AND APOLOGY
To the Editor of THE LANCET
Smr,—In the booklet recently issued by our firm
in connexion with a block of flats in Dolphin-square
the name of Mr. Hope Carlton, F.R.C.S., was
mentioned as being a doctor in residence there and
available in emergency. We regret to say that
Mr. Hope Carlton’s name was inserted in this booklet
without any authority from him, without his authority
being sought, and without his knowledge, and we
desire to express to him our sincere apology for the
unauthorised use of his name and any inconvenience
that he may have been: caused thereby. Mr. Hope
Carlton is not practising at or from Dolphin-square,
which is his private residence, but he is continuing
to carry on his practice as a consulting surgeon as
before. We are, Sir, yours faithfully,
RICHARD COSTAIN LTD.
Dolphin-square, Grosvenor-road, S.W., May 11th.
THE FRUITS OF IDLENESS
To the Editor of THE LANCET
SIR, —Last week your Scottish correspondent again
mentioned plans to shorten the students’ summer
vacation. Far be it from me to interfere with the
traditional sport of overburdening the curriculum ;
nevertheless I venture to hand on the opinion of a
group of young London consultants whom I lately
heard discussing medical education. The question
arose why the new Scottish graduate is a better
doctor than his English contemporary. The answer
was that his long summer holiday, his life in lodgings,
and his habit of frequenting places of public refresh-
ment bring the Scottish student into ‘closer touch
with real human beings and so promote an earlier
maturity of judgment. The holiday also prevents
staleness in teacher and taught.
Of course the argument breaks down at the source
if the Scottish University authorities do not agree
that their graduates are superior.
I am, Sir, yours faithfully,
Sussex, May 18th. VULPIS.
——
MEDICAL PRAYER UNION.—On May 26th, at 8 A.M.,
in the refectory of University College, Gower-street,
London, W.C., this society is holding its annual missionary
breakfast. The speaker will be Dr. Clement Chesterman.
Those who wish to attend should notify Dr. Tom Jays,
Livingstone College, Leyton, E.10.
THE LANCET]
[may 22, 1937 1253
OBITUARY
S. A. KINNIER WILSON, M.D., D.Sc. Edin.,
F.R.C.P. Lond.
THE death of Dr. S. A. Kinnier Wilson removes
from neurological medicine a great figure, who gained
early in life an international renown which was well
deserved. If his name carried even greater weight
abroad than at home this is not to imply that he
lacked honours here but that his command of
languages, his power of lucid exposition, and his
forceful personality carried his fame to places where
the achievements of other British neurologists had
not been accorded recognition. Perhaps his repute
abroad depended on the fact
that neither in thought nor
in teaching could he be con-
sidered as typical of the
British school. Rather he
kept up the tradition of the
Salpétriére in the days of
Pierre Marie, which had been
one of his earliest inspira-
tions ; and no doubt he owed
much also to Hughlings Jack-
son, of whom he was an
enthusiastic disciple.
Samuel Alexander was the.
son of the Rev. James Kinnier
Wilson of Co. Monaghan,
Ireland. He was born in New
Jersey, U.S.A., in 1878 and
educated in Edinburgh at
George Watson’s College and
the University, of which he
became M.A. in 1897. Bur-
saries and scholarships fell
early to his hand before and
after he began to study medi-
cine; he qualified M.B. in
1902 and took his B.Sc. with
first-class honours in physio-
logy in 1903 after a period
as house physician in the
Royal Edinburgh Infirmary.
In the same year he became
a Carnegie research fellow
and went to work in Paris
with Pierre Marie. On his
return to England in 1904 Kinnier Wilson
was made house physician to the National Hos-
pital, Queen-square, and he continued to serve
this hospital in various ‘capacities for the rest of
his life, becoming in turn resident medical officer,
registrar, and pathologist, before his appointment to
the honorary staff as assistant physician (1913),
physician to out-patients (1921), and physician to
in-patients (1925). . These were years not only of
preparation but of achievement. After taking the
M.R.C.P. Lond. in 1907 Wilson produced what was
acclaimed as an excellent translation of a French
book by Meige and Feindel on tics and their treat-
ment, and in the next year published his first con-
tribution to the study of apraxia. From 1909 to 1911
he held a B.M.A. research scholarship, and in the
latter year took his M.D. Edin. with a gold medal.
In 1912 he contributed to Brain the description,
which was to become a classic, of a familial nervous
syndrome which has come to be known throughout
the world as Wilson’s disease. In the same year he
was made assistant physician to the Westminster
DR. KINNIER WILSON
Hospital, becoming dean of the medical school in
1914, when he was elected F.R.C.P. Lond. He
resigned from the Westminster in 1919 on his
appointment to King’s College Hospital as junior
neurologist and lecturer in neurology in the medical
school ; he became neurologist to the hospital in 1927
and senior neurologist in 1928, on the retirement of
Dr. W. Aldren Turner.
During the last 20 years the esteem in which Wilson
was held for research, clinical acumen, and for written
and oral explanations of difficult neurological con-
ceptions grew to such an extent that his leisure
hours were few and were still further curtailed when
in 1920 he became editor of
_ the newly established Journal
of Neurology and Psycho-
pathology. Yet it was only
within the last few years that
he became only an occasional
instead of a regular contri-
butor of leading articles on
neurological subjects to our
columns and relinquished,
with evident reluctance,
routine reviewing duties,
Though Wilson’s name is
chiefly connected with cer-
tain aspects of disorders of
motility and of muscle tone,
aphasia and apraxia, narco-
lepsy and hysteria, which he
chose as subjects for mono-
graphs or official lectures—
e.g., the Croonian lectures of
the R.C.P. Lond. in 1925,
and the Morison lectures of
the R.C.P. Edin. in 1930—
we have good reason to know
that his interests were as
extensive as his knowledge
was wide. At short notice he
could, and would, supply
wise comment, generous
appreciation, reasoned critic-
ism in words so nicely chosen
that notices from his pen
were a delight to read. His
spoken words—as president
of sections of the Royal Society of Medicine,
at the annual meetings of the British Medical
Association, at congresses or at public dinners
—were no less apt in allusion and stimulating in
content. This gift and the fact that he was no less
agreeably fluent in German or French brought him
more invitations to take a prominent part in profes-
sional gatherings than he could possibly accept. He
was made an honorary member of the neurological
societies of almost every European country and of
the American Neurological Association, and his
personal contacts with: workers in other countries
were renewed and extended at his clinics at the
National Hospital which were frequented by post-
graduates from every land.
His interests in recent years are clearly reflected in a
book entitled “ Modern Views on Neurology,” pub-
lished in 1928, which is much more than the collection
of lectures and essays it looks to be. It starts with
five chapters on the epilepsies, followed by one on the
narcolepsies in which Wilson examines the analogies
between various narcoleptic symptoms with those
1254 THE LANCET]
usually termed epileptic. An essay on the old (striato-
spinal) and the new (cortico-spinal) motor systems
forms an excellent introduction to the survey of the
disorders of motility and of muscle tone, with special
reference to the corpus striatum, which formed the
subject of his Croonian lectures, here reprinted. The
three final chapters are on pathological laughing and
crying, on dyszsthesia and their neural correlates,
and on the Argyll Robertson pupil. To all the
subjects dealt with in this book and to many others
he had made a personal contribution which never
remained an isolated observation but was woven
with infinite care into the complex pattern of current
neurological ideas. It is a matter for deep regret
that a man with such a power of clear logical thought
on intricate neurological problems should not have
been able to finish the text-book of neurology on
which he had been engaged for the last decade. The
book is nearly complete; over three-quarters of the
text is ready. A further eighth has been written,
but he wanted to rewrite it, and there remains an
eighth which existed only in the form of rough notes,
His colleagues and disciples had expected this work
to become a standard international text-book as
important to modern neurologists as was ‘“ Gowers ”’
in the late ’nineties, and it is greatly to be hoped that
they will be able to arrange for its completion.
Wilson’s knowledge of his subject was encyclo-
pedic; he read widely and possessed a remarkable
memory in which the enormous clinical material
that passed through his hands during his many years
as out-patient physician at the National Hospital,
and as consultant neurologist to the Metropolitan
Asylums Board, and, later, the London County Council
was safely stored. He was a splendid teacher, with
a flair for the unusual phrase that remains in the
memory when most of the rest is forgotten, and a
delightful informal talker. His lectures and demon-
strations were always crowded because there was
always something fresh, if not in the case or the subject
at least in the manner of presentation. An assistant
medical officer at the Fountain Hospital writes :
“Dr. Kinnier Wilson’s visits to this hospital for
mentally defective children were a stimulus and an
inspiration. His avid curiosity and his provocative
speculations set us hunting for material between his
visits and gave a new impulse to routine physical
examinations. If we had some _ half-formulated
theory to put forward he was always eager to discuss
it, drawing on his own profound experience to check
and encourage our reasoning. He was a teacher in
the Hippocratic tradition.”
The personal side of “ Sam ”’ Wilson is not easy to
convey to those who did not know him. Strangers
were apt to take for hauteur what was only abstrac-
tion. He had no facile social grace, nor could the
barrier round him be scaled once and for all. The
approach remained difficult for all but a band of
close friends who knew that he welcomed their
advances. even if he was unable to help them to
reach and retain intimacy; and the depth of his
affection was apparent when his friends were in any
trouble. His interests outside his library were golf
—as a left-handed player—his garden at Thorpeness,
and his family. He married Annie Louisa, daughter
of Dr. Alexander Bruce, who survives him with two
sons and a daughter.
Dr. Macdonald Critchley writes: ‘‘ A mere recital
of international honours and academic distinctions
does not adequately describe the place occupied in
British neurology by the late Dr, Kinnier Wilson.
Although trained on a firm foundation of physiology,
OBITUARY
[may 22, 1937
anatomy, and pathology, Wilson was at heart
essentially a clinician with a philosophical and
reflective outlook. In this respect he was inspired by
the friendship and precepts of his revered Hughlings
Jackson, with whom as a very young man he became
closely acquainted. Besides his outstanding abilities
Wilson was gifted with an exceptional memory and a
sure command of language. He wrote easily and clearly
in a style which was individual. His writings, which
covered a large range of neurological subjects, had the
uncanny faculty of throwing light from an unusual
angle upon the problem concerned. In this way his
papers were particularly inspiring, always refreshing,
and sometimes provocative. Wilson’s approach
to a problem invariably went beyond a simple
recording of observed data—a style of publication
which he dubbed as merely ‘ descriptive’—and he
would always inquire in a reflective and thoughtful
manner into the modus operandi of clinical phenomena.
In this way all his writings were rich in speculative
and stimulating matter. The monograph, published
while yet a registrar at the National Hospital, which
won him international fame was his well-known
thesis on ‘progressive lenticular degeneration,’ a
malady which bears his name. This particular work
may be regarded as the impetus to the world-wide
interest in the normal and morbid physiology of the
basal ganglia. ` Wilson felt that much of the subse-
quent work went considerably too far into the realms
of the imagination, and his Croonian lectures on
‘Disorders of Motility’ were written as a protest
against this striatal jerry-building.
“ Wilbon will especially be remembered by his
pupils as a lecturer. He was probably one of the finest
modern medical speakers, eloquent and witty in his
choice of language, with a supreme ability for arousing
the interest and attention of his listeners, and for
stage-managing his material. His clinical demonstra-
tions at the National Hospital were attended by
throngs of students from all over the world. His
numerous pupils and assistants will be the poorer
without his genial and stimulating inspiration. No
one was more gifted than he in the ability to iluminate
difficult neurological problems and his valuable
time was always at the disposal of his juniors. In
these days of mediocrity, Wilson stood out as a
‘big man’—one who will be remembered for his
bonhomie, brilliance, and kindliness of heart. His
keen sense of humour—rare in one so witty—will be
sadly missed wherever neurologists foregather.”
GEORGE EVERARD DODSON, M.R.CG.S. Eng.,
D.T.M. and H.
WE regret to announce the death of Dr. G. E.
Dodson from typhus fever on May 9th at Kerman,
Iran (Persia), where he had charge of the Church
Missionary Society’s Hospital. Born in 1872 at
Higher Crumpsall, Manchester, he was educated
at Giggleswick grammar school and St, Bartholomew’s
Hospital. He qualified in 1897 and became extern
midwifery assistant and assistant in the orthopedic
department at Bart.’s, gaining experience which he
turned to good use later. After further hospital
work at Norwich, Bath, Nottingham, and elsewhere,
he was accepted by the Church Missionary Society
for service in Persia, and with his wife, Miss E. L.
Wells, a trained nurse, he left England in 1904.
“ During his 34 years of service under the C.M.S.,”
writes a colleague, “Dr. Dodson did a work for
Iran which will never be forgotten. He was a gifted
surgeon, and laid the foundation of a social service
THE LANCET]
and welfare activities—especially at Kerman—which
has been of inestimable value. Two outstanding
features of his professional practice were his ortho-
pædic work amongst the crippled carpet-weavers, and
the skilful obstetrical and gynzcological work which
has saved the lives of large numbers of dwarfed
cripple-mothers in that industry. No less important
were the preventive and welfare services which he
instituted, and which led to legislation that has gone
far towards revolutionising the conditions of the
PUBLIC HEALTH
[may 22, 1987 1255
carpet industry in the cities of Iran. As a missionary
he was honoured for his high sense of duty, his
lovable personality, and his unsparing self-sacrifice.
He died, as he would have wished, among the people
whom he had served, and for whom he has given his
life.”
During the late war Dr. Dodson held a captain’s
commission in the Royal Army Medical Corps and
was surgical specialist at the Colaba War Hospital,
Bombay.
PUBLIC HEALTH
The Smoke of Britain
On the whole the pollution of the atmosphere in
this country has been reduced during the last twenty
years. This is the conclusion reached in a report by the
Department of Scientific and Industrial Research!
which summarises measurements by 72 municipal
and other bodies. Some of the figures show a small
increase during the last two years—presumably
because of increased industrial activity—but the
outstanding feature of the curves is the large decrease
in pollution at many places before the industrial
depression of 1930-33 started.
The records for London show improvement between
1915 and 1922, but from then until 1936 there was
little change in the total solids, an increase in the
deposit of sulphates and, if anything, an increase
in the deposit of tar. On the other hand, it is
considered encouraging that in the winters of 1931-35
central London enjoyed 52 per cent. of the sunshine
obtainable at Kew (which naturally shows a small
deficiency compared with the remoter countryside)
compared with 20 per cent. in 1881-85. In Edinburgh
(Princes-street) the pollution is getting rather worse.
Glasgow records a steady improvement from 1915 to
1923, but from then onwards there has been little
change. At St. Helens the total solids deposited
has fallen from 612 tons per square mile in 1917-18
to 447 tons in 1935-36, but the improvement has not
been continuous. The total deposit at Wakefield
fell from 613 tons per square mile in 1924 to 227
tons in 1935—that is, by almost two-thirds in ten
years. Sulphates fell from 136 tons in 1924 to 22 tons
in 1930, rising somewhat later to 24 tons in 1935.
Tar decreased from 8 tons in 1924 to 6 tons in 1936.
An attempt has been made to trace the trend of
affairs for suspended impurities which produce smoke
haze as well as matter deposited from the air. In
this respect the London stations do not all tell exactly
the same story, but there is again a general indication
of improvement. In four out of five of the observing
stations, however, the results for 1935-36 indicate
a higher degree of pollution than 1934-35. In
Glasgow there has been almost no change. The
results for Cardiff, which indicate a lower level of
pollution than most of the others have a slight
tendency to get worse.
The figures for tar in 1936 indicate an increase.
One of the worst stations for tar deposits was Golden-
‘lane, London, where the tar deposit in the gauge was
at the rate of 10:44 tons per square mile, an increase
of 243 per cent. on the general average for the last
five years. The deposit of total solids which, the
report states, may be regarded as a summary of all
the others indicates that 1936 compares unfavourably
as a whole with 1934-35. The greatest increase was
found in London (Finsbury Park) with an annual
1 Investigation of Atmospheric Horution: London: H.M.
. 683.
Stationery Office. 1937. Pp. 128
_ education and enlightenment.”
deposit of total solids at the rate of 405-12 tons, or
158 per cent. of the general average. Finsbury
Park also showed a large increase in the deposit
of sulphates with a figure of 341 per cent. of the
general average. The next greatest deposit of
sulphates was at Halifax (Westview Park) with `
242 per cent.
Records of the amount of sulphur gases in the
atmosphere, which are believed to have a considerable
effect on the deterioration of building stone and .
possibly (in high concentrations) on health, were made
at eleven stations. The sulphur appears to be
mainly a winter problem. London shows the highest
average pollution of any of the cities and a very
obvigus seasonal variation pointing again to the
domestic fires as a contributory cause, although
doubtless the electric generating stations also burn
more fuel in winter than in summer. Of the London
stations, Westminster Bridge and Westminster City
Hall show the most sulphur pollution. Last year the
highest concentration was found in London, but this
year the highest figure found was in Salford during
December. Sulphur pollution at Greenwich appears
to be about one-third of that in the vicinity of .
Westminster. It seems that Greenwich, although
suffering from smoke haze as much as London, does
not suffer equally from sulphur pollution and this
suggests that in London there are sources of sulphur
which are not serious sources of smoke. This again
points to industrial furnaces which have no provision
for absorption of sulphur.
Publicity for Venereal Disease
The Minister of Health has sent a circular asking
counties and county boroughs to tell him what steps
they are taking to disseminate information about
venereal diseases. There is evidence, the circular
says, that the public in many parts of the country
are still insufficiently informed about the importance
of these infections and the necessity for early and
skilled treatment. The reports from treatment
centres suggest that in many areas only a small
proportion of women with the venereal diseases—
especially with gonorrhoa—take advantage of the
facilities offered. Moreover, a substantial proportion
cease attendance while they are still potentially
infectious. It is of the utmost importance, in the
Minister’s opinion, that patients should appreciate
the necessity—in their own interest and in that of the
community—for completing their treatment. To
this end he commends a policy of ‘continuous
So as to be able to
judge how this policy may be developed and rendered
more effective he is asking for full particulars of the
arrangements at present made. One of the questions
asked is whether a contribution is made to the British
© Social Hygiene Council, and if so, what work is done
by the Council in the area.
1256
THE LANCET]
s‘ Flying Clinics” in Somerset
In order to deal with the medical supervision of
maternity and child welfare work in rural areas,
Dr. W. G. Savage, the medical officer of health
for Somerset, has instituted a system of “ flying
clinics’? which he considers to be far superior to a
system of small fixed welfare centres covering the
county. The clinics are held when and where occasion
arises, often at the request of the infant visitor,
and may take place at a nurse’s house or at a room
taken for the purpose; or visits may be undertaken
to several scattered houses in a district. The visiting
of children at their homes makes it possible to include
those who might well be unable or unwilling to bring
their children to a centre. Where the clinics prove
welcome and popular they are repeated at short
intervals and if the need in any such area later
diminishes, the clinic can easily be discontinued and
-the work done elsewhere. In his annual report
Dr. Savage states that the four medical officers held
311 of such sessions during 1935 and attendances
totalled 3525, including 115 antenatal and 126 post-
natal mothers. It would seem that such clinics
might be of very real value to practitioners in out-
lying districts by providing opportunities for con-
sultation where circumstances would otherwise make
a second opinion very difficult to obtain.
INFECTIOUS DISEASE
IN ENGLAND AND WALES DURING THE WEEK ENDED
MAY 8TH, 1937
Nolifications.—The following cases of infectious
disease were notified during the week: Small-pox, 0 ;
scarlet fever, 1662; diphtheria, 985; -enteric fever,
36; pneumonia (primary or influenzal), 949;
puerperal fever, 35; puerperal pyrexia, 99; cerebro-
spinal fever, 33; acute poliomyelitis, 1; acute polio-
' encephalitis, 1 ; encephalitis lethargica, 0 ; dysentery,
20; 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 May 14th was 2969 which included: Scarlet
fever, 797; diphtheria, 852; measles, 77; _whooping-cough,
481; puerperal fever, 18 mothers (plus 11 babies) ; encephalitis
lethargica, 283; poliomyelitis, 0. At St. Margaret’s Hospital
there were 24 babies (plus 12 mothers) with ophthalmia '
neonatorum.
Deaths.—In 123 great towns, including London,
there was no death from small-pox, 2 (1) from enteric
fever, 19 (0) from measles, 4 (3) from scarlet fever,
- 12 (1) from whooping-cough, 35 (5) from diphtheria,
64 (23) from diarrhoea and enteritis under two years,
and 31 (7) from influenza. The figures in parentheses
are those for London itself.
Five deaths from diarrhoea and enteritis under two years
were reported from Liverpool and 3 each from Nottingham
and Bradford. Salford, Sunderland, and Liverpool each had
3 fatal cases of diphtheria. There were 3 deaths from measles
at Birmingham and 3 from whooping-cough at Liverpool.
The number of stillbirths notified during the week
was 291 (corresponding to a rate of 41 per 1000
total births), including 38 in London.
THE SERVICES
ROYAL NAVAL MEDICAL SERVICE
Surg. Rear-Admiral P. T. Nicholls, C.B., K.H.P., “to
President for service inside Admiralty Medical Depart-
ment.
Surg. Capt. R. F. P. Cory to President for course.
Surg. Capt. J. H. Burdett, professor of medicine at
Haslar Ho: pital, to R.N. Hospital, Chatham.
Surg. Cmdrs. M. B. Devane and A. W. Gunn, M.V.O.,
to Victory for R.N.B., J. A. Cusack to Pembroke for R.N.B.,
and A. W. McRorie to President for course.
Surg. Lt.-Cdr. F. Dolan to Drake for R.N.B.
THE SERVICES
[way 22, 1937
Surg. Lts. G. H. C. R. Critien to Drake for R.N. Hospl.,
Plymouth; D. B. Jack to Pembroke for R.N.B.; R. M.
Kirkwood to Pembroke for R.N.B. and to Pegasus; R. M.
Bremner to Hastings; D. D. Steele-Perkins to Pembroke
for R.N.B. and to Ganges; and I. C. Macdonald to Cardiff
and to R.N.B., Chatham.
ROYAL NAVAL VOLUNTEER RESERVE
Surg. Sub-Lt. C. P. Nicholas promoted to Surg. Lt.
ARMY MEDICAL SERVICES
The War Office announces the following appointments :
Colonel R. W. D. Leslie, O.B.E., L.R.C.P., Officer
Commanding, The Queen Alexandra Military Hospital,
Millbank, S.W.1, has been selected for promotion to the
rank of Major-General from August 10th, 1937, and to be
Deputy Director of Medical Services, Northern Command,
York, in succession to Major-General G. G. Tabuteau,
D.S.O., who is taking up the appointment of Director of
Medical Services in India. `
Colonel A. D. Fraser, D.S.O., M.C., M.B., who commands
the Royal Army Medical Corps Depôt and Training
Establishment at Aldershot, has been selected for promo-
tion to the rank of Major-General from Oct. 13th, 1937,
and to be a Deputy Director of Medical Services in India,
in succession to Major-General D. S. Skelton, C.B., D.S.O.,
honorary physician to the King, who will vacate the
appointment on completion of four years’ service as a
Major-General. .
ROYAL ARMY MEDICAL CORPS
Maj. J. R. S. Mackay retires on ret. pay.
Short Service Commissions : Lt. P. Coleman to be Capt.
The following candidates have been selected for short
service commissions as Lts. on probation: F. Livesey
(Manchester Univ.), C. E. McCloghry (Queen’s Univ.,
Belfast), C. McNeil (Cambridge Univ. and St. Bartholomew’s
Hosp.), G. G. Sherriff (Edinburgh Univ.), G. M. Curtois
and E. Gareh (Guy’s Hosp.), J. B. Bunting (Cambridge
Univ. and St. Thomas’s Hosp.) R. B. Robertson
(St. Andrew’s Univ.), A. T. M. Glen (Westminster Hosp.),
K. F. Stephens (London Univ. and St. Bartholomew’s
Hosp.), G. M. Robertshaw and O. W. W. Clarke (The
London Hosp.), R. L. Townsend (Cambridge Univ. and
University Coll. Hosp.), F. J. S. Baker and J. B. Dancer
(St. Bartholomew’s Hosp.), O. Jordan (St. Mary’s Hosp.),
and N. Bickford (Cambridge Univ. and Middlesex Hosp.).
The following Lts. (on prob.) are secd., under the prov.
of Art. 213, Royal Warrant for Pay : C. McNeil and F. J. S.
Baker.
REGULAR ARMY RESERVE OF OFFICERS
Lt.-Col. G. H. Stevenson, D.S.O., having attained the
age limit of lability to recall, ceases to belong to the
Res. of Off.
TERRITORIAL ARMY
F. C. Angior to be Lt.; P. Hawe (late Offr. Cadet,
Liverpool Univ. Contgt., Sen. Div., O.T.C.), to be Lt. ;
E. H. P. Smith (late Cadet Serjt., Epsom Coll. Contgt.,
Jun. Div., O.T.C.), to be Lt.; K. G. S. Bavidge (late Offr.
Cadet, Durham Univ. Contgt. (Med. Unit), Sen. Div.,
O.T.C.), to be Lt; and A. G. McCallum (late Offr. Cadet,
Glasgow Academy Contgt., Jun. Div., O.T.C.), to be Lt.
The Efficiency Decoration has been conferred under the
terms of the Royal Warrant dated Sept. 23rd, 1930, on
Maj. Alfred Pain.
TERRITORIAL ARMY RESERVE OF OFFICERS
Capt. D. M. Mackenzie from Active List to be Capt.
ROYAL AIR FORCE
Flight Lts. promoted to the rank of Squadron Leader :
R. E. Alderson and J. Kemp. i
INDIAN MEDICAL SERVICE
Lts. (on prob.) to be Capts. (on prob.).—S. C. Colbeck,
- J. H. Bowie, W. S. Empey, O.B.E., A. G. Miller, E. H.
Wallace, and J. F. Thomson. :
Lts. (on prob.).—G. R. Kerr, B. J. Doran, and J. D.
Munroe are restd. to the estabt.
To be Lts. (on prob.): S. Shone, J. H. Walters, C. F.
Mayo-Smith, W. C. Templeton, G. W. Palmer, G. F. J.
(Continued at foot of opposite page)
THE LANCET]
[may 22, 1937 1257
MEDICAL NEWS
University of Oxford.
The board of the Faculty of Medicine has codpted Prof.
H. W. B. Cairns, fellow of Balliol College, for the statutory
period.
University of Cambridge
On May 14th the following depress were conferred :—
M.D.—D. G. Macdonald, J. M. Vaizey, and C. A. Clarke.
Sc.D.—*C. C. Okell, F.R.C.P. .
M.B., B.Chir.—*Wilfrid Raffle, *O. L. Lander, Cuthbert
Adamson, and R. S. Castle.
M.B.—*D. W. C. Gawne, *P. R. Soodtellow, *D. C. G.
Pallingall, *C. E. Bevan, O.C. L et hea E. C. Manson-Bahr,
E. C. Herten-Greaven, R. Kerr, D . F. Lawson, T. W. S.
Hills, and J. R. O Wiliams. l
s By proxy.
Royal College of Surgeons of England
At an ordinary meeting of the council of the College
held on May 13th, with Sir Cuthbert Wallace, the president,
in the chair, Mr. E. E. Young and Mr. A. G. Wells were-
admitted to the Fellowship. The Jacksonian prize for
1936 was presented to Mr. W. E. Underwood, and the
John Hunter medal and triennial prize were presented to
Mr. Laurence O’Shaughnessy.
The honorary gold medal of the College was awarded
` to Sir Frank Colyer in recognition of his mary contributions
to scientific odontology and to the service of the College.
The posts of resident surgical officer and first, second,
third, and fourth house surgeons at the Royal Infirmary,
Bradford, and of second house surgeon at the Cumberland
Infirmary, Carlisle, were approved for recognition for the
six months’ surgical practice required of candidates for
the final examination for the fellowship.
- Diplomas of membership and diplomas in tropical
medicine and hygiene were granted to the candidates
named on pp. 1147 and 1148 of our issue of May 8th.
Royal College of Surgeons of Edinburgh
At a recent meeting of the College, with Mr. Henry
Wade, president, in the chair, the following were admitted
to the fellowship :—
Alice Margaret Ross, M.B. Edin. ; To Shedden Adam,
M.B. Sydney; John Frederick Birrell, M.B. Edin. Andrew
Geoffrey Butters, M.R.C.S. Eng. ; John Ajoxander Maxwell
Cameron, M.D. Manitoba ; Leon Chanock, M.B. Aberd. ;
Graham ruce Alastair Cowie, M.B.N.Z Gladys Helen Dodds’
M.D. Edin.; Thomas Byerley Field, WLB. Lond. : Geoffrey
Charles Huxtable Hogg, M.B.Sydney; Brian Southron Jones,
M.B.Camb.; Adrian Charles Kannai M.R.C.S. Eng.; Alan
Arnold Klass, M.D. Manitoha; William Martin Martin, M. B.
Belf.; James Davidson Mill, M.B. Edin. William Rowan
Donovan Mitchell, M.B. Belf.; James Monigomery, M.B. Belf.
William Arthur Morton, M.B. Kdin.; Frank Louis Rifkill,
M.B. Edin.; Raphael David Rowlands, M.R.C.S. Eng. ; Susanta
Kumar Sen, "M.B. Camb. ; Raymond Shaw Trueman, M. B. Lond. ;
Denys Wainwright, M.B. Liverp.; Wilbert Donaldson Whyte,
M.D. Manitoba : and Jack Wilton, M.R.C.S. Eng.
The following candidates received the higher dental
diploma :—
C. F. Mummery, J. C. P. Besford, and D. H. T. M. Robertson-
Ritchie.
(Continued from previous page)
Thomas, G. C. A. Jackson, R. Y. Taylor, J. W. R. Sarkies
(secd.) A. E. B. de Courcy-Wheeler (secd.), N. P.
Woodgate-Jones (secd.), and W. H. A. Thorne (secd.).
DEATHS IN THE SERVICES
` The death occurred on May 12th in London of Brevet
Colonel EpGar JENNINGS, I.M.S.(retd.). He was born
in August, 1864, and was educated at University College,
London. He qualified M.R.C.S. Eng. and L.S.A. in
1886 and took the D.P.H.Camb. in 1909. He joined
the I.M.S. on March 30th, 1889, and was in military
employ till April, 1896, when he was appointed Civil
Surgeon in the Central Provinces. He was transferred
to the United Provinces as Superintendent of Prisons in
November, 1898, and reverted to military duty in
February, 1914. He became Major in 1901, Lt.-Col.
in 1909, and retired in February, 1920, with the rank of
Bt. Col.
University of Sheffield
Dr. M. S. Spink has been appointed assistant bacterio-
logist and demonstrator, and Mr. W. H. Waldman hon.
lecturer in dental prosthetics.
The council of the University have accepted the offer
of the local medical and panel committee of the West
Riding of Yorkshire to award annually to final year students
& prize of £25 in clinical medicine.
Ex-Services Welfare Society
The third annual conference of this society will be held at
10 a.m. at the Grosvenor Hotel, Victoria, on Friday,
June 25th. Dr. Edward Mapother will be in the chair,
and there will be a discussion on the control of the incidence
of war neurosis. Further information may be had from the
medical director of the society, 51, Victoria-street, London,
S.W.1.
Scholarship in Orthopedic Surgery
Particulars will be found in our advertisement columns
of a Lord Nuffield scholarship in orthopedic surgery,
tenable for two years at the Wingfield-Morris Orthopedic
Hospital, Oxford, followed by three months’ travel.
Further information may be had from Prof. G. R. Girdle-
stone at the hospital.
International Union against Tuberculosis
At a meeting held in Paris with Prof. Fernand Bezancon
in the chair it was decided that the tenth conference of
the Union be held in Lisbon from Sept.’5th to 9th. The
discussion wil] be limited to three main subjects: radio-
logical aspects of the pulmonary hilum and their inter-
pretation, to be opened by Prof. Lopo de Carvalho
(Portugal); primary tuberculous infection in the adolescent
and the adult, to be opened by Dr. Olaf Scheel (Norway) ;
and the open case of tuberculosis in relation to family and
domestic associates, to be opened by Dr. J. Hatfield
(United States) and Dr. D. A. Powell (Great Britain).
Further information may be had from the secretary of
the National Association for the Prevention of Tubercu-
losis, Tavistock House North, Tavistock-square, London,
W.C.1
Public Health Congress _
The Royal Institute of Public Health and the Institute
of Hygiene are holding a congress in Margate from May 25th
to 29th over which Lord Horder will preside. The work of
the congress is to be divided into five sections. In the
section of State medicine and industrial hygiene Dr.
J. Greenwood Wilson and Dr. Thomas Peirson will open a
discussion on housing at the first session and at the other
sessions Dr. E. R. Jones, Dr. E. W. Caryl Thomas, and
Dr. N. E. Chadwick will speak. A discussion on milk
will be opened by Dr. L. Meredith-Davies and Dr. H. C.
Maurice-Williams. At the section of women and children
and the public health Miss Margaret Basden, Colonel R. J.
Blackham, Dr. Elizabeth Hurdon, Dr. W. P. H. Sheldon,
Mr. William Ibbotson, Dr. D. R. MacCalman, Dr. Doris
Odlum, and Dr. Letitia Fairfield will be among the speakers.
There will also be a symposium on the staffing of antenatal
and infant welfare clinics. Dr. R. A. Young as president
of the section of tuberculosis will read a paper on the
problem of the chronic open case of pulmonary tuberculosis,
and Dr. F. G. Chandler, Mr. A. Tudor Edwards, Dr. J.
Browning Alexander, and Dr. G. S. Todd will join in the
discussion which will follow. Papers will also be read by
Mr. W. Greenwood Sutcliffe, Dr. J. G. Johnstone, Dr. Alan
Moncrieff, Dr. J. B. McDougall, Dr. C. H. C. Toussaint,
and Dr. È. L. Sandiland. Sir Robert Stanton Woods will
preside over the section of rheumatism and allied diseases
and speakers will include Dr. Douglas Collins, Dr. Sinclair
Miller, Mr. A. G. Timbrell Fisher, Mr. C. E. Kindersley,
Dr. Gilbert Scott, Dr. R. Fortescue Fox, and Dr. F. J.
Poynton. The section of nutrition and physical training
will meet under the presidency of Sir Stanley Woodwark
and speakers will include Prof. S. J. Cowell, Miss E. M.
Widdowson, Ph.D., Dr. G. D. Morgan, and Dr. Alister
Mackenzie; Dr. J. W. Starkey will open a discussion on
the significance of nutrition to a medical officer of health.
Further information may be had from the secretary of the
institute, 28, Portland-place, London, W.1.
~
1258 THE LANCET]
MEDICAL NEWS.—APPOINTMENTS
[may 22, 1937
King’s College Hospital
The Listerian Society of this hospital will meet on
Wednesday, May 26th, at 8.15 P.M., when Dr. Edward
Mapother will deliver a presidential address. His subject
will be the psychiatry that is coming.
Medical Caricatures and Cartoons
_ The Staatliche Medico-Historische Sammlung in Berlin
intends to hold next autumn an exhibition of caricatures
and cartoons dealing with medicine. It will comprise
both caricatures of individual members of the profession
and cartoons concerned with various methods of treat-
ment and diagnosis; and it will cover the past as well
as the present. The organisers feel sure that many
sketches will be available in various publications of
medical and students’ societies, while periodicals such as
Punch and the New Yorker should also furnish plenty
of material. Anyone in possession of such material or
knowing where it may be found is asked to communicate
with the Staatliche Medico-Historische Sammlung at
the Kaiserin Friedrich-Haus, Robert-Koch-Platz 7,
Berlin, NW.7.
British Postgraduate Medical School
An intensive course, intended primarily for practitioners,
will be held at this school from May 3lst to June 12th
(10.30 to 4.30 daily). Among those giving lectures and
demonstrations will be Prof. Thomas Beattie, Prof. G.
Grey Turner, Dr. E. R. Cullinan, Mr. R. J. McNeill Love,
Dr. R. T. Brain, Dr. Evan Bedford, Dr. J. R. Rees, Mr. C. I.
Naunton Morgan, Dr. T. C. Hunt, Dr. James Maxwell,
Dr. Janet Vaughan, Dr. J. Chassar Moir, Dr. W. Gunn, `
Mr. St. J. D. Buxton, and Dr. H. Gardiner-Hill. Sessions
will also be held at the Central London Throat, Nose, and
Ear Hospital, the Red Cross Clinic for Rheumatism, the
Royal London Ophthalmic Hospital, the Hospital for
Sick Children, Great Ormond-street, and the National
Hospital, Queen-square. 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. Similar courses lasting a fortnight
will begin on June 28th, Sept. 20th, Oct. 18th, and
Nov. 15th.
Beginning on May 25th, -at 4.30 p.m. on Tuesdays
Dr. Donald Hunter will give six lectures on occupational
diseases. Prof. M. Greenwood, F.R.S., will lecture on
experimental epidemiology on June 2nd, 9th, and 16th
at the same hour.
Medical Sickness, Annuity and Life Assurance
Society
At the annual meeting of this society held in London
on May 10th, Dr. F. C. Martley, the chairman of directors,
reported a very satisfactory result of the actuary’s valua-
tion for the 44 years ending last December. The total
surplus on sickness and life assurance funds amounted
to £225,639, of which it was proposed to distribute
£153,000 as bonus and to carry forward the remainder.
The bonus was to be increased from 12s. to 15s. per
annum on the main class of sickness policies for each guinea
per week insured, and from 23s. to 25s. per annum on the
life assurance side for each £100 insured, together with a
bonus on all combined policies at the same rates as if
separate policies had been effected for the two benefits.
During the year under review the new sums assured under
life assurance amounted to close upon half a million; the
total premium income in this department was now
£111,856. <A large proportion of the total premiums was
in respect of the deferred annuities under the scheme
which the society helped to operate for members of the
British Medical Association and for insurance practitioners.
The society’s family provision policy was also proving
very popular. Its chief advantage was that at the age
of sixty the premiums paid did not disappear but a
guaranteed sum was payable. On the sickness fund the
new annual premiums totalled to £10,702, which constituted
a record ; the premium income on this fund amounted to
£108,637. Not only were the society’s rates lower than
were obtainable elsewhere, but it paid a bonus at the
normal termination of each contract. The expenses of
management were just over 9 per cent. of the premium
income, and represented a reduction on previous years.
Dr. Martley concluded with a word of appreciation of the
staff, in particular Mr. Bertram Sutton, manager and
secretary, Mr. E. A. J. Heath, and Mr. C. L. Venus.
The meeting unanimously adopted the report of the
directors and re-elected those who retired by rotation
(Dr. W. Knowsley Sibley and Mr. R. J. McNeill Love).
On the proposition of Mr. Cecil Wakeley, seconded by
Dr. Fairfield Thomas, the meeting also unanimously
agreed to an increase in the remuneration of the directors.
Sir William Willcox moved a vote of thanks to the chair-
man and this was seconded by Dr. G. de Bec Turtle.
Inter-Hospitals Sports
The sixty-sixth annual inter-hospitals sports will be
held on Wednesday, May 26th, at 2.30 p.m., at the Duke of
York’s Headquarters, Chelsea.
Greater London Provident Scheme for District
Nursing ; . |
For nearly 70 years district nursing has been provided
in London largely as a charity, but as the work grew
it has been found necessary to ask for payment, by the
visit, from those who could afford it. This sometimes
caused a financial strain in times of illness. To avoid
this under the new scheme launched last month (Lancet,
April 24th, p. 1029) payment will be made in the form
of small weekly contributions. Any person who works
in a place where five or more people are willing to join
the scheme, and whose earnings do not exceed £6 per
week, can call upon the services of a district nurse for
himself and his dependents for a weekly contribution of
ld. If all his fellow-workers take advantage of the scheme,
the subscription for each employee will be only 3d. per
week. Anyone whose income exceeds £6 per week but does
not exceed £400 a year may join the scheme for a weekly
contribution of 14d. Further information may be had
from the offices of the scheme, 1, Sloane-street, London,
S.W.1.
Maternity and Child Welfare Conference
The seventh English-speaking conference on maternity
and child welfare will be held at B.M.A. House, Tavistock-
square, London, W.C., on June Ist, 2nd, and 3rd. The
following is a list of speakers and subjects: Dr. Mary
Blacklock, Dr. Mabel Brodie, and Mrs. Randa] Hosking
(the promotion of maternity and child welfare in backward
and in rural areas); Mr. R. J. Howard Roberts and Miss
Eleanor Harwarden (progressive legislation in connexion
with maternity and child welfare); Dr. Eric Pritchard,
Dr. Ursula Cox, and Mrs. Charlesworth (the education of
parents in the care of their children) ; Dr. Robert McCance
and Dr. Reginald Jewesbury (nutritional problems in
relation to mother and child); Dr. Margaret Lowenfeld
and Dr. J. A. Hadfield (the future of preventive psycho-
logy in relation of parent and child); Dr. B. E. Schlesinger
and Mr. E. S. Evans (preventive work for cripples and
invalid children). Visits will also be paid during the
conference to various institutions in and near London,
and on May 30th and 3lst a short post-graduate course
has been arranged by the maternity and child welfare
group of the Society of Medical Officers of Health. A child
welfare exhibition will be held in connexion with the
congress at Woburn House (exactly opposite B.M.A.
House). Further information may be obtained from the
hon. secretary, Carnegie House, 117, Piccadilly, W.1.
Appointments
ANSON, C. E. H., M.B. Lond., has been appointed Medical
Puperintendent of the Royal National Sanatorium, Bourne-
mouth.
AscrorT, P. B., M.S. Lond., F.R.C.S. Eng., Assistant Surgeon
to the Middlesex Hospital.
BIRNIE, C. R., M.D., M.R.C.P. Lond., D.P.M., First Assistant
Medical Officer at West Park Hospital, L.C.C.
*BULLOUGH, A. S., M.B. Manch., Resident Assistant Medica)
Officer (Grade II) at Withington Hospital, Manchester.
*CuRTIS, F. R., M.B. Leeds, Assistant Pathologist at White-
chapel L.C.C. Clinic.
DALZELL, A. C., M.D. Lond., D.P.M., Second Assistant Medical
Ofticer at Bexley Hospital, L.C.C.
GIMOUR, J., M.B., F.R.C.S. Eng., Hon. Surgeon to the Royal
Victoria Infirmary, Newcastle-upon- e.
MCGUCKIN, FRancis, M.D. Durh., F.R.C.S. Edin., Consulting
Surgeon for Throat, Nose, and Ear Cases at the Newcastle-
upon-Tyne General Hospital.
THE LANCET |
MEDICAL DIARY
[may 22, 1937 1259
PENNYBACKER, J. B., M.B. Edin., F.R.C.S. Eng., First Assistant
to the Department of N euro-surgery at the London Hospital.
PERCIVAL, R. C., F.R.C.S. Eng., First Assistant to the Depart-
ment of Gynecology and Obstetrics at the London Hospital.
*SCHILLER, SOPHIE, M.B. Witwatersrand, D.C.0.G., Resident
Assistant "Obstetrical Officer at Withington Hospital,
Manchester.
*SULLIVAN, J. F., M.B. Dubl., Resident Assistant
Medical Officer (Grade II) at D Barley Sanatorium, Man-
chester
WARWICK, W. TURNER, M.B. Camb., F.R.C.S. Eng., Surgeon
to the Middlesex Hospital.
Victoria Cottage Hospital, Barnet.—The following appointments
are announced :—
MONCRIEFF, ALAN, M.D., F.R.C.P. Lond., Hon. Consulting
Children’s Physician ; :
REaD, C. D., M.B. N.Z., F.R.C.S. Edin., M.C.0.G., Hon.
Gynecologist : and
Morr, E. G., M.S. Lond., F.R.C.S. Eng., Hon. Consulting
Surgeon.
ventying Surgeons under the Factory and Workshop Acts:
. E. HAWEIN8S (Beckenham District, Kent).
* Subject to confirmation.
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 te MEDICINE, 1, Wimpole-street, W.
MONDAY, May 2
Odontology. 8 E M. eter College of SUTECODS: Lincoln’s
Meeting of Fellows. 5 P.M., nomination of officers and
council for 1937-38. 5.30 P.M., ballot for election
to the fellowship.
Medicine. 5 P.M., annual] genera] meeting.
Pathology. 7 P. M. .. summer meeting at Fike Wellcome
Physiological Research Laboratories, Langley Court,
Beckenham, Kent.
WEDNESDAY.
Comparative Medicine. 5 P.M.,
Sir Weldon Dalrymple- Champneys : Snake-venom,
its Source, Method of Collection, and Uses. (Illus-
strated by an extract from a coloured film taken in
Brazil.) Mr. G. Buttle, D.Sc., and Dr. H. J.
: Parish : Observations on the Chemotherapy of Bacterial
Infections in Mice. Dr. A. W. Stableforth : Cutaneous
Streptothricosis—a Case in this Country.
annual general meeting.
- Hudson: Cutaneous Streptothricosis—the Deae in
other Countries.
THURSDAY.
Urologu. 8.30 P.M., Mr. James Carver: Observations on
Genito-urinary Tuberculosis.
AY.
Disease in Children. 5 P.M. (Cases at 4.30 P.M.) Annual
general meeting. Mr. Poole Wilson and Dr. C. Paget
Lapage: 1. Specimen of a Case of Neuroma of the
Spinal Cord. Dr. F. Dudley Hart (introduced by
Dr. B. Schlesinger): 2. Mediastinal Neuroblastoma.
Dr. O’Donoghue (introduced by Mr. Harold Edwards):
3. An Unusual Deformity of the Genitalia. Dr.
Wilfrid Sheldon and Mr. Harold Edwards: 4. Con-
genital Rectosigmoid Stricture.
Epidemiology and State Medicine. 8 P.M., annual general
meeting. 8.15 P.M. (with Section of Medicine), Mr.
R. NS Air Conditioning. Mr. C. W. Price
and Dr. M. Fraenkel will also speak.
BRITISH INSTITUTE OF RADIOLOGY, 32, Welbeck-
ree
THURSDAY, May 27th. per 30 P.M., annual general meeting.
Melical Commilltee.
AY.—11 A.M., visit to the radiological department of
the Queen Alexandra Military Hospital, Millbank,
S.W. 5 P.M., case demonstration and discussion.
MEDICO-LEGAL SOCIETY.
THURSDAY, May 27th.—8.30 P.M. (Manson House, 26,
Portland- -place, W.), Dr. Alexander Baldie: The
Prevention and Treatment of Delinquency.
EUGENICS SOCIETY.
TUESDAY, May 25th.—5.15 P.M. (Burlington House, W.),
Dr. R. R Kuczynski: Future Trends in Population.
ASSOCIATION Rip INDUSTRIAL MEDICAL OFFICERS.
FRIDAY, May 28th.—9.30 A.M., Business meeting (Metropole
Hotel, Swansea). 10.30 A.M., Visit to Nickel Refinery,
Clydach. Noon, Visit to Clydach Hospital with demon-
stration of X rays, by Dr. A. J. Amor. 2.30 P.M.,
Visit to Tereni Colliery.
CHELSEA CLINICAL SOCIETY.
TUESDAY, May 25th.—8.30 P.M. (Hotel Rembrandt,
Thurloe-place, S.W.), Dr. Philippe Bauwens and Dr
Howard Humpbris: Short Wave Therapy.
LECTURES, ADDRESSES, DEMONSTRATIONS, &c.
ROYAL COLLEGE OF PHYSICIANS OF LONDON, Pall
Mall East, S.W.
TUESDAY, May 25th, and THURSDAY.—5 P.M., Dr. Edwin
Bramwell: Clinical Retlections upon Muscles, Move-
ments, and the Motor Path. (Croonian lectures.)
UNIVERSITY OF LONDON. .
MONDAY, May 24th. TER 30 P.M. (University College, Gower-
street, W.C.) D. McKie, D.Sc.: Development
of Theories aa dng Combustion and Respiration
in the Eighteenth Century.
MONDAY, May 24th, TUESDAY, and WEDNESDAY.—5.30 P. x
(Imperial College of Technology, S.W.), Prof. I.
bron, F.R.S.: The Chemistry of the Garctenoide
an Vitamin A. 5.30 P.M. (University College), Prof.
Lewis H. Weed: The Meninges and the Cerebro-
spinal Fluid.
TUESDAY. — 5. 30 P.M. (University College), Mr. F. G. Young,
a E Development of Certain Aspects of Metabolism
g the Nineteenth Century.
ROYAL A OF PUBLIC HEALTH.
TUESDAY, May 25th, to SaTURDAY.—Congress at Margate
with the Institute of Hygiene.
CHADWICK LECTURE
‘26th.—5.30 P.M. (Manson House,
WEDNESDAY, Ma
face, W. ), Prot. J. G. Fitzgerald (Toronto):
26, Portland-
Preventive Medicine—An Avenue of Goodwill.
Ba ee POSTGRADUATE MEDICAL SCHOOL, Ducane-
road, W.
TUESDAY, May 25th.—4.30 P.M., Dr. Donald Hunter:
Occupational Diseases.
WEDNESDAY.—Noon, ence ethereal conference
(medical). 2 P.M., Mr. E. Spee D.: Acid-base
Metabolism. 3 P.M. i“ clinical ea Deeholosioal con-
ference (surgical).
THURSDAY.—2.15 P.M., Dr. Duncan White: Radiological
Demonstration. 3.30 P.M., Mr. A. K. Henry : Demon-
strations of the Cadaver of Surgical Exposures.
FRIDAY.—2 P.M., operative obstetrics. 2.30 P.M., Mr.
Russell Howard: Diseases of the Breast. 3° P.M. 3
clinical and pathological conference (obstetrics and
gynæcology).
Daily, 10 A.M. to 4 P.M., medical clinics, surgical clinics
and operations, obstetrical and gynæcological clinics
and operations.
WEST LONDON HOSPITAL POST-GRADUATE COLLEGE,
Hammersmith,
MONDAY, May 24th.—10 A.M., Dr. Post: X ray flm demon-
stration, skin clinic. 11 A.M., surgical wards. 2 P.M.,
operations, surgical and gynecological wards, medical,
surgical, and gynecological clinics. 4.15 P.M., Mr.
Green-Armytage : Pelvic Inflammation.
TUESDAY.—10 A.M., medical wards. 11 A.M., surgical wards.
2 P.M. , operations, medica], surgical, and throat clinics.
WEDNESDAY.—10 A.M. , children’ 8 ward and clinic. 11 A. M.,
medical wards. 2 P. M., gyneecological operations,
medical, surgical,and eye Clinics. 4.15 P. M., Dr. Redvers
Ironside: Trigeminal Neuralgia and its Treatment.
THURSDAY. —10 A.M., neurological and gynecological
clinics. Noon, fracture clinic. 2 P.M., operations,
medical, surgical, genito-urinary, and eye clinics.
4.15 P.M., Mr. Davenport : Treatment of Commoner
Ophthalmic Conditions.
FRIDAY.—10 A.M., medical wards, skin clinic.
Lecture on Treatment. 2 P.M. operations,
surgical, and throat clinics. 4.15 P.M., Dr. Owen:
Artificial Feeding in Infants.
SATURDAY.—10 A.M., children’s clinics.
11 A.M., medical wards.
The lectures at 4.15 P.M. are open to all medical prac-
titioners without fee.
FELLOWSHIP OF MEDICINE AND POST-GRADUATE
MEDICAL ASSOCIATION, 1, Wimpole-street, W.
MONDAY, May 24th, to SUNDAY, ay 30th. "BROMPTON
HOSPITAL, S.W. All-day course in thoracic surgery.—
PRINCESS "ELIZABETH OF YORK HOSPITAL, Shadwell, E.
Sat. and Sun., Course in children’s diseases. —ST. J OHN’ 8
HOSPITAL, 5, ’ Lisle- street, W.C. Afternoon course in
dermatology. —MAUDSLEY HOSPITAL, Denmark-hill,
S.E. Afternoon course in psychological medicine.
ST. MARY’S HOSPITAL, W.
TUESDAY, May 25th —-5 P.M. (Institute of Pathology and
Research), Prof. E. C. Dodds: Observations on the
Structure of Substances, Natural and Synthetic, and
their Reaction on the Body.
HU TAL FOR SICK CHILDREN, Great Ormond-street,
THURSDAY, May 27th.—2 P.M., Mr. J. H. Doggart: Origin
and Treatment of Squint. 3 P.M., Dr. W. G. Wylie:
Pitfalls in the Diagnosis of Tuberculous Meningitis.
Out-patient clinics daily at 10 A.M. and ward visits at
Noon,
medical,
and surgical
2 P.M.
LONDON SCHOOL OF DERMATOLOGY, 5, Lisle-street,
MONDAY, May 24th.—5 P.M., Dr. H. MacCormac: Treat-
ment of Syphilis.
TUESDAY.—5 P.M, Dr. W. N. Goldsmith: Acneiform
Eruptions.
THURSDAY.—5 P.M., Dr. W. Griffith: Bullous Eruptions.
FRIDAY.—5 P.M., Dr. A. M. H. Gray: Scleroderma and
Allied Conditions.
HOAN FOR EPILEPSY AND PARALYSIS, Maida
ale, ;
THURSDAY, May 27th.—3 P.M., Dr. Russell Brain: Clinical
Demonstration.
MANCHESTER ROYAL INFIRMARY.
TUESDAY, May 25th.—4.15 P.M., Dr. T. H. Oliver: The
New Insulins.
FRIDAY.—Dr. Fergus R. Ferguson: Demonstration of
Neurological Cases.
GLASGOW POST-GRADUATE MEDICAL ASSOCIATION.
WEDNESDAY, May 26th.—4.15 P.M. (Ophthalmic Institu-
tion), Dr. J. N. Tennent: Tumours of the Lye.
1260 THE LANCET]
NOTES, COMMENTS,
THE RED CROSS RHEUMATISM CLINIC
- THE annual report of the British Red Cross Society’s
Clinic for Rheumatism shows that the work is steadily
increasing and that the attendances in the general
department were 5812 more than in any previous
year. While this increase is a tribute to the value of
the work carried out at the clinic the figures also
imply that its accommodation is being unduly
strained, and the burden imposed on the staff is
heavy. If long periods of delay before patients
urgently needing treatment can be accepted are to
be avoided, it is essential that the premises should be
enlarged. We understand that schemes to this end are
already under consideration and it is to be hoped that
the authorities will soon be in a position to carry
them out. More funds are urgently needed. The
results of treatment according to the records appear
to be very satisfactory; 60°3 per cent. patients
were discharged free from symptoms and a further
29 per cent.: were definitely improved. The medical
board modestly point out that these figures should
be accepted with some reserve. The clinic is not only
a centre for treating professional and industrial
workers; research is being actively pursued on the
valuable clinical material available under the direction
of a special committee formed last year for the
study and investigation of rheumatism. The lack of
in-patient accommodation hampers research and that
also should be made available when funds permit.
INSTITUTIONAL TREATMENT OF EPILEPSY
IN SCANDINAVIA
THE alertness of the Scandinavian countries about
each other’s virtues and vices is partly responsible
for the high level of their culture. For one country
to lag behind in some good work is to invite dis-
paraging comparisons in the other countries; and at
the present time, Denmark, Sweden, and Finland
are being held up as examples to Norway as regards
the institutional treatment of epilepsy. Denmark
comes first in this comparison with 2 beds for
epileptics for every 10,000 inhabitants; Finland
comes next with 1 bed; and Sweden comes third
with 0°9 bed; whereas the corresponding figure for
Norway is only 0°25. A census of epileptics conducted
in Norway in 1929 by medical officers of health
showed that there must be about 1900 epileptics, of
whom more than 400 require institutional treatment.
It is more than probable that this census failed to
include many slight cases of epilepsy, and the figures
quoted are assuredly under-estimates. For the more
than 400 epileptics requiring institutional treatment
there are at present only 68 beds in Norway, and this
glaring discrepancy between supply and demand
has led to the appointment by the Government of a .
committee charged with the task of estimating the-
country’s requirements for beds for epileptics, and
with drafting legislation for their care. This com-
mittee’s studies have been extended to England and
Germany as well as to the other Scandinavian
countries.
The experiences of Denmark have proved most
instructive. She is the only Scandinavian country
in which a hospital for adult epileptics has been
created. It is ‘‘ Filadelfia,” with accommodation for
445 epileptics over the age of fifteen. Of its seven
medical officers, two are specialists in neurology and
mental disease. Epileptics who are imbecile from
birth are drafted as much as possible into institutions
for the mentally defective, and the inmates of
Filadelfia are encouraged to find recreation in work
such as carpentering, shoe-making, tailoring, book-
binding, &c. In addition to this hospital there are
four smaller institutions, the accommodation of all
five being 680 beds. In Sweden there are eight
institutions for epileptics, and ‘‘ Stor Sköndal,” with
212 beds, serves as the central hospital in the neigh-
bourhood of Stockholm. Altogether there are some
[may 22, 1937
AND ABSTRACTS
700 beds for epileptics in Sweden, and it is the
ambition of Prof. Petrén to centralise the institutional
treatment of epilepsy as much as possible, and to
attach to a large epileptic hospitala department for
mentally defective and insane epileptics. In Finland,
with some 300 beds for epileptics, there is the same
tendency as in Denmark and Sweden to favour a
large central institution. It is held that the larger
the institution, the more skilful will be the treatment.
The institution which is too small to employ a resident
medical officer: is bound to give comparatively
inadequate service.
DANGERS OF ARTERIOGRAPHY
SINCE arteriography is sometimes recommended
as innocuous E. Verschuyl has thought it well to
bring forward a number of cases in which it gave
rise to complications (Ned. Tijdschr. Geneesk. 1937,
81, 1007). Two of these were in his own practice.
(1) A man, aged 70, was admitted to hospital with a
history of sudden pain and numbness of the right leg.
The entire limb was blanched and could not be moved
actively ; it was tender and felt cold. No pulsation could
be detected in the dorsalis pedis, popliteal or femoral
arteries. The vessels did not feel hard or thickened.
A systolic murmur was heard over the heart. The diagnosis
was thought to lie between acute spasm and embolic
obstruction of the femoral artery, and arteriography was
decided upon. The abdominal aorta was punctured,
20 c.cm. of 35 per cent. Perabrodil was rapidly injected,
and an X ray photograph was taken. This showed that
the solution had not passed on the right side beyond the
upper part of the common iliac artery. Immediately
afterwards, however, the pain ceased, the limb resumed
its normal colour and temperature, and could be moved
actively. A diagnosis of spasm was made. A few days
later the patient suddenly died and at autopsy a rupture
of the ascending aorta was found. Verschuyl attributes
this to damage caused by the injected fluid, for apart
from a few small plaques of atheroma the aorta appeared
healthy.
(2) A woman, aged 28, complained of pain in the right
forearm, with cyanosis and swelling. Other abnormal
signs were absent and there was no history of trauma.
The diagnosis of angioneurosis was made and arterio-
graphy was performed, 20 c.cm. of perabrodil being
injected into the subclavian artery. The patient was
immediately seized with a typical epileptic fit lasting
about two minutes and followed by severe headache.
She recovered completely in about 30 hours, and the
arteriogram revealed no abnormality.
Verschuyl concludes that arteriography is by no
means devoid of danger and that it should not be
lightly employed.
PULMONARY EMBOLISM AFTER INJECTIONS
INTO VARICOSE VEINS
Dr. Anders Westerborn of Varberg, Sweden, has
recently published ! a study which should do much to
dispel fears about fatal pulmonary embolism more
or less directly due to the thrombosis induced by
injections of various substances into varicose veins.
His investigations were in part prompted by a lurking
suspicion that such fatalities do not always get into
the medical press, the urge to publish successes being
notably greater than any willingness to admit
disasters however instructive they may be. In 1928
H. O. McPheeters and C. O. Rice (J. Amer. med Ass.
1928, 91, 1090) found in reports by various authors
a mortality of only 0:0075 per cent., and a similar
review by K. Kettel in 1931 (Zbl. Chir. 1931, 58, 1498)
raised the figure to 0:017 per cent. To avoid the
sources of error inherent in such compilations, Wester-
born addressed inquiries to all the 93 hospitals in
Sweden. Information was obtained from 86, and he
was able to calculate that in the period 1927-34
some 30,000 patients with varicose veins must have
1 Acta chir. scand. 1937, 79, Fasc. iv, p. 321.
THE LANCET]
been treated in the 93 hospitals by the injection of
thrombogenic solutions. The 11 deaths from pul-
monary embolism and the 6 severe cases with recovery
in this material represented what may be considered
as a comparatively accurate picture of the embolism
risk, The mortality was 0:036 per cent.—considerably
higher than that obtained from other published
work, yet many times lower than that for more
radical operations on varicose veins. In the five-year
period 1921-25, 6994 operations not yet ousted by
the injection treatment were performed on varicose
veins in 82 Swedish hospitals, and 18 patients died of
pulmonary embolism—a mortality of 0-26 per cent.,
the corresponding figure obtained by McPheeters
and Rice being 0:54 per cent. (36 deaths from
embolism among 6671 cases). Though this comparison
with operative treatment is favourable to the injection
treatment it is not quite fair to the latter, which
is still in its youth and many of whose fatalities may
be due to avoidable mistakes. Westerborn traces a
goodly proportion, of the embolism fatalities to
infections, local or general, ‘and to the stagnation
of circulation promoted by confinement to bed after
an injection. He regards the bedridden state as a
definite contra-indication and he is in favour of
keeping a patient out of bed as much as possible
just after injections. His comparison of the embolism-
rates for. the different chemicals used shows that
there is little to choose between them so long as they
are not introduced as isotonic solutions, It is curious
how different countries prefer different chemicals.
In the past, quinine-urethane has been the most
popular in Sweden, America, and England, whereas
Germany and Central Europe have preferred solutions
of sugar and sodium chloride. Now it seems that
quinine-urethane is being displaced by sodium
morrhuate which has the advantage of not provoking
necrosis of the tissues when a perivascular injection
is given by mistake.
CECIL HOUSES
FOUNDED ten years ago by Mrs. Cecil Chesterton,
the public lodging-houses for women known as
Cecil Houses fill what was a very serious gap in the
provision for Londo~’s homeless. With the reopen-
ing this year of the house in Devonshire-street,
'Theobald’s-road, there will be five houses in the
London area, each providing clean beds, hot baths,
and facilities for washing clothes for from fifty to
sixty women at a cost of a shilling a night for each
woman. There is also accommodation for babies
at the houses, which are non-sectarian ; any homeless
woman is admitted and no questions are asked.
Once the initial capital expenditure of some £7000
is found, a house becomes entirely self-supporting,
although subscriptions are much needed for replenish-
ments and the extension of activities. In addition
to their primary object of providing lodging, the
staff are able to find employment for a number of
those who are in need of it and do much to help
the women to regain their self-respect by the distribu-
tion of gifts of clothing and boots and shoes.
NEW PREPARATIONS
THE Crookes Laboratory (British Colloids Ltd.),
of Park Royal, London, N.W.10, now issue their
Collosol Brand PHOSPHO-MANDELATE in a box
containing all that the patient wants for carrying
out six days’ treatment. The ammonium phosphate
is white; the mandelic acid is coloured pink; and
containers showing the exact doses are provided,
together with a book of test papers for determining
' the approximate pH of the urine.
The PROPHYLL ATOMISER is used as a spray for
throat or nose. Its chief advantages are that it has
a screw cap which closes it when travelling; that
it can be conveniently used with one hand ; and that
it provides a fine .vapour. The manufacturers
(Prophyll Co., Ltd., 7, Princes-street, S.W.1) make
an oily antiseptic fluid (Prophyll No. 1) for use, as a
spray, in the prevention or treatment of colds and
influenza. The formula is given as hexyl resorcinol
NOTES, COMMENTS, AND ABSTRACTS.—VACANCIES
[may 22, 1937 1261
0°025; phenol, 0'2 ; iodine 0°02; sodium ricinoleate,
O'l; menthol, 0°02; liquid paraffin to 100.
A booklet on the Technique of Parenteral Calcium
Medication with special reference to CALCIUM-SANDOZ
is published by J. Flint, Sandoz Products, 134,
Wigmore-street, London, W.1. It points out that the
ease and safety of giving calcium in adequate doses
by injection has extended the applications, and
improved the results, of this form of treatment.
With excellent illustrations it describes exactly how
Calcium-Sandoz is best injected, including an account
of intrapleural administration and of intranasal
submucous injection as recommended in THE LANCET
by Prof. Bárány shortly before his death. The
manufacturers claim that a satisfactory solution of
calcium gluconate is by no means easily prepared,
and state that Calcium-Sandoz, the first to be intro-
duced, is always tested clinically, for each batch,
before general issue. The ampoules now contain
calcium gluconogalactogluconate, which has advan-
tages over the ordinary gluconate.
Particulars of the many bismuth products of
PHARMACEUTICAL SPECIALITIES (May and Baker)
Ltd., Dagenham, are given in a small book on
BISMUTH THERAPY in which they summarise the
history of bismuth as a remedy, its mode of action,
its clinical application, and the way in which it is
used. For the intravenous injection of bismuth it
is recommended that the needle when introduced
should have an empty syringe attached to it. When,
by withdrawing blood, it has been ascertained that
the needle is in the vein a second syringe filled with
the drug is substituted for the first. Deep subcutaneous
injection may be preferred; but in any case deep
and firm massage is advisable to spread the bismuth
after its administration. Precautions against stomatitis
and other possible complications are mentioned.
A NEW REMEDY FOR HZMORRHOIDS
IN a preliminary. note on the use of an extract of
Microscolex dubius in the treatment of hemorrhoids
H. E. Mercante and J. E. H. Piazza describe their
results in 12 cases (Rev. sud.-amer. Endocrin. 1937,
20, 61). The method adopted was continuous
application on cotton-wool of a 5 per cent. oily
solution of an extract of the whole worm. The
result, it is said, in all 12 cases was cessation of pain,
pruritus, and other subjective symptoms, and bleeding
too ceased almost at once. In recent cases a course
of treatment lasting 15-20 days was followed by
clinical cure with no relapses during a period of
observation of nine months. The solution was
successfully employed also in a case of varicose
ulceration of four years’ duration, and the ulcers
were fully healed after 11 days of treatment. Clinical
and laboratory investigations of the new remedy are
being continued.
CLINICAL AND LABORATORY PHOTOGRAPHY.—
Messrs. Kodak Ltd. have constructed what they
call a clinical camera outfit—an ‘‘ advanced photo-
graphic unit ” intended to have a precision comparable
with that of other instruments that scientific workers
are accustomed to handle. It is meant to satisfy
the exacting demands of the medical worker, but
also to find many applications outside medical work.
Particulars may be had from the makers at Kodak
House, Kingsway, London, W.C.2.
Va cancies
For further information refer to the advertisement columns
Altrincham General Hosp.—Sen. and Jun. H.S., at rate of £150
and £120 respectively.
AIOE 5 ETE CO enne and Anglesey Infirmary.—Sen. H.S.,
Bath City.—M.O. for Poor Law Infirmary, £500.
Birkenhead Education Committee.—Asst. School M.O., £500.
Blackburn Couey Borough.—Asst. School M.O. and Asst.
.O.H., £600.
Blackburn Royal Infirmary.—Res. H.S., £175.
Blackpool Corporation.—Additional Med. Asst., £500.
1262 THE LANCET]
Bournemouth, Royal National Sanatorium.—Res. Asst. M.O.,
£200.
Bradford Royal Infirmary.—Hon. Asst. Physician.
Brighton, Royal Alexandra Hosp. for Sick Children.—H.S., £120.
Brighton, Royal Sussex County Hosp.—H.P., £150. f
Brighton, Sussex Eye Hosp., Eastern-road.— H.S., at rate of £150.
British Postgraduate Medical School, Ducane-road, W .—Asst.
in Bacteriology in Dept. of Pathology, £300.
Chelsea Hosp. for Women, Arthur-strect, S.W.—Jun. H.S., at
rate of £100.
Cheltenham General and Eye Hosp.—H.S., £150.
Connaught Hosp., Walthamstow, E.—Sen. Res. M.O., at rate of
£175. Also H.P., H.S.,and Cas. O., each at rate of £110.
Coventry and Warwickshire Hosp.—Res. H.S., Cas. O., and Res.
H.S. to Aural and Ophth Depts., each £150.
Coventry, City of —Asst. M.O. (Woman), £500.
Derbyshire Hosp. for Sick Children.—Res. H.S., at rate of £130.
Dewsbury and District General Infirmary—Sen. H.S., £200.
Also Second H.S., £150.
Dudley, Guest Hosp.—Second H.S., £120.
Eastbourne, Princess Alice Memorial Hosp.—Surgeon. Also
Asst. Physician.
Edinburgh Royal Infirmary.—Jun. Asst. Radiologist, £350.
Elizabeth Garrett Anderson Hosp., Euston-road, N.W.—Temp.
Hon. Asst. Surgeon and Temp. Hon. Asst. Obstet. Surgeon.
BNE ToD: for Sick Children, Southwark, S.E.—H.P., at rate
o
Gloucestershire Royal Infirmary.—H.S., at rate of £150.
Gordon Hosp. for Rectal Diseases, Vauxhall Bridge-road, S.W.—
Res. H.S., £150.
Guildford, Royal Surrey County Hosp.—H.S., at rate of £150.
Hampshire Joint Mental Health Institutions Commitiee.—
Principal Medical Adviser, &c., £1400.
Hawkmoor Sanatorium, near Bovey Tracey.—Res. Asst. M.O.,
at rate of £250.
Hebron, St. Luke’s Hosp.—Asst. Res. M.O., £200.
ae Colonial Medical Service—Vacancies for M.O.’s, £600-
700.
Hosp. for Sick Children, Great Ormond-street, W.C.—Res. H.P.
and Res. H.S., each at rate of £100.
Hosp. of St. John and St, Elizabeth, 60, Grove End-road, N.W.—
Ophth. Surgeon.
Hoey ot Women, Soho-square, W.C.—Res. M.O., at rate of
Huddersfield Royal Infirmary.—Cas. O., at rate of £200.
Hull Royal Infirmary.—H.S. to Ophth. and Ear, Nose, and Throat
Denies Second H.P., and Second Cas, O., each at rate of
Əd
, 150.
Ilford Borough.—Res. M.O. for Maternity Home, £400.
Ilford, King George Hosp.—Reg. Surg. O., £250. Med. Reg.,
£150. Also Two H.S.’s, each at rate of £100.
Isleworth, West Middlesex and County Hosp.—Cas. M.O., at
rate of £350.
Kensington Royal Borough.—Deputy M.O.H., £900.
Keltering and District General Hosp.—Res. M.O. and Second
? Res. M.O., at rate of £160 and £140 respectively.
Kingston and District Hosp.—Res. Asst. M.O., at rate of £375.
Lancashire County Council.—Asst. County M.O.H., £800. Also
Temp. Asst. Tuber. O., 15 guineas weekly.
pasa Spa Loyal Borough—M.O.H. and School M.O.,
Liverpool University.— Research Asst.in Dept. of Medicine, £600.
- , Also Demonstratorship in Anesthesia, Part-time, £100
London Homeopathic Hosp., Great
W.C.—
Gynecological H.S., at rate of £100.
London Lock Hosp., 283, Harrow-road, W.—Res. M.O. to Male
Dept., at rate of £175.
London University.—University Readership in Obstetrics and
Gynecology for British Postgraduate Med. School, £800.
Te TOP a M.O. to New Maternity Hosp. and Asst.
.O.H., .
Manchester, Ancoats Hosp.—Res. Surg. Q., £200.
Manchester, Duchess of York Hosp. for Babies.—Hon. Asst.
Anesthetist.
Manchester Royal Infirmary.—Med. Chief Asst., £300.
Middlesex County Council_—Asst. M.O., £600. Also Asst.
Dental O., £500.
Ministry of Health, Whitehall.—Staff M.O.’s, £847.
MELLO Mon., Royal Gwent Hosp.—Two II.S.’s, each at rate of
Ormond-street,
Nolltingham General Dispensary.—Res. Surgeon, £300.
Nottingham General Hosp.—H.S. for Ear, Nose, and Throat
Dept. and two Res. Cas. O.’s, each at rate of £150.
Oldham Municipal Hosp.—Res. Asst. M.O., at rate of £200.
Oldham Loyal Infirmary.—H.S., at rate of £175.
Ozford, \Wingfield-Morris Orthopedic Losp., Headington.—
Lord Nuttield Scholarship in Orthopedic Surgery, £200.
Plymouth, Prince of Wales’s Hosp., Devonport.—Jun. H.S., at
rate of £120.
Plymouth, Prince of Wales’s Hosp., Greenbank-road.—H.P.,
at rate of £120.
Preston and County of Lancaster Royal Infirmary.—R.M.O. and
H.S., each £150.
S.W.—Med. Reg.,
Princess Beatrice Hosp.,
30 guineas.
Princess Llizabeth of York Hosp. for Children, Shadwell, E.—
H.P., H.S., and Cas. O., each at rate of £125.
Queen Charlolte’s Alaternity Hosp., Marylebone-road, N.W.—
Hon. Gen. Surgeon. Also Obstet. Surgeon to In-patients.
Quecn’s Hosp. for Children, Hackney-road, E.—H.P. and Cas.
O., each at rate of £100.
Queen Mary's Hosp. for the East End, Stratford, E.—Res. M.O.,
Two Cas, and Out-patients O.’s, each at rate of £150.
Also Two H.S.’s, H.P., Obstet. H.S., and Res. Anwsthetist
and H.P., each at rate of £120.
Reading, Royal Berkshire Llosp.—Res. Cas O., and H.S. to
Special Depts., each at rate of £150. :
Rotherham Hosp.—Cas. H.S., £150.
Earl’s Court,
VACANCIES.—BIRTHS, MARRIAGES, AND DEATHS
[may 22, 1937
Royal Free Hosp., Gray’s Inn-road, W.C.—First H.P. Also
Res, Cas. O., at rate of £150.
Royal Naval Medical Service.—M.Q.’s.
Royal Waterloo Hosp. for Children, &c., Waterloo-road, S.E.—
Cas. O., at rate of £150. Also H.S., at rate of £100.
St. John’s Hosp., Lewisham, S.E. —Orthopædico Registrar.
St. Thomas's Hosp., S.E.—Physician.
Salford Royal Hosp.—Psychiatrist, £52.
Salisbury General Infirmary.—Res. M.O., £250. Also H.P.,
at rate of £125.
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The Chief Inspector of Factories announces vacancies for
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Births, Marriages, and Deaths
BIRTHS
CooKE.—On May 12th, at Fulwood, Preston, the wife of R. T.
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GRAY.—At Little Mead, Holtye, Cowden, Kent, on May 12th,
' A. Charles E. Gray, O.B.E., M.D. Faneral at Holtye
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JENNINGS.—On May 12th, at Cornwall-gardens, S.W., Brevet
Col. Edgar Jennings, I.M.S., retired.
Lypon.—On May 15th, Helen Anderson, M.B.N.U.L, wife
of Dr. F. L. Lydon of Golders Green, aged 34.
Mocrcuison.—On May 12th, Finlay Murchison, M.B. Edin.,
late Resident Licensee of Wyke House, Isleworth.
RoweE.—On May 11th, at Bradford, Joseph Hambley Rowe,
~ M.B. Aberd., aged 66.
SCOTT-TURNER.—On May 12th, at Anerley, Arthur Scott-
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of Streatham-hill, S.W.
N.B.—A fee of Ts. 6d. is charged for the insertion of Notices of
Births. Marriages, and Deaths.
THE LANCET]
ADDRESSES AND ORIGINAL ARTICLES
THE B.I.P.P. METHOD OF TREATMENT
OF ACUTE OSTEITIS *
By James H. Sarr, M.D. Durh., F.R.C.S. Eng.,
| F.A.C.S.
CONSULTING SURGEON TO THE THOMAS KNIGHT MEMORIAL
HOSPITAL, BLYTH, AND SENIOR SURGICAL REGISTRAR AT THE
ROYAL VIOTORIA INFIRMARY, NEWOASTLE-ON-TYNE
(Concluded from p. 1217)
Discussion of the Various Modern Methods
While most methods of treatment of acute osteitis
consist of some form of operative attack on the bony
focus with or without some special type of general
treatment of the blood condition present, there
appears to have been only one surgeon who had the
courage to ignore entirely the bony focus. This
- was the late H. Tyrrell-Gray, who employed intra-
venous mercuric chloride together with anti-staphylo-
coccal or anti-streptococcal serum, according to which
organism was found on blood culture. Although
he did not mention the number of cases he had so
treated, he stated in 1934 that in the last five years
he had lost only one case, and that there had been
no case of sequestration. He admitted that in
desperate cases there was a great deal of anxiety for
the surgeon who wished to hold rigidly to these
principles of treatment, and while lack of courage
alone to face such an anxiety will probably always
prevent this form of treatment from becoming
popular, the principle of disregarding the bony
focus does not appear to be sound. As mentioned
previously, before infection of the bone occurs—
_that is, before the case actually becomes one of
acute osteitis—there is present a mild form of septi-
czmia, but the more severe systemic infection that
forms part of the clinical picture of acute osteitis
becomes evident only after the development of the
bony focus and must be due to the passage of toxins
or organisms into the blood stream from that focus,
a fact that does not appear to be generally recognised
and one that calls at once for the immediate treat-
ment of the bone involved. Furthermore, the absence
of sequestration, recorded by Tyrrell-Gray, after
total disregard. of the bony focus appears extra-
ordinary, for since pus is usually present it seems
unlikely that sequestration can be prevented unless
it is removed or at the least some means is provided
for its escape. Since the Bipp method of treatment
is soundly based on the pathology present, and will
save life, shorten the illness, prevent sequestrum
formation, and lead to a minimum of morbidity, it
is considered that this method provides sufficient
reasons for not having to face the anxiety that
Tyrrell-Gray mentioned.
The value of antiserum and immuno-transfusion
therapy remains questionable, for the results obtained
by those who advise and apparently practise them
do not appear to recommend their use. It is best,
however, that an open mind be kept on this subject
It is considered that, of general measures, by far
the most important consists in putting the patient
on a balcony where he is in the open air and at the
same time can obtain as much sunshine as may be '
available, while nourishing food and plenty of fluids
are a sine qua non.
* Based on a Hunterian lecture delivered at the Royal College
of rh a of England on Feb. 5th.
[may 29, 1937
OPERATIONS
The operative procedures employed in this disease
will be discussed in order from the least to the most
radical.
Incision of the soft tissues down to the bone.—This,
as a method of treatment, is usually mentioned in
connexion with subperiosteal abscess, the opening
and drainage of this being the only treatment
employed. Such an abscess, representing as it does
a complication due to spread of infection from the
bony focus, indicates not only delay in diagnosis
but suggests that pus is present in the bone. This
being so, it seems that to ignore that pus means
inadequate treatment, since its presence in the bone
must always be a factor threatening either necrosis,
because of compression of blood-vessels, or a more
severe blood infection by its escape into the blood
stream through the wide, valveless veins in the bone.
While both Starr (1922) and Holman (1934) favour
this form of treatment, the latter actually advocates
delay in treatment until there is definite evidence of
pus formation, on the grounds that such conservative
measures give the patient a chance to develop some
degree of immunity. He states that if the patient
is seriously ill and the local signs not well-marked,
then expectant treatment should be instituted.
With this I would agree if I had ever found this
combination but, in my experience, patients who are
seriously ill have the local signs only too well-marked,
indicative of a delay in diagnosis that may cost the
patient his life. It also shows that the patient’s
serious plight is due not to the original mild septi-
cemia that made possible the development of the
bony focus but to the severe septicemia caused
through reinfection of the blood stream from the
bony focus, this forming a potent reason why that
focus should be attacked without delay and why
early diagnosis is essential to obtain the best results.
Holman lost 3 cases out of 31, a mortality of only
9-7 per cent., but he states that most of his cases
had to have one or more secgndary operations for
the removal of sequestra, thus indicating how
prolonged the illness may be that results from this
form of treatment. Mitchell (1928) has pointed out
that operations for the removal of sequestra are by
no means devoid of risk and that prolonged illness
lessens the chance of a good functional result. To
show that a case treated by this method can heal
without sequestrum formation Starr gives as an
example a case of acute osteitis of the lower end of
the humerus that healed completely in three weeks
after operation, but unfortunately neither the
description of the case nor the radiograms accompany-
ing it would prevent it from having been one not
of acute osteitis of the lower end of the humerus
but of suppuration of the epitrochlear gland. In
a later publication Starr (1927) describes “a
typical case” treated by this method. The
patient was admitted in May, 1922, and had two
subsequent operations for the removal of sequestra
in September and in December, 1923, the wound
having discharged during the whole of this time and
not healing until two months after the removal of
the -second sequestrum. A recurrent abscess was
opened in March, 1924, and healed quickly after
drainage was established. Although Starr states
that some time after healing examination of the
patient showed that there was no deformity and
that the function of the leg was normal, yet it
is difficult to be enthusiastic about a method of
bg i ;
1264 THE LANCET]
FIG. 64a.—Acute osteitis of lower end of femur treated by
incision of the soft tissues. Radiogram three months after
operation, to show great thickening of bone and sequestrum.
FIG. 6B.—Same case seven months after operation. The
sequestrum has been removed and another has formed. See
text and compare with Fig. 11.
treatment resulting in such a protracted post-operative
history.
As illustrating a common result of this method
of treatment, Fig. 6 is of interest. The case was
one of acute osteitis ‘of the lower end of the femur
treated by incision and drainage of a subperiosteal
abscess. The radiogram Fig. 64 was taken three
months after operation and shows a sequestrum
surrounded by recent periosteal bone of great thick-
ness. This was removed and seven months after the
first operation—the wound never having ceased to’
discharge copiously—a further radiogram (Fig. 6B)
showed that another sequestrum had formed, accom-
panied by still greater thickening of the femur.
So that, after being ill for this length of time, the
patient is now faced with the necessity of at least
one more operation, will probably have a discharging
sinus for several more months, and even at this stage
he has a completely ankylosed knee-joint.
Another case that came under my notice was one of
acute osteitis of the lower end of the fibula which was
treated by this method, a subperiosteal abscess being
opened and drained. The temperature continued to swing
(Fig. 7) and the condition of the patient gave rise to much
anxiety. Treatment by the Bipp method was then under-
taken with a striking result. The chart shows how the
temperature came down, pain was abolished, and the
patient immediately improved, being quite a different
person after his second operation. No further operation
was necessary for the removal of sequestra.
It seems that the institution of the Bipp method of
treatment at least aborted what would otherwise
have been a lengthy illness and may have prevented
an even more serious result.
MR. J. H. SAINT: B.I.P.P. IN ACUTE OSTEITIS
[may 29, 1987
, Drilling the bone.—Since Starr published his well-
known paper in 1922, this method of treatment
has been widely adopted, although he himself
appears to reserve it for cases where no subperiosteal
abscess is present. It is one method of bone-drainage
therapy and, as such, does not appear to be adequate.
Even inadequate drainage, however, is better than
none at all. It will probably have been the experience
of most surgeons that drill holes become occluded
almost immediately with purulent debris or granula-
tions and that it is expecting too much of them to
drain efficiently even if the dressing, as advocated
by Sir John Fraser (1934), consists of gauze soaked
in a fluid which theoretically keeps the discharge
in solution as it tracks up through the holes in the
bone. With this method of treatment the illness is
also liable to be prolonged, for judging from the
writings of both Starr and Fraser it is not uncommon
for sequestration to take place. Starr (1927), for
example, reports 207 cases and states that, of these,
26 healed completely without sequestration. These
figures mean that sequestra formed in no less than -
88 of every 100 cases, a huge percentage and one that
compares very unfavourably with that reported
above of the Bipp method. Simple trephining of
the bone, sometimes carried out, appears to be very
little more efficient as a method of drainage than
that of multiple drill holes.
While discussing this method of treatment, the
following case of acute osteitis of the lower end of the
femur is interesting.
When operation was performed a large subperiosteal
abscess was found; two large (} in.) drill holes were made
in the bone but no pus was found; gauze drainage was
provided and the wound left open. The temperature
chart of this case is shown in Fig. 8. A few days after
operation the remittent type of temperature indicated
a purulent focus that was either not draining or doing so
inadequately, while the thigh had become much swollen.
The treatment of this case by the Bipp method was
undertaken 12 days after the first operation. The wound
at this time was about 2 in, wide and at operation
both drill holes were found plugged with inspissated
pus. Guttering of the bone revealed the cancellous tissue
of the distal 3 in. of the diaphysis to consist almost entirely
of pus. Two weeks later the Bipped gauze was removed
and the cavity in the bone filled with a pedicled muscle
graft from the vastus externus. The rise in temperature
7 I9 2i
JUNE
23 25 27 29
FIG. 7.—Temperature chart of case of acute osteitis of lower
end of fibula treated first by incision of soft tissues and later
by Bipp method.
midway between the times of the last two operations
was due to the development of a subcutaneous pyæmic
abscess near the left axilla. After the last operation there
were two rises of temperature which were not explained,
for the patient did not complain of any pain or malaise
and examination of the wound and urine showed both
to be satisfactory.
the reputation of this operation.
THE LANCET]
MR. J. H. SAINT: B.I.P.P. IN ACUTE OSTEITIS
[may 29, 1937 1265
Guttering of the bone.—This procedure appears
to have been brought into disrepute largely through
the false impressions about it appearing from time
to time, these indicating either a lack of appreciation
of its proper use or excessive zeal on the part of the
operator. Platt (1928) states that upon the con-
ception, now proved erroneous by the work of Starr,
that infection extends along the interior of the bone
pari passu with the subperiosteal spread, the treat-
ment of acute osteitis by the gutter operation was
based. While this may be true, it is pointed out at
once that the basis of this operation, as used in the
Bipp method, has nothing to-do with the question
of subperiosteal versus internal spread of infection,
but has for its foundation the pathological fact that
the infection of the bone begins as a small focus which
can and should be removed and that the most efficient
way in which this can be done is by the use of the
gutter operation. Platt further states that where
a long gutter has to be made owing to extensive
spread of infection, this will imperil the viability
of the shaft as a whole, that it must tend to add to
the amount of necrosis already determined by vascular
obliteration, and that in bones with a considerable
subcutaneous surface the gutter has the disadvantage
of leaving an avascular adherent scar. Such anti-
gutter propaganda, well summarised by Platt, has
gained much credence and done a great deal to injure
In reply to it I
would say that the first two statements have not
been borne out by my personal experience, and that
the third describes a condition which can be largely
avoided. In 3 of my cases of acute osteitis a gutter
FIG. 8.—Temperature chart of case of acute osteitis of lower
end of femur treated first by drilling of bone and later by
Bipp method. See text.
over 7 in, long, necessitating opening into the medul-
lary cavity, had to be made in order to reach the limit
of the spread of infection ; in none of these cases was
the viability of the rest of the shaft impaired and
there was no sequestrum formation. Where a long
gutter has to.be made in a bone with a considerable
subcutaneous surface, if the cavity is allowed to
fill up by granulation tissue then an adherent avas-
cular scar will form (Fig. 5), but by using a pedicled
muscle graft or free fat graft, as described previously,
a satisfactory scar will be obtained (Fig. 10). Fraser
(1934) states that he has abandoned the gutter
operation because it did not appear to afford more
efficient drainage than that provided by the method
of multiple drill holes, while the trauma necessarily
lessened the reaction and encouraged sequestrum
formation. With the first statement I am unable to
agree, having seen several cases similar to that
described in the last paragraph, while my answer
to the second is to be found in the nearly complete
absence of sequestration in the present series of
cases.
It would be well, at this point, to emphasise certain
features which must be borne in mind when performing
the gutter operation as used in the Bipp method of
treatment. In the first place, the size of the gutter
should be such as to permit of the removal of the
infected tissue and no greater. Hence, if a gutter
only 1 in. long is sufficient for this purpose, no
further increase in its size is necessary or justifiable.
There seems no doubt that, in times past, many
gutters have been made indiscriminately without
FIG. 9.—Same case as in Fig. 8. FIG. 10.—Acute osteitis of
Wound one month after the upper end of tibia. Wound
institution of Bipp treatment. three weeks after filling of
It is healed except for two cavity with free fat grafts.
small areas from which there Wound healed by first inten-
is a little discharge. tion. Compare with Fig. 5.
any regard to the size of the infected focus, with
consequent infection of healthy tissue and that this
accounts in no small measure for the bad results
obtained. Secondly, the idea that the gutter operation
is synonymous with the opening up of the medullary
cavity is an appalling misconception that must be
corrected, for to do this unnecessarily is asking for
trouble and at the same time it indicates ignorance
of both the fundamental pathology on which the
operation is based and of the technique of its
performance,
Furthermore, it should be pointed out that accept-
ance of Starr’s contributions to the pathology of acute
osteitis in no way contra-indicates the performance
of the gutter operation, provided this is done in the
manner already described and not indiscriminately.
The essential difference between the Starr and
the Bipp methods of treatment is that while the
former seeks to drain the bony focus of infection,
it is the aim of the latter to remove the focus. The
advantages to be gained by removal as opposed.
to drainage have already been discussed, and ample
proof of their practical significance is demonstrated
by the excellent results obtained in the present series of
cases,
Fig. 11 illustrates the results obtained by the
Bipp method. They are radiograms from a case
of acute osteitis of the lower end of the femur
taken one month, six months, and fourteen months
after operation. The case is one referred to pre-
viously under the heading ‘‘ Length of stay in hos-
pital,” the wound being allowed to heal by granula-
tion and the patient leaving hospital 75 days after his
admission with the wound completely healed. The
cavity, of moderate size, formed by the guttering
of the bone is well shown in Fig.114. At the end
of six months (Fig. 11 8B) it is seen to be much smaller,
while after fourteen months (Fig. 11c) it has been
1266 THE LANCET]
completely obliterated by sclerosed bony tissue, the
structure of the bone itself being almost normal.
No sequestrum formation occurred and there has been
no thickening due to the formation of new periosteal
bone. These radiograms should be compared with
those in Fig. 6.
Winnett-Orr method of treatment.—This is placed
under a separate heading because, owing to Orr’s
FIG. 11.—Case of acute osteitis of lower end of femur treated
by Bipp method. Radiograms taken one month, six months,
and fourteen months after operation. Note absence of bony
thickening, gradual obliteration of cavity, and restoration of
bony structure almost to normal. See text and compare
with Fig. 6.
publications (1927) it has become known by his name
and seems to have been accorded the status of one
which apparently differs from any other. Since,
however, it consists of the gutter operation, the treat-
ment of the wound with alcohol followed by iodine,
the packing of the wound with vaselined , gauze,
and the immobilisation of the affected part, its
similarity to the Bipp method of treatment becomes
at once apparent. At the time, towards the end of
the late war, when Orr was formulating his method
of treatment, the Bipp method was already estab-
lished and widely practised in the British Armies.
While the principles of this method are the same
as those governing the Bipp method—namely, the
removal of the bony focus of infection, the use of an
antiseptic and immobilisation, and it has the same
advantage of obviating the necessity for frequent
dressings—yet it is different in one or two important
details. In the first place, the iodine as used by
Orr will be absorbed in a very short time and no
further supply will be available under his method
of treatment. The use of Bipp, on the other hand,
results in a continuous supply of nascent iodine to the
tissues as long as the paste is present in the wound.
Secondly, anyone who has had experience of the
Orr method need not be reminded of the offensive
smell which develops and which makes its use so
objectionable. It will be seen, therefore, that the Bipp
method of treatment possesses definite advantages
over the Orr method in that it is cleaner, more
pleasant to use, and is a more adequate means of
arresting the spread of infection.
Diaphysectomy.— Of this operation I have had
no personal experience. Mitchell (1928) reports a
series of 13 cases with only 1 death, which indicates
that the operation need not be associated with a
MR. J. H. SAINT: B.LP.P. IN ACUTE OSTEITIS
[may 29, 1937
forbidding fatality-rate, although he does not mention
which bones were treated in this manner. Apart
from the radical nature of the operation, one objection
to it that will always carry much weight is the lack
of guarantee of regeneration, the partial or complete
failure of which in most of the long bones would
lead to considerable deformity and disability. In
the rare advanced case in which the diaphysis is found
lying loose under the periosteum it could easily be
removed but with its removal there would be taken
away the best means of ensuring the essential thick
involucrum, for the presence of ‘necrotic bone acts as
a stimulant to the formation of new bone by the
periosteum. The fibula is the only long bone where -
the question of regeneration does not assume such
paramount importance, and four cases of successful
total diaphysectomy for acute osteitis of this bone have
been reported by Hamilton Bailey (1929). It is felt,
however, in view of the results that can be obtained
by the more conservative Bipp method of treatment,
that diaphysectomy appears to be an unnecessarily
radical procedure.
Carrel-Dakin solution.—One cannot omit from a
discussion of the various methods of treatment of
acute osteitis the mention of Carrel-Dakin solution,
since many bony cavities, the result of the gutter
operation, are treated with this antiseptic. It has
the advantage of being a more powerful antiseptic
than Bipp, but it is very soluble, the effect being so
transitory that it is necessary to renew it at frequent
intervals. To ensure this renewal special apparatus
is necessary, this in its turn requiring attention ; the
dressings are continually wet, Sometimes giving rise
to severe irritation of the skin surrounding the wound
unless precautions are adopted, and some individuals
have a decided distaste for its pungent odour. Bipp,
though less powerful, is able to ensure a continuous
supply of nascent iodine without requiring renewal for
‘days or even weeks, no special apparatus is necessary
for its application, there is usually little or no dis-
charge, and there is no associated smell to upset the
patient or his attendants, these features, in my
Opinion, representing distinct advantages rendering
the use of Bipp preferable to that of Carrel-Dakin
solution.
Summary and Conclusions
Acute osteitis is a serious disease commonly asso-
ciated with a high mortality and much subsequent
morbidity.
The term “osteitis” is used as meaning the
inflammation of any or all of the constituent parts
of the bone, and such terms as “ osteomyelitis ” and
“ periostitis ” are considered superfluous as well as
having the disadvantage that they tend to denote
separate diseases.
It is important to realise the fact that the disease
begins as a small, delimited focus of infection in the
cancellous tissue of the metaphysis, for this focus can
be completely removed, and that its removal con-
stitutes the rational treatment. While the develop-
ment of the bony focus of infection presupposes a
septicemia to be already present, this septicsemia
must be mild since it gives rise to no symptoms as
such. The general symptoms that point to a blood-
stream infection appear only after the development of
the bony focus. In consequence of this sequence of
pathological events it is suggested that the severe
systemic infection seen in acute osteitis is due to a
reinfection of the blood stream from the bony focus,
a view that calls for the removal of that focus at the
earliest possible moment.
THE LANCET] ©
Stress is laid on the necessity for diagnosis in the
early stage of the disease—that is, before complica-
tions, due to the spread of infection, have occurred.
The triad of a continuous pyrexia, intense pain of
sudden onset over the metaphysis of a long bone,
and exquisite tenderness on palpation of the same
region, associated with a polymorphonuclear leucocytosis,
are the clinical features that appear early and.establish
the diagnosis.
A description is given of the characteristics of
bismuth-iodoform-paraffin paste, including its formula,
‘bacteriological and chemical actions.
The principles governing the Bipp method of treat-
ment of acute osteitis and the technique of its per-
formance are described, followed by a synopsis of
21 personal cases treated by this method during the
past six years. Two cases died, giving a fatality-rate
of 9-5 per cent., one of the lowest on record. Com-
plications were few and the average period of hos-
pitalisation short. The late results concerning growth
and function were excellent, and a striking feature
was the almost complete absence of sequestration.
One case is described of recurrence three years after
the initial illness.
The various methods of treatment of acute osteitis
in use at the present time are discussed in some
detail.
In the Bipp method of treatment of acute osteitis
the surgeon has at his disposal one for which the
following claims are made :—
(1) It has a low mortality-rate.
(2) The technique is relatively simple.
(3) It avoids the necessity for frequent dressings.
(4) The dressings themselves are painless, a considera-
tion of no small moment in children.
(5) It enables the surgeon to exercise personal super-
vision of the case instead of. delegating this important
duty to other people, as when frequent dressings are
necessary.
(6) It is clean to use and there is no unplegsanit
associated odour.
(7) No special apparatus is required.
(8) Little or no sequestration occurs, thus avoiding the
formation of chronic sinuses and the necessity for secondary
operations.
(9) Wounds heal in a comparatively short time, thus
avoiding a lengthy period of hospitalisation and the
interference with function so liable to row a protracted
illness involving a limb.
(10) The late results concerning growth and function
are excellent,
It is considered that the advantages, enumerated
above, to be gained through the use of this method of
treatment of acute osteitis merit its wider recognition
and adoption,
REFERENCES
Anderson, E G., Chambers, H., and Goldsmith, J. N.
I. ancet, 1 ; 331. ;
Bailey, H. (1929) Brit. J. Surg. 17, 641.
Fraser, J. (1934) Brit. med. J. 2, 539.
— Ibid, p. 272.
Holman, C. C. (1934) Lancet, 2, 867.
Lloyd, E. (1928) Proc. R. Soc. "Med. 21, 1377.
Mitchell, A. (1928) Ibid, 21, 1377.
Morison, R. (1918) Oxford War Primers, London.
— (1922) Surg. Gynec. Obstet. 40, 642.
Ogilvie, W. H. (1928) Proc. R. Soc. Med. 21, 1377.
Orr, H. W. (1927) Surg. Gynec. Obstet. 45, 446.
Platt, H. (1928) Proc. R. Soc. Med. 21, 1377.
Pyrah, L. N., and Pain, A. B. (1932) Brit. J. Surg. 20, 590.
Starr, C. L. (1922) Arch. Surg. 4, 567.
— (1927) in Lewis’s Practice of Surgery, vol. 2.
Tyrrell-Gray, H. (1934) Brit. med. J. 2, 272.
Wakeley, C. P. G. (1932) Ibid, 2, 752.
Williams, G. (1932) Proc. R. Soe. Med, 25, 617.
(1917)
DR. SHIRLEY SMITH AND OTHERS: LEFT INFRAMAMMARY PAIN [may 29, 1937
1267
LEFT INFRAMAMMARY PAIN
A METABOLIC INVESTIGATION
By K. SHIRLEY Smr, M.D., B.Sc., F.R.C.P. Lond.
PHYSICIAN TO CHARING CROSS HOSPITAL AND TO THE CITY OF
LONDON HOSPITAL FOR DISEASES OF THE HEART AND LUNGS
A. STEPHEN HALL, M.D. Camb., M.R.C.P. Lond.
FORMERLY PHYSICIAN TO THE ROYAL CHEST HOSPITAL; AND
JOCELYN PATTERSON, M.Sc., Ph.D. St. Andrews
CHEMICAL PATHOLOGIST TO CHARING CROSS HOSPITAL
_ Tat pain in the centre of the chest or over the
left mammary region should suggest heart disease is
not unnatural. Indeed many such pains are
undoubtedly due to heart disease. It is usually easy
to recognise, for example, the pain of effort angina
with its relation to exertion, and the prolonged pain
of coronary thrombosis. Similarly pain due to acute
pericardial disease or to aneurysm is likely to be
traced to its true source by careful investigation.
There is, however, another variety of pain over the
heart which is commonly called left inframammary
pain. It is rather sharply distinguished from the
others by its situation roughly over the apex-beat,
its independence of exertion, and its good prognosis.
In these patients the pain is often the solitary sug-
gestion of heart disease, and on examination none of
the ordinary evidence of heart disease, such as
cardiac enlargement, arrhythmia, valvular disease, or
high blood pressure is found. The subjects of such
pain are usually women, sufferers from chronic
anxiety, imagining that they have heart trouble, and
indeed, as the pain is over the place where the heart
may be felt beating, what more natural supposition
than that it is somehow associated with the heart ?
Yet because of the absence of features of the ordinary
recognised heart disease, because the pain is unlike
those known to be associated with cardiac pathology,
and because the psychological state of the patient is
sometimes abnormal, this symptom of left mammary
pain has been consistently dismissed by physicians as
“ functional.”
It may be profitable to consider more closely what
is meant by this term. It may mean that symptoms
are present ahd related to disturbances of physio-
logical function which are perhaps not recognisable by
the methods at our disposal, and which at any rate
are not sufficiently gross to be classed as pathological ;
on the other hand, it may mean that symptoms are
present, that these are unrelated to morbid or even
physiological deviations, and that the source of the
symptoms is psychogenic. The term functional is all
too frequently used by clinicians at the present day
to embrace both of these groups—the truly functional
and the psychogenic. The use of the word “ func-
tional”? in connexion with left inframammary pain
insidiously suggests to the physician some inferiority
in moral fibre in his patient, and a lack of significance
in the complaint ; he therefore feels both unworthy
of his attention and the patient is sent away assured
of a sound heart and the prospect of a long life. Yet
the pain persists and has somehow or other to be
borne. Is it not possible that the patient was
originally right in her fears, that there is something
wrong with the heart, and that our methods of
examination are so crude as only to discover the
grosser forms of disease? May it not be that some
disturbance of nutrition as opposed to structural
damage is responsible for the production of pain,
and that there exists in these patients some mechanism
correlating their anxious state with metabolic dis-
turbance and pain ?
1268 THE LANCET]
_ hat there is some relationship between a person’s
psychological structure and the disease to which he
is liable there can be little doubt, as witness the
observations of Draper (1924), although it is unknown
whether that relationship is endocrine or biochemical.
There is the excitable temperament of the rheumatic
child, the anxious pessimistic man who develops
peptic ulcer, and the cheerful optimistic woman who
gets gall-stones. These associations are so common
that they cannot be fortuitous but the links remain
to be discovered.
It was in this frame of mind that we began to
study patients afflicted with left inframammary pain,
subjecting them to clinical, biochemical, radiological,
and electrocardiographic investigations, and attempt-
ing to find some abnormality that might indicate the
link between physical and mental fatigue and the
symptom-complex of left inframammary pain. In
this paper we record the results of our investigations
and suggest a working hypothesis of the mechanism
of the syndrome.
THE CLINICAL FEATURES
Pain below the left breast is a symptom, common
enough in women, which has been recognised for
many years and which does not respond to the
methods of treatment usually adopted. It differs
absolutely from angina pectoris by its lack of imme-
diate relation to exertion. It is situated in its greatest
intensity in the neighbourhood of the apex-beat.
Frequently the pain is accompanied by liability to
palpitation and suspirious (sighing) respiration as
described by Herz (1910). Associated pain and hyper-
æsthesia about the angle of the left scapula was first
observed by Parkinson (1919). The pain may come
on at any time, but is specially apt to occur after
physical or mental fatigue. Any exertion that
involves stooping or stretching upward with the arms
seems likely to produce or aggravate the pain.
Characteristically it is a dull ache, but it may be
paroxysmal and of extreme severity as described by
Gallavardin (1928); the differential diagnosis from
spasmodic angina may then present difficulty. Left
inframammary pain is not directly relieved by rest.
Other symptoms commonly associated are headaches,
depression, trembling, and manifestations of vaso-
motor instability such as sweating and sensations of
heat and cold. In consequence of these the pain is
regarded by many physicians as neurotic in origin.
In times past it was generally regarded as due to
heart disease, and indeed its accompanying phenomena
of dyspnea and palpitations served to emphasise
this conception. This pain does commonly occur in
heart disease and one of us (Smith 1929) has shown
that pain at and below the left breast is a frequent
manifestation in congestive heart failure, tending to
become more severe with enlargement of the heart
and tachycardia. Nevertheless, left inframammary
pain occurs much more frequently in patients who
have none of the accepted evidence of heart disease,
and Baker (1930), in an analysis of 332 consecutive
patients at the National Heart Hospital, found this
pain complained of in 42-3 per cent. of cases with no
other evidence of heart disease, and she compiled
similar figures in a further series of 266 consecutive
patients. Thus a patient with this pain is more
likely to have a “ normal ” heart than not.
EXPERIMENTAL GROUP
The series investigated in the present work com-
prised 26 patients (all female except 2), who gave
left inframammary pain as the main, sometimes the
sole, complaint, and who on careful examination by
DR. SHIRLEY SMITH AND OTHERS : LEFT INFRAMAMMARY PAIN
{may 29, 1937
the usual clinical and cardiographic methods showed
no evidence of any recognised form of heart disease,
Their ages ranged from 20 to 64. In each instance
the patient was admitted to hospital and a very full
history was elicited with special reference to the
nature, site, radiation and duration of the pain, the
associated symptoms, the menstrual cycle, and the
presence or absence of factors pointing to anxiety,
fatigue, or toxemia.
Radiological and electrocardiographic examinations
were made in each case. An estimation of the fasting
blood-sugar was made, that is to say, the patient
took no food from the evening before until the blood
was taken at 7 A.M. Sugar-tolerance curves were made
in nearly every case, while determination of alkali
reserve and the basal metabolic rate by the British
Benedict method were made in the majority. Re-
peated urine tests for acetone bodies were carried out.
Although there are available numbers of statistics
relating to the range of the normal fasting blood-
sugar, it was thought best to study a small series of
controls. Accordingly, estimations of fasting blood-
sugar were made in a group of 11 young women in
sound health awaiting various minor orthopsdic
operations. Such a group reproduced the condition
of hospitalisation of the experimental series and at
the same time comprised a number of subjects free
from any symptoms or constitutional maladies,
RESULTS
Fasting blood-sugar.—Out of 26 patients—
17 showed 80 mg per 100 c.cm. or less
11 9? 70 mg. a9 99 99
8 99 65 mg. 99 99 99
In a control series the fasting blood-sugars. in 11
“normal” female patients had the following values:
98, 89, 87, 85, 85, 82, 80, 79, 75, 73, 71.
Sugar-tolerance curves.—These were obtained in 23
patients. In 9 a peak of 140 mg. per 100 c.cm. or less
was found, and in 6 of these the peak was 130 mg. per
100 c.cm. or less. Three curves reached a level of 200 or
more, In one of these (peak 230) glycosuria was dis-
covered ; in the other two no glycosuria. l
Alkali reserve.—Estimations were made in 9 patients
and were within normal limits, ranging from 50-77 vols.
of CO, per cent.
Basal metabolic rate.—Investigation of 22 patients,
in one of whom it was not possible to obtain a figure.
In 4 patients it was between —5% and +5%
Ing .,, » - +6% and +25%
In 7 - $5 ne —6% and —25%
In the remaining two patients values of +28 and -+-30
were obtained. These patients and some others were
regarded as unsatisfactory subjects for the test.
Urine.—Consistently normal in every patient except —
those two in whom glycosuria was found in association
with a reduced sugar-tolerance curve.
Body-weight.—The patients were with few exceptions
spare in build and under-weight rather than over-weight.
This was specially the case in the younger age-groups
(20-30).
X ray.—Antero-posterior teleradiograms did not disclose
cardiac enlargement or deformity in any case. Generally,
the heart was found to be of rather small size.
Electrocardiograms.—The following were regarded as
findings that would ordinarily be grouped among normal
tracings but which occurred with such: frequency among
these patients that they have received special attention :
(i) T, not greater than P, in amplitude; (ii) T, not
greater than P, in amplitude; (iii) diphasic T, or T,
with or without (i), or (ii), or (i) and (ii). One or more
of these conditions were fulfilled in 16 out of 24 patients.
The Figure shows four typical electrocardiograms.
ASSOOIATED FACTORS
(i) Blood pressures ranged within normal limits.
(ii) Menstrual disturbances or derangements existed
THE LANCET]
DR. SHIRLEY SMITH AND OTHERS: LEFT INFRAMAMMARY PAIN [may 29, 1937 1269 >
in 14 out of 24 female patients. In 3 of these patients
the menopause was in progress (ages between 48 and 54).
(iii) Fatigue in the history—work or special circum-
stances—in 10.
(iv) Anxiety in 18.
(v) Toxic factors such as excess of tea, coffee, or tobacco
did not appear to be of any importance.
(vi) Indigestion was conspicuous by its absence in the
histories.
DISCUSSION OF RESULTS
It will be seen from the foregoing results that the
subjects of left inframammary pain show deviations
from the normal in two principal directions: first,
an abnormality in the sugar metabolism was found in
a high proportion of cases, and secondly, particular
types of electrocardiogram were found with con-
siderable frequency.
experimental series there were 12 patients with a
fasting blood of 70 mg. or less, it is seen that approxi-
mately half our group were hypoglyc#mic, whether
compared to our own standard of the normal or to
the widest range of normal variation given by the
authorities quoted above. At the same time the
fasting blood-sugar in the remaining 14 of our patients
fell largely into the lower half of the normal range.
Sippe (1933) has found fasting blood-sugar values
ranging from 65-77 mg. per 100 c.cm. in four patients
complaining of left inframammary pain.
Departures from the normal were also found in the
sugar tolerance. The curyes in our patients tended
to be low, and showed an unusually early peak, the
estimation at the one-hour period being lower than
at the half-hour stage. On the other hand, we dis-
covered the presence of unsuspected glycosuria in one
Sugar metaboltism.—No agreement regarding the
normal variations of the fasting blood-sugar and the
level below which hypoglycemia may be said to
exist is to be found among the various authorities.
Sigwald (1932) regards 90 mg. per 100 c.cm. as the
lower limit of the normal, while Peters and Van Slyke
1931 give 70-120 mg. as the normal range. Graham
(1933) and Bourne and Stone .(1929) suggest 80-120 mg.,
while Wright (1936) gives 80-100 mg. Hawk (1931) claims
that values below 90 mg. are abnormal, and Joslin (1935)
names 100 mg. as the limiting low value. Wauchope (1933)
says that 100 mg. is the normal, and that hypoglycemic
symptoms may appear at or below 80 mg. Sendrail and
Planques (1927) after an extensive survey of the subject
concluded that a reading of about 90 mg. or below
constituted hypoglycsemia.
The discrepancy between these results depends to
some extent upon the diversity of methods used for
the estimations. Methods such as those of MacLean,
and of Hagedorn and Jensen, give on an average
readings which are 10-20 mg. lower than those
which, like Folin and Wu, employ tungstic acid
filtrates. Whether capillary or venous blood is
examined is of practically no moment in fasting blood-
sugar determinations.
In our present series of analyses MacLean’s method
has been used on capillary blood. Our previous
experience of this procedure has indicated that the
normal range of fasting blood-sugar is from 70 to
105 mg. per 100 c.cm. Thus the 11 cases taken for
controls varied between 71 and 98 mg. per 100 c.cm.
materially covering the normal range... Since in our
patient and indisputable hyperglycsemia in two others.
It is generally accepted that derangement of sugar
tolerance in either direction is the outcome of endo-
crine disease or dysfunction, although the nature of the
mechanism is far from being thoroughly understood,
Electrocardiograms.—The special features of electro-
cardiograms taken from our patients related entirely
to the ST segments or T-waves. The T-waves were
found usually to be of less amplitude than the P-wave
of the same lead, and were frequently diphasic or
inverted (see Figure), Such changes as these have
been recorded chiefly in relation to nutritional or toxic
disturbances, and the frequency with which they were
found in our series has led us to the view that they
are here related in some way to the anomaly of sugar
metabolism just described. Similar electrocardio-
graphic variations have been found by Taterka
(1929) in diabetic coma, by Smith and Hickling
(1932) in diabetes. Wittgenstein and Mendel (1924)
and Haynal (1925) have made similar observations
in hypoglycsemia in diabetes, and a flattening of the
T-waves has been demonstrated in starvation in
children by McCullough (1920). It seems likely
that the underlying factor in all these states is a
nutritional disturbance of the heart muscle due
either to a lack of sugar supply or an inability to
metabolise sugar.
Comments.—From .the foregoing considerations
it is clear that there is a possible basis of relationship
to connect the two principal abnormalities found in
our investigation. A review of the personal history
1270 THE LANCET]
in the experimental group brought out clearly facts
which have already been established regarding the
subjects of left inframammary pain. Fatigue and
anxiety appeared to play an important part not only
in the production of the syndrome, but also in
determining the frequency and severity of the pain.
When physical fatigue and emotional stress operated
together, as for example in the nursing of a sick
relative, the liability to the pain seemed to be especially
eat.
= MECHANISM OF PRODUCTION
The states of anxiety and fatigue, predisposing
to and aggravating the pain, are the outstanding
associated factors in the syndrome of left infra-
mammary pain. It must be considered whether there
is any possible link to correlate mental or physical
fatigue with the group of somatic symptoms which
are the subject of the present investigation. Many
of the physical manifestations of emotion are so
much part of everyday life that except in extreme
forms they arouse no comment; others are more
subtle and may only be observed by the discerning
eye; again, some are too slight to be detected by
the observer, and it is in this last field of manifestations
that explorations by biochemists and physiologists
are beginning to bear fruit.
There can be no doubt that the influence of the
emotions on the bodily functions is a profound one,
and the literature of this subject has lately been
exhaustively explored by Dunbar (1935). But it is
upon the endocrine system particularly that emotions
seem to exert their most direct effects. Thus Bram
(1927) found that in 2842 out of 3343 patients with
exophthalmic goitre a clear history of psychic
trauma as a cause was obtained. Goodall and
Rogers (1933) have made similar observations. The
deleterious effects of anxiety upon the diabetic is
universally recognised, and Cannon (1929) has found
glycosuria at times of anxiety in normal animals
and men. Again Williams (1912) has remarked upon
the action of chronic fear which he believes to play
a part in the genesis of hyperthyroidism and hypo-
adrenalism ; he has recorded cases in which prolonged
stress has apparently led to Addison’s disease and
death, no other condition than suprarenal atrophy
being found at autopsy. Marañon (1929) has reported
three similar instances. It should be noted in this
connexion that low blood-sugar and curves of increased
sugar tolerance are the rule in Addison’s disease.
No record of associations between mental or physical
stress and pituitary lesions has been disclosed in a
search of the articles on the subject.
The substantial body of evidence indicating the
concrete effects upon the bodily functions of emotional
disturbances has led us to review our own findings
in this light. The salient points in our problem were:
(i) the existence of a group of symptoms of which
left inframammary pain was the chief; (ii) the
obvious rôle of physical or mental fatigue in producing
or aggravating the syndrome; (iii) a condition in
which the blood-sugar generally tended to fall to
abnormally low. fasting levels, and in which a state
of increased sugar tolerance was found; and (iv)
the prevalence among these patients of particular
types of electrocardiogram. It seemed to us most
likely that the endocrine system must be the inter-
mediary factor here linking the mental state with the
physical. Considering in turn the various endocrine
organs, there was in the first place nothing in the-
literature or in our findings to suggest a pituitary
anomaly. The thyroid had also to be rejected on
several grounds; first, that in thyrotoxicosis a
reduced sugar tolerance is found as opposed to the
DR. SHIRLEY SMITH AND OTHERS : LEFT INFRAMAMMARY PAIN
[May 29, 1937
increased tolerance seen in the majority of our patients ;
secondly, our patients presented none of the signs
of frank or even masked thyrotoxicosis ; and thirdly
the basal metabolic rate was found to present no
significant deviations from the normal. The con-
clusion that no thyroid element operated in our
patients was supported by the findings of Gallavardin
(1935), who in a recent investigation of the comparable
syndrome of nervous tachycardia found no evidence
of abnormal thyroid function.
The thyroid and pituitary being thus excluded,
it remains possible that alterations in fasting blood-
sugar may relate either to pancreatic or supra-
renal causes. Since the tendency of alteration is
in the direction of increased sugar tolerance, the
glandular derangement would be either in the direction
of hyper-insulinism or hypo-adrenalism. As no
evidence was forthcoming to suggest the presence of
primary hyper-insulinism in our experimental group,
we have been led to the hypothesis that in the subjects
of left inframammary pain a relative hyper-
insulinism frequently exists in association with a
‘ state of exhaustion or hypofunction of the supra-
renal gland. We suggest that left inframammary
pain arises in the heart as the cardiac expression
of a metabolic derangement that affects the body
asa whole. This metabolic derangement is envisaged
as the consequence of endocrine dysfunction brought
about by emotional or physical stress. It may be
argued that if left inframammary pain is of this
origin patients with hypoglycemia should also be
subject to this pain. It is true that precordial
pain is not common in hypoglycemia, but it does
occur sometimes as mentioned by Sonne (1929)
who also observed palpitation in 44 per cent. of cases.
This author also refers to the fact that serious
symptoms may relate to little fall in blood-sugar,
while in other cases a sharp hypoglycemia produces
no symptoms. And even though left inframammary
pain be related to defective bodily and cardiac
nutrition it is not necessarily an invariable accompani-
ment any more than neuritis is to be found in
every subject of diabetes. Moreover, the condition
of our patients was not exactly comparable with
insulin hypoglycemia, since in the latter an actual
hyper-insulinism exists as opposed to the suggested
relative hyper-insulinism in left inframammary
pain. It has been observed by Ernstene and Altschule
(1931) that hypoglyczmia causes an increased load
on the heart since the minute volume is increased
during the condition ; similar observations have been
made by Chasanoff (1929). It seems likely that the
explanation of exertional dyspnea accompanying
left inframammary pain lies in these facts.
SUMMARY
1. The syndrome frequently known as left infra-
mammary pain is briefly described. Modern concep-
tions regarding the nature and source of this pain
are discussed.
2. An account is given of an investigation into
the clinical features and metabolism of 26 patients
suffering from the left inframammary pain syndrome,
but from no recognised organic disease in any system.
3. It is found that approximately half of the
experimental group showed abnormally low fasting
blood-sugar, even though the figure of 70 mg. per
100 c.cm. be taken as the lower limit of the normal.
Sugar-tolerance curves often showed an increased
tolerance, the curves reaching an early, and frequently
low, peak. On the other hand, in two patients an
unsuspected diabetes was brought to light, and in
three others hyperglycemia without glycosuria.
f Toterke,
THE LANCET]
DR. BARR AND DR. TINDAL: GAS-AND-OXYGEN ANALGESIA IN LABOUR [may 29, 1937
1271
4. The electrocardiogram in the subject of left
inframammary pain is found frequently to show
certain features hitherto regarded as normal.
5. Examination of alkali reserve, basal metabolic
rate, and heart size by radiography shows no
abnormality.
6. The nature and origin of left inframammary
pain are discussed. It is suggested that this pain
is the cardiac expression of a metabolic derangement
that affects the body as ,2 whole. It is further
suggested that this disturbance is related to an
underlying endocrine imbalance,
Sooo uae
Baker, D. (1930) Lancet, 1,
Bourne Stone, x. 75929) The Principles of Clinical
Patho logy in Practice, London.
Bram, I. (1927) E ;
Cannon, W. B. (1929) Bodily Changes in Pain, - Hunger, Fear,
and Rag age, New York and London.
Chasanoff, M . (1929) Klin. Wschr. 8, 934.
Draper, G. au 924) Human Constitution, Philadelphia and Lonđon.
Dunbar, H. F. (1935) Emotions and Bodily hangos New York.
Emsione C., and Altschule, M. D. (1931) J . Clin. Invest.
21.
Gallavérdin L. (1925) Les Angines de Tone T ane.
935) Les Tachycardies N aeronau T
Gooda T S., and Rogers, L. (193 ed. J. eee 138, 411.
Graham G. (1933) Text-book of Medicine, London
Hawk, P. (1981) Practical Physiological Chemistry, London.
ynal, E Tn: Klin. Wschr. 4, 403 and 1729.
Herz, 10) St. Petersburg med. Wschr. 35, 72.
Joslin E. 1935) The Treatment of Diabetes "Mellitus, London.
PR (1920) Amer. J. Dis. Child. 20, .486
fion, G (1929) TrA med. 83, 30 (quoted by Dunbar).
Parkinson J. (1919) L 550.
Peters, J. P., and Van Siyke, D. D. (1931) Quantitative Clinical
emistry, London
Sendrail, P and Planques, J. ve bans Hôp., Paris, 100, 1137.
Sigwald, J (1932) L Hypogiyo mie Pari
Sippe, G. (1933 ) Med. aoa,
Smith, E one (1929) ore 1080.
. A. (1932 y toed, 1, Raat
Sonne, O. “(1929) D Ata med. scand. Supp. , 223.
ee) Klin. Wschr. 8, 11
ae Quart. J ‘Med. 26, 117.
Williams, T A. (19 12) Med. Pr.
Witt enstein, A., and Mendel, B. 7 4) Klin. Wschr. 3, 1119.
Wright, S (1936) Applied Physiology, London.
Wauch ope, G
A NEW MACHINE FOR THE SELF-
ADMINISTRATION OF
GAS-AND-OXYGEN ANALGESIA IN
LABOUR
By ApAam Barr, M.B. Glasg., F.R.F.P.S., M.C.0.G.
SENIOR ASSISTANT TO THE REGIUS PROFESSOR OF MIDWIFERY,
UNIVERSITY OF GLASGOW; VISITING SURGEON TO THE
GLASGOW ROYAL MATERNITY AND WOMEN’S HOSPITAL ;
VISITING OBSTETRICIAN AND GYNZECOLOGIST TO
STOBHILL GENERAL HOSPITAL, GLASGOW ; AND
ANDREW TINDAL, M.B. Glasg.
VISITING ANZESTHETIST TO THE WESTERN INFIRMARY AND THE
ROYAL HOSPITAL FOR SICK CHILDREN, GLASGOW,
AND TO THE GLASGOW DENTAL HOSPITAL
(
DuRING the past few years many attempts have
been made, in response to a growing demand from
all sections of the community, to evolve some safe
method of producing relief from pain during labour.
In domiciliary practice the majority of women go
through the greater part of labour with no mitigation °
of pain. Most practitioners administer, during the
second stage of labour, ‘‘intermittent chloroform
anesthesia.”” Nevertheless, this is not the stage
at which the patient is most in need of relief. Observa-
tion and examination reveal that the most fatiguing
and certainly the most painful part of labour is the
latter part of the first stage—and it is at this stage
that relief is demanded—the pains are increasing
in intensity, and yet the patient feels that the present-
ing part is not progressing ʻand she can do nothing
to help herself. Prolonged intermittent chloroform
anesthesia is obviously, because of late dangers,
inadvisable at this stage, and to this risk must . be
added the disadvantages-that labour is delayed and
the incidence of forceps delivery is increased.
Administration of sedative drugs, because of their
uncertainty of action, associated restlessness, and
possible effect on the child has never been a popular
method of relieving pain in ‘domestic midwifery
practice.
The community and the profession are indebted to
Minnitt, who in 1934 devised an apparatus for the
self-administration of nitrous oxide gas in air to
produce analgesia. Although this has not proved
entirely satisfactory in use, it has become obvious
that future developments in this method should
prove the ideal means of producing analgesia in
labour. Administration of nitrous oxide gas and
air or oxygen possesses advantages over all other
methods in that while it relieves the pain of labour
it is in no way dangerous to the mother or the child,
nor does it prolong labour—the frequency of pains
is not interfered with and the strength of contractions
is not diminished. The incidence of instrumental
interference therefore should not be increased.
During the past two years we have endeavoured to
evolve an apparatus which would. fulfil certain
conditions which we considered essential if it were
to be of value in general practice midwifery. It
must (1) be safe and foolproof, (2) deliver a fixed
proportion of nitrous oxide gas and oxygen, (3) be
low in initial cost, (4) be low in running expenses,
(5) be compact and easily portable, (6) have a minimum
of moving parts to go out of order and have a
mechanism which is easily understood, (7) if possible,
be capable of producing some degree of analgesia at
the moments of birth. After much experimenting,
constructional and clinical, we have produced such
an apparatus.
Essentially it consists of a rubber bag of I0 gallons
capacity. Two tubes enter this, one leading direct from
a nitrous oxide cylinder, and the other from an oxygen
cylinder. In order to measure the oxygen, a l gal. rubber
bag, which has a tap at either end, is connected up as in
the Figure. Two corrugated rubber tubes lead from the
bag to the face-piece—directional valves are fitted so
that the gas mixture in the bag is inspired through one
tube, and the expired breath is exhaled into the bag.
A valve is incorporated in the face-piece in such a way.
that when the plunger, which is spring loaded, is depressed,
gas is permitted to enter the face- -piece from the bag
and, when ‘it is released, the flow of gas-and-oxygen is
automatically stopped and air only is breathed.
METHOD
The procedure is as follows, All air in the bags
is expressed by folding them flat, at the same time
depressing the plunger on the face-piece. The tap (A)
1272 THE LANCET] DR. BARR AND DR. TINDAL: GAS-AND-OXYGEN ANALGESIA IN LABOUR
proximal to the oxygen bag (capacity 1 gal) is closed
and the distal one (B) opened, and the bag then filled
with oxygen. This small bag, which now contains
1 gal. of oxygen, is emptied into the reservoir by
opening the proximal tap and squeezing the bag.
The tap (A) is then closed. The reservoir, which
now contains 1 gal. of oxygen, is then filled to capacity
with nitrous oxide to a point just short of stretching
the rubber. The tap between the cylinder and the
reservoir is now closed. The reservoir now contains
approximately 10 gal. of gas—90 per cent. nitrous
oxide and 10 per cent. oxygen.
The apparatus is now ready for use. Whenever the
approach of a pain is appreciated, the patient expires
to the fullest extent, then placing the face-piece over her
nose and mouth, presses the plunger valve and takes a
long inspiration from the reservoir—the following expira-
tion passes back into the reservoir. She continues in this
manner until the contraction is over, when she releases
her grip on the plunger and removes the face-piece. The
apparatus is ready for the next pain. One filling may
last from 4 to 2} hours, depending upon the frequency
of the pains. It will be observed that as time passes
the reservoir tends to sag. Before itis completely emptied,
its contents, now diluted with exhaled air, are expressed
by folding the reservoir flatly and depressing the plunger
as before. It is then refilled as in the beginning.
The concentration of nitrous oxide permits
sufficient analgesia of rapid onset, and the 10 per
cent. oxygen is sufficient to prevent anoxzmia.
The concentration of carbon dioxide in the reservoir
never becomes high enough to cause any divergence
from the normal rate of respiration.
The apparatus is manipulated by the patient
herself, an attendant being required from time to
time to refill the bags.
If sufficient relief from pain is not obtained for
the actual birth of the head, the nurse or medical
attendant may, by applying the face-piece con-
tinuously with the plunger depressed, obtain adequate
analgesia for this purpose. The same procedure
will allow of episiotomy or insertion of perineal
- sutures,
Our experience has been that where the analgesia
is begun early enough, the patient becomes so expert
in the use of the apparatus and so assured of relief
from pain that she frequently sleeps naturally between
pains, only waking sufficiently to reapply the face-
piece at the beginning of the next contraction.
This form of analgesia can be carried on indefinitely,
one of our cases lasting over thirty hours with no
ill effects.
RESULTS
In order that the degree of analgesia produced by
‘this machine might be accurately estimated, we have
adhered to certain standards throughout our investiga-
tions. (1) The cases here reported were delivered
in one institution where certain nurses were instructed
in the use of the machine or, in private practice,
by ourselves. (2) In order that the actual relief from
pain might be correctly assessed, no preliminary
sedative drugs were administered in any case. (3)
In each case a record was kept of the effects of the
gas noted by the nurse in attendance, and also of the
‘Opinion expressed by the patient herself at the time
of labour. .
A total of 100 cases were treated. Of these 29 were not
aware of the birth of the child, and voluntarily expressed
surprised relief that the labour was concluded. There
were 20 patients who were extremely nervous when the
treatment began, and 12 of these became calm and
controlled, codperating readily shortly after they realised
the effect of the gas; 8 of these 20 cases, however, proved
[may 29, 1937
unsatisfactory throughout because of a lack of self-control
or an inability to obey the instructions for using the
apparatus—it seemed noteworthy that none of these
occurred in our private practice where codperation was
intelligent. After a very satisfactory analgesia in the
first stage, 3 multipare preferred to dispense with the
apparatus during the second stage on the plea that labour
was being delayed, although there was no diminution
in the force and frequency of the uterine contractions—
this seemed to us an argument for the efficiency of the
analgesia. The remaining 48 patients had a very good
relief from pain although they felt the actual birth of the
child. There were 6 cases of forceps delivery for reasons
not associated with the analgesia—persistent occipito-
posterior position and contracted pelvis—chlorofornY’
was administered in these cases for delivery.
There were no stillbirths in the series and no neonatal
deaths, and in all the child cried vigorously at birth.
At no time was cyanosis observed other than the
discoloration which is normal in the downbearing
of the second stage of labour.
COMPARISON WITH OTHER MACHINES
In 1935 a committee of the British College of
Obstetricians and Gynecologists reported on an
investigation into the use of analgesics suitable for
administration by midwives. The records of almost
4000 patients who received analgesia from the Minnitt
apparatus (35 per cent. nitrous oxide in air) were
considered. In 23 per cent. of these cases the
analgesia was reported as either doubtful or
unsatisfactory.
Chassar Moir (1937) has recently expressed his
disappointment, which confirms our own experience,
at the meagre benefits which this type of machine, ©
delivering 35 per cent. nitrous oxide in air, confers,
and has shown that the inefficient analgesia results
from the inability of many women to inhale a sufficient
amount of nitrous oxide before the full force of the
uterine contraction is upon them. In his apparatus,
pure nitrous oxide gas sufficient for two deep breaths
is delivered from a reservoir. In the apparatus
here described, 10 per cent. oxygen is added to nitrous
oxide gas, and the patient is able to obtain sufficient
analgesia for even the prolonged and severe uterine
contractions which are typical of the second stage of
labour, without fear of anoxæmia.
The apparatus is very moderate in price, light in
weight (24 lb.), and can be used at a cost of from 3d.
to 6d. per hour. No mechanical adjustments are
necessary—the principle on which it operates is
obviously simple. (Many nurses and practitioners
have expressed to us their feeling of insecurity when
working with complicated machines the meclianism
of which they do not understand.)
SUMMARY
A new machine for obtaining analgesia by means of
nitrous oxide gas and oxygen is described, It is
cheap, easily portable, and foolproof in use.
A series of cases is described in which 92 per cent.
obtained a satisfactory analgesia—in 29 per cent. a
perfect analgesia.
Less than 10 per cent. proved unsuitable—a more
or less irreducible minimum with a certain unintelligent
and nervous type of patient who is always troublesome
with any form of inhalational anzsthesia.
The apparatus is assembled and distributed by the
British Oxygen Co., Ltd., Polmadie, Glasgow, and is
known as the Tindal-Barr Analgesia Apparatus.
REFERENCES
Ann. Rep. Brit. Coll. Obstet. Gyneec., 1935, p. 30.
Minnitt, R. J. (1934) Lancet, 1, 1278.
Moir, C. (1937) Ibid, March 13th, p. 615.,
THE LANCET]
CHEMOTHERAPY OF STREPTOCOCCAL
INFECTIONS WITH p-BENZYLAMINO-
BENZENE-SULPHONA MIDE
By B. A. PETERS, M.D. Camb., D.P.H.
MEDICAL SUPERINTENDENT TO THE HAM GREEN HOSPITAL AND
SANATORIUM, BRISTOL; AND
R. V. Havard, M.R.C.S. Eng.
ASSISTANT RESIDENT MEDICAL OFFICER, HAM GREEN HOSPITAL
AND SANATORIUM, BRISTOL
DURING the past winter 150 cases of scarlet fever,
47 cases of erysipelas, and 18 cases with other
types of streptococcal infection were treated with
Proseptasine (p-benzylamino-benzene-sulphonamide),
an ample supply of which was placed at our disposal
by the makers, Messrs. May and Baker.
SCARLET FEVER
In the scarlet fever test group no antitoxic serum was
given. As controls, 150 alternate cases were treated
with serum when considered necessary (56 cases)
and the remainder expectantly. The dose given was
0-75 to 6 g. per day according to age by mouth in tablet
form, divided into four-hourly doses. The full dose was
given for two days, and half the quantity for another
two to four days according to the course of the
illness. The maximum quantity given in all to any
one patient was 22-5 g. The results are shown in
the Table.
It will be oþserved that in the test series, 53
(35 per cent.) developed one or more of the complica-
tions tabulated, whilst 84 (56 per cent.) of the control
cases showed some complications. This difference is
statistically significant. The sum of the individual
complications is almost identical, but the complica-
tions in the test series occurred in fewer patients.
The mean duration of the primary fever from onset to
termination was twelve hours longer in the test
series. Since antitoxin was administered to a third
of the control series, this might be expected, for
antitoxic serum undoubtedly reduces pyrexia. Our
TEST SERIES OF SCARLET FEVER CASES TREATED WITH
PROSEPTASINE
Cases showing complications
AGES .. ae 0-5 | 5-10 | 10-15 | 15-20
Cases os i ae we 27 72 24 9
Cases with complications ee 12 25 8 2:
Mean day of disease on admission 2'1 2°4 2°2 1°6
Mean duration of pyrexia salad
admission .. . 3°2 3°6 2°8 3'1
Adenitis 9 17 1
Otitis sa we oe oe 5 5 — —
Secondary tonsillitis ee oe 2 2 1 1
Endocarditis =e oe oe 1 2 — —
Rheumatism . . oe — — 1 —
Albuminuria as a és 1 8 3 —
Nephritis * és T sn — 3 2 1
Mastoiditis . . os — 1 — —
Died “ie wk ee oe — — — —
* 1 case of nephritis developed ursemia.
DRS. PETERS AND HAVARD : PROSEPTASINE IN STREPTOCOCCAL INFECTIONS
[may 29, 1937 1273
results would suggest, therefore, that the drug has
some effect on the invasive side of this streptococcal
infection and the results might be better if the drug
could be given earlier. If spaces such as nasal sinuses,
the middle ear, or bone are infected, the organism
is probably less accessible to the drug. Possibly a
combination of drug and serum would be more
effective, and this is now being investigated.
ERYSIPELAS
The results here were very striking. A series of 47
cases of erysipelas of varying severity, from mild to
very severe, was treated with similar doses of the
drug. The youngest patient was four months; three
were 70, 81, and 87 respectively. In 31 cases the
temperature was normal within twenty-four hours,
in 12 within forty-eight hours, in 3 within seventy-two
hours, and in 1 only did pyrexia continue until the
fifth day. The spread of the disease was arrested
within twenty-four hours in every case. Two
developed relapses ten days after the primary attack,
which responded at once to further doses of the drug.
All the cases made satisfactory recoveries, even the
aged ones.
OTHER STREPTOCOCCAL INFECTIONS
In 15 severe cases of tonsillitis, notified as diph-
theria, there was recovery within forty-eight hours of
treatment with the drug.
In one case of puerperal sepsis, showing signs of
early involvement of the broad ligament, which gave
a pure growth of hxmolytic streptococcus from the
cervix, the temperature settled within eighteen hours
and the patient made an uninterrupted convalescence
with rapid resolution of the infiltrated broad ligament.
One very ill patient with cellulitis involving the
fauces arising from an impacted wisdom tooth
lost his fever within seventy-two hours and recovered.
In one case of influenzal pneumonia with a turbid
pleural effusion, from which a pure growth of hemo-
lytic streptococci was cultured, the effusion dried up
after two ‘aspirations following the administration
of the drug and the patient recovered. In our former
experience, such effusions invariably became purulent
and necessitated operation for cure.
CONTROL SERIES (56 CASES RECEIVED
ANTITOXIC SERUM)
Cases showing complications
les
5-10 | 10-15 15-20 | OJ" | AN ages.
ere | i cementite | eee
67 33 9 13 150
44 16 4 6 84
2°9 3°3 1°4 2°5 2°6
2°2 2'2 3'4 3°3 2°5
8 6 2 1 27
4 - 4 — — 10
=> 2 2 3
4 — 1 1
2 4 2 2 10
4 5 2 3 19
4 1 — — 5
1 So = PS
1t — — — ' 2
` s !
t Abdominal case died after e loration.
$ a following nephritis.
Y
1274 THE LANCET]
TOXIC EFFECTS
One child with erysipelas developed a macular
rash; two very fat women complained of nausea
and vomited once; no case showed any cyanosis or
clinical signs suggesting sulphzemoglobinemia. It
seems, therefore, that the drug produces few toxic
symptoms in the doses we gave and is well borne at
all ages.
SUMMARY
The administration of proseptasine to scarlet fever
patients reduced the number of patients having
complications from 56 per cent. in the control series
to 35 per cent. The drug seems to affect chiefly
the invasive stage and results might be better if
it could be given earlier.
In erysipelas the spread of the disease was arrested
in 24 hours in all of 47 cases. In 31 cases the tem-
perature was normal within 24 hours and in a further
12 within 48 hours. A similar result was seen in other
types of streptococcal infection.
SOME OBSERVATIONS ON A CASE OF
PULMONARY ŒDEMA
By GEORGE GRAHAM, M.D. Camb., F.R.C.P. Lond.
PHYSICIAN, ST. BARTHOLOMEW’S HOSPITAL; AND
RONALD Burn, M.R.C.S. Eng,
WE have made two observations on a patient with
pulmonary edema which seem so important that we
are recording them now, as it may be long before
we have the opportunity of making detailed investiga-
tions on another patient with this condition,
The patient, a woman aged 64, has been seen at intervals
by one of us (G. G.) since 1925. In that year she developed
the symptoms of a mild toxic goitre, and was treated by
Sir Thomas Dunhill with rest and iodine. Glycosuria
and hyperglycemia were also present at that time, and
were treated with dietetic restrictions and insulin. The
symptoms abated, and after two to three years did not
cause any further trouble. The diabetic condition improved
greatly with insulin, and she was able to take 180 g. of
carbohydrate without insulin in 1928. Since then the
diabetic condition has become worse and in January,
1936, she needed 18+ 16 units for a diet containing 130 g.
of carbohydrate. At that time she was complaining of
lassitude and had a slight degree of pyrexia. No cause
for this fever was discovered and the temperature gradually
decreased and the symptoms abated. In March she was
again feeling unwell with slight pyrexia, and then had an
acute attack of B. coli pyelitis, which lasted for five
weeks. An intravenous pyelogram showed that she had a
large cyst of the kidney, which was thought to be con-
genital. The B. coli infection was at first treated with
alkalis and later with mandelic acid; the symptoms
were quickly relieved with mandelic acid but it was not
until August that the urine was rendered sterile,
Her general health had greatly improved, but she was
still easily tired, and was only up for about five hours in
the day. She had occasionally noticed a little wheezing
and tightness of the chest when falling asleep.
On Dec. Ist, 1936, she had a slight coryza, and on
Dec. 4th at midnight a feeling of tightness of the
chest. This was followed at once by an acute attack of
ulmonary cedema. She became ashy grey in colour.
P. 140, R. 36, B.P. 180/100. Many rales were heard over
both lungs, but there was little expectoration. She was
given at intervals injections of Asthmolysin 1 c.cm.,
atropine sulphate gr. 1/100, Coramine 2 c.cm., and atropine
gr. 1/150. The acute attack lasted about two hours and she ©
gradually recovered. She was seen two days later by Sir
Maurice Cassidy, who agreed that the attack was one of
acute pulmonary cedema. The electrocardiogram was quite
DRS. GRAHAM AND BURN: PULMONARY (EDEMA
` was 160 to 180/80; hemoglobin, 82 per cent.;
_ 5.50 P.M., morphine gr. },
[may 29, 1937
normal. She was kept in bed for 4 weeks but was then
allowed to resume her ordinary convalescent life. She
still had a slight pyrexia (99-99°5° F.). Blood pressure
colour-
index, 0-7 ; red cells, 5,600,000; and white cells, 23,000.
On Feb. 6th, 1937, she had another acute attack which
started suddenly at midnight. The respiration was 40, pulse
144, Many rales were heard all over the lungs and there was
again little expectoration, but she vomited several times.
She was given at intervals coramine 2 c.cm., morphine
gr. 1/6, atropine gr. 1/100, coramine 2 c.cm., atropine
gr. 1/150. The attack passed off in about 2 hours. She was
very unwell the next day, vomiting several times and
passing a great deal of sugar in the urine,-and was seen
- by G. G. on this account. The following were the results
sugar, 230 mg. per
alkali reserve,
of examinations made of the blood :
100 c.cm.; urea, 52 mg. per 100 c.cm.;
63-5 vols. (Dr. H. E. Archer).
The blood-urea had been estimated several times during
the previous illness and was usually between 32 and 36 mg.
per 100 c.cm. The rise to 52 mg. suggested that the kidney
might have failed because of the acidemia which was
probably present during the acute attack of dyspnea.
As both the attacks started so suddenly the possibility
of her being sensitive to some substance was considered.
Her rooms were always full of flowers, but no unusual
flower had been brought into the rooms in the last few
days.
A week later the general condition was better. The
blood-urea was 32 mg. per 100 c.cm. and the diabetic
condition was under much better control with 224 23
units of insulin. The blood pressure was 170/80. The
patient was allowed to get up after tea on this day, and
while walking in her room complained of a tight sensation
in her chest. She was put to bed at once and given, at
atropine gr. 1/50, adrenaline
0-5 c.cm. In spite of this treatment the symptoms developed
rapidly, and when she was seen by R. B.'at 6.5 P.M. was in
great distress. She was given, at 6.5, coramine 1-7 c.cm.
at 6.20, morphine gr. 1/6, atropine gr. 1/100; at 7. 10,
atropine gr. 1/100. The blood pressure was 200/80, a
rise of 30 mm. from the morning. The pulse-rate was
140 and feeble, and the respiration 46. Moist rales were
heard all over both lungs. During the next one and a half
hours she vomited two or three times, bringing up a good
- deal of fluid. Two hours after the onset she was seen by
G. G. The attack was then passing off, although she was
still very ill. The respiration was 40 and the pulse 140 ;
moist rales were heard all over the lungs. Ten
c.cm. of blood was collected at this stage for analysis.
An injection of adrenaline 0°5 c.cm. was then given sub-
cutaneously, after ascertaining that the point of the
needle was not in a vein by first withdrawing the plunger
of the syringe. Ten minutes later the breathing was
quieter and she said she felt better. The blood pressure
at this stage was 170/100, pulse-rate 144. Half an hour
later another 0°5 c.cm. of adrenaline was injected, using the
same precautions, and the condition continued to improve.
An hour later she was well enough to be left although the
pulse was still 120 and the blood pressure 170/80.
When the estimation of the blood-sugar was made
that night it was noticed that the blood flowed up the
pipette with difficulty. This condition had been observed
before in a case of diabetic coma (Graham, Spooner, and
Smith 1926) and a week previously in a case of severe
vomiting after influenza (G. G.). The hæmoglobin was
estimated at over 130 per cent. on a Sahli apparatus, and
the next day by Dr. H. F. Brewer, using a standard
Haldane apparatus, at 135 per cent. When the blood
had stood for a while the amount of plasma was very small
compared with the number of red cells, but a hematocrit
estimation was not made. The alkali reserve was 49 vols. ;
blood-urea was 36 mg. per 100 c.cm., and blood-sugar
260 mg. per 100 c.cm. The hemoglobin had been 82 per
cent. in January and two days after the attack was 80 per
cent.
DISCUSSION
The two observations to which we wish to draw
attention are the rise in the blood pressure and the
increase in the hemoglobin percentage, as we believe
they may throw light on the cause of the condition,
THE LANCET]
One hypothesis regarding the etiology of pulmonary
cedema is a failure of the left heart and this is supported
by the experiments of Welch (1878). He showed
that partial obstruction of the aorta caused odema of
the lungs. The rise of the blood pressure in the
brachial artery in our case, and the statement by
Hamman (1934) that the attacks are often preceded
by, or at least accompanied by, a marked rise of
blood pressure, a “so-called blood pressure crisis,”
shows that a failure of the left heart in the ordinary
sense does not cause the attack. The high blood
pressure might be associated with some obstruction
distal to the brachial artery. Such an obstruction
occurs in wound shock, but pulmonary edema is not
a feature of this state. This evidence suggests that
the left ventricle and presumably the left auricle are
not to blame.
The only structures between the lungs and the left
auricle are the intra- and extra-pulmonary veins.
A contraction of these veins somewhere between
the lung capillaries and the left auricle would make the
return of the blood to the left auricle very difficult,
and would cause an outpouring of fluid into the
alveoli of the lungs. All those who have made experi-
ments on the pulmonary circulation of animals have
found that any interference with the pulmonary veins
leads to the early onset of edema of the lungs. The
outpouring of fluid into the lungs would deprive the
blood of plasma and explain the rise in the per-
centage of hæmoglobin from 80 to 135 in the peri-
pheral circulation in our case. The blood would
become much more viscid and be more difficult
to drive round the circulation, and cause a rise in the
blood pressure at first. Another point in favour of this
hypothesis is the improvement in the clinical condition
which was noticed after the injection of adrenaline.
This was given with the idea of relieving any spasm
of the bronchi which might be present and thus easing
the breathing. The improvement may have been
due to another cause. In recent years many experi-
ments have been made on the pulmonary circulation,
but they are difficult to carry out and the results
are not easy to interpret. Gaddum and Holtz (1933)
made their observations on lungs which were not
ventilated but were perfused at a constant pressure.
Adrenaline caused an increase in the outflow from the
dungs in five out of ten cases, and a decrease in two
cases, Alcock, Berry, and Daly (1935), who ventilated
the lungs, showed that a minimal effective dose of
adrenaline generally caused an increase in the venous
outflow, with little or no change in the pulmonary
artery pressure. Larger doses tended to raise the
pressure considerably, without causing a comparable
increase in outflow.
. We have recorded these observations in the hope
that others who have the opportunity may make
extended observations on this condition. If the
following routine were adopted our hypothesis could
easily be proved or disproved.
(1) An injection of morphine tartrate gr. 4 should
be given at once since all observers seem to agree on
its value.
(2) The collection of 1 to 2 c.cm. of blood in an
oxalate tube. This should be done as soon as possible,
and repeated every 15 to 30 minutes until the attack
ceases. The hemoglobin, hematocrit value, red and
white cells should be estimated in each sample.
(3) The estimation of the blood pressure at
frequent intervals.
(4) The injection of adrenaline, 1 c.cm. sub-
cutaneously. The plunger should always be with-
drawn to make certain that the point of the needle
is not in a vein.
DR. J. SHAFAR : ACUTE ASCENDING FLACCID PARALYSIS
[may 29, 1937 1275
If the attack is not very serious it will probably be
sufficient to repeat the injection every 15 or 30 minutes
until the attack is over. If the attack is very severe
the dose should be increased to 2 c.cm. and perhaps
given at more frequent intervals, but we have not
sufficient data from our one case to determine the
point,
REFERENCES
Alcock, P., Berry, J. L., and Daly, I. de Burgh (1935) Quart. J.
exp. Physiol 25, 369. 7
Gaddum, J. H., and Holtz, P. (1933) J. Physiol. 77, 139.
Graham, G., Spooner, E. T. C., and Smith, W. (1926) St Bart’s
Hosp. ined. Rep. 62, 55.
Hamman, L. (1934) Oxford Medicine, New York 2, pt. i., p. 57.
Welch, W. H. (1878) Virchows Arch. 72, 375.
ACUTE ASCENDING FLACCID PARALYSIS
By J. Saarar, M.B. Glasg., D.P.H.
RESIDENT MEDIOAL OFFICER, WEST END HOSPITAL FOR NERVOUS
DISEASES; LATE HOUSE PHYSIOIAN TO THE HOSPITAL OF
ST. JOHN AND ST. ELIZABETH, LONDON
CASES of acute ascending paralysis are sufficiently
rare to merit individual publication. Moreover,
differencesexist between authorities. as to the correct
classification of these cases.
Landry in 1859 published a report of a patient in
whom there was acute flaccid paralysis beginning
in the periphery of the lower extremities, and which
spread rapidly upwards, involving the arms, trunk,
and respiratory muscles, death ensuing from respira-
tory failure; no objective sensory changes were
present. Examination of the spinal cord and brain
failed to reveal any gross abnormality, macroscopically
or microscopically. The term lLandry’s paralysis
has since then been used to describe such cases.
Giving the name of Landry’s paralysis to all types
of acute ascending paralysis of a lower motor neurone
variety by some and its limited use by others has
led to some confusion. Collier (1933) considers the
distinction between Landry’s paralysis and acute
polyneuritis to be an artificial one, based on the
presence or absence of objective sensory disturbance.
He regards the sensory changes as an expression
of the peculiar selective capacity of the poison,
and points out the not uncommon case of poly-
neuritis with no objective alterations in sensation.
Russell Brain (1933) similarly holds that Landry’s
paralysis and acute polyneuritis are identical. Drake
(1935) accepts as Landry’s paralysis any acute
ascending paralysis of a lower motor neurone type,
irrespective of the stiology—syphilis, infectious
diseases, poliomyelitis, &c.
According to Goldby (1930) there are three forms
of this variety of paralysis. He has collected
and tabulated in all 54 cases. In the first group he
places those cases in which there is little or no febrile
reaction and in which post-mortem examination reveals
few if any changes. This group is almost exclusively
confined to males in his series, and occurs usually
during the third decade of life. Sphincter control
is nearly always preserved and sensory changes are
subjective ; the stiology is unknown. In the second
group an acute paralysis of the lower motor neurone
type ascends symmetrically on both sides of the
body, as in the first group, but this subdivision is
‘characterised by objective as well as subjective
sensory changes, and post-mortem changes in the
parenchymatous and interstitial tissue ‘of the nervous
system. Sphincter trouble is more common than
in the first group, although the age-incidence is
1276 THE LANCET]
much the same. An important feature is the general
‘toxemia present. Ætiologically this group is closely
related to acute polyneuritis. The third group
comprises those cases in which the post-mortem
findings are very similar to those of poliomyelitis.
In such cases the paralysis is preceded or accom-
panied by a febrile illness and clinically signs of
increased intracranial pressure with meningeal irrita-
tion are present.
CASE REPORT
The following is an account of a fatal case of acute
ascending paralysis in a girl of 144 years.
The child was admitted at 8 p.m. on Oct. 15th, 1936,
and died at 30’clock next morning. Ininfancy she had had
chicken-pox, measles, and whooping-cough.
only child and still at school, where there were other
children ill with ‘‘ colds,” and others absent on account
of illness. She was perfectly well until her present condi-
tion. Her father and mother are alive and well. She
had been well until 12 days before admission when she
developed a headache over the frontal area. With this
headache there was a sense of congestion in the nose,
which however did not actually run. No sore-throat
was complained of. She went to bed on the same day and
the headache did not abate. A severe pain in the back
of the neck began 2 days later; this was, continuous
but it disappeared on the day before admission. The
headache. also persisted and was present until the day
before admission. Her lower limbs became weak 8 days
after the beginning of the illness, This weakness increased
until she was unable to move them. Next day her upper
limbs became similarly affected and difficulty in breathing
commenced. At no time was there any pain in the limbs.
There had been no incontinence of urine or fæces, no
rigors, diplopia, or convulsions. Insomnia had been
severe,
On admission her temperature was 99-5° F., respira-
tions 40, and pulse-rate 105. She was a well-developed
and very intelligent child. She answered questions
clearly and was able to give a lucid account of her condi-
tion. The face was flushed and the ale nasi working
markedly. The lips were cyanosed. Pulse regular in
force and rhythm. Tongue coated.
Central nervous system.—Pupils equal, regular and
central, reacting to light and accommodation. Vision
and fields of vision unimpaired. The eyeballs move in all
directions with no sign of muscle weakness or nystagmus.
Cornea] sensitivity and sensation in the face apparently
normal.
paralysis. There was no difficulty in speaking or swallow-
ST RECA WO ae
PRIS SEG,
PER. SEA
~ :
Ar
Ser
to
FIG. 1.—Lumbar cord: anterior horn (Lenhossek’s stain), showing
destruction of large anterior horn cells. (x 150.)
ing, and the palatal muscles moved well and equally on
both sides. Tongue protruded in midline; jaw muscles
unaffected. The muscles of the neck were paralysed and
the patient was unable to move her neck in any direction
at all. Considerable pain was elicited on passive flexion
of the neck which was very rigid.
Both upper limbs were in an advanced stage of paralysis,
the right more than the left. On the left, slight flexion
and extension of fingers and wrists, and very limited
extension of forearm were present. The right arm showed
DR. J. SHAFAR: ACUTE ASCENDING FLACCID PARALYSIS
She was an:
Some paresis in left lower face, but no actual .
[may 29, 1937
only slight flexion of the wrist. Absence of muscle
tone in both limbs. Motor reflexes present and equal
on both sides ; no sensory loss.
There was no disturbance of objective sensation in the
trunk or abdomen ; the intercostal and abdominal muscles
considerably weakened but not actually paralysed ;
abdominal reflexes present and equal on both sides. In
the lower limbs there was loss of all movements except
of microglia cells. (x 6520.)
some degree of flexion and extension of the left foot and
extension of the left knee. The right leg appeared com-
pletely paralysed. The muscles of the lower limbs were
very hypotonic ; reflexes present and equal on both sides ;
plantar responses flexor; no sensory loss in either leg.
Throat.—Generalised inflammation. Signs of left
follicular tonsillitis.
Chest and abdomen.—Normal.
Lumbar puncture.—Clear, colourless fluid; pressure
130 mm. Pathological report on cerebro-spinal fluid :—
Total cells vi -. 14 perc.mm. (lymphocytes).
Globulin vi A trace.
Total protein .. -. 0°025 per cent.
Chlorides ie -. 0676 is
Sugar .. ete -. Normal.
Lange’s gold curv 0012220000.
The stained specimen revealed no organisms and cultures
remained sterile after 7 days.
Progress.—The dyspnea and cyanosis became
increasingly worse. Just before death the tem-
perature became subnormal and the pulse-rate
dropped to 78. l
A post-mortem was performed and the cord
and brain removed under aseptic precautions.
Portions of the cord and brain at varying levels
were submitted for pathological examination,
while similar portions were dispatched to the
Lister Institute of Preventive Medicine.
Pathological report.—To the naked eye the
pial vessels were engorged, especially over the
cord and brain-stem. The cord was soft and
cedematous, but showed no gross softening.
Portions of the cord were taken at all levels,
and from the mid-brain and cortex, and were
fixed in 75 per cent. alcohol and 10 per cent.
formol-saline. The sections, stained with Len-
hossek’s stain and hematoxylin and van Gieson’s,
showed that no portion of the cord had escaped
severe damage. The large anterior horn cells, particu-
larly in the lumbar and cervical enlargements, were
greatly reduced in number. Some were degenerated,
with swelling of the cytoplasms, disappearance of Nissl’s
granules, and necrosis of the nucleus. Round about these
degenerated nerve-cells there was considerable focal
glial reaction. Cell nests of microglial cells, many of
them rod-shaped, were visible in some of the sections.
THE LANCET]
DR. JOAN HARAM : LYMPHATIC LEUKAIMIA WITH MAMMARY CHANGES [May 29, 1937 1277
Virchow-Robin spaces showed cedema and congestion,
with perivascular “‘cuffing.” In many areas, minute
capillary hemorrhages were visible about the vessels.
In the lumbar region there was destruction to the central
canal of the cord, and much congestion of the pia and
nerve-roots (Figs. 1 and 2). The spleen and lymphatic
tissues in the ileum were not examined.
Animal inoculation.—At the Lister Institute an emulsion
was made of the material sent and 1 c.cm. injected into
the brain of a monkey on Oct. 17th. The monkey
remained well until Oct. 23rd when it seemed lethargic,
and its movements became weak and incodrdinated.
Next day the condition was much worse and the animal
was unable to eat. It remained huddled up and immobile
in a corner and when disturbed only moved with great
difficulty. On Oct. 26th it was very ill indeed and the
weakness was even more pronounced. The temperature
was well below normal. The animal was not expected to
survive the day and so was killed. The brain and cord
were removed and sectioned, but nothing abnormal was
found beyond slight congestion of the meninges and brain
surface. The other organs revealed no abnormal findings.
The monkey’s brain was then emulsified with portions
of the cord at various levels. 1 c.cm. was injected directly
into the brain of a second monkey, and 1 c.cm. of emulsion
which had been filtered into the brain of athird. Neither
injection produced any effect on either monkey, both being
alive and well two months after the inoculation. Then
into the brain of two rabbits was injected } c.cm. of the
emulsion obtained from the brain and cord of the original
monkey. Neither inoculation was subjected to previous
filtration. One rabbit died and again autopsy failed to
reveal anything abnormal in the central nervous system
or other organs. The other rabbit remained unaffected.
From the rabbit which died, the brain and cord were
emulsified and injections were made intracerebrally into
two other rabbits which are alive and well six weeks after
inoculation.
COMMENTS
Dr. G. H. Eagles, who has kindly performed the
inoculation work, states that the first monkey, which
died, did not behave at all like a case of poliomyelitis.
The restlessness, nervousness, and apprehension found
in monkeys suffering from poliomyelitis were absent,
as was the high-pitched cry which is so typical.
There also was no flaccid paralysis in any of the
monkey’s limbs.
An inquiry was made whether there was any
poliomyelitis in the district in which the girls’ school
and house were situated. The M.O.H. of that area
had received one notification only during the whole
of 1936. `
The case is singular in some respects. A period
extending over eight days, of generalised symptoms,
preceded the onset of the paralysis. The throat
showed definite inflammatory changes, and it is
possible that this was the origin of the toxin—if
toxin it was—that caused the changes in the central
. nervous system. Pathological changes were very
considerable in the sections of the spinal cord of the
girl, this being very unlike the usual negligible post-
mortem findings of the cases described originally
by Landry. Also the case does not fit in with a
diagnosis of poliomyelitis because of the clinical
picture and behaviour of the animals inoculated with
an emulsion of the spinal cord and brain.
My thanks are due to Dr. Eagles for the inoculation
work at the Lister Institute, and to Dr. Redvers Ironside
for the pathological report and for his very kind advice.
REFERENCES
Brain, w R. (1933) Diseases of the Nervous System, London,
D. : :
Comen. 7.0223) in Price’s Text-book of Medicine, London,
D. .
Drake, R. L. (1935) Med. Rec. 142, 232.
Goldby, F. (1930) J. Neurol. Psychopath. 11, 1.
LYMPHATIC LEUKAMIA WITH
BILATERAL MAMMARY CHANGES
REPORT OF A CASE
By B. Joan Haram, M.R.C.S. Eng.
ASSISTANT PATHOLOGIST, ELIZABETH GARRETT ANDERSON
HOSPITAL, LONDON
THE patient, an unmarried woman of 39, was first
seen on April 7th, 1936, when she complained of a
swelling in the left breast of three months’ duration.
It had gradually increased in size and was associated
with neuralgic pain. There had been no discharge from
. the nipple, and no pain in the breasts during the
menstrual periods.
Past history.—A small swelling, thought to be'a cyst,
had been removed from the right breast ten years pre-
viously. Apart from curettage for dysmenorrhea in
1927, a ‘‘nervous breakdown ” in 1935, and a tendency
to winter coughs, the patient had always been healthy.
Clinical findings.—The left breast was seen to be larger
than the right and a mass was visible in the upper quad-
rants. The nipple was not retracted. On palpation,
a tumour about the size of a very large hen’s egg was
felt in the upper part of the breast, attached to skin
but not to deep structures, and a hard gland was palpable
in the left axilla. The chest was radiographed and no
evidence of secondary growth was found, but there was
some fibrosis of the right lung. The cardiovascular system
was normal except for a soft apical murmur, and no other
abnormality was found.
Operative findings —On April 21st the patient was
admitted for operation, and frozen section from a piece of
the tumour showed infiltration of the breast tissue by a
small round-celled growth, and much inflammatory
change. Radical amputation was performed and the
patient ultimately made a satisfactory recovery, although
this was delayed by massive collapse of the left lung with
marked cardiac displacement.
During her convalescence a blood film was examined on
the advice of the pathologist, and this showed no abnor-
mality, polymorphonuclear leucocytes being present in
norma] numbers.
The full pathological report on the left breast confirmed
and amplified that on the frozen section (Fig. 1). The
breast measured 8 in. x 6 in. x 2 in., and the nipple was
not retracted. A tumour occupied the upper part through-
out its whole thickness, extending from the nipple to the
margin of the breast in all directions. This tumour was
firm, smooth, and not encapsuled. A slice taken for section
appeared to consist of solid growth without demarcation.
Microscopically, large areas of the breast tissue were
infiltrated with densely packed mononuclear cells, invading
the lymphatics and growing in sheets along the planes of
the connective tissue. The appearances suggested sarcoma,
in view of the fact that many of the cells had oval nuclei
and areas of unchanged breast alveoli were present
(Fig. 2). On examining the axillary tissues, six glands
were found, the largest being 1} in. x in. x l in. This
showed lymphatic infiltration at one end by small round
mononuclear cells (Fig. 3). Projection of this part of.
the gland showed the average size of the infiltrating
cells to~be 5-8 while that of the lymphocytes in the
norma] glandular tissue was 3-6 These measurements
are naturally smaller than would be found in fresh unfixed
tissue. l
SECOND ADMISSION
Four months after her discharge the patient returned
complaining of pain in the right breast, and a swelling which
she had noticed a fortnight previously.
Clinical findings and operation.—A very tender mass, .
l in. in diameter, was palpable in the upper outer
quadrant of the right breast, and an enlarged gland was
felt in the corresponding axilla. The patient was
readmitted on Dec. 8th and apart from her looking very
pale and thin, routine pre-operative examination revealed
no abnormality. The lungs were clear and showed no signs
1278 THE LANCET]
of the previous collapse. Local amputation of the breast.
was performed under Evipan followed by gas-and-oxygen.
Pathological report on right breast—The size was
6 in. x 5 in. x 22 in., and firm areas of indefinite outline
were irregularly distributed throughout the breast. Mid-
way between the inner margin and the nipple and on a level
with the nipple was a circular, hard area ? in. in diameter,
FIG. 1.—Left breast sliced from above downwards, showing
extensive growth. A = nipple. B = growth. C = axillary
tail. D = normal breast tissue. ,
which did not appear to be encapsuled. The alveolar
tissue was fairly profuse, and immediately above the
nipple was a small fibro-adenoma. There was a diffuse
cellular infiltration in the outer part of the breast. Micro-
scopically the hard nodule internal to the nipple consisted
of an area of breast tissue infiltrated with tightly packed
cells resembling large lymphocytes.
A full blood count was advised, and gave the following
result: hemoglobin, 42 per cent.; red cells, 2,184,000
per c.mm.; colour-index, 1:0; white cells, 17,800 per
c.mm. (polymorphonuclears 0:5 per cent., lymphocytes
99-5 per cent., mostly large). No other types of white
cell were seen among the 200 cells counted but several
normoblasts and megaloblasts were present. Projection
showed the diameter of the large lymphocytes to vary
between 12-3 and 15-7.
Further progress—Two days after the operation the
patient became extremely ill, with a pyrexia of 103°-104°F.,
rapid pulse, dyspnoa, and drowsiness. Examination
showed collapse of the whole of the right lung and the left
base. A leucocyte count was taken three days after
the previous one and showed 20,400 cells per.c.mm.,
again nearly all being large lymphocytes. The general
condition rapidly deteriorated, and twelve days after
the operation her blood picture showed what proved to be
a terminal leucopenia, the white cell count being 2000
(polymorphonuclears 16 per cent., lymphocytes 83 per
cent., hyalines 1 per cent.). The hemoglobin had fallen
to 28 per cent. The bases of both lungs gradually
re-expanded but the patient died three days later.
POST-MORTEM FINDINGS
It was remarkable that the amount of lymphoid tissue
in the whole body was extremely small. There were no
enlarged glands palpable, and very few lymph nodes along
the vessels. The mediastinal, aortic, and mesenteric glands
were all unusually small, the largest found being 34 in.
in diameter, and although the gall-bladder was distended
with bile and the bile passages enlarged, there were no
glands causing pressure on the common duct. The
spleen was dark purple in colour, of firm consistence,
and weighed 84 oz. Section of this organ showed con-
gestion and small patches of infiltration by cells resembling
large lymphocytes. Films were made of the bone-marrow
from a piece of rib and from the lower end of the femur.
~ The former showed a few mononuclear cells and nucleated
red corpuscles, and the latter showed fat only. Sections
of liver and kidney showed no leukæmic infiltration.
DISCUSSION
This case presented some unexpected difficulties,
for although the possibility of a leukemic process
DR. JOAN HARAM: LYMPHATIC LEUKAMIA WITH MAMMARY CHANGES
[may 29, 1937
was suspected after the first operation, the examination
of a blood film failed to reveal its presence. There
cannot have been any considerable increase in the
number of white cells in the blood at that time, and the
post-operative increase in polymorphonuclear cells
was sufficient to mask any change in the lympho-
cytes that may have been present. A complete
blood count might have led to a correct diagnosis.
In this connexion it is noteworthy that Parsons
(1936), in recording blood changes associated with
experimental mouse sarcoma, says that before
formation of the: tumour no large increase in the
leucocyte count was found, although a few abnormal
cells appeared in the blood, but with the development
of the sarcoma an increase in the total leucocytes
and also a reversal of the relationship between the
cells occurred. Cellular changes were also seen in
the liver, spleen, and bone-marrow. The results
suggested that a substance which stimulated the
formation of certain types of leucocytes was present
in the tumour.
‘In the case described, the second difficulty was to
determine the site of the primary lesion. There
was a definite hyperplasia of the axillary lymph
glands, but here the lymphocytes were of normal
size except in the connective tissue surrounding one
end of the largest lymphatic gland, where they
simulated malignant infiltration. (Fig. 3). The
monocytes found in the breast nodule were, however,
large and pleomorphic, and pale areas resembling
endothelial cells surrounded by closely packed,
densely staining large lymphocytes were present.
If these cells originated in the axillary glands and
spread to the breast by retrograde lymph flow, then
they underwent further development in that tissue.
Dawson (1936) refers to localised mammary
involvement in blood diseases when discussing
She describes a case
metastatic breast tumours.
in which a
primary
growth was
found in the
stomach and
was associ-
ated with PR ss ny | WAGGA
extensive EEE “i. sear cae
lymph- vessel ME Ta N
carcinosis in
both breasts
without the
formation
of obvious
metastases.
The path of
invasion into
the breast
was thought
to be by = ia :
retrograde FIG. 2.—Section of breast.
(x 100) A=
mononuclear infiltration. B = mononuclear
lymph flow infiltration in sheets along the connective-
f TO m the tissue planes.
axilla, after
blockage of the supraclavicular glands from the
primary tumour.
In the case under discussion it was curious that in
the first specimen the infiltration was strictly limited
to the upper part of the breast, the tumour though
not encapsuled having a sharp margin (Fig. 1).
Even microscopically there was no lymphocytic
' infiltration in the lower half of the breast, nor could
any excess of white cells be detected in the blood-
vessels. Attempts to make a differential count failed
through lack of material. In the second specimen,
THE LANCET]
DR. W. PAGEL: REACTIVATION OF A TUBERCULOUS FOCUS
[may 29, 1987 1279
however, the infiltration was very irregularly distri-
buted throughout the whole breast. It would appear
that the mammary glands of this patient were for
some reason specially favourable sites for the pro-
liferation of mononuclear cells. There must have
FIG. 3.—Section of läigest gland, TEEN infiltration by ké
TAN aaa cels (A). B = normal lymphatic tissue.
been some reason for the different distribution of
the lesions on the two sides, but this has not been
determined.
A study of the literature shows that breast nodules
are not uncommonly associated with chloroma
and myelogenic leukemia but are rare with lym-
phatic leukemia, the only really similar case being
described by McWilliams and Hanes (1912).
Their patient was a married woman of 33 who was
found to have a tumour in the right breast which on
excision showed the microscopic appearances of lym-
phoma. Five months later the patient returned with further
nodules in the same side, a mass in the other breast,
and enlarged axillary glands. Microscopically the nodules
showed a huge number of small cells with round or oval
nuclei resembling lymphocytes, and the diagnosis of
lymphosarcoma, was made, A blood count gave: hemo-
globin, 30 per cent.; red cells, 3,000,000 per c.mm.;
white cells, 117,000 "(90 per cent. lymphocytes). The
spleen became palpable shortly before death, but there was
never any enlargement of the superficial lymph nodes
except in the axillæ. At the post-mortem examination all
the blood-forming tissue showed transformation to a
tissue in which the predominating cell was the mono-
nuclear leucocyte.
Whitby and Britton (1935) mention atypical forms
of chloromata which may occur in any tissue,
and be unassociated with green coloration. The
blood picture in these cases may be of either the
lymphatic or myeloid type.
Trevithick (1903) describes a case of chloroma in a
girl of 13, with bilateral enlargement of cervical and
axillary glands, and bluish, firm, globular tumours in
both breasts. Later, multiple bony swellings appeared.
No blood count was taken but a film revealed a
leucocytosis which before death showed a rapid and
large increase in mononuclear cells. Post-mortem
examination showed multiple deposits of green
material with the microscopic appearancé of normal
tissue invaded by densely packed mononuclear
leucocytes. A rather similar case is described by
Simon (1912) in a girl of 16 who had a four weeks’
history of a rapidly growing tumour in the breast,
attached to the skin. Radical amputation was
performed, and the tumour found to be a chloroma.
Subsequent blood counts showed a progressive
anemia, eosinophilia, and many myeloblasts. At
the time of operation there was no lymphatic enlarge-
ment except in the axillary glands of the affected
side, but there were generalised metastases before
death. Post-mortem examination was not allowed.
Ziegler (1911) describes a pseudo leukæmic mammary
granuloma, and mentions that deposits simulating
growth may occur in any organ in cases of myelogenous
or lymphatic leukemia.
In conclusion, the experience gained by the case
described suggests that it would be worth while to
make a complete blood examination in any patient
under 40 who presents herself with a breast tumour
simulating malignancy.
SUMMARY
(1) A case of lymphatic leukemia is described in
which the only gross manifestations were in the
breasts. (2) The tumour removed from the left
breast had a pathological appearance simulating
sarcoma, with dense infiltration by large mononuclear
cells. (3) Five months later a similar tumour was
removed from the right breast. (4) At the time of the
first operation the blood film showed no abnormality
but after the second operation 99-5 per cent. of the
white cells were lymphocytes. (5) The post-mortem
findings were remarkable in that there was extremely
little lymphoid tissue present in the body.
My thanks are due to Miss E. Sylk, the surgeon
in charge of the case, for her permission to publish these
notes.
bearable
Dawson, E. K. (1936) J. Tah Bact.
McWillane, A. ana Hanes, F i1912) Amer. J. med. Sei. 143, 518.
Parsons J. Path. B 53.
936
Simon, L. ae Pa 12) ) Bari apak pe 49, 893.
Trevithick, Æ. (1903 , 158.
Whitby, L: E. H., RE Britton, C. J. C. (1935) Disorders of the
Bloo d, London, p. 38 382.
Ziegler, E. (1911) Z. klin. Med. 72, 53.
REACTIVATION OF A TUBERCULOUS
FOCUS BY MICRO-ORGANISMS
OTHER THAN THE TUBERCLE BACILLUS
By W. PaGet, M.D. Berlin
(From the Sims Woodhead Memorial Laboratory, Papworth
Village Settlement, Cambridge)
REACTIVATION of a tuberculous focus usually
follows its liquefaction. The old view that this
liquefaction was caused by a mixed infection,
especially with staphylococci, streptococci, and
pneumococci, has been almost entirely abandoned.
The view was chiefly based on the observation of
mixed infection in foci already liquefied—particularly
in cavities. This is clear from the careful histological
investigations of Sata (1899). The same has been
pointed out recently by Kasper (1932) and Roulet
(1936). But exact histological or bacteriological
evidence of the liquefaction of a solid focus by these
micro-organisms has never been brought forward.
The clinical significance of liquefaction as the
phenomenon leading to active tuberculosis (Pagel
1931, 1936, Long 1935) may justify the report of a
case in which there was clear evidence that micro-
organisms other than the tubercle bacillus caused
liquefaction of a tuberculous focus, even if such an
event is exceptional.
CASE REPORT
A male cook aged 45. From March, 1933, to the end of
April, 1936, tubercle bacilli were consistently found in the
sputum. From then until his death in December, 1936,
the sputum was negative. In March, 1936, the
1280 THE LANCET]
DR. W. PAGEL: REACTIVATION OF A TUBERCULOUS FOCUS
[may 29, 1937
sedimentation-rate (Westergren, 1 hour) was 17, in October
it was 4. At the end of November lobar pneumonia of
the right lower lobe developed, and he died from heart
failure on Dec. 3rd, 1936.
A series of skiagrams taken between December, 1933,
and November, 1936, showed disappearance of a cavity
in the right upper lobe and shrinking of areas of infiltration
in both upper lobes with formation of typical sharply
defined “‘ round foci.” In addition small calcified nodules
were scattered over the right lung.
Post-mortem examination.—Lobar pneumonia of the
right lower lobe (grey hepatisation) with exudative
pleurisy. Multiple encapsulated tuberculous round foci.
In the right lower lobe in the centre of the pneumonic
tissue there was one encapsulated caseous round focus
the size of a small cherry; a small bronchus filled with
purulent exudate was seen to enter the caseous focus,
which was liquefied so that only half of its original volume
remained as caseous material, the other half forming a
` small cavity (Fig. 1). Macroscopically it looked like a
partially liquefied tuberculous focus. Histological examina-
tion confirmed this impression. It was a typical partially
liquefied caseous round focus with a fibrotic capsule.
A purulent exudate consisting of leucocytes with very
numerous pneumococci covered the wall of the cavity and
seemed to invade the cáseous focus which, in its marginal
parts, was being destroyed by the exudate and the pneumo-
cocci (Fig. 2). There were only a small number of tubercle
bacilli in the centre and margins of the focus and in the
leucocytic exudate invading the focus.
COMMENT
The above case shows the gradual healing by
encapsulation of multiple tuberculous round areas
of infiltration watched for three years. Death was due
to a pneumococcal lobar pneumonia unrelated to the
tuberculous process.
One of the encapsulated caseous round foci in the
centre of the pneumonic lobe was partially liquefied.
Macrosco-
pically this
looked like
tuberculous
liquefaction
and there-
fore it was
. suspected
that the
pneumonic
process was
perhaps due
to aspiration
of liquefied
caseous
material and
therefore
a caseous
rather than
a pneumo-
coccal pneu-
monia. His-
tological
: examina-
tion, however, clearly showed that it was a non-
tuberculous pneumonia, and that even the lique-
faction of the focus was not tuberculous in origin,
that is, not due to an increase of tubercle bacilli
within the focus.
The small number of tubercle bacilli seen in the
focus were apparently set free from the caseous
material by its liquefaction. Moreover, there were no
tubercle bacilli in the cavity produced by the partial
liquefaction of the focus and in the purulent exudate
of the bronchus entering the focus at one end, whereas
innumerable pneumococci were found in these places.
In tuberculous liquefaction, enormous numbers of
tubercle bacilli are found. The small number of
FIG. 1.— Histological appearance of the focus.
(x 7.) B = bronchus. C = small cavity.
F = liquefied parts of the caseous focus.
tubercle bacilli set free by the liquefaction of the
focus shows that the presence of large numbers of
tubercle bacilli in tuberculous liquefaction cannot
merely be due to liberation of the bacilli by the
liquefaction of the solid parts, which make it im-
possible to detect them. There is ample histological
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FIG. 2.—-Marginal parts of the focus. (Microscope 1000,
enlarged x 2.) Leucocytic infiltration rich in pneumococci.
proof that in this case the liquefaction of the caseous
focus was due to its invasion by a leucocytic exudate
rich in pneumococci; it was therefore the result of
pneumococcal infection—a non-specific inflammation.
I can find no report of a similar case. Carl Weigert
50 years ago said that flaring up and generalisation
of a tuberculous process following measles are not
caused by weakening of the general resistance or by an
alteration in the response of the organism to the
tubercle bacillus due to the intercurrent diseases ; but
a non-specific inflammatory process in the lungs may
involve the capsule of a caseous lymphatic gland, invade
the latter and thereby liberate the tubercle bacilli
enclosed in the caseous focus. The anatomical and
histological findings of such an invasion of tuberculous
foci by non-specific inflammatory processes have,
however, hitherto not been described. More recently
Bézangon, Delarue, and Vallet-Bellot mentioned
that if an inflammatory process of sufficient activity
occurs, an old lipiodol deposit trapped in the lung
may be suddenly liberated and thus disappear ;
but these authors also do not provide anatomical
evidence,
The value of the case described above does not
therefore lie only in the evidence of liquefaction of a
tuberculous focus due to micro-organisms other
than the tubercle bacillus, but also in that it shows
how quiescent foci may flare up after pneumonia.
This is certainly one way in which active tuberculosis
may follow a non-specific inflammation of the lungs.
SUMMARY
A case is described in which one of the tuberculous
round areas of infiltration was found partially liquefied
in the centre of a lobar pneumonia. Histological
evidence showed this liquefaction to be due to an
invasion of pneumococci into the caseous focus.
Liquefaction and reactivation of a tuberculous
focus can therefore be due to micro-organisms other
than the tubercle bacillus.
REFERENCES
Bézancon, F., Delarue, J., and Vallet-Bellot, M. (1935) Ann.
Anat. path. méd.-chir. 12, 229.
Fraenkel, A. (1904) Specielle Pathologie und Therapie der
Lungenkrankheiten, Berlin and Wien. i
(Continued at foot of opposite page)
THE LANCET]
[may 29, 1987 1281
CLINICAL AND LABORATORY NOTES
CONTINUOUS VENOUS HUM IN °
BILHARZIAL CIRRHOSIS OF THE LIVER
By M. R. KEnawy, M.D. Cairo
REGISTRAR TO THE MEDICAL UNIT OF KASR-EL-AINI HOSPITAL,
CAIRO UNIVERSITY, EGYPT :
CIRRHOSIS of the liver is endemic in Egypt among
the cultivator class. It is caused by infestation with
bilharzia ova, usually of the mansoni type, and their
deposition in the liver. In the last two years I
have been able to collect 6 cases of bilharzial cirrhosis,
with or without splenomegaly, in which a continuous
venous hum could be easily heard over a localised
area over the xiphoid process. The murmur has
the following characters: (a) it is a continuous hum
which increases in loudness during inspiration and
decreases during expiration; (b) it is louder in the
sitting or standing position than while the patient
is recumbent; (c) it is localised and not propagated
and not heard at the back ; and (d) it is not associated
with any cardiovascular abnormality. As there has
been much controversy about the source of such a
hum, I thought the following record might be helpful :
A male, aged 20, was admitted to hospital on July 29th,
1936, complaining of an abdominal swelling for a year.
He gave a history of diarrhea and terminal hematuria
two years before. He was pale and was stunted in growth.
The abdomen looked distended; the liver was enlarged
three fingers-breadth in the mammary line and hard in
consistence ; the spleen was enlarged down to left iliac
fossa. Nothing abnormal was detected in heart or lungs,
and there was no free fluid in the abdominal cavity.
Over the xiphoid process a continuous venous hum with
the characters described above could be heard. The stools
contained Bilharzia mansoni ova; the urine contained
albumin and blood. Rena] function normal. Wassermann
reaction negative. A blood count showed: hemoglobin
50 per cent., red cells 3,800,000, and white cells 3200
(polymorphs 75 per cent., lymphocytes 25 per cent.). Blood
. pressure 100/65. Sigmoidoscopic examination showed
a slight granularity of the mucous membrane and
nothing else abnormal. The patient was treated with
iron and a full course of tartar emetic. On Sept. 23rd
splenectomy was performed. Immediately after the
operation and on the following days the hum had dis-
appeared. He was discharged on Oct. 19th.
_ From my experience in the other 5 cases there is
no relationship between the hum and the presence
of ascites, nor had specific treatment with antimony
(tartar emetic) any effect on the hum, The degree
of ansmia and its further improvement under treat-
ment also had no effect.
In the case recorded above the hum disappeared
entirely after splenectomy. This suggests that during
the removal of the spleen the source of the hum was
also removed. Since the hum occurs in cases of
cirrhosis of the liver without splenomegaly, it could
not be assumed that the spleen was the actual source,
and most probably it arose in some venous communica-
tion which was severed during the operative manipula-
tions. The increased loudness of the murmur during
(Oontinued from previous page)
Kasper, M. (1932) Zbl. Bakt. 126, 252.
Long, E. R. (1935) J. Amer. med. Ass. 104, 1883.
Pagel, W. (1930) Beir. Klin. Tuberk. 76, 414.
— (1936) J. Path. Bact. 42, 417.
Roulet, F. (1936) Acta Davos, 1, 1.
Sata, A. (1899) Beitr. Path. Anat. Suppl. III.
Weigert, O. (1886) Virchows Arch. 104, 31.
inspiration and its greater loudness in the standing
or sitting position, where the action of the diaphragm
is more free and thus allows a greater rise of intra-
abdominal pressure, afford further corroborative
evidence. Its disappearance after splenectomy as
well as its complete absence on auscultation of the
back excludes the possibility of stenosis of the vena
cava by “a perivenous hepatic fibrosis” such as
Dr. J. L. Bates suggested in THE LANCET of May 8th
(p. 1108).
CONCLUSIONS
(1) The continuous venous hum previously
recorded in Hanot’s cirrhosis and Banti’s disease
also occurs in endemic (bilharzial) cirrhosis of the
liver in Egypt, with or without splenomegaly.
(2) Six cases have been collected in the last two years.
In one of them the hum disappeared after splenectomy.
(3) Its disappearance was probably due to removal —
of some venous communication during the operation.
My thanks are due to Prof. H. B. Day for kind advice
and encouragement,
. LYMPHATIC CYST OF THE EAR
By Min Sein, M.B. Calcutta, M.R.C.P. Lond.
CAPTAIN, INDIAN MEDICAL SERVICE, BURMA
I HAVE not been able to find any published account
of the condition described in this note, which I have
named ‘‘lymphatic @yst of the ear.” I believe
however that it is not uncommon.
Clinical features.—A painless, tense and cystic
swelling, translucent on illumination, appears in the
concha on the lateral aspect
of one or both ears. Its pro-
gress is extremely slow, and
it may not be noticed for a
long time. When well developed
it may completely fill the
concha (see Figure). The pinna
is not thickened and the
auricular glands are not
enlarged. The six patients I
have seen have all been adult
males living in Burma,
Astiology.—There is no evi-
dence of leprosy or filariasis. On
aspiration of the cyst a thick
straw-coloured fluid is obtained.
Dr. N. Hamilton Fairley,
who was kind enough to examine the fluid from one
of them, reported that it contained no micro-organisms
or cells and expressed the opinion that it was from a
simple cyst. Evidently there is lymphatic obstruction
of some sort and it is noteworthy that 5 of the 6
patients wore spectacles with curved aural supports
which pressed against the angle formed by the ear and
the skull. The spectacles had been worn for periods
varying from 2 to 27 years. The sixth patient had
no spectacles but wore a Burmese headdress called
gaungbaung which consists of a fine silk scarf worn
tightly round the head along a line passing across
the forehead, just above the ears and downwards
and backwards over the occiput. All these patients
had seborrhea, and often the irritation of the aural
supports produced crops of acne and boils behind
the ear. It is possible that the pressure exerted
by the aural supports and the gaungbaung interfered
with the lymphatic drainage of the ear resulting in
1282 THE LANCET]
CLINICAL AND LABORATORY NOTES -
[may 29, 1937
intermittent obstruction and cyst-formation in the
area drained, and the repeated subminimal infections
may also have favoured the onset and progress of the
cysts. The Wassermann reaction was done in 2
cases and found to be negative.
~- Treatment.—The pressure behind the ear must be
relieved and spectacles changed and fitted properly.
The local treatment consists in evacuating the cyst —
through a medium-sized hypodermic needle and
injecting a sclerosing solution through the same —
needle. The cyst is emptied by applying pressure
from the periphery towards the needle. The presence
of blood indicates that too much pressure has been
applied. Quinine urethane solution (Parke, Davis
and Co.) was used but other sclerosing fluids would
serve. Pressure is applied for a few minutes, and a
pressure bandage could be applied for a few hours if
blood appeared during the evacuation. The condi-
tion may recur but can be treated in the same way
again if need be. My six patients have had no
= recurrence in the 2-7 years that have elapsed since
the last treatment.
SUMMARY
A cystic swelling developed in the concha of the
ears of 5 persons who wore spectacles with curved
aural supports. A similar condition developed in a
patient who had pressure of a different kind applied
round his head. The cyst is believed to be the result
of lymphatic obstruction. Treatment by evacuation
and injection of sclerosing fluid gives good cosmetic
results.
A CASE OF NZVQID AMENTIA
By RatpH Bates, F.R.C.S. Eng., D.P.M.
MEDICAL OFFICER, STOKE PARK COLONY, STAPLETON, BRISTOL
NZ£VOID amentia is rare enough to justify the short
description of a characteristic case. Tredgold}
summarises the syndrome as a combination of nevoid
growths of the skin and meninges, mental defect
(usually idiocy or
imbecility), hemi-
plegia, and epilepti-
form fits. The
frequency of the
condition is given
as about 1 in 800
mental defectives,
but the case des-
cribed below is the
only one discovered
in an examination of
more than 2000
defectives. Vascular
nevi are discussed
in greatest detail in
the standard text-
books on skin
diseases, but these
do not usually
mention the
drome nor do they
call attention to
the association
between vascular nevi of the skin and vascular
abnormalities in the meninges.
A feeble-minded woman, aged 36, has been under
observation at Stoke Park Colony for the past five years.
As Fig. 1 shows, there is an extensive nevus of the right
FIG. 1.—Photograph showing extent
of the neevus.
1 Tredgold, A. F. (1929) Mental Deficiency, London.
syn- ©
side of the face limited below by the lip margin and a
line from the angle of the mouth to the malar bone.
Above the orbit, the nevus extends to the hair margin
of the forehead and on to the hair-bearing area of the
temporal region. There is no extension across the middle
line of the face or scalp and the cartilaginous portion
of the nose is not involved. On the buccal aspect the
FIG. 2.—Radiogram of skull showing calcification jn frontal
region.
nevus covers the right cheek and extends on to the
palate, but is again limited by the midline.
The lower limit of the nzvus corresponds with the lower
limit of the embryological maxillary process. The area
covered by the nevus corresponds to that part of the
face which is formed by the maxillary, lateral nasal, and
median nasal processes, while the nasal part of the fronto-
nasal process is normal. The exception to an otherwise
exact correlation is the fact that the ala nasi (which is
formed from the lateral nasal process) is covered with
normal skin. The islands of nævoid tissue below the main
nevus are good examples of Virchow’s “fissural angiomata”’
situated at the junction of maxillary and mandibular
processes.
The conjunctival vessels of the right eye are dilated and
tortuous. Examination of the left fundus shows a normal
disc with rather full veins. The right fundus shows a
very deep physiological cup (—7D) with the fundus
raised around it. The vessels at the cup edge can be
focused with —3D and those in the periphery with —1-5D.
The veins are very tortuous and dilated but diminished
in number compared to the left side and the arteries are
small.
Examination of the limbs shows a difference in develop-
ment on the two sides. The left hand is smaller than the
right and the left upper limb is shorter by 14 in. The
left lower limb is an inch shorter than the right. Both
upper and lower limbs show muscular weakness and
increased tendon reflexes on the left side. There is slight
rigidity of the left lower limb, but the plantar reflex gives
a flexor response. There is no alteration in sensation.
An X ray photograph of the skull (Fig. 2) shows irregular
areas of calcification in the frontal region competia
with calcification in a plexiform angioma.
This patient has suffered from epileptic fits since
coming under observation. Before the attack she
complains of “‘ pins and needles ” in the left upper limb,
and sometimes that the left upper and lower limbs
“feel stiff.’ On regaining consciousness she feels
“as if she has no strength ” and the left upper and
lower limbs “feel stiff ”, for a short time. Under
ordinary epileptic treatment major fits now occur
about once in six months.
My thanks are due to Dr. R. J. A. Berry, director of
medical services at the Stoke Park Colony, for permission
to publish this case.
THE LANCET]
MEDICAL
ROYAL SOCIETY OF MEDICINE
`” SUBSECTION OF PROCTOLOGY
At the meeting of this subsection on May 19th,
under the presidency of Mr. G. GoRDON-TAYLOR,
æ discussion on the incidence and treatment of
Diseases of the Colon
was opened by Sir Epmunp Spriecs (Ruthin).
Much, he said, had been written and stated about
the colon in recent years, and a good deal had been
done to it; there were those who would soothe,
those who would stimulate, and those who would
bind, loosen, or denervate. It had been abused for
its sins and pitied for its sorrows. The condition
of the colon had a profound effect on the body.
It shared with the gullet and with the stomach
(not with the small intestine) proneness to disease.
In a classification of over 8000 consecutive cases
at Ruthin Castle, of all kinds of disease, it was found
that one-third suffered from vascular disorders which
were prevalent in middle age and beyond. The
group of alimentary diseases, including rectum, liver,
and pancreas, totalled nearly half the 8000. There
‘were 1574 persons who had some affection of the
colon, including colitis, diverticulosis, diverticulitis,
and carcinoma. The diverticulosis cases numbered
612; in two or three hundred of these, diverticula
were associated with other complaints. There were
51 cases of ulcerative colitis, 33 of dysentery, and
64 of growth, excluding growths of the rectum.
There were 28 cases of obstruction, 8 of volvulus,
142 of redundant sigmoid. Also 1520 patients had
simple delay—i.e., longer than 72 hours. These
‘were not included in the 1574 cases under review ;
nor were cases of ptosis of the colon, of which there
were 304. The average age for dropped colon was
43, for colitis 44, for colon delay 47, for diverticulosis
58, and for the later stages of diverticulitis 62, which
was also the average age for cancer. There were
three cases of colitis in women to each one in men,
while the sexes, surprisingly enough, were equal
as regards colonic delay. Of diverticulosis cases
there were two males to each female, while for
diverticulitis the proportion was nine to one. Among
patients with new growths, males predominated
in the proportion of three to one. Cases of colon
disease were still missed, said Sir Edmund, because
the simple precaution of examining the rectum was
omitted ; examination of the fæces and the use of the
sigmoidoscope were of the utmost value. He
deprecated the growing habit of attempting a radio-
logical diagnosis by means of a barium enema alone.
Flatulence was a term used often in medical reports
without a definition; it might mean that a patient
was bringing up wind from the stomach or was trying
to do so, or removing wind from the bowel or trying
to do so, or that he had distension or thought he had.
Aerophagy was too often diagnosed nowadays.
A patient with hypertrophic gastritis might retch
hard and belch as long as the barium was in contact
with the hypertrophic area. The effect of a small
degree of distension of the small intestine was much
greater than that of the same amount of distension
in the large gut.
Of 1000 cases in which the patients were said to
be constipated, 10 per cent. did not show radiological
evidence of delay. In 1000 cases of real delay shown
radiologically, the seat was the rectum in 11 per cent.,
[may 29, 1937 1283
SOCIETIES
the sigmoid and rectum in 33.per cent. A fourth
of the patients were unaware of delay and of these
nine out of ten had no disorder referable to the colon.
Failure was due to over-drying of the faces, or loss of
stimulus, or a lesion of the anus or rectum. <A purge
emptied two or three days’ fæces ; therefore aperients
should not be given more often than this. Of stimuli
to the colon, distal ones were best. The main use
of paraffin was to prevent the stool becoming hard ;
a dessertspoonful night and morning was usually
enough ; too much caused gurgling and discomfort.
It was not normal for the cecum to be a cesspool,
but it could be made one. He believed that mucous
colitis was now less common than formerly, and some
credit for that could properly be taken by doctors
for better teaching about purgatives.
Were redundant sigmoid loops congenital or
acquired? Or were they in part congenital, and in
that case did they develop as age advanced? X rays
showed that when the bowel relaxed it became both
longer and wider. If it did not do so, and this failure
occurred many times, the elongation of loops could
be explained. His view was that they developed
during life, but twenty years’ observation was
needed to establish that idea. In his series, redundant `
sigmoid was commoner in people over fifty than under
thirty. If surgery was contemplated, it should be
ascertained whether or not the bowel shortened
after evacuation. If it did, the case was less suitable
for surgery. In cases of constipation sympathectomy
had not been very helpful, though it was so in
Hirschsprung’s disease.
Twenty per cent. of patients with ulcerative colitis
still died from it. Among the advances in his own
time were the giving of these patients a less restricted
diet. Secondly, gentle douching was a great help,
but not more often than on alternate days. Rectal
lesions must be dealt with, and a patient search
made for entameba; in five cases that organism
was found only after months or years. He had
usually found bacteriological methods disappointing,
but some physicians reported good result from sera.
Dr. J. R. Bell used Sir Arthur Hurst’s method care-
fully and obtained 60 per cent. of recoveries in 64
cases, working in Australia, where, however, dysentery
was commoner and the serum (originally prepared
by Penfold and Patterson) was more embracing than
that used in this country. If the patient had not had
dysentery, he was being given a non-specific protein
therapy. But when 20 per cent. of people died and
when some remarkable recoveries were recorded by
another method of treatment which yet had a
mortality of 20 per cent. it did not follow that they
were the same 20 per cent., and.he asked whether a
patient would have recovered if he had had serum
therapy. Many, probably a greater number, had
been treated with Dr. Bargen’s diplococcal serum made
from the patient’s own organism. After the dis-
appointment of fair hopes the reaction might tend
to go too far, and one American physician of wide
experience said he had abandoned all methods except
rest and the usual symptomatic treatment, not even
using the douche. Sir Edmund thought that douching
helped, and he had seen recurrences when that measure
had been omitted. Ulcerative colitis was a recurrent
disease, in a way similar to gastric ulcer, and lives
were lost because that fact was not universally
recognised. The physician could enjoin living quietly,
resting, avoiding strain and stress, and eating simple
food. He had seen recurrences associated with a
1284 THE LANCET]
period of stress and worry, with drinking beer,
which was known to disagree, with colds, with
pregnancy, and with other strains.
In 5116 examinations there were 11 per cent. of
cases of diverticulosis, a term applied when pouches
were present but did not cause inflammation of the
bowel wall, the term diverticulitis being reserved for
the stage at which inflammation and induration of the
bowel wall had occurred. The distinction was of
clinical importance, especially as many lay people
now knew that diverticulitis could be a serious
disease, and might prove fatal. His own view was
that “ sac” was a better term than *“‘ diverticulum.”’
In 1920 Mr. Marxer at Ruthin Castle discovered a
“ prediverticular’’ stage, and that stage had now
been observed in 132 patients. Its distribution and
characteristics suggested an inflammatory rather
than a mechanical origin. In the present series
of cases the incidence of diverticulitis was 120 out
of 612 cases (20 per cent.). Instantaneous photo-
graphs of diverticula contracting showed that the
element of emptying was the important one;
hence it was the muscular wall of the bowel which
should be kept in good state so as to prevent diverti-
culitis, A not uncommon form was that in which
mucosal folds occurred; it was this kind which
was most likely to cause acute obstruction; some-
times it proceeded to definite polyposis. Almost
20 per cent. of cases of diverticulitis showed some form
of polyposis. The treatment he recommended
consisted of giving paraffin, using a douche every
2-7 days according to the condition, avoiding rich
foods and especially alcohol, and enjoining a hygienic
life. Great fatigue or worry sufficed to cause the
disease again to raise its head. Massage to that
part of the abdomen must be avoided; he had seen
real harm follow it. Purges were better avoided as
a rule. Excision could be carried out in an occasional
case—i.e., if the patient was well enough for the
operation and the affected area was localised. It
was well known that a pouch might burst and cause
general peritonitis. Diverticula might also perforate
into the connective tissue; Mr. Marxer had demon-
strated 5 such cases in a series of 120 cases of diverti-
culitis. Later stages accompanied by abscesses
constituted grave surgical risks. If a diverticulosis
was recognised soon enough and treated many of
these sequels could be prevented.
Referring next to new growths, which his colleague
Dr. Patterson had classified, Sir Edmund said the
average age of patients with growths was 62 (the
youngest being 39, the oldest 92), and the chief age-
range was 50 to 70. They were three times commoner
in men than in women and half of them were in the
sigmoid. He was surprised that diverticulitis so
seldom led to cancer, bearing in mind the prevailing
view of the association of cancer with chronic irritation.
In this, as in so many conditions, treatment of the
growth with success depended on its early recognition.
In his series the length of the history varied from a
week to three years. The average time from the
first symptom to examination was 11 months. If
discovered at a suitable stage there was no region
in the body in which excision of cancer was more
successful than in the colon. A more general
recognition of its early stages would mean a distinct
step forward in its treatment. He noted the curious
ways in which cancer of the colon showed itself.
Sometimes it became well established without show-
ing asymptom, but in most cases there was a symptom
which dated back a long time. Of 64 cases of growth
36 had a bowel onset—i.e., constipation, diarrhæa,
or irregular motions—17 had pain, many of them a
ROYAL SOCIETY OF MEDICINE: PROCTOLOGY
[may 29, 1937
long history of pain; 11 had a dyspeptic onset, and
these were dangerous ones, because they were some-
times treated for months for peptic ulcer. If barium
was given to examine the stomach, it should be
followed right through the bowel. Eleven of the
cases had rectal bleeding as a first symptom, and all
those were sigmoid cases. In 7 cases no blood, mucus,
or pus was detected in the fæces, showing that there
was no ulceration. Every case of uncertain nature
should be given a thorough examination. In all,
38 cases were operated upon. In 2 nothing could
be done. In most a palliative operation was per-
formed. Excision was done in 13, and in 8 it was
successful ; 2 were living ten years after the operation,
and one of these had had a large lump with great
dilatation of the bowel behind. The features
determining whether excision would succeed were the
character of the growth, and whether secondaries
had developed.
In conclusion Sir Edmund said that in applying
scientific methods one point which emerged was the
amount of suffering which could be avoided by early
and adequate examination wherever there was an
element of doubt. On this occasion he had been
speaking of the objective signs of disease, but perhaps
in no other group of disease was it so necessary to
consider also the mind of the patient—an aspect
of medicine which should never be forgotten.
DISCUSSION
Mr. J. P. Lockwart-MUMMERY expressed his
agreement with everything Sir Edmund Spriggs
had said. He had been increasingly impressed by
seeing cases of apparent ulcerative colitis which had
been tested many times for entamæœba without
success, but turned out eventually, after a long time,
to be chronic dysentery. Whenever he suspected
chronic dysentery he had emetine treatment given ;
in one such case the patient, a clergyman, was
supposed to be dying after two months’ illness, but
was cured in two days and remained well to this day.
He agreed that ulcerative colitis often recurred, and
he attributed that fact to some hereditary disability ;
in some people the colon was less resistant than it
was in others, and in three instances he had treated
father and son for the same condition. One man
had remained well ten years after treatment and when
he came back with a recurrence he was found to have
two very septic molar teeth. After removal of one
of them he ran a temperature of 105° F., and was
mentally il. A vaccine was made from his pus,
and after it had been given and the other tooth had
been extracted he recovered. The speaker did not
doubt that the recurrence was due to the septic
teeth. Sympathectomy for chronic constipation,
though a satisfactory operation, did not give
permanent results. For colectomy to he justifiable
a case must be a very bad one. Ulcerative colitis
might be followed by a stricture extending from the
cecal angle to half way to the splenic angle.
Mr. ERIC Crook asked how far constipation
caused the development of redundant loops of gut.
In a large mental hospital the incidence of volvulus
seemed to be much greater than among ordinary
people, being greater than the incidence of appendi-
citis. He did not know how far that was due to
habitual neglect of bowel requirements.—Sir ROBERT
ARMSTRONG-JONES said his recollection was that at
Claybury Mental Hospital volvulus was very rare,
as also was appendicitis.
Dr. G. E. VILVANDRE said he found it increasingly
difficult, as a radiologist, to diagnose with certainty
Ne ne Rie E A Bhs ta lp ge teh oly on wk
THE LANCET]
carcinoma of either the bowel or the stomach in
an early stage, and he often hesitated in his verdict.
He was sure it was right to employ the sigmoidoscope
as an aid to diagnosis, and in helping to decide whether
to give a barium meal.
Mr. R. S. CORBETT spoke of the occurrence of
intussusception in cases of new growth of the colon.
The PRESIDENT agreed that sympathectomy was
of relatively little value for chronic constipation in >
adults and adolescents. The figures showing that
diverticulitis and cancer are seldom associated were
“confirmed by the experience of Mr. Harold Edwards,
of King’s College Hospital, as set out in his Jacksonian
essay. He asked whether any patient had had
perforative diverticulitis twice; he had not known
such a case.
Sir EDMUND SPRIGGS, in a brief w said he did
not know of a patient having perforative diverticulitis
twice. He had one series of four cases of ulcerative
colitis in a family, but with that exception no apparent
family tendency was apparent.
SOCIETY OF MEDICAL OFFICERS OF
HEALTH
A GENERAL meeting of this society was held on
May 25th, Dr. ERNEST Warp, the president, taking
the chair, when a discussion on the
Future of Obstetric Practice
was opened by Dr. W. G. SAVAGE (Somerset). He
said that with the present rapid fall in birth-rate
and in the number of potentially fertile women the
value of each potential mother would be greatly
enhanced. In the national interest any steps known
to be the right steps should be taken to make mother-
hood safe, to preserve potentially fit infant lives, and
to encourage wives not to avoid motherhood. There
was however no sort of agreement as to what were
the right steps: in spite of much knowledge about
the needs and deficiencies of nutrition during
pregnancy the actual foods required and their qualities
were unknown. Nor was the relation of adequate
nutrition to the complications of pregnancy, labour,
and the child’s health understood.
One of the most important things to be decided
was the relative spheres of the doctor and midwife ;
and on this question there were two views which
were not consonant. The British Medical Association
memorandum required for every case efficient ante-
natal care by, or under, a medical practitioner ; the
attendance of a midwife on every case before, during,
and after delivery ; and attendance by the practitioner
at the confinement whenever he or the midwife thought
necessary. This scheme tended to relegate the
position of the midwife to that of a maternity nurse
with midwifery qualifications acting under the medical
practitioner chosen by the patient. The official
and legal view recognised the midwife to be an
independent practitioner capable of undertaking
complete charge of a maternity case. The midwife
was bound to call in a medical practitioner to her
assistance in certain circumstances; the speaker
took the word assistance to mean that the midwife
still remained in charge and the doctors rôle was
like that of a consultant. ` The scale of fees confirmed
this view, but he thought the majority of medical
practitioners translated “ assist’ into ‘‘ supersede ”
even if called in to some condition such as albumimuria
SOCIETY OF MEDICAL OFFICERS OF HEALTH
on the word “ consultant,”
[may 29, 1937 1285
not immediately connected with the confinement.
The exact relation of the two professions equally
entitled in law to conduct midwifery practice urgently
demanded the clearest determination. The divergent
points of view could be reconciled if the midwife
for her part clearly understood her responsibilities
and their limits and the doctor abandoned the ideas
that a midwife was just a kind of nurse and that
when he appeared he was entirely in charge of the
case until the end of the puerperium.
Dr. Savage held that the training and experience
of a great many general practitioners was inadequate
to fit them to act as consultants to assist midwives
in emergencies except, say, that of illness of the
child, or medical conditions of the mother. The
B.M.A. suggestion that steps should be taken to
increase the number of maternity cases which the
general practitioner would attend did not give due
consideration to two modern factors—the high
proportion of cases taken by midwives (now 58 per
cent. in Somerset) and the declining birth-rate. The
cases taken by medical practitioners in Somerset
(yearly average of 1935 and 1936) were :—
Doctors taking less than 3 cases a year .. 42
ae “3 3 to 5 cases a year << “Oz
99 99 6 to 10 99 99 oe 46
r » lltol9,, ,, .. 31l
99 99 20 to 29 9 2? ee 14
s9 », 30 or more 5 as $
193
Some weeks before the publication of the Maternal
Mortality Report (see Lancet, May 8th, 1937,
p. 1125) Dr. Savage had suggested as the report had
done that only medical practitioners with necessary
experience should be called in by midwives.
The midwife of the past and of the present in many
instances was a victim of that most terrible type of
education, a specialised technical training built on a
very limited general education. No group of people
were more liable to make mistakes than one receiving
such an education; hence the pattern of the rules
which now harassed the midwife. The rules were
being added to and the number of calls for medical
assistance had increased enormously; this was
unsatisfactory as it was expensive to the local
supervising authority, it weakened the midwives’
sense of responsibility, while the calling in of a
doctor was not necessarily in the interests of the
mother. The midevife of the future, the product of
the 1936 Act, should be able to grasp the general
principles as to what she could manage and when
help was required. Dr. Savage felt that the rules
of the Central Midwives Board should be simplified.
Dr. ELwin Naso (Heston and Isleworth) drew
attention to the disastrous effects of puerperal
morbidity, from sickness of the mother and
impoverishment from big medical bills. Speaking
of the B.M.A. proposal that the services of a con-
sultant should be provided when considered necessary
by the practitioner, he said that much depended
It might be taken to
mean merely the next doctor down the road. The
problem of the maternity services presented many
difficulties to the medical officer of health and to the
general practitioner. In his district the average
number of deliveries attended by doctors was 6 a
year; could such limited experience fit a man to
be called in as an expert in emergencies? The B.M.A.
was anxious to keep midwifery in the hands of the
practitioner and to retain the family relationship
s
1286 THE LANCET]
which in that sphere of medicine was the strongest
and deepest of a general practitioner’s work; but
Dr. Nash felt that in view of the decline in numbers
of the population the B.M.A. had left its effort until
too late, and he foresaw that in time every mother
would be confined in some institution. If the practi-
tioner could be sure of his patients going to institutions
and bemg attended by someone who was not compet-
ing with him he might be glad to be free of midwifery
work. If, however, there should be a panel of local
practitioners doing obstetric work and yet remaining
in general practice there might be the most horrible
rows until the scheme were withdrawn. The Scottish
report had suggested that nutrition did not matter
but the work done by Lady Williams in the Rhondda
Valley seemed to demonstrate the need for considera-
tion and investigation of this possible factor. It
might be better for the individual to have at her
disposal the latest scientific information and skill,
with highly trained specialists working as a team,
as part of a health. service, on an insurance basis;
but on the other hand the loss of the old relation
between family doctor and patient with its profound
psychological influence might be breeding a race of
neurotics. Since he had written his communication
to the meeting, said Dr. Nash, three reports had come
out, and in them mention of the general practitioner
was seldom made. It was perhaps well to ponder
Sir Ewen Maclean’s saying that a national maternity
service which excluded the general practitioner from
its responsible personnel was impossible and
unthinkable.
Dr. J. A. NEWMAN (Seaham Harbour) spoke from
35 years of general practitioner experience. He
contrasted the opportunities of a present-day practi-
tioner with those of thirty years ago and mentioned
also that he had found modern midwives inexperienced
too. To his eyes they were just flappers thinking
much of their day off and keen to call in help to
hurry on their cases. Dr. Nash had referred to the
large bills impeding some mothers’ recovery; some
young practitioners regrettably looked on their
profession as a trade or business, although the
doctor’s position was a privileged one; he himself
had always eliminated bills which might cause the
patient or the children to suffer. There was said to
be a higher proportion of abnormal cases nowadays,
` an idea derived perhaps from the midwives’ statements
on calling in practitioners in cases where no true
abnormality existed. Dr. Neilan thought that pelvic
abnormality might be due to the wearing of high
heels.
Dr. AGNES NIcoLL thought some difficulties would
arise in the coming schemes from the fact that a
woman needed to be under a doctor during her
pregnancy and puerperium. She felt that the health
authorities should provide general practitioner
attendance. The midwives were going to be specialists
in normal midwifery but they were not doctors and
could not supervise the puerperium as a doctor could.
Was there any reason why a woman should not
have her doctor in charge of her at her own or the
public health authorities’ expense? She held that
the general examination should be made by the general
practitioner and the obstetrical antenatal examina-
tion by an obstetric specialist. It had been said
that it was impossible for a practitioner to call in a
local colleague as a specialist but she did not think
the practitioner need necessarily lose his patients’
confidence.
Dr. J. B. HowELL (Hammersmith) referred to the
very rapid increase in use of institutional beds for
NEW INVENTIONS
[may 29, 1937
confinements in his area and to the reduction in
maternity work among the doctors. In the near
future sufficient accommodation would be provided
to take every case. There had been a great reduction -
in maternal mortality in that area.
Dr. CATHERINE MorRIS JONES (Gloucestershire)
drew attention to the great difference between town
and country practice. It would be very hard for
two country practitioners in partnership to make
a distinction between them and to state which of them
was competent in midwifery ; many country doctors
had extremely good results. In Dr. Jones’s area»
delay and perineal tears were the two common
abnormalities; the bulk of the midwifery practice
went to the midwives who often had no afternoon
off and were reluctant to take their scanty fortnight’s
holiday because of the difficulty of leaving their
patients.
Dr. Nora WartTIE spoke of the difficulty experienced
in Scotland of setting up complete medical and
midwifery services in six months.
The PRESIDENT wondered whether enough women
would be obtainable to stay the course in the coming
midwifery services.
Dr. - SAVAGE, in reply, thought there had been
general agreement that the present position could
not go on. He pictured a few obstetric consultants
with the big consultants over them. That left no
room for the general practitioner and he saw no need
for a triple arrangement. He agreed that the calls
for perineal tears had increased and doubted whether
the present arrangement gave value for money. He
referred to the possibility that the general practitioner
might become a dodo.
' NEW INVENTIONS
AN IRRIGATION CATHETER
THE catheter illustrated has been found to provide
an easy and efficient means of irrigating the prostatic
urethra. The procedure is as follows. After the
passage of the catheter (size 16, Charriére) the rubber
balloon, A, is distended with water through a separate
channel to which access is given at B. The catheter
= The catheter in sections.
is then pulled upon gently so that the distended
balloon makes contact with the bladder wall at the
internal orifice. Fluid in the prostatic urethra is
thus prevented from flowing into the bladder. The
irrigating fluid is introduced at c, traverses the main
channel of the catheter, reaches the prostatic urethra
through numerous small holes at D, and is returned
along the catheter to be voided at the external
meatus.
The instrument has been evolved and made for
me by the Genito-Urinary Manufacturing Co. of
London. l
PERCIVAL P. Cote, M.B. Birm., F.R.C.S. Eng., L.D.S.
Senior Surgeon to the Seamen’s Hospital, Greenwich,
and Queen Mary’s Hospital for the East End, London.
THE LANCET]
[may 29, 1937 1287
.
REVIEWS AND NOTICES OF BOOKS
Fluorine Intoxication
A Clinical Hygtenic Study. By Dr. Kay ROHOLM.
London: H. K. Lewis and Co. 1937. Pp. 364.
208.
THis book contains much new and original matter.
It opens with an adequate review of the known
facts concerning the effects of fluorine upon health.
The action of fluorides on the skin are first described,
and then the symptoms, signs, and occurrence of
acute “‘ fluorine poisoning by ingestion ” are discussed.
The frequency of poisoning by ingestion appears to be
increasing; 53 cases were recorded between 1918
and 1935. Insecticides, rat poisons, disinfectants,
corrosives, and preservatives provide the common
sources of this kind of acute fluorine poisoning :
sodium fluoride (NaF), sodium fiuosilicate (Na,SiF 6),
and dilute hydrofluoric acid are the compounds which
are usually responsible. Accidental ingestion is the
rule; suicide is rare. The symptoms of fluorine
when taken by the mouth are those of an acute gastro-
intestinal irritation, followed by restlessness and then
collapse.
On the subject of chronic poisoning Dr. Roholm,
after referring to some records of doubtful cases,
presents an excellent account of the original work
carried out in 1931-32 by Moller and Gudjonsson in a
factory in Copenhagen in which cryolite (Al, F..6NaF)
was cleansed and ground. Moller found that the
workers suffered from “a peculiar sclerotic bone
affection, affecting especially the vertebral column
and the pelvis,’ and the authors assumed that the
affection was caused by fluorine. In 1916 Black and
McKay studied a peculiar dental disease, which
showed, as a characteristic symptom, dark patches
upon the enamel of the teeth (mottled teeth). This
disease was found to be widespread in Colorado
and elsewhere. It affected the permanent teeth
only of children who had actually grown up in
Colorado, and the teeth were not usually deformed.
Two changes were observed: irregular patches of the
enamel lost their transparency and came to resemble
chalk or unglazed paper; this change was evident
as soon as the permanent teeth erupted. As a
secondary condition, these white patches became
stained with a dark pigment. The degree of staining
varied from yellow to black. Transverse bands of
‘*mottled’’ enamel might be noticed, occurring
especially on the labial surface of incisors and canines,
in areas exposed to the light. The enamel was brittle
but the teeth were not otherwise especially subject
to caries. Petry and later Churchill in the U.S.A.
traced the source of this condition to a high fluorine
content in the water. It appeared that the threshold
value is about 1 mg. per litre. Cases of dental disease
of this kind have been recorded all over the world,
including certain parts of England.
A valuable chapter follows upon the effects of
fluorine upon plants and animals. The damage
to plant and animal life around superphosphate
works, certain chemical factories, copper, aluminium,
glass and metal (blast) factories is described. After
a discussion on the natural occurrence of fluorine,
experimental chronic intoxication is described in
great detail. The identity of the animal disease
with the human appears to be established beyond
question. In the second part of the book a detailed
account is given of the author’s special contributions
to the subject. These consist of (a) a clinical study
of a large number of workers (and their families)
who are exposed to fluoride both in Greenland and -
in the factories of Copenhagen, and (b) a careful
experimental investigation of the effects of fluoride
intoxication in rats, pigs, calves, and dogs.
This book is of interest and importance to practising
doctors, medical officers of health, to industrial medical
officers in any industry in which felspar and other
fluorine-containing materials are used, to veterinary
surgeons, and to agriculturists. We hope that it
will be widely read. The translation from the
Danish is good, though quaint expressions have
crept in—e.g., we do not say that an animal has an
“ unthrifty ” appearance when we mean that it is
out of condition. The attention of radiologists should
be drawn to the bone conditions described in this
monograph. Are the bone changes resulting from
chronic fluoride poisoning discoverable in any British
industrial areas ?
Radiothérapie gynécologique
Curie- et Renitgenthérapie. By R. MATHEY-CORNAT,
Radiologiste des Hôpitaux ; Médecin de la Fonda-
tion Bergonié (Centre anticancereux de Bordeaux
et du Sud-Ouest); Chef du Service central d’Elec-
trologie des Hôpitaux du Groupe Pellegrin-Le
‘Tondu. Paris: Masson et Cie, 1936. Pp. 370.
Fr.60.
THis book gives an interesting survey of recent
French opinion on the treatment of gynzcological
conditions by radiotherapy. The first chapter dis-
cusses the physiological basis of treatment, and
describes the effect on the constituent cells of ovary
and uterus, and the varying sensitivity of Graafian
follicles, interstitial cells, normal connective tissues,
and neoplastic cells of fibromyoma. In assessing the
effects of radiation the work of Regaud on the time
factor and the relative sensitivity of the malignant
tissues is accepted. The author suggests seven to
ten days for intracavity radium, and four to eight
weeks for external radiation, as periods which make
it possible to give a maximum dose without increasing
the resistance of the tumour. The measurement of
dosage is discussed in the chapter on technique,
which is clearly written but not up to date.
The problem, still exercising the minds of experts,
of the use of the Röntgen (r) to express the dose
received in the tissues is dismissed briefly, and a list
of methods is given without consideration of all the
necessary factors. On the clinical side there is a
short general account of the changes produced by
radiation, and a careful and interesting section on
each type of disease that the author regards as
suitable for radiation therapy. He begins with non-
malignant diseases, and the chapter on fibromyoma
is particularly interesting. Lipiodal injection is used
in making the diagnosis, and allows the size and
shape of the tumour to be visualised. The question
of operation or radiation is discussed. without bias
and various methods of treatment are described. The
author prefers to give daily treatment over a period
of from 20 to 35 days, and delivers quite a high
tumour dose—2000 to 2500 r. He claims that if
suitable cases for radiation are selected, 95 per cent.
are cured, a figure which includes small fibromyomata
complicated by hemorrhage. For menorrhagia and
metrorrhagia either radium or X rays give satisfactory
results. The dose need not be high when, as often
happens, the patient is near the menopause; 1000
milligramme hours is usually enough. X ray therapy,
but not radium, is recommended for inflammatory con-
ditions—a point of interest to British gynecologists,
1288 THE LANCET]
who seldom make use of this possible method
of attack. The doses given are very small, and in
` young patients produce only temporary amenorrhea.
The treatment of malignant tumours is discussed at
length, and the whole section provides a useful survey ©
_ of possible techniques, and their results. Such a
survey is badly needed for reference, and this one
will certainly be welcomed ; its interest would have
been increased to our readers by the inclusion of
results from one or two British clinics.
The final chapter is on cancer of the breast, which
organ is included in France with gynzcological con-
ditions. The problems discussed are so different
from those connected with disease of the female
genital organs in the pelvis that the section must
stand alone. For this purpose, it is incomplete, and
the mere mention of conditions such as lympho-
sarcoma and nevocarcinoma of the breast is only
confusing. The glancing technique of Finzi and
Holfelder is not described.
The book, which is written for the surgeon and
gynecologist as well as for the radiologist, is printed
in clear type and is well illustrated.
Materia Medica, Toxicology and Pharma-
cognosy
By Wu11am MANSFIELD, A.M., Phar.D., Dean
and Professor of Materia Medica and Toxicology,
Union University, Albany College of Pharmacy.
London: Henry Kimpton. 1937. Pp. 707. 30s.
Tus book is said in the preface to be a “ text and
reference book on the therapeutics, toxicology,
pharmacognosy, and posology of the official drugs
in the United States Pharmacopeia XI and the
National Formulary VI.” The author is rather
optimistic in hoping that it will prove of value to
people of such varied experience and needs as
physicians, pharmacists, and students of pharmacy,
medicine, and nursing. The section of the book
devoted to pharmacognosy, which fills more than
two-thirds of its total bulk, is mainly of interest to
the pharmacist, since the medical student of to-day
is not usually expected to recognise more than a
very few crude drugs nor are physicians greatly
interested in the ultimate origins of the preparations
they use. Each crude drug is well illustrated by
photographs and adequately described. The section
on toxicology opens with a general discussion of
poisons and of antidotes and details of individual
poisons follow. This section again is unlikely to
appeal to the physician for both symptoms and
treatment are dealt with very briefly and without
adequate indications of rationale. Some of the
statements made are inaccurate as for example that
atropine is a cardiac stimulant and ‘that iodides
‘* dissolve sclerosis’’ in arterio-sclerosis. The book
concludes with a list of drugs arranged both in order
of doses and alphabetically, and a glossary of botanical
terms is appended, The volume as a whole is more
likely to give help to the pharmacist than to the
physician; it is a valuable work of reference on
pharmacognosy.
Quarterly Journal of Medicine
THE April number (Vol. VI, No. 22) contains the
following papers :—
TREATMENT OF ACUTE RuEUMATIC POLYARTHRITIS
WITH CONCENTRATED ANTISCARLATINAL SERUM. By
John Eason and Gurth Carpenter (Royal Infirmary,
Edinburgh). Forty-four cases were treated, most of
REVIEWS AND NOTICES OF BOOKS
[may 29, 1937
them receiving no salicylates. They remained febrile
longer than salicylate-treated patients, but suffered
fewer relapses and recrudescences. The authors plead
for further experimental use of serum in the hope that it.
may prove less unsatisfactory than salicylates.
THREE Cases OF IĪDIOPATHIO STEATORRHG@A (Gee-
Thaysen’s Disease). By Erik Mogensen, Copenhagen.
Detailed reports are given, and the relationships of this
condition, celiac disease, sprue, and pernicious anemia
are discussed.
THE Hamoporetic ACTIVITY or Human Liver. Part Il.
Achrestic Anemia and Aplastic Anemia. By John
Frederick Wilkinson, Louis Klein, and Charles Amos
Ashford (Manchester). Extracts prepared from the livers
of four cases of achrestic anemia, two of aplastic ansemia,
and one of untreated pernicious anemia were tested for
their content of anti-anzemic liver principle by injection
into patients suffering from pernicious anzmia in relapse.
A typical reticulocyte response was obtained with all
extracts except that from the liver of the case of pernicious
anemia. This is proof that in patients dying of achrestic
and aplastic anzemias the liver contains normal amounts
of anti-anzemic liver principle.
OBSERVATIONS ON THE SITE OF THE ANTAGONISTIC
ACTION OF POSTERIOR PITUITARY EXTRACTS on INSULIN
Hypoctyc@#mMi1a. By Henry Cohen and Julius Libman
(Liverpool). Posterior pituitary extract, given by injection
in man (eleven experiments) causes an increase in the
hyperglycemia that follows the ingestion of 50 g. glucose,
and at the same time a diminution in the arteriovenous
sugar difference—i.e., it antagonises the peripheral action
of insulin. A similar peripheral antagonisation, rather
than a mobilisation of liver glycogen, will therefore explain
the observation that posterior pituitary extract counter-
acts insulin hypoglycemia.
OBSERVATIONS ON SKIN SENSITIVITY IN ASTHMATICS
AND CONTROL SusgEcts. By R. S. Bruce Pearson (Guy’s
Hospital). Intradermal] testing for skin sensitivity to
one or more of four substances (horse dander, feathers,
wheat, and egg-white) was carried out on some hundreds of
asthmatics and of control subjects. Skin sensitivity to the
inhalants is fairly common among the controls, but in
general the asthmatics give a higher percentage of positive
reactions and a higher proportion of large reactions.
Controls with past or family histories of “‘ atopic ” condi-
tions occupy an intermediate position between the controls
giving no such history and the asthmatics. Multiple
sensitivity iscommon. Sensitivity to inhalants is greatest,
both in asthmatics and in controls, between the ages of
15 and 30.
SYSTEMATISED ATYPICAL AMYLOIDOSIS WITH MaAcRo-
@Lossia. By F. Parkes Weber, Stanford Cade, A. W.
Stott, and R. J. V. Pulvertaft (Westminster Hospital).
One case is reported, in a woman of 48, showing enlarge-
ment of the tongue, pain in the finger-tips which were
hard and pinkish-red, and pain in the legs resembling
intermittent claudication. Microscopically, an amyloid
change, with atypical staining reactions, and a nodular
often eccentric distribution, was found in the walls of
arteries and arterioles in tongue, ¢inger-tips, and gastroo-
nemius. Tongue muscle was also involved. None of
the usual causes of amyloid disease was present. Ten
other cases are cited from the literature.
ACHLORHYDRIA, ANEMIA, AND SUBACUTE Com-
BINED DEGENERATION IN PITUITARY AND GONADAL.
INSUFFICIENCY. By I. Snapper and J. Groen, D. Hunter,
and L. J.Witts (from the Wilhelmina Gasthuis, Amsterdam,
the London Hospital, and St. Bartholomew’s Hospital,
London). The authors describe six cases of a syndrome
involving alopecia, hypogonadism, depression of meta-
bolism, and anzmia (macrocytic or microcytic) associated
with proved or probable anterior pituitary lesions. Five
of the patients had achlorhydria and they suggest that
this is a result of the pituitary deficiency, and in turn is
the immediate. cause of the anemia. They suggest a
similar pathogenesis for the syndrome of pituitary disease,
achlorhydria, and subacute combined degeneration known
as pituitary pseudo-tabes.
PLASMA PHOSPHATASE IN DISEASE:
Noah Morris and Olive D. Peden.
A Review. By
‘THE LANCET]
THE LANCET
LONDON: SATURDAY, MAY 29, 1937
ROCKEFELLER BOUNTY
Wits the death of JoHN D. ROCKEFELLER
at the great age of nearly 98 years an almost
legendary figure has stepped quietly, almost
imperceptibly, from the present into the past.
The day will come when his life and endeavour
' will be written at full length, for almost alone
among the world’s rich men he has found a lasting
place in the human imagination. There was
something heroic in his mould, something dramatic
in the dénouement of his life, which made him
the very sign and epitome of his times and the
last and almost tragic representative man of an
age of individualism which has perhaps passed
for ever. The plot of his life is briefly told.
Unbounded and self-sufficing ambition, machine-
like industry and efficiency, riches amassed unemo-
tionally and perhaps ruthlessly until they surpassed
the count of man. In the plenitude of power
and wealth came the conviction born of a deep
puritanism that what had been wrenched without
mercy from the world must be returned to it with
interest; the machinery of his great wealth
was put in reverse and the redistribution was
carried out with the same genius and unrelenting
thoroughness which went to its amassing.
To medicine J. D. ROCKEFELLER has been the
greatest monetary benefactor of all time, not
only as measured by the vast sums he expended,
but also by the skill and forethought with which
the money was invested. He was fortunate in
his choice of medical advisers or perhaps it would
be fairer to say he was incomparably skilful in
choosing them. As. his great wealth had been
acquired with a vision which went far beyond the
limits of his own country, so it was spent without
consideration for national boundaries. In this
country alone the Rockefeller benefactions have
been of unexampled magnitude and as we look
back on them we are glad to think that it would
be hard to suggest how they could have been
made to better advantage. Thus the schools
of London, Oxford, Cambridge, Edinburgh, and
Bristol were given princely sums for important
and overdue schemes of expansion. In London
outstanding gifts were those to University College
and its Hospital, to the London School of Hygiene
and Tropical Medicine, and towards the building
of the new university premises in Bloomsbury.
Many other universities and medical schools
ROCKEFELLER BOUNTY
[may 29, 1937 1289
throughout both the British Empire and the
world have likewise benefited according to their
needs and deserts. In the United States itself
there can be few medical schools or research
institutions which are not indebted to the Founda-
tion which for some ten years or so after the war
seemed never to fail to meet every really deserving
demand. The central monument of the Founda-
tion is of course the Rockefeller Institute in
New York. In this institute medical research in —
its widest sense was given a home and endowment
on a scale paralleled by no other medical research
institution in existence. The finest medical brains
in the world were there attracted by the facilities
for research. In this institute were conducted the
work of FLEXNER on meningitis, of Cecm, DooHEz,
and AVERY on pneumonia, the brilliant researches
of Peyron Rovs on transmissible tumours,
Nocvomrs spectacular if sometimes misleading
investigations on syphilis, yellow fever, and barto-
nella infection. Here too KARL LANDSTEINER built
up the great school of immunological chemistry
the fruit of which is now only beginning to be fully
borne ; while even wider in interest and passing far
beyond the confines of medicine was the work of
ARMAND CARREL on tissue culture, and of
JACQUES LOEB on the dynamics of living matter.
Not the least inspired of the views of the Rockefeller
Foundation was the realisation that there are
no real boundaries to scientific knowledge and
that the problem of medical education and research
is not so much one of medical education as such,
but of education in general. Thus as the Founda-
tion grew in experience and wisdom it became less
purely medical in its activities, and in England
we profited by this outlook in the benefactions
to libraries and to such institutions as the London
School of Economics. Relatively few of the great
sums distributed by the Foundation took the
form of permanent endowments. It was considered
sufficient to plant the sapling and leave it to others to
make the salutary effort by tending it and bringing
it to fruition; but the Foundation never went by
hard and fast rules and where endowment was
necessary and advisable it was arranged in the
most elastic way possible. No institution and
no individual who benefited from the Foundation
ever felt the dead hand of formal charity. It
is this tact and true understanding of the very
spirit of learning and research which has earned
the gratitude of the medical profession and which
has been a model to countless benefactors who
have followed the example of the great American
philanthropist. To the medical profession J. D.
ROCKEFELLER will always be something more
than the wizened and eccentric old gentleman
who gave new dimes to passing children—some-
thing more too than the richest man in the world, ©
whose name became as proverbial as Crcesus.
For the medical world, perhaps alone, is in the
position to realise the grandeur of the drama of
restitution which was played out in his life. In
the midst of the murkiness and cruelty of
the arena of nineteenth century commercialism,
where he stood a peerless victor, he saw a vision
and of that vision was born an ideal.
1290 THE LANCET]
FOOT-AND-MOUTH DISEASE
Tue task of investigating this important and
damaging disease of livestock has proved to be
one of exceptional difficulty. As long ago as 1924
the British Foot-and-Mouth Disease Research
Committee was formed ‘to initiate, direct and
conduct investigations into foot-and-mouth disease,
either in this country or elsewhere, with a view of
discovering means whereby the invasions of the
disease may be rendered less harmful to agri-
culture.” The fifth progress report! now published
covers work carried out during the years 1930-35,
and despite its high standard no dramatic solution
of the problem set in the terms of reference has
been reached. Needless to say, as a result of
prolonged and intense study a better definition of
the disease and its problems has been obtained
and the presence of a standing scientific committee
must have helped the Ministry of Agriculture
even in carrying out with efficiency the older
methods of control. The educational value of the
research has been considerable, notably. in the
opportunities afforded to British veterinary research
workers of mastering the . difficult methods of
virus study; the veterinary study of viruses in
this country has advanced to the forefront during
the last few years from a position of insignificance.
That foot-and-mouth disease may be caused by
several closely allied but serologically different
viruses makes the difficulty of prevention by
any type of vaccine almost insuperable and the
failure to work out an effective method of inocula-
tion represents the major disappointment of the
investigation. Valuable information has, however,
been accumulated as to the resistance of the virus
to physical and chemical influences. It has been
shown, for instance, that the virus may resist
cold-storage temperatures for prolonged periods
and that it can be dried on fabrics and other
materials and retain its virulence. These observa-
tions have led the Ministry to introduce orders
compelling the cooking of animal products before
feeding them to livestock and to make certain
requirements as to wrapping materials. These
regulations should eliminate some at least of the
outbreaks. Important advances have also been
made in the simplification and effectiveness of
disinfection methods. Increasing reliance is now
being placed both here and in Germany on alkalis,
such as washing soda or dilute caustic soda, in
disinfecting contaminated objects and premises.
The possibility of the disease being imported
into this country by birds has often been discussed,
but the recent work of the committee has shown
that though certain kinds of birds, such as ducks
and gulls, can be experimentally infected, their
susceptibility is low and they seem unable to
propagate the disease by contact. Evidence
that rats or other rodents take any serious part
in the propagation of the disease has also been
wanting. Of recent observations undoubtedly the
most interesting is that hedgehogs are not only
1 Ministry of Agriculture and Fisheries. Fifth Progress
Report of the Foot-and-Mouth Disease Research Committee.
London. 1937. H.M. Stationery Office. 7s.
FOOT-AND-MOUTH DISEASE.—THE WAYWARD PEDESTRIAN
[may 29, 1937
highly susceptible to experimental infection but
can also acquire the infection naturally. Not
only were infected hedgehogs able to infect one
another by contact but they appeared to be able to
transmit the disease to a cow when placed in the
same stall. Obviously much more information is
desirable on the extent of infection among hedge-
hogs and also on the experimental course and
character of the disease in these animals; but
even if, as seems likely, the hedgehog is of no special
importance in the natural propagation of the
disease among livestock, the discovery of a highly
susceptible and easily obtainable small mammal
may prove to be a great help in future study.
Further work has confirmed the view previously
held that arthropod vectors are of little, if any,
significance in the transmission of the disease.
From the purely practical standpoint it may be
felt that these are meagre results to be gleaned
from so prolonged and costly an investigation, but
the by-products of the research have a definite
value of their own. The high standard of scientific
work recorded in this and previous reports on the
subject makes it clear that if the practical problem
of preventing foot-and-mouth disease has eluded
solution it is not due to any lack of efficiency and —
devotion on the part of the investigators.
THE WAYWARD PEDESTRIAN
‘THE report of the Commissioner of Police of
the Metropolis shows that, after a reduction in
1935 of the number of persons killed or injured
in traffic accidents, there has been an increase in
1936 and the number killed or seriously injured
has risen to 7363. The figure for pedestrians has
slightly fallen, but they and pedal cyclists still
make up roughly 70 per cent. of the total of
57,325 killed or injured, and a special analysis
of 35,851 accidents during eight months led to the
assessment of 83-5 per cent. in which pedestrians
were regarded as to blame; another analysis
for the whole year produced a figure of 76:4 per
cent. Among pedestrian children there were 5459
casualties, 89-9 per cent. of the total, for which
they themselves were deemed responsible.
Such phrases as “to blame” and ‘“ deemed
responsible’ are perhaps unavoidable, but they
tend to obscure the fact that modern traffic is
demanding from mankind a new set of responses
and reactions for which his previous experience
has not prepared him. “ Hesitating in traffic”
accounts for 5-4 per cent. of accidents to blame-
worthy pedestrians and is, especially for the very
young and the old, a form of behaviour not likely
to be eliminated even by a strict application of the
law of the survival of the fittest. “It may be
irritating,” says Sir Paume Game in his report,
“to have to walk warily and to be thinking
constantly of traffic when there are much more
interesting things to think about”; but it may
be not only irritating, it may be impossible, to
maintain a forced attention which, unlike the
process of avoiding collision with fellow pedestrians,
cannot be relegated to centres below the level of the
cerebral cortex. We must, in short, be ready to
THE LANCET]
recognise difficulties and limitations in the demands
to be made upon the conscious control of human
actions in these new circumstances, and to accept
the need for restrictions which would not be
necessary if we all could be sure of doing the right
thing at the right time. There are, however,
helping to swell the distressing totals, human
factors dependent not upon the inadequacy of
perception and reaction but upon the positive
development of harmful behaviour. The sense
of power and the thrill of speed called forth by the
command of a modern car become dangerous
incentives whose results can be studied in news-
paper reports of fatalities. On the other side
exists a resentment against speed and the domina- -
tion of weight and power which expresses itself
in unreasonable behaviour. The objection of
cyclists, for example, against carrying rear lights
was supported by the rational argument that, if
rear lights were compulsory, then the cyclist
whose light failed was in far more danger than he
is at present when the motorist is compelled to
watch for the unlighted machine. Behind this
objection there probably lay the unexpressed
desire not to make things more easy for the
motorist. It has been said that many a dead
man had the right of way; but the vindication
of his claim has brought little of value to him or
to posterity. Add to this the British character-
istic, whether for good or evil, of a preference for
independence, and we can understand Sir Philip’s
suggestion that something might be done to
check by law the most flagrant of the suicidal
wanderings of pedestrians. It seems unquestion-
able that further measures of control are necessary.
The American prohibition of crossing a road
diagonally (called “jay walking”) might help
to set up a new and safer behaviour to the advantage
of all users of the road, and both drivers and
pedestrians are familiar with the indecision at a
marked crossing called forth by the pedestrian’s
doubt whether an oncoming car intends to give
him the right of way, and the driver’s irritation
consequent upon his need to wave on the hesitant
one; some means might be devised of indicating
automatically the intention of the driver. These
and other measures call for trial ; but there remains
an uncomfortable feeling that perhaps the greatest
danger of all is of becoming reconciled to a casualty
list equal to that of a rather important war.
EXPERIMENTS ON THE AETIOLOGY OF
LUNG TUMOURS
SINCE the beginning of the experimental produc-
tion of cancer with carcinogenic substances it
has been believed that the carcinogenic effect: of
these substances is confined to the site of applica-
tion—usually the skin. This belief is probably
correct for the skin in the sense that cancer of the
skin hardly ever develops outside the area treated
with the carcinogen. But the production of
mammary cancer in both males and females by
cutaneous application of cestrogenic hormones
has shown that cancer can develop at a site remote
from the skin to which they are applied, even
EXPERIMENTS ON THE ZTIOLOGY OF LUNG TUMOURS
r
[may 29, 1937 1291 .
although the skin itself never responds to these
hormones by carcinogenesis. This effect is not
restricted to animals from a highly inbred strain
with a high incidence of mammary cancer in the
females, as has been suggested, but has been
observed in animals from an inbred strain with
a low incidence and in mice of mixed strains with
a low incidence of mammary cancer in the females.
It is seen that the cestrogenic hormones, which
in physical properties and in chemical constitution
are closely allied to such carcinogenic substances
as benzpyrene or dibenzanthracene, may be
absorbed by the skin without inducing a cancer
locally, but may have a carcinogenic action on
one particular tissue remote from the site of
application—the mamma—to which they travel
in the blood.
These new facts have reawakened interest in
the occurrence of lung tumours in mice whose skin
has been painted with tar. This sequence had
been noted by a number of observers, beginning
with MURPHY and Sturm, but hitherto has not
been thought significant. The reasons for ignoring
it were, first, that it is not of universal occurrence,
being seen most often in stocks of mice that
developed lung tumours spontaneously ; secondly,
that the spontaneous lung tumours of mice are
mostly benign, and in records of growths in the
lungs of mice subjected to tar-painting a clear |
distinction has seldom been made between benign
and malignant growths. To account for these
tumours arising in an organ to which tar had not
been directly applied it was often assumed that
the tar had reached the lung by inhalation:
that the inhalation of dust particles coated with
tar may give rise to malignant lung tumours in
mice has been demonstrated by ARGYLL CAMPBELL.
Recently, however, CLARA LyNcHm? and subse-
quently ANDERVONT’ have shown that subcutaneous
injection into mice of dibenzanthracene dissolved
in lard, which is followed by development of
sarcomata at the site of injection, will also produce
lung tumours. This effect was seen in a mixed
strain of mice and in a highly inbred strain, A,
which showed a high incidence of spontaneous lung
tumours. In this latter strain the lung tumours
arising after the injection of dibenzanthracene
appeared more rapidly and in greater numbers
than they would have done spontaneously. In
seven other highly inbred strains which do not
show a high incidence of spontaneous lung tumours
the subcutaneous injection of dibenzanthracene
did not produce lung tumours, although it was
followed by the appearance of what ANDERVONT
calls ‘‘spontaneous tumours” (presumably
sarcomata) under the skin. Since P. R. PEACOCK
has ingeniously demonstrated that such carcino-
genic substances as dibenzanthracene, when
injected subcutaneously, are carried away rapidly
from the site of injection by the blood stream
and thus reach internal organs the appearance of
lung tumours after cutaneous or subcutaneous
application is easily explained. But why is the
ì Campbell, J. A. (1934) Brit. J. 7. ea. Path. 18, 287.
° Lynch, ©. J. (1935) Proe Soc Biol., N.Y 33, 401
3 Andervont, . B. (1937) Publ. Hu. Rep., a, 52,212, 347.
1292 THE LANCET] | THE COST OF SALVAGE : [may 29, 1937
carcinogenic action of these substances focused
on one organ—in this case the lungs? We have
to postulate a special organ-susceptibility to cancer,
which varies in different strains and even in
different mice, and it becomes clear that there is
a close similarity between the production of lung
tumours by injecting dibenzanthracene and of
mammary tumours by painting the skin with
cestrogenic hormones. The findings of ANDERVONT
greatly complicate the problem of the etiology of
lung tumours in man. For we can no longer
confine our attention to carcinogenic agents
capable of reaching the lungs by inhalation, but
must also consider the possibility of carcinogenic
agents reaching the lungs by the blood stream.
In one paper ANDERVONT refers to the growths
in the subcutaneous tissue and in the lungs as
“ subcutaneous tumours” and “lung tumours ”
without giving details of their benign or malignant
nature ; but it can be taken for granted that all
the subcutaneous tumours were sarcomata, In
another paper he gives illustrations of some of
these tumours, which establish their malignancy,
and he describes the successful serial transmission
of four lung tumours obtained in Strain A by
dibenzanthracene and of one spontaneous lung
tumour from a mouse of the same strain. The
last-mentioned tumour was an adenocarcinoma
and retained its structure in the course of propaga-
tion, but in three other growths the morphological
appearance underwent a change which ANDERVONT
describes as a sarcoma development, similar to that
observed by M. Haatanp in 1908 in a mammary
carcinoma. Among the skin tumours of mice
obtained by tar-painting there have been many,
composed of spindle-cells and having the morpho-
“logical appearance of a sarcoma, which on closer
histological analysis proved to consist of cells
which were derived from the epithelium but had
assumed a spindle shape. It is not clear why
ANDERVONT has not considered this possibility,
and until it is excluded there must be some doubt
whether the change he has observed really represents
the development of a sarcoma in a carcinoma.
ANNOTATIONS
THE COST OF SALVAGE
RECENT questions in Parliament elicited the fact
that in an average year a sum of rather over two
million pounds is expended on the medical inspection
and treatment of children in the public elementary
schools of England and Wales, and a like sum on the
education and treatment of children of the same age
in special schools. In each case the expense is met in
equal parts by the Exchequer and the local rates.
And it was evident from the form of the questions
that not everyone is satisfied of the justification for
expenditure on this scale. The general work of the
school medical service needs little extenuation, it is an
integral part of the campaign for national fitness ;
less obvious to those without inside knowledge is the
justification for the heavy cost of special education
and treatment of the blind, the deaf, and the mentally
defective. Practically speaking these defects cannot be
removed, though they may be arrested; the victims
cannot be made normal, and yet the cost of their
treatment and education is twice or thrice as great
as that of those who are of so much greater value to
the community. The answer lies in the word “ train-
ing,” for though the defects themselves may be
permanent the resulting handicaps can be so lightened
that after special training for a few years the deaf
can communicate with their fellows, the blind can
read and write, and the mentally defective acquire
stability, while the majority of each group is taught
occupations which save them from being in misery
themselves, a hopeless drag on the education of the
normal, and a life-long burden on the community.
Even with the mentally defective, experience in
areas like London and Birmingham shows that about
half the known ex-pupils are more or less self-
supporting, and less than a fifth are inmates of any
kind of public institution. In schools for the blind and
deaf the results are better than this. The process
may not be the creation of a national asset, as is the
prevention and cure of disease in the more normal,
but it is the liquidation of a debt. Looked at merely
from the economic aspect a long view reveals the fact
that a generous outlay wisely dispensed is sound
finance ; as in the modern legislation for the training
of the blind, wisdom and humanity go hand in hand.
To ignore the existence of defectives—physically
and mentally—would be foolish as well as cruel
and proper provision for them is inevitable. It must
be realised also that the more expensive measures
often give the better results and are in the long run
the least wasteful. With the higher type of defective
a little more spent on treatment and training for a
few years may save the expense of upkeep for a life-
time. The principle must be applied with discretion
and, in fact, precautions are taken to prevent waste
of effort in. attempts to train the untrainable, the
selection of suitable cases falling mainly on the
medical officers. The work of prevention, cure, and
salvage is admittedly incomplete, but as far as it
goes it is well carried out and well worth the money.
GASTRIC ACIDITY AND CHRONIC ALCOHOLISM
ABUSE of alcohol has been for long regarded as
a cause of impaired gastric secretion, Statistical
data upon this point have, however, been scanty,
and in recent years it has been found that increased
acid secretion may be present in certain types or
in certain stages of gastritis. Information on the
gastric acidity of 105 alcohol addicts, all of whom
had consumed large quantities of alcohol either
daily or periodically over months or years, has been
collected by P. M. Joffe and N. Jolliffe The alcohol
test-meal was used, and if free acid was absent in the
first three samples, histamine was given in addition.
Of the 105 patients examined, 77 men and 28 women,
achlorhydria was noted in about one-third; that is,
no free acid was secreted after administration of
histamine. Of the remainder about half showed
a gastric acidity below the average normal value,
and half an approximately normal secretion. This
incidence of achlorhydria is about three times as
high as would normally be expected in a series of
control subjects of the same age- and sex-distribution.
These figures might at first sight seem to confirm the
view that alcohol per se is a frequent cause of achlor-
hydria, but certain difficulties arise in accepting
this explanation. Many of the subjects examined
1 Amer. J. med. Sci. 1937, 193, 501.
THE LANCET]
suffered from complications. The authors state,
without giving any explanation of what seems a
remarkably high incidence, that 26 per cent. had
pellagra and 70 per cent. polyneuritis (including
22 also having pellagra). Of those addicts not
suffering from one or both of these complications
only 15 per cent. were found to have achlorhydria,
an incidence which is only very slightly higher than
might normally be expected—i.e., 12 per cent.
Amongst the polyneuritic patients 29 per cent.
showed absence of free acid and amongst the pellagrins
52 per cent. The amount of alcohol consumed and
the length of time it had been taken did not appear
to be concerned in these differences, and nine of
those with normal gastric acidity had drunk from
8 to 24 ounces of whisky daily for periods up to 40
years. The association of alcohol excess, achlor-
hydria, and proved lack of vitamin B was somewhat
striking, but other workers have shown that in beri-
beri achlorhydria is not a frequent finding.
No relationship was found between the degree of
anæmia or of liver dysfunction (as far as this could
be judged and tested) and the frequency of achlor-
hydria, and the authors suggest that some factor
closely associated with vitamin B may be concerned
in the prevention of achlorhydria; this they refer
to as the ‘“achlorhydria preventive factor” and
regard as distinct from either vitamin B or the
pellagra preventive fraction. It is not necessary to
postulate such a factor when recognising the importance
of dietetic factors in the maintenance of normal
gastric secretion, thus lessening the significance of the
direct effects of prolonged irritation from abuse of
alcohol in reducing this secretion. If aman must drink
to excess, it would seem that he will better preserve
his gastric acidity if he takes his wine with bran.
THE BLOOD PICTURE IN INFANCY
Mackay’s classical study of the hemoglobin level
in infancy, published in 1931,! has been followed by
similar large-scale investigations in all parts of the
world. Two recent surveys, one from Gothenburg
and the other from Aberdeen, bring out further
important facts about the cause of the so-called
nutritional anemia of infancy. Dr. Nils Faxén,?
using well-controlled technique and statistical
methods of analysis, studied all the red cell elements
in 374 infants which he considered were in every-
way healthy. They all weighed at least 3000 grammes
at birth; they were breast-fed with the addition
of vitamins until six or seven months, when mixed
feeding was gradually begun; and they all lived at
home under the care of visiting nurses from the
children’s care centre. All children who had had
any illness were excluded. His curve for hemoglobin
levels during the first year of life is considerably
higher than that of other observers, though he notes
the same tendency to a lower level of red cells and
hæmoglobin and smaller cell size that has been found
by all workers in the second six months. Faxén
himself attributes his satisfactory figures to the careful
selection of his material, and his children must be
regarded as healthy infants living under the best
conditions. He found no lowering of hæmoglobin
during the winter months, as others have done, and
believes this is explained by his exclusion of children
showing any infection. The'truth of this conclusion
is only too obvious from different results obtained
by Dr. Fullerton * working with less carefully selected
THE BLOOD PICTURE IN INFANCY
(may 29, 1937 1293
children in Aberdeen. He found subnormal hemo-
globin levels in 87 per cent. of 298 infants from poor
homes between the age of nine and twenty-three
months, and he concludes that this anæmia is due
mainly to iron deficiency dependent on low birth-
weight, artificial feeding, and infective illness.
The part played by even mild infections, originally
suggested by Josephs‘ is well brought out. A
group of 26 infants aged six to twenty-two months
was observed for a year in an institution under
excellent dietetic and hygienic conditions. The
“ hemoglobin level was lowered with unfailing regularity
after each infection, however mild; even pyrexia
associated with teething was effective. This fall
occurred even when iron was already being given
and no response to therapy was made until several
weeks after pyrexia had subsided. Why fever
causes a fall in hemoglobin is unknown. Possibly
the sum of unobserved and mild infections are
responsible for the slight fall seen even in Faxén’s
admirable children. Unlike other workers, Fullerton
does not regard maternal iron deficiency as likely
to be a significant ætiological factor. From theoretical
calculations he decides that this anæmia of infancy
cannot justifiably be called “ nutritional,” since
during the first nine months deficiency of iron intake
has little effect on the hæmoglobin level. On
theoretical grounds alone his conclusion that the
importance of a deficient iron intake in infancy can
be at present only a matter of conjecture is possibly
correct, but the practical fact demonstrated by
Mackay remains—namely, that infants. given iron
gain weight better and resist infections better than
children not given iron. Fullerton himself holds that
all children should be given medicinal iron after even
mild infections. Since mild infections seem inevitable
under the present conditions of town life and over-
crowding, and the healthy babies fulfilling Faxén’s
ideal criteria are probably rare in this country, it
seems wise to attempt the widespread prophylaxis
of the anemia of infancy, whatever its cause, by
the use of medicinal iron.
FRIENDLY GIVING
“ Not only do we help to support the needy by grants
of money, food, coal and clothing, by advising them when
in difficulties or ill-health, by providing medical or dental
attention, invalid comforts and medical appliances, we
arrange for holidays, and even for Christmas gifts through
our special Fund. We recommend suitable schools for the
young, help with fees and outfits and advise as to future
careers. We also try to re-construct those lives which
have been shattered by bereavement, lack of means and
ill-health...”
These words are quoted from the annual report
of the Ladies’ Guild of the Royal Medical Benevolent .
Fund and the detailed reports of the various com-
mittees show how well and truly this work is being
carried out. It is a record of personal service of
which the guild may well be proud. The hon,
visitors have paid more than 225 visits to beneficiaries
during the year and the case committee has dealt
with 462 persons, while assistance and supervision
have been given in the education of 86 boys and girls.
The clothes committee reports a successful year
with 681 parcels sent to 370 beneficiaries in spite of
the extra work entailed by a flood in their premises.
Three new branches of the guild have been opened
at Weston-super-Mare, East Devon, and Grays
Thurrock, and others are in view. But the need is very
great and the work of the guild and society is always
increasing, since their help is not limited to any
4 Josephs, H. (1934) Bull. Johns Hopk. Hosp. 55, 259.
1294 THE LANCET]
particular district or to those who have previously
subscribed to the funds. Subscriptions, donations,
and gifts of clothing are therefore urgently required
and should be sent to the guild at Tavistock House
North, Tavistock-square, London, W.C.1.
INJECTION TREATMENT OF HERNIA
THE treatment of hernia by injection is evidently
becoming popular in the United States. Individual
clinics are now able to report the results in many
hundreds of cases, and it appears that, with carefully
standardised technique, the fear of serious complica-
tions need no longer be deterrent. The treatment was
introduced into the surgical department of the
University Hospital of Minnesota in 1931, and in a
recent symposium ! A. F. Bratrud and F. S. McKinney
relate their experience of no less than 700 cases of
hernia treated during five years. Of these, 300
were selected for statistical study because they had
had at least six injections each and had been admitted
to the clinic for treatment before 1936. In the
greatest number the hernia was indirect inguinal ;
a few were scrotal, and there were also some indirect
and recurrent. In all, 83 per cent. of the patients
were cured. Among factors in success the fitting
of the truss and the coöperation of the patient in its
use rank high. At the Minnesota University Clinic
the fitting of a new truss is part of the routine;
it has to be worn day and night during treatment,
and its use is not discontinued till six months after
the last injection. The selection of a sclerosing solution
has also been given very careful attention and Bratrud
reports that the best results are now obtained with
the solution known as Proliferol with the addition
of two drops of a phenol-thuja mixture to each
cubic centimetre. Proliferol is a distillate of several
vegetable drugs to which have been added tannic
acid, benzyl alcohol and thymol in various strengths
up to 1 per cent. The phenol-thuja mixture contains
phenol 50 parts, alcohol 25, and Lloyd’s specific
tincture of thuja 25. Either solution can be employed
alone, or they can be injected alternately or in
combination. C. O. Rice of the Minneapolis General
Hospital reports favourably on a mild soap solution,
which causes less pain and requires no preliminary
injection of a local anzsthetic. He claims cures in
379 patients with 445 hernias, no case being pronounced
cured until there has been no impulse for six months
after the last treatment and until the patient has been
without his truss for at least four months. Another
preparation used is sodium psylliate, sold under the
trade name of Sylnasol; it is a solution of low
viscosity that spreads through fascial planes over a
wide area,
Martin Biederman? of New York classifies the
causes of failure under three headings—unsuitability
of the truss, failure of coöperation, and unsuitability
of the solution—and he points out that all three
factors are controllable. The selection of cases
still presents some difficulty, especially at this stage,
because the protagonists of the method naturally
want to keep an eye on their statistics of results.
The indirect inguinal hernia gives the best results ;
but the value of the method is really more apparent
in cures of the much more difficult hernias and in
cases where operation has repeatedly failed. Opinion
seems to be divided as to whether the method is
applicable to femoral hernia, and Bratrud holds that
femoral and umbilical hernia should not be treated
by injection unless a truss completely relieves the
1 Ann. Surg. March, 1937, p. 321.
2 Med. Rec. March 17th, 1937) P. 239.
INJECTION TREATMENT OF HERNIA
[may 29, 1937
symptoms. Sliding hernias and irreducible hernias
are not to be treated by injection. Its use for patients
in whom operation is dreaded because of respiratory
or cardiovascular disease is likely perhaps to make
most appeal to surgeons in this country.
Complications have been remarkably few, and
the great majority of patients do not require rest
in bed, even for afew days. The commonest complica-
tion seems to be swelling of the spermatic cord,
and fears have been expressed about sterility, but
after a special investigation C. E. Read decides
that there is no such danger. Atrophy of the testis
has not occurred in the Minnesota clinics and
strangulation supervened twice only. With faulty
technique the sclerosing fluid may be forced into
the peritoneal cavity, and lower abdominal pain
is a signal that injection should be stopped. Ordinary
precautions should preclude the intravenous injection.
Excessive local reaction, with sloughing and abscess-
formation, does not seem to occur with the use of the
solutions now recommended, but as Bratrud says,
it must always be borne in mind that there is a
definite technique, and that unless this is learned
great harm may be done. The placing of the solution
at the desired site may not be so easy as the
descriptions suggest. Thus N. N. Crohn ? says that
he experimented with injections of methylene-blue
in cases prepared for operation and at the first few
attempts was astonished at the failure of the injected
solution to be at the expected sites. With experience,
however, accuracy can be assured. Crohn says that.
the aim of injection should not be to produce a large
mass of scar tissue filling a large gap. Scar tissue
is vulnerable because it is inelastic, and repair by
a small amount of fibrous tissue at the right place is
more likely to give permanent cure, although the
larger scar may give a fallacious sense of security.
AN IMPROVED TOMOGRAPH
In thick parts of the body the interpretation of
radiograms is often rendered difficult owing to the
super-imposition of shadows. This is especially
true for the chest, where shadows arising within the
lung are partly or completely masked by those cast.
by the bony and muscular chest wall. Since 1921
attempts have been made with increasing success.
to photograph a selected plane in the interior with the
elimination of all other planes. This technique is
now generally known as “tomography” (tewvetv,
to cut), the terms “‘ planigraphy ”’.and “‘ stratigraphy ’”
being also used. The method is based upon the
principle of similar triangles. The distance from the.
film to the plane or stratum which it is desired to
investigate is first determined. During the exposure
tube and film move in opposite directions, being
coupled so that their movement takes place about a
pivot in the selected plane. The result is that.
objects in this plane are sharply outlined on the film
since they are projected on to the same part of the
film during the excursion of the tube and film. Objects
in other planes are blurred in varying degrees up to
complete extinction according to their distance from
the plane selected. Thus, for example, a clear view
of the pulmonary vessels can be obtained with
complete elimination of the shadows of the ribs.
In Grossmann’s apparatus, a photograph of which
was reproduced in a recent article’ in our own
columns by McDougall, the tube moves at the upper
end of a pendulum while the film moves at the lower.
Twining has now ingeniously devised a much simpler
3 J. Amer. med. ae Feb. 13th, age; & 540.
* McDougall, J. B. (1936) Lancet, 185.
THE LANCET]
and less expensive method.’ This is an adaptation
of the movement of the tube and of the Potter-
Bucky under-carriage already provided in the X ray
couch in common use. Tube and under-carriage
are coupled so as to provide the movement required.
The tomograms published by Twining appear to us
to be at least the equal of those of Grossmann. At
this stage in its development the ultimate value
of tomography in practice cannot be assessed. Its
application must however necessarily be limited
by the fact that few structures lie in one plane for
any distance. Nevertheless sufficient progress has
been made to establish its worth in certain situations,
notably the lungs, where for instance it can reveal
an abscess invisible in the ordinary radiogram.
It also promises to be of value in certain hitherto
inaccessible regions of the skull and spine despite the
fact that it fails to exhibit the cancellous tissue of
bone. The interpretation of tomograms will how-
ever always call for judgment and experience in a
high degree.
THE MORTALITY OF JEWS
In the literature of racial susceptibilities a good
deal of attention has been paid to the incidence of
disease and mortality from different causes amongst
the Jews. An addition to this subject matter has
been made by Drs. Franz Goldmann and Georg
Wolff, who have published a careful study ê of the
mortality experienced by Jews in Berlin during two
periods of years, 1924-26 and 1932-34.
For the earlier years population figures are available
by sex and age so that death-rates at ages and
standardised rates can be calculated. The importance
of the latter is shown by the fact that although the
crude death-rate of the Jewish population is about
20 per cent. higher than the rate of the total popula-
tion of Berlin, their standardised rate is 10 per cent.
below. The Jewish population contains propor-
tionately more persons at the two extremes of life,
where mortality is highest. In the latter years,
1932-34, only the total populations are available so
that the comparisons of the mortality of Jews and
non-Jews.are limited to crude rates which the authors
interpret with proper caution. The death-rates at
ages in 1924-26 from all causes show the Jews in a
very favourable position in the first few: years of life,
holding a slight advantage from ages 15 to 40, but
unfavourably placed at ages over 50. Their infant
mortality-rate is particularly low, 49 per 1000 live
births in 1932-34, compared with the figure of 64
for the total population. From infectious diseases
their mortality experience is considerably more
favourable than that of the non-Jewish population,
their advantage being particularly striking in the
death-rate from tuberculosis. According to the
figures for 1924-26 the standardised rate of the Jews
from this cause is less than half the corresponding
rate of the non-Jews.
The crude rates of 1932-34 also favour the Jews
but to a much smaller extent. This narrowing of the
difference in a short space of time between the two
races suggests to the authors that the lower mortality
of Jews is likely to have been due rather to more favour-
able economic circumstances amongst the Jews than
to a greater degree of immunity peculiar to the race,
From cancer they show a slightly lower death-rate
than the non-Jews and some considerable differences
in the sites mainly concerned. For instance, in the
5 Twining, E. W. (1937) Brit. J. Radiol.
* Tod und Todesursachen unter den Berliner alan Reichs-
Fore ng. er Judenin Deutschland. Berlin-Cbarlottenburg,
antstr. 1
THE MORTALITY OF JEWS
+
[may 29, 1937 1295
total male population 42 per cent. of the deaths were
referred to the œsophagus and stomach, in the Jews
only 27 per cent.; in the total female population
19 per cent. of the deaths were referred to the uterus,
in the Jews only 9 per cent. The higher death-rate
of the Jews from diabetes, which has often been
commented upon, is confirmed by these figures. The
standardised death-rate of males exceeds the rate of
all males by 42 per cent., of females by 75 per cent.
On the other hand the Jewish rates at under 40 are
below those of the total population ; it is not until
age 50 is reached that their experience becomes
unfavourable and at ages over 60 the rates of both
sexes are approximately double the rates of the
general population of Berlin. They also show dis-
tinctly high death-rates from diseases of the circu-
latory system and arterio-sclerosis, and a relatively
unfavourable experience as regards suicide. Between
1924-26 and 1932-34 their crude death-rate from
suicide has increased to an appreciably greater
extent than is apparent amongst the non-Jewish
population.
How far these various differences can be ascribed
to racial characteristics it is difficult to determine.
Economic status, personal hygiene, occupations, and
customs may all play their parts. Goldmann and
Wolff fully recognise this and plead for the further
collection of data in Palestine and elsewhere to aid
in the interpretation of their own excellent analysis.
EXCESSIVELY RAPID HEARTS
For the human ventricle to beat at a rate of 300
per minute seems to be very rare; only three cases
of a ventricular rate exceeding 300 have been
reported and only sixteen of a rate above 280. Experi-
menting with animals, Lewis and others found that
when the auricles of the mammalian heart were
stimulated to rates higher than 300 per minute, the
ventricles did not respond and dropped beats or a
two-to-one rhythm ensued. Lyon?! reports the case
of a negro infant, aged 44 weeks, with acute strepto-
coccal meningitis, in which the ventricular rate,
recorded electrocardiographically ten days before
death, was from 310 to 313 per minute. At autopsy
the heart appeared normal to the naked eye and,
microscopically, it showed no sign of infection or
fibrosis. Copies of the electrocardiogram were sub-
mitted to a number of cardiologists, both in America
and in Europe, nineteen of whom diagnosed
paroxysmal auricular flutter with 1 to 1 block and
intraventricular block due to myocardial fatigue. Six
others agreed but could not with certainty rule out
the possibility of some other diagnosis. Six others
diagnosed paroxysmal ventricular tachycardia, and
one, paroxysmal auricular tachycardia. In 12 of
the 16 cases collected from the writings, the outcome
was a return to normal rate; in one of these, a case
of exophthalmic goitre, the return to normal followed
thyroidectomy. Of the remaining 4, the outcome in
one case was not stated and 2 other patients died.
Of these, one who died on the third day after the
onset proved at autopsy to have a widely patent
foramén ovale and congestion of the cardiac vessels ;
in the other, who died a year after the onset, myo-
carditis, dilatation, and hypertrophy were found
post mortem. The type of arrhythmia was diagnosed
as paroxysmal auricular tachycardia in 11 of these
cases, aS auricular flutter in 4, and as paroxysmal
ventricular tachycardia in the remaining case. It
seems that, in the absence of pre-existing heart
disease or congenital abnormality or other grave
1 Lyon, J. A., J. Amer, med. Ass. April 24th, 1937, p. 1393.
1296 THE LANCET]
extracardiac disease, an excessively rapid heart-beat
is not in itself of serious import; but how long
elapsed before normal rates were re-established in
_ these cases, nor how long they remained normal, is
not stated.
GASTROSTOMY
RaAPip deterioration after gastrostomy is one of
the disappointments of surgery. It is all the more
regrettable if the gastrostomy is part of an operation
from which a cure is hoped, as for example in radical
excision of the cesophagus. But even when gastros-
tomy is purely palliative in intent, permission
to perform it has been obtained by promises to the
patient that he will feel better when properly fed.
Discussing the reasons for failure, E. S. J. King?
concludes that gastrostomy should not be attempted
if the patient is in an advanced state of dehydration
and malnutrition, especially in the presence of
pulmonary and circulatory complications. This
contra-indication does not apply to cases of sudden
complete csophageal obstruction, but to chronic
cases in which the patient has gone steadily downhill.
Death from infection of the wound and from peri-
tonitis may follow the operation, and it only hastens
an end already not far off. If parenteral administra-
tion of fluid does not bring distinct improvement
in the general condition, gastrostomy is best avoided.
The nature of the operation performed is also
important. King divides all types of gastrostomy
into two classes—those that result in a narrow track
between the stomach and the skin surface, lined
(in part at least) by granulation tissue, and those
that give a track lined by gastro-intestinal mucosa.
Gastrostomies of the first class are always liable to
stenosis of the opening, and if the tube is left out,
for reasons of comfort or because normal swallowing
for a time returns, its reinsertion may be difficult.
In the Janeway gastrostomy, which King has found
most satisfactory, the opening is fashioned from a
flap of stomach wall, cut in the transverse axis of
the stomach, with its base at the greater curvature.
The operation is not severe, it can be performed under
local anesthesia, and need not take longer than half
an hour. The preoperative administration of fluid
has already been mentioned, and King is keen about
it. By far the most important consideration, how-
ever, is the choice of a suitable diet. He says, in
effect, that many gastrostomy patients are suffering
from severe starvation. It is necessary that the
diet requirements in calories should be estimated
and that the estimate should be adhered to. There
is a tendency to overload the diet with fat, and to
omit certain essential amino-acids. Salts may be
deficient, and it is not unknown for a patient fed
by gastrostomy to develop scurvy or pellagra. In
King’s experience of 50 gastrostomies, the administra-
tion of solid food, through a grease-gun, has had
such obvious advantages that he strongly advocates it.
The completeness of the diet is much more easily
assured ; the food is more readily prepared when the
patient goes home; and the meals provide a degree of
gastric comfort quite different from anything
obtainable from a fluid diet. The importance of
adding saliva and of controlling the acidity of the
stomach contents are points he mentions.
THE PHYSIOLOGY OF SLEEP
ALL will recognise the fascination of the subject
Prof. E. D. Adrian, F.R.S., chose for his John Mallet
Purser lecture at Trinity College, Dublin, last week.
The fact that we need to sleep—that the central
1 Brit. J. Surg. April, 1937, p. 749.
GASTROSTOMY .—THE PHYSIOLOGY OF SLEEP
[may 29, 1937
nervous system must cease work after a time—is
not in itself surprising; but very remarkable is the
process of falling asleep, and still more (he thinks)
that of waking up again. The behaviour of different
animals varies according to whether they have one
rest period or several: the monophasic ringed snake
rises at noon and goes to bed at 1.30 P.M.; the
polyphasic rabbit has 16-20 regularly spaced rest
periods in the twenty-four hours. Babies are poly-
phasic, adults monophasic; but after the first few
hours of deep sleep adults have several lighter
periods. As the brain remains at rest in normal sleep
it becomes more and more capable of activity, whereas
the narcotised animal does not get the same refresh-
ment. ‘‘ What happens in the brain,” asked Prof.
Adrian, ‘‘ when we cease dreaming and become our
own masters again? Is there a particular’ region
which comes into play to establish full integration,
or is the half-awake state due to a general low level
of excitability in the cortex?” Naive introspection
suggests that there is some unifying part of the mind
which is in action only when we are wide awake, and
electrical methods should make it possible eventually
to record the activity of different parts of the brain
from moment to moment. How is this awareness
brought into action when we are asleep? A loud
noise in the street may not arouse us; but a child’s
cry at the end of the passage may make us instantly
awake. Somewhere then, as Prof. Adrian put it,
there must be a controlling region which decides the
relative importance of the different incoming messages,
and the tendency is to locate this in the diencephalon.
“The induction of the sleepy state by stimulating
the diencephalon shows that a change in this region
can diminish the general level of nervous integration
in the brain. From this it is a short step to the idea
of a diencephalic centre regulating the flow of impulses
to the cortex, directing attention when the brain
is awake—in fact a region specially concerned with the
neural activities which are essential to consciousness.’
He quoted Penfold as pointing out that the neuro-
surgeon can remove large areas from the cortex
of conscious patients without their being aware of any
change, whereas lesions of the diencephalon commonly
involve a total loss of consciousness. The cortex
judges whether the noise is important; the dien-
cephalon, if need be, spreads the neural activity which
‘‘wakes’’ the sleeper. Hess, however, has shown that
stimulation of the diencephalon will produce not
increased vigilance but sleep. The question arises
whether sleep is ‘‘ a state in which the central nervous
system has been reduced to a passive inactivity
which tends to perpetuate itself,’ or whether there
is not a constant activity in one region maintaining
an inhibition everywhere else.
Prof. Adrian’s lecture will appear in due course in
the Irish Journal of Medical Science.
WE publish on another page an account of the
evacuation of Basque children from Bilbao last
week, written by the two doctors sent to Spain by the
National Joint Committee for Spanish Relief. The
committee, which has undertaken the care of the
children in this country, may be addressed at
35, Marsham-street, Westminster, London, S.W.1.
THE Minister of Health has announced the personnel
of the interdepartmental committee he has set up,
under the chairmanship of Mr. Norman Birkett, K.C.,
to inquire into the prevalence of abortion and to
consider what steps can be taken to mitigate its
dangers. The names are given in our Parliamentary
Intelligence (p. 1313). They include two medical
women and four medical men.
THE LANCET]
[may 29, 1937 1297
PUBLIC HEALTH
RAPID DETECTION OF
B. TUBERCULOSIS IN MILK
By Mary L. Cowan MAITLAND, M.B. Toronto
(From the Department of Bacteriology and Preventive
Medicine, University of Manchester)*
THE routine examination of milk for the presence
of tubercle bacilli is done in this laboratory. by
biological test—i.e., inoculation of guinea-pigs—or
by microscopic examination or by both methods.
All “ bulk ” samples of milk—i.e., mixed milk from
a herd or part of a herd—are spun in 50 c.cm. amounts
for 15 minutes at 3500-4500 r.p.m., and the deposits
inoculated into-two guinea-pigs. If the sample of
milk has come from a single cow, a film is made
from the deposit before the remainder is inoculated
into two guinea-pigs. This film is stained and
examined microscopically. Cowan and Maddocks
(1935) found that tubercle bacilli when appearing
in these films were usually associated with a particular
kind of cell group. This point has been emphasised
by Torrance (1927), Matthews (1931), and Davies
(1933). They found it quicker, easier, and more
efficient to examine the films for cell groups and
then to examine these for tubercle bacilli.
I have attempted to increase still more the ease and
efficiency of microscopic examination of milk films
for tubercle bacilli. In all cases the films were
examined under the low-power objective (4 in.)
and, if any cell groups were seen, these were examined
under the oil-immersion objective to see whether
they contained tubercle bacilli. The tuberculous
cell groups are made up of pale-staining cells larger
than other cells in milk, and rather loosely piled up.
The group may have a definite outline, though this
is not always true since other types of cells may
overlie the large pale cells, but the latter are the
distinctive feature.
METHOD
Method of obtaining a deposit from milk for micro-
scopic examination.—Milks known to contain tubercle
bacilli were examined after varying treatments.
(a) Acid and alkali of various strengths were
mixed with the sediment after the milk was centri-
fuged in an attempt to break up the deposits. It
was found these did not make examination easier
but rather destroyed cell groups.
(b) The milk was heated at about 65° C. for about
20 minutes before centrifuging but this coagulated
the cell groups and decreased the number of tubercle
bacilli found.
(c) Milk was left in the ice-chest overnight and
different layers spun—i.e., cream, milk below cream,
and milk at the bottom of the bottle were spun
separately. There was no regular difference in the
number of tubercle bacilli in the different layers.
This may have been due to mechanical difficulty of
getting the layers definitely separated.
(d) Matthews (1931) reported the results of an
examination of 500 samples of milk for the presence
of tubercle bacilli. He spun the milk comparatively
slowly for a short time and was very successful
in finding the tubercle bacilli microscopically and
the tubercle bacilli were associated with cell groups
* This work has been supported and made possible by a
grant from the Milk Marketing Board which is gratefully
acknowledged. .
such as Cowan and Maddocks found later. I therefore
decided to use varying times and speeds for spinning
milk known to contain tubercle bacilli and to compare
the films from each. The times were 2, 5 10, and
15 minutes at speeds of 1000, 2500, and 4000 r.p.m,
I found that a film made from a deposit after spinning
a milk for a short time at low speed was much easier
to examine than a film from a deposit after a long
rapid spin. The cell groups came down at the lower
speeds and there was less other material in the films.
As the deposits from different milks vary greatly in
amount and consistence, many samples had to be
examined before deciding on the approximate time
and rate of spinning to give the best average results
when films were made from these deposits. This
seemed to be between 2 and 5 minutes at 1000-2500
r.p.m.
- Method of making films from deposits from milk.—
Milk which was known to contain tubercle bacilli
was centrifuged and films made from the deposit in
various ways.
(a) The milk was poured off after centrifuging and the
drops from the sides of the tube allowed to mix with the
deposit before making the film.
(b) The milk was poured off and the centrifuge tube held
inverted while films were made from the deposit, allowing
no milk to mix with it.
(c) A capillary pipette was used to transfer the deposit
from the tube to the slide.
(d) A loop bent at a right angle was used to transfer the
deposit from the tube to the slide.
; (e) The deposit placed on the slide was spread with the
(070)
C The deposit was spread on the slide with another
glass slide as in making a blood film.
The films most easily and efficiently examined
were those made by holding the tube with the deposit
in it, inverted, while a loop bent at a right angle trans-
ferred the deposit to a slide (two loopfuls), this deposit
then being spread with another slide. Clean new.
slides were used in every case. `
Preparation of films for microscopical examination.—
The films were allowed to dry in the air for at least
half an hour and then fixed in a flame—not too hot.
After cooling they were placed in alcohol and ether
(equal parts) for 15 minutes and then washed with
ether to get rid of the fat; they were then stained
in steaming carbol-fuchsin for 8 min., washed in
water, decolorised in 3 per cent. hydrochloric acid
in alcohol for 3 min., washed in water, decolorised
in fresh acid-alecohol for 3 min., washed in. water,
counterstained with Löffer’s methylene-blue for
2 min. and washed well with water before drying
in the air.
In staining large numbers of films simultaneously
it has been found useful to put the slides into glass
slide-holders and each solution into a large photo-
graphic tray, with the exception of the carbol-fuchsin
which is put into a Staybrite steel vessel to be heated
over a gas-ring. Each holder contains 10 slides
and each tray will take 9 holders so that 90 films can
be stained at one time. All the solutions can be
poured back into bottles and used repeatedly.
These methods were developed by working with
milk which was known to contain tubercle bacilli.
I decided to try them with milk which came into the
laboratory for routine examination,
Eighty-five samples of milk from single cows were
spun for 3 min. at 1000 r.p.m. and also for 3 min.
at 2500 r.p.m. as well as by the routine examination
for 15 min. at 3500 r.p.m. The deposits after
1298 THE LANCET]
spinning for 3 min. at 2500 r.p.m. gave better films
on the whole than the slower spinning but the films
from both these were definitely easier to examine than
the films made after the routine method of spinning
for 15 min. at 3500 r.p.m. The slowest spinning
was discontinued and 195 more samples of milk were
examined using slow spinning and fast spinning. Of-
these samples 24 were found to contain tubercle
bacilli by guinea-pig inoculation, 15 were found to
contain tubercle bacilli by microscopic examination
after slow spinning for a short time, 13 were found
to contain tubercle bacilli by microscopic examination
after fast spinning for a longer time.
It was thus evident that deposits from milk after
spinning for 3 min. at 2500 r.p.m. were more easily
examined and more frequently found to contain
tubercle bacilli than deposits from milk after fast
spinning for a longer time. The former was there-
fore adopted as a routine. .
Quarter samples—Matthews (direct communica-
tion) always examined milk from each quarter
separately of the udder of a cow. Thus there was no
dilution of the milk containing the tubercle bacilli
and so the chance of finding them microscopically
_ Was increased, I have been able to examine micro-
scopically a very few samples of milk from each
quarter of the udder as well as a mixed sample from
the whole udder, but there was no doubt that the
films from the “ quarter samples ’’ were more easily
and quickly examined than those from a whole udder
sample of the same cow.
Examination of films.—In the foregoing description
of a method for the microscopic examination of
milk, stress has been put on ‘‘ease’’ as well as
“ efficiency,” since, if the method was to be applied
to routine examination of milk, which would involve
a very great number of films, it was necessary to
make the final examination by microscope as easy
as possible. It takes slightly longer to spread a
deposit with a glass slide than with a loop, but in
the former case the cell groups tend to accumulate
around the edges of the film so that under the micro-
scope the edges can be examined first and, if there
are no cell groups in this part, the slide does not need
further attention ; if they are there, they are found
quickly and can be examined for tubercle bacilli.
Again, if the fat is not removed from the films
before staining, much time is lost when examining
the films under the microscope because there are many
red-stained particles which are fat and not tubercle
bacilli and cause confusion.
With the fat removed and the films spread evenly
so that the cell groups are more numerous at the edges,
it is usually possible to examine 40 films in an hour
without difficulty.
As stated above, the films are examined with a
low-power objective for the presence of tuberculous
cell groups and only these cell groups are examined
with the oil-immersion lens for tubercle bacilli. The
general description of these cell groups has been given
but the best way of becoming familiar with them is
by the study of films made from milk known to
contain tubercle bacilli. When beginning to examine
milk that may or may not contain tubercle bacilli,
it would be of great advantage to inoculate guinea-
pigs with deposits from milk which show micro-
scopically a grouping of cells about which the observer
is dubious as to whether they constitute a true tuber-
culous cell group. By comparing the biological
findings with the microscopic appearance confidence
in differentiation is established. My own experience
has been that, in examining quarter samples, when
PUBLIC HEALTH
[may 29, 1937
tuberculous cell groups are present it is almost always
possible to find tubercle bacilli in some of them.
ROUTINE MICROSCOPIC EXAMINATION OF QUARTER -
SAMPLES
First series —Having found a technique by which ©
it was possible to make films from milk which could
be easily and quickly examined microscopically I
decided to try the efficiency of the method when
used in a practical way. It was only by the keen
coöperation of Mr. Locke, chief veterinary officer of
Manchester, that this series was possible.
When he received a report, after guinea-pig
inoculation, that milk from a farm supplying
Manchester contained tubercle bacilli, he obtained
quarter samples of. milk from each cow on this farm
when possible. Such samples have been examined
from 36 farms, using the microscopic method described
above. These‘are the results.
(a) On 11 farms no cow was found to give milk
containing tubercle bacilli or cell groups indicating
udder tuberculosis. These results have been con-
firmed by inoculation into guinea-pigs in 6 cases.
There was a history of the sale of a cow or cows
from each farm since the taking of the original
sample which gave a positive biological test for tubercle
bacilli. .
(b) From each of 2 farms milk from 1 cow was found
to contain cell groups but no tubercle bacilli. It
was possible to get repeat samples from one of these
cows and in these tubercle bacilli were found as well
as cell groups. No further sample could be obtained
from the other cow but the local veterinary officer
found tubercle bacilli in the milk by microscopic
examination.
(c) From 21 farms 1 cow and from 2 farms 2 cows
were found to give milk containing tubercle bacilli
in films. These findings were confirmed by inoculation
of the milk into a guinea-pig or by post-mortem
examination of the cow or by both methods. The
cows giving milk in which tubercle bacilli were found
by microscopic examination were removed from
18 of these farms; the milk from the cows remaining
was found to have no tubercle bacilli as tested by
guinea-pig inoculation. The results of the test of
the milk from 4 farms is not yet available and from
1 farm it was impossible to get a sample from the
remaining cows.
Second sertes.—Through the kind coöperation of
Mr. Amoss of Haslingden the milk from a second
series of 26 farms was examined microscopically.
In this series the milk had not been previously tested
in any way.
Quarter samples were taken from each cow and
examined as described above. From each of 2 farms
‘2 cows were found to give milk containing tubercle
bacilli, In these 4 cases the milk was tested later by
guinea-pig inoculation and found to produce tuber-
culosis. Bulk samples from the remaining cows on
each farm showed no tubercle bacilli when tested
biologically. |
Bulk samples of the milk from 16 of the other 24
farms were tested in guinea-pigs and found to have no
tubercle bacilli. The negative microscopic results
from the milk of the other 8 farms were unfortunately
not checked by guinea-pig inoculation.
COMMENT
To sum up, quarter samples have been examined
microscopically from approximately 950 cows and
in 1 case only has the finding not been the same
as the result from biological examination of the milk
THE LANCET]
. PUBLIC HHALTH.—THE SERVICES
[may 29, 1937 1299
or post-mortem examination of the cow. This was the
case referred to above in which cell groups were found
microscopically but no tubercle bacilli, although
these were found by another examiner. No false
Positive results have so far been obtained.
Thus it would seem that the microscopic test for
tubercle bacilli in milk, when it is done on quarter
samples from individual cows, is very reliable. All
films have been made from the milk within twelve
hours after the samples were taken. This has only
been possible by close coöperation between the field
and laboratory workers and we do not know how
successful the method would be if the milk were
delayed in transit. Some samples of tuberculous milk
have been kept in the ice-chest for 24 hours and
re-examined, The impression is that some cell groups
disintegrate, but in no case has it been difficult
to confirm the finding made on the fresh sample.
The value of a quick reliable method to diagnose
tubercle bacilli in milk is obvious from the point of
view of farmer, veterinary inspector, and consumer.
A particularly careful clinical examination detected
the infected cow in 66 per cent. of cases on the 36
farms in the first series reported above. The average
number detected by the usual clinical examination is
probably lower, and many cows with non-tuberculous
mastitis are mistakenly suspected. Therefore, in at
least 33 per cent. of farms visited for inspection the
infected cow is missed, and, after waiting six weeks
for a report of a biological test, the farm has to be
visited again and more samples taken, whereas it
is possible to examine microscopically the milk’ from
a whole herd in 48 hours.
REFERENCES
933) Vet. Rec. 13, 1046.
1931) Ibid, 11, 403.
The Atmosphere of Halifax
THROUGHOUT 1935 monthly records of deposited
atmospheric pollution were obtained at five stations
in Halifax and the results are discussed in the annual
report of Dr. G. C. F. Roe, the medical officer of
health for the borough. At the Wade-street station,
in the centre of the town, more than twice the
quantity of insoluble solids was deposited than at
West View Park, 14 miles to the west. There is not
such an obvious difference in the amount of soluble
solids. The influence of rain in bringing down soluble
solids is well shown in diagrams, as is the amount
of daylight which the centre of the city loses by
reason of its hazy atmosphere. In 1935 there was an
increase in deposit of more than 25 per cent. over
1934, This is explained partly by the greater rainfall
in the former year and partly by the better trade
conditions resulting in more factory smoke. Dr.
Roe comments on the unskilful way in which the
boilers of many factories are stoked and hopes that
employers will not only allow but encourage their
employees to attend the classes of instruction in
stoking provided by the local education authority.
As regards domestic smoke, the increased use of gas,
electricity, and solid smokeless fuels does not appear
to have had much effect, but this may have been over-
shadowed by the large number of new houses built
during the year. Dr. Roe emphasises that if full
use is to be made of smokeless appliances, adequate
supplies of smokeless fuel must be available at
reasonable cost and the public must get rid of what
he regards as an obsession—that ‘‘ there is nothing
like a coal fire.”
‘THE SERVICES
ROYAL NAVAL MEDICAL SERVICE
Surg. Capt. E. Moxon-Browne to Barham as Fleet M.O.,
and as Specialist in Hygiene (on transfer of flag).
Surg. Comdrs. R. W. Higgins to Warspite, and R. W.
Mussen to Malaya (on recommg.).
Surg. Lt.-Comdrs. F. W. Gayford to Malaya (on
recommg.); L. P. Spero to Devonshire > C. H. Egan to
Shropshire; and E. R. P. Williams to R.N.B., Chatham,
and R.M. Infirmary, Deal.
Surg. Lts. P. G. Stainton to Enchantress ; M. G. Ross to
Pembroke for R.M. Infirmary, Deal; and I. C. Macdonald
to Pembroke for R.N. Hospl., Chatham.
To be Surg. Lts. (D): F. B. Gamblen and J. B. Knight.
Surg. Lts. (D) G. P. Pearse to Wildfire; A. G. K.
Hoberlein to Devonshire; W. L. Mountain to Ramillies ;
S. R. Wallis to Victory for R.N.B.; and D. N. Williamson
to Malaya.
The following have been appointed Admiralty Surgeons
and Agents: Mr. R. A. M. Humphrey, Beer, East Devon ;
Mr. G. Young, of Redcar, at Coatham; Mr. E. Gallop,
of Vincent-square, S.W.1, for London District No. 15
(Westminster, Victoria, &c.); and Mr. J. A. Matheson
Lochgilphead, Argyll. 7
ROYAL NAVAL VOLUNTEER RESERVE
Surg. Comdr. R. Hall to Ramillies.
Proby. Surg. Lt. L. F. Donnan to Revenge.
Proby. Surg. Lt. J. K. Sargenston and Surg. Sub-Lt.
R. F. Hand to be Surg. Lts.
ROYAL ARMY MEDICAL CORPS
Capt. N. H. Lindsay retires on account of ill health
receiving a gratuity.
. TERRITORIAL ARMY
-Capt. A. T. Ashcroft to be Maj.
N. C. Oswald (late Offr. Cadet, Camb. Univ. Contgt.
(Med. Unit) Sen. Div., O.T.C.), H. Mannington and
G. B. Ebbage to be Lts.
Arrangements for the encampment of London District
Territorial Army troops, R.A.M.C., for annual training
from August Ist-15th have been made as follows:
13th Genl. Hosp. at Shorncliffe; 167th Fd. Amb.,
140th Fd. Amb., 8th Hygiene Coy. H.Q., and 12 Section
at Currenden; 13 Section at Dibgate (prov.).
ROYAL AIR FORCE
Squadron Leader D. A. Wilson to Princess Mary’s
R.A.F. Hospital, Halton, for duty as Medical Officer.
Flying Ofir. J. D. Milne to R.A.F. Station, Worthy
Down.
Short Service Commissions as Flying Officers for three
years on the active list: J. H. L. Newnham (seconded
for duty at the London Hospital) and P. A. Wilkinson
(seconded for duty at the Derbyshire Royal Infirmary).
INDIAN MEDICAL SERVICE
Capt. W. J. Shipsey to be Maj.
Lt. (on prob.) W. J. Young is restd. to the estbt.
DEATHS IN THE SERVICES
Colonel Wirm Arran May, C.B., late R.A.M.C.,
who died at Bath on May 18th in his 87th year was the
son of Joseph May, F.R.C.S. Eng., of Devonport. He
was educated at Tavistock Grammar School and qualified
M.R.C.S. Eng. (1873) and L.S.A% Lond. (1874). In the
latter year he entered the Army Medical Department,
becoming surg. major in 1886 and colonel in 1903.
He retired in 1907. He served in South Africa (1900—02)
as P.M.O., 8th Div. Field Force, was mentioned in
dispatches, and created C.B. (Mil.). He was P.M.O.
in Natal (1902-03), in Egypt (1903-04), and for Tidworth
district (1905-07). He served in the European war at
home and was twice mentioned. He married in 1876
Cecilia Adele, daughter of the late Gen. G. A. von
Ohlhaffen, Colonial Engineer, British Honduras.
1300 THE LANCET]
[may 29, 1937
| GRAINS AND SCRUPLES
Under this heading appear week by week the unfettered thoughts of doctors in
various occupations.
Each contributor is responsible for the section for a month;
his name can be seen later in the half-yearly index.
FROM A MEDICAL ECONOMIST
vV.
THERE is an idea, often impressed upon young
resident medical officers by their chiefs, that hos-
pitals, in common with other institutions, possess a
spirit. I used to believe this myself and even to
imagine that I could feel the spirit of the hospital
in which I served, But I am sure now that I was
mistaken. The alleged spirit of the hospital was in fact
the inspiration of my chief and his colleagues. I have
lived long enough to see hospitals go down so that
their lack of “spirit” was only too obvious and I
have also seen hospitals restored by the exertions
of able and single-minded men.
They know all about this process in the public
schools and, in consequence, exercise the greatest
care in the choice of a head master. If they select
the right man the school quickly becomes famous
and attracts the sons of the most distinguished
men of the time ; but if a bad choice is made deteriora-
tion immediately occurs. There is nothing in bricks
and mortar, in other words, to guarantee enthu-
siasm; nor is the memory of great service, unless
it be supported by an active leadership, proof against
human frailty. l
The point is important in a world where the use of
abstractions has assumed formidable shape. Schools,
hospitals, towns, cities, countries—all, nowadays,
‘are endowed with “ spirits’ and spoken of as if they
were Men and women. Books are written to investi-
gate and analyse these modern monsters who, indeed,
constitute a kind of Godhead. :
The idea behind the fashion is, of course, that man
in the mass differs from man the individual. This
is accepted as axiomatic; is not mob psychology
a fact of history? Men, according to Rousseau,
become wholly different from their former selves
when they are subjected to the influence of society
and it is only necessary, therefore, to transform
society in order to transform all its members. We
have been working upon that idea for more than a
century. The progress, in the best sense of that word,
which was hoped for does not seem to have materialised.
The idea itself deserves scrutiny for it amounts to
the assertion that an abstraction, society, is capable,
over a longer or a shorter period, of effecting a kind
of sexless regeneration. The individual plays no part ;
he is ‘‘ influenced ” just as the R.M.O. is supposed to
be influenced by the hospital.
This remarkable process stands in the sharpest
contrast to the kind of influences with which we are
all familiar in our personal lives—for example, the
coming of an enthusiasm or vocation, the birth of a
deep friendship, or the love of woman or man. In
these latter cases the person does experience a rebirth
but the experience belongs exclusively to his or her
own spirit and is, throughout, active and conscious.
Again “society” as Rousseau used the word
is an elastic term. It may mean the State, the city,
or the village. It may also mean the whole of
humanity in reaction to the circumstances of nature.
The constant reference to ‘‘ the savage” in French
Revolutionary writing conjures up a picture of man’s
ascent, by and through society, from the cave to the
castle. Thus, on the one side, are ranged a whole
world of dangers and threats of calamity and on the
other a “social organism” capable of effecting an
unlimited number of transformations and trans-
mutations, whereby danger is discounted and calamity
overcome,
* + #
Students of English history are aware that the same
idea underlay the philosophy of the Puritans. In
that case, however, society meant the Presbyterian
Body, association with which “uplifted”? the unre-
generate human creature to heights of spiritual
strength. Nature was the enemy. So much so that
Luther, who was by no means strict in his puritanism,
denounced as a great heresy the idea that Nature
might not be wholly vile. Nor was his opinion
peculiar to himself or his age; the Stoics had said
the same thing, though, again, in different language.
These inheritors of Plato’s philosophy, indeed,
demanded, like their master, some ideal social
structure by which men might be saved, From age to
age philosophy concerned itself with the ascent not of
man but of mankind. And the conclusion reached was
always the same—namely, regeneration by abstrac-
tion, society, church, State, even war.
Nor has our own age failed to tread this hard-
beaten path. As was to be expected the ancient
doctrine in its most modern form wears the complexion
of science, but the features, nevertheless, are unmis-
takable. If for “ society ” we read “ natural selection ”
we shall find ourselves immediately in familiar
surroundings. Here, again, is the ascent of mankind,
sexlessly, en masse, in the face of a hostile and
unrelenting nature. As usual, all difficulties arising
out of the character and behaviour of the individual
man are swept aside. Man is vile and cannot ascend
except by process of evolution.
What, in fact, does this doctrine of evolution teach ?
There are few things about life which are more fully
substantiated than the rigidity of species. Whereas
within the species almost any change can be effected
by suitable mating, the species itself is a walled city.
Evolution, therefore, in the sense in which Darwin
and Huxley used that term can scarcely have come
about as the result of mating in the ordinary accepta-
tion. Evolutionists are apt to avoid this difficulty by
retreat into geology—that is to say into Time. But
the difficulty is not thus overcome, If the contention
be merely that a given species has undergone morpho-
logical adaptation there is no ground of dispute ;
if, on the contrary, breeding across the type is
suggested then more substantial evidence than
geology can supply is necessary.
For what, in effect, is being said is that there are
two kinds of reproduction, the ordinary kind and
another in which masses and not individuals play the
active part. These masses are the evolutionary vehicle
and by their regenerative power the species is changed.
It is true that, when Darwin wrote, the science of
genetics had scarcely been born. But the doctrine
of evolution is still preached like a gospel and forms,
now, the basis of the thinking of millions of men and
women. a.
These millions in consequence experience not the
slightest difficulty in looking upon the abstraction
society (that is to say non-ecstatic regeneration)
as author and finisher and so in acknowledging their
debt to it. All their ideas, even their religious ideas,
are coloured by this attitude. Thus the teaching
THE LANCET]
that love alone can create and that the Creator
himself is love has undergone subtle changes of
emphasis. Above love, it is insisted, stands justice
to which love must needs make sacrifice. Justice
is a social idea. Thus, love is in debt to society,
individual creation to social creation; God the
Father to God the Unknowable, that is to say to a
‘‘ mathematical point” or to nothing at all.
This is a most convenient philosophy for the
salesmen of debt and it is interesting, therefore,
to note that it has been most actively taught and
most widely believed in those periods when money-
lending was most rampant. The Greeks of the
Athenian period were so bowed down by usury that
great numbers of them had sunk into slavery. The
Romans adopted the Stoic philosophy and Gibbon
is of opinion that it was money-lending, debt, which
ruined and destroyed their civilisation. During the
‘“ Age of Faith” on the contrary, money-lending
was forbidden; every man, in those centuries,
had his personal dignity as “father and Christian.”
The Renaissance brought back classical learning
—i.e., Greek and Roman ‘philosophy—and soon
Calvin, in Geneva, was giving his blessing to usury.
Since then the march to ruin has been swift. To-day,
buttressed by evolution, the money-lender and his
magic are enthroned in the heavens and upon the
earth. Evolution, society, the State, the common-
wealth—all these are pretty names for debt.
* * *
Social regeneration is monstrous untruth, For,
PANEL AND CONTRACT PRACTICE
[may 29, 1937 1301
as has been said, creation is by love, by ecstasy, and
not otherwise. And this applies equally to all creation
whether in the family, in the arts, or in the sciences.
Again, creation is by persons and occurs independently
of any social structure. Social structures, indeed,
exist by and through the creator’s ecstasy—as
witness the dissolution of beehives and termitories if
the queen is removed. There is no mass regeneration
or reproduction and even the devices by which
artificial insemination is brought about are vain
if there be not what corresponds to an ecstasy of the
reproductive cells. In other words, as was said in a
previous article, the leader, of his King-thought,
creates the social organism just as the father of
his love creates the family.
Unless these facts of experience are borne in mind
abstract ideas are poison. The great central fact of
life is the ecstasy of the individual being out of
which creation proceeds. That ecstasy, if it is real,
is always made flesh whether as offspring or as art,
music, literature, scientific discovery, the doctor’s
office of healing, or the craftsman’s work. And always
that process is attended by danger for the individual
who nevertheless experiences great joy of it. Love,
in short, is death and the resurrection from the dead ;
it is the incarnation of spirit in flesh as well as the
transmutation of flesh into spirit. This, and this only,
is the ascent of man, which ascent every man must
make for himself by and through agencies which
in time past very wise men did not hesitate to call
supernatural and divine,
PANEL AND CONTRACT PRACTICE
A SOUTH AFRICAN HEALTH INSURANCE
SCHEME
THE report of the Departmental Committee
appointed by the South African Government to
consider the introduction of national health insurance
into the Union of South Africa has now been published
and almost the whole of it is reprinted in the issue of
the South African Medical Journal for April 24th.
The question has long been under consideration in
the Union. As early as 1926 the South Africa
committee of the British Medical Association passed
resolutions in favour of establishing in the Union a
scheme of insurance against sickness and invalidity,
to include all races and the dependents of the insured,
resting on a compulsory and contributory basis and
starting in urban areas. The resolutions have been
repeatedly reaffirmed, and were included in the
evidence submitted to the Departmental Committee
by the Medical Association of South Africa (B.M.A.).
The recommendations of the Association, including
those relating to the capitation fee, were in substance
accepted by the Committee, and the report may
therefore be taken as expressing not only the results
of a thorough official investigation but also the views
of the representative body of the South African
medical profession. The two medical members of the
Committee, though they have signed the report with
their colleagues, have each submitted a minority
report dissenting from some of the Committee’s con-
clusions relating to the provision of medical services
in rural areas; but the South African Medical Journal,
the official organ of the Medical Association of South
Africa (B.M.A.), states emphatically that though the
signatories of the minority reports were nominated
by the Association, their reports ‘‘ must not be taken
as representing the views of the medical profession in
South Africa or of any branch or division of our
Association.”
The report is a valuable and workmanlike document.
The Committee made a careful study of what has
been written on the subject; they were at pains to
ascertain the views of interests likely to be affected
by a national health insurance scheme ; they visited
many areas; and they had, early in their inquiries,
the advantage of conferring with Sir Walter Kinnear,
who was on a holiday visit in the Union.
The Committee, like all other bodies that have
attempted to draw up health insurance schemes in
the Dominions, were impressed by the difficulties of
providing health insurance in outlying rural areas,
In South Africa the difficulties are specially formidable,
because of the relative scarcity of doctors. In 1931
the population of all races in the Union was 8,132,600,
and the number of practising doctors was 1533, or
5305 persons per doctor, as compared with 800 in
Australia and 1500 in England. The Committee
conclude that the “time is not yet ripe for the
initiation of a scheme of health insurance for our
rural areas.” )
A SCHEME FOR THE URBAN AREAS
A scheme, however, is formulated and recom-
mended for applying health insurance, on a com-
pulsory and contributory basis, to all employees,
both manual and non-manual workers, earning not
more than £400 per annum and employed within the
areas of urban local authorities: “and such other
areas as the Government may from time to time
proclaim.” In the Committee’s opinion this would
bring within the scope of the scheme all workers
resident within a radius of three miles from an
insurance practitioner’s surgery. It is estimated that
the number of such employees is 882,683. The
insured persons would be placed in eight wage-groups,
the lowest wage being up to £36 per annum, and the
highest from £320 to £400; and within each wage-
group the contributions and the cash benefits would be
uniform, The weekly contributions payable by the
1302
THE LANCET]
PANEL AND CONTRACT PRACTICE
[may 29, 1937
Government, the employer, and the insured are as
follows :—
Weekly contribution.
our Of which payable by—
Total.
Government.|; Employer. Insured.
3 s. d. &. d. s. d. s. d.
(a) 1 0 0 3 0 9 —
(b) 1 5 0 6 0 9 0 2
9 1 10 0 6 1 0 0 4
d) 2 6 0 6 1 2 0 9
(e) 3 0 0 4 1 5 1 3
(f) 3 10 0 4. 1 9 1 9
g 4 8 0 4 2 2 2 2
) 5 6 0 4 2 7 2 7
It is estimated that at the beginning of the scheme
the annual contributions will amount to a total of
£5,331,691, to which the employers will contribute
49-95 per cent., the insured 35-48 per cent., and the
Government 14°57 per cent. Expenses of adminis-
tration are estimated to amount to 10 per cent.
of the total contributions. The contributions of
employers and employees would be collected, as in
Great Britain, by means of insurance stamps affixed
weekly by the employer on the insurance card of each
employee.
The scheme would be administered by a central
board of management consisting of an equal number
of representatives of the Government, the employees,
and the employers, one of the Government’s repre-
sentatives being a doctor, and locally by district
boards consisting of representatives of the Govern-
ment, employees, and employers, and of the medical
profession, one of the latter being chosen by the local
medical committee, to be set up in the area of each
district board. Local medical committees would
deal with such matters as the range of insurance
medical services, the control of unnecessary prescrib-
ing and lax certification, and disputes between
insurance practitioners. Disputes between prac-
titioners and insured persons would be dealt with
by a subcommittee of the district board consisting
of an equal number of representatives of the board,
and of persons appointed by the local medical
committee, with a neutral chairman.
BENEFITS
The scheme would provide cash benefits and medica]
and ancillary services. The most important of the
former is sickness benefit, which is the payment of
weekly sums to insured persons rendered incapable of
work by sickness. The sums stated vary with the
wage-groups of the insured persons. In the lowest
group the sum stated is 4s.; in the highest it is 32s.
The insured, person would receive also an additional
payment for a dependent wife, or husband, and for
each child, up to four, below 16 years of age. The
additional sums also vary with the wage-group in
which the insured person is placed. Sickness benefit
would be paid at these rates for 26 weeks, and at half
rates for 52 subsequent weeks of sickness.
In providing cash allowances for dependents the
scheme follows the precedent of unemployment
insurance, but not health insurance, in this country.
The Committee think that the difficulties of adminis-
tering sickness benefit, especially those relating to
certification, appear to be serious in all countries,
and are likely to be exceptionally serious in South
Africa, and they therefore submit an alternative
scheme in which no provision for sickness benefit
is made.
The scheme provides a maternity benefit, consisting
full-time attendance at home from a nurse.
of (a) a lump sum payable on the confinement of the
uninsured wife of an insured man or of an insured
woman, and (b) in the case of an insured woman,
weekly payments during the four weeks following
confinement. The lump sum varies according to the
wage-group from £2 to £9, and the weekly payments
from 4s. to 32s., together with a supplementary
allowance for an incapacitated husband and for each
dependent child under 16.
Unlike most national insurance schemes, this
scheme provides a funeral benefit, which is a lump
sum payable on the death of an insured man, or the
dependent wife of an insured man, or of the dependent
child of an insured person.. The amount varies
according to age-group from £4 to £11 for a man or
a woman, and from £2 to £5 10s. for a child. .
MEDICAL BENEFIT
The most important, and most costly, benefit is
medical benefit, which is described under three
categories: ordinary, specialist, and hospital.
Ordinary medical benefit includes (1) general prac-
titioner services, excluding attendance on a confine-
ment, and for an illness directly arising therefrom
during the subsequent four weeks, and (2) the supply
of drugs and of such appliances as may be included
in a list to be prescribed by regulation. Specialist
medical benefit includes all other medical and surgical
treatment, the division between the two categories to
_be in accordance with regulations made after con-
sultation with the medical profession.
Hospital
medical benefit consists of the payment of 9s. per
day for not more than thirteen weeks in a case in
which a person is admitted, on his doctor’s request,
to a hospital or approved nursing-home, or, where
such accommodation cannot be obtained, is receiving
The
dependents of the insured as well as the insured
themselves are entitled to medical benefit.
The Committee recommend that the capitation fee
should be that put forward by the Medical Association,
which, however, they say is somewhat higher than
they contemplated. It is 9s. for persons with an
income below £180 per annum, and 13s. for those
with incomes between £180 and £400. They also
recommend, in agreement with the Association, that
a sum equal to 25 per cent. of the total value of the
capitation fees should be provided to form a pool for
the remuneration, on an attendance basis, of the
specialists, and that the administration of this pool
should be vested in the medical profession. It is
contemplated that a contract will be entered into
between the insurance authorities and the Medical
Association for the provision of the general prac-
titioner service, which will be open to all practitioners
who desire to participate in the scheme, and that
the insured persons will be free to choose their doctors
from among such practitioners. - The specialist services
will be provided by a contract between the same
parties on somewhat similar lines.
It is estimated that the costs of the benefits in the
early stages of the scheme will be as follows :—
Medica]l— £
Ordinary 1,599,412
Specialist 247,922
Hospital 675,995
Maternity . 569,276
Funeral : 161,407
Sickness 1,358,309
Total .. sa .- £4,812,321
The scheme follows that of Great Britain in many
important respects—in particular the right of all
doctors to take part in insurance practice, free choice
THE LANCET]
of doctor, the capitation method of remunerating
general practitioners, and the assumption by the
medical profession of important administrative func-
tions. In the extended range of medical services
provided, and in the division of the insured popula-
tion into wage-groups with different rates of contri-
bution and of cash benefits, it is more in line with
the German system. For the varying of the capitation
fee according to the income of the patient there
appears to be no precedent in national health
insurance administration. It seems likely to give rise
to considerable administrative difficulties, and the
same may be said of the division of the insured
population into eight wage-groups.
Though the Departmental Committee do not feel
SPECIAL
FOUR THOUSAND BASQUE CHILDREN
[may 29, 1937 1303
justified in recommending any form of insurance
scheme for the rural areas, or the native areas, they
make certain proposals for improving the medical
and nursing services of those areas. The measures
proposed do not, however, appear to be precisely
defined or adequate to deal with the difficulties
described, and seem in some degree open to the
objections expressed in the minority reports of the
medical members. But this is a subject on which
no one unacquainted with the local conditions could
venture to form a confident opinion.
The report of the Committee is being widely
circulated, and will doubtless be much discussed ; and
it is not unlikely that their recommendations will be
materially modified before they reach the Legislature.
ARTICLES
FOUR THOUSAND BASQUE CHILDREN
By Ricuarp W. B. Erus, M.D., M.R.C.P.
ASSISTANT PHYSICIAN FOR CHILDREN’S DISEASES, OUa S HOSPITAL,
LONDON ; AND
AUDREY E. RUSSELL, M.B. |
ASSISTANT IN THE CHILD WELFARE DEPARTMENT, UNIVERSITY
COLLEGE HOSPITAL, LONDON
THE shipload of children from Bilbao who arrived
at Southampton on Saturday is a grim reminder of
the magnitude of the refugee problem created by
modern warfare. When it is realised that the ship
could have been filled many times over with children
whose parents would prefer to be separated from
them for an indefinite time rather than let them face
existing, and imminent, conditions in Bilbao; that
very many more have already been evacuated to
France; and that the population of Bilbao is still
nearly double its normal figure, some idea may be
gained of the work of evacuation which still remains
to be done. As the arrival of this group of children
has already aroused interest and sympathy in this
country, we feel that a few particulars of existing
conditions in the Basque capital and of our impressions
gained of both parents and children during the medical
examinations carried out there may be enlightening.
THE SITUAT.ON IN BILBAO
On visiting the Assistencia Social (the ministry
directly concerned with the refugee problem) and the
institutions for orphans and the aged under its
control, it became obvious that the Basque Govern-
ment is making magnificent efforts to. deal with
difficulties becoming daily more impossible. Most of
the public services are still operating though the
schools have had to be closed owing to the incessant
air raids, the women and children spending most of
the day on the steps of the ‘“ refugios” (or bomb-
shelters) ready to take cover when the sirens give
the alarm. Fortunately the many attempts to bomb
the waterworks have as yet been unsuccessful, so
that a good water-supply is still available and no
severe epidemics have broken out.
The strictest rationing is in force, and though a
‘few food ships have run the blockade there is only
ten days’ food in hand for the city. For many weeks
the people have been living on beans, rice, cabbage,
and 35 grammes a day of black bread. Owing to the
evacuation of the surrounding farms and villages,
eggs, meat, milk, and butter are almost unobtainable.
There are small supplies of oranges and olive oil, but
only a minimal amount of fresh vegetables. There is
no coal, and owing to the air raids, little opportunity
for cooking. In many cases it is obvious that the
women have starved themselves to provide for the
children, One pregnant mother who brought up five
healthy looking children for examination was herself
so weak she could hardly stand, and said, smiling,
that perhaps she would find “ time ” to eat when her
children were safe in England. Some idea of the
state of general disruption caused by the continual
aerial bombardment of the town may be gained
from the conditions under which the medical examina-
tions had to be carried out. The group of children
selected for the “ Expedicion a Inglaterra ” had been
numbered, and the first five hundred numbers notified
by an announcement in the papers to attend the
Assistencia Social at 8 a.m. The examinations had
hardly begun when the sirens sounded the alarm,
and the children scattered to the nearest refugio.
The air raid lasted 40 minutes. This happened four
times during the morning, by which time only about
sixty children had been seen, and the rest had all
dispersed. Next day it was impossible to get any to
attend, for it was Coronation Day and manifestos had
been dropped from the air saying that that day
would be chosen to bombard Bilbao ‘‘ from air, land,
and sea.” The following day it was decided to work
in a garden containing a refugio (which served as a
convenient ` dressing-room), but even then inter-
ruptions were so frequent it became clear that most
of the work must be done at night if it was ever
to be completed. And so a continuous queue filed
by each night until 2 a.m., without the slightest
complaint, children often attending alone or with an
older child, and not, infrequently unable to get home
that night. We cannot speak too warmly of the
courage and coöperation both of the children and of
their parents. Those who have examined many
throats will realise what this implies: not a dozen
children out of the whole four thousand cried during
the examination, and only four had to be held !
RESULTS OF MEDICAL EXAMINATION
The group is not, strictly speaking, exclusively
Basque in origin, though the majority are of an
obviously different physical type from the southern
Spaniard. Many have light brown or even red hair,
a few are blue-eyed, and very few could be described
as swarthy. Their facial colouring would usually pass
for that of a sunburnt English child. Perhaps the
most surprising feature of the examination was the
good health of the group as a whole, in spite of the
conditions of deprivation, anxiety, and overcrowding
in which they had been living for many weeks. It
was evident that even the poorer peasants have a
1304 THE LANCET]
high standard of care for their children, and that
before the blockade almost all the latter were well
developed and well fed. It was impossible to weigh
and measure the whole group at this time or to apply
any strict standards of nutrition, but the impression
was definitely gained that although the majority
showed loss of subcutaneous fat, the period of mal-
nutrition had not been long enough to cause permanent
damage or muscular weakness, and that recovery
under proper conditions should be rapid and complete.
A few of the smaller children, however, showed really
severe Marasmus, and were immediately recognisable,
even before being stripped, by their blank apathetic
faces, their slow movements and whispering speech,
and their distended abdomens.
No gross evidence of vitamin deficiency was found
with the exception of hyperkeratinisation around the
hair follicles, which was relatively common, giving
the skin a peculiarly rough feel. It was unfortunately
impossible to test for night-blindness. The very high
incidence of dental caries, however, is probably
attributable at least in part to the deficient diet.
Amongst 4090 children examined, the following
conditions were noted (furunculosis, impetigo, and
pediculi not being included) :
Rheumatic carditis > 9 | Scabies i 13
Old anterior poliomyelitis 5 | Ringworm .. 1
Pott’s disease .. 3 | Mumps 9
Otorrhca : .. 17 Diphtheria . 1
Cervical adenitis .. 17 p
Hutchinson’s teeth > 4 | Bronchitis .. . 4
Clutton’s joints and inter- Pulmonary fibrosis 1
stitial keratitis Trachoma .. 2
The two cases of trachoma (occurring in brothers
who had come from Valencia) were of course
excluded from those allowed to embark, as were the
families of those with mumps and diphtheria.
There were also the following congenital abnor-
malities :—
Congenitalmorbuscordis 2
Dextrocardia .. is A
1
Hemiatrophy of face ..
Inclusion dermoid
copeenter dislocation of
p
Congenital absence of pec-
toralis major .
Two interesting features of the findings, if compared
with any corresponding figures for English school-
children in the same age-group (5 to 15), are (a) the
extreme rarity of respiratory infection, and (b) the
entire absence of chorea. On the face òf it, Bilbao
would provide sufficient terror, anxiety, and over-
crowding to produce chorea in any normal child if
these were the only factors necessary, and one jis
forced to the conclusion that they are not. Amongst
a group of 200 young schoolmistresses and nannies,
however, examined at the same time, 2 had to be
excluded because of early Graves’s disease.
Another revealing feature of the group was the
appearance of the children’s throats. Less than
2 per cent. had had tonsillectomies performed, and
in a very great number of cases the tonsils were as
large or larger than walnuts. But the incidence of
both cervical adenitis and otorrhoea was only approxi-
mately 0-4 per cent., and that of obvious respiratory
infection almost incredibly low. The same is true of
nasal discharges and respiratory obstruction. The
important question arises as to what will happen to
these children now they have reached England.
Owing to the difficulty of obtaining parents’ consent
to operation, it is devoutly to be hoped that they will
retain their tonsils, since it might well prove disastrous
if these were to be removed before the children had
had opportunity of acquiring general immunity to
catarrhal infections. (It is also perhaps of interest
that. of the 200 adults examined none showed
appreciably enlarged or unhealthy tonsils.)
GENERAL MEDICAL COUNCIL
[may 29, 1937
THE CHILDREN IN ENGLAND
Having been passed by the port medical authority,
the children are at present lodged in camp at East-
leigh. It is intended that they shall be drafted from
here to homes throughout the country, being kept as
far as possible in groups with their appropriate
school-teachers. Funds are urgently needed for this
work, which is being carried out by the National
Joint Committee for Spanish Relief in association
with the Catholic, Salvation Army, and other
organisations. It was impossible not to be touched
by the absolute faith the parents had in handing
over their children to the care of England. It will
surely be the desire of everyone to see that their
faith is justified, and that those children who have
parents still living return to them under happier
circumstances safe and well.
GENERAL MEDICAL COUNCIL
PRESIDENT’S ADDRESS
OPENING the 145th session of the Council on Tuesday
last, Sir NoRMAN WALKER spoke of the death of two
former members, Prof. Theodore Cash and Sir Grafton
Elliot Smith, and of Sir William Hansell who served
as legal assessor from 1920 to 1927. Sir Henry Dale
had unfortunately been unable to accept-reappoint-
ment as a Crown nominee, and Sir Norman expressed
the Council’s gratitude to him for successfully guiding
their early steps in their close and cordial collabora-
tion with the British Pharmacopeia Commission.
“It is enjoined by tradition,’ continued the
President, ‘‘ that the summer session shall be primarily
devoted to the first object of the Council’s existence,
medical education, and that they shall deal with
disciplinary cases, as a Council of Medical Registra-
tion, mainly at the session in November. But in
recent years, at any rate, it has seldom been possible
to achieve this aim, because the penal cases com-
mittee are not in a position to regulate the numbers
of cases of convictions of registered medical practi-
tioners reported, or of complaints made, to the
Council,. which in their judgment call for the holding
of inquiries before the Council at the next ensuing
session. On this occasion, fortunately, circumstances
seem more favourable than they sometimes are, and
though a substantial number of disciplinary cases
awaits your consideration, none appears likely to be
exceptionally lengthy, and time should be available
within the week for ample discussion of the reports
of the three committees whose work ee in the
sphere of medical education.
“ The report which will call for the fullest donnder
tion is that of the education committee, who have been
dealing with the concluding stages of the revision
of the curriculum initiated in 1934. There has been
a little variation in method, though not in principle,
in the procedure adopted on this occasion. Instead
of leaving the matter to the education committee,
as was usually done in the comparatively recent past,
the executive committee recommended to the Council
the appointment of a special curriculum committee
composed of the chairmen of the three standing com-
mittees on education, examination, and public
health, who were individually recognised as authorities
on physiology, anatomy, and public health, with the
addition of a physician, a surgeon, an obstetrician,
and a member engaged in the general practice of
medicine. The Council adopted the recommendation
THE LANCET]
on June 2nd, 1934. The committee elected Dr. Tidy
as their chairman, and commenced work at once,
reporting progress to the Council in November, 1934,
and making interim reports in May and November,
1935. Constant communication with the licensing
bodies was maintained, and most of the deans
manifested their interest in, and their criticism of,
some of the proposals made. As time went on, and
all who are familiar with the working of the Council
know that in reform of the medical curriculum it is
wisest to hasten gently, the true meaning of a reform
of the curriculum was more and more understood.
= “ This Council is a team composed in the first
instance of a representative from each of the licensing’
bodies. To these are added five nominees by the
Crown, and seven practitioners elected by the direct
vote of the profession in each of the three divisions
of the United Kingdom. To the Council is committed
a general supervision of medical education, and in
their early days perhaps the licensing bodies were the
only persons actively interested. Admission to the
Register was easy in 1858, but in process of time, by
general agreement among the bodies, the minimum
curriculum was fixed at three winter and two summer
sessions. Then came four years, and in 1890 the Council
unanimously approved an extension to five years,
afterwards modified to 57 months, mainly because
university ‘ years.’ were nsually of nine months.
** On no previous occasion have the proposals of the
Council been more thoroughly hammered out on the
anvil of discussion, and a large measure of agreement .
has apparently been reached. Thus with certain
reservations there seems to be approval of the age of
18 for registration of students.
“ The question of biology, chemistry, and physics
has always been a problem, and I remind the Council
that it was only in 1893 that the Council ordained
that the first and last of these subjects must be
contained in the medical curriculum. Chemistry
was defined then as ‘including the principles of the
science, and the details which bear on the study of
medicine.’ In 1893 in most parts of the country the
teaching of chemistry and physics in schools was of an
elementary character, and biology only appeared in
the curriculum of one or two of them. Times have
changed, and the chemistry and physics taught in
the majority of the schools is of high standard, even
if it does not include any ‘ details which bear on the
study of medicine.’ These must, of course, be learned
in medical schools. The teaching of biology of a
sufficient standard has not advanced so far as that of
the other two subjects: schools capable of under-
taking it are not uniformly scattered over the British
Isles, and there is a feeling in some quarters that the
minds of some young people are perhaps too much
devoted to the study of those three subjects to the
detriment of their general education.
‘ Here we are helped by the elasticity of our system.
If we agree, in order to furnish the requisite knowledge
and skill for the efficient practice of the profession,
that the medical curriculum proper requires to be
extended to five years, the licensing bodies (all
represented here) will frame their regulations accord-
ingly. Already Birmingham, Bristol, Liverpool,
Manchester, Oxford, Wales, and University College,
Galway, require six years, Cambridge, Leeds, London,
and Sheffield five and a half, and it is common
knowledge that others have'in contemplation an
extension of their curricula. This is the way in
which medical education in this country progresses.
The Council prescribes a minimum below which no
body which wishes to retain its right of admission
IRELAND
[may 29, 1937 1305
‘ well done’ for those bodies which raise the standards
for admission to their own degrees.”
A vote of thanks to the President for his address
was proposed by Mr. E. W. Hey Groves, seconded
by Dr. T. G. Moorhead, and carried unanimously.
Mr. Harold Collinson, ¥F.R.C.S., representative of
the University of Leeds for three years from
August lst, 1936, was introduced by Mr. R. E. Kelly.
The Council then passed to the consideration of
penal cases.
TRELAND
(FROM OUR OWN CORRESPONDENT)
A SEQUEL TO INOCULATIONS
A DEATH folowing immunising injections against
diphtheria has lately been investigated at an inquest
held at Ring, Co. Waterford. From the evidence
given it appears that there is no conflict about the
facts. A child of 12 years of age was treated with
injections of T.A.F. on Nov. 9th, 17th, and 24th,
1936. She complained of a sore arm early in January, -
1937, and Dr. D. T. McCarthy of Dungarvan, who had
given the injections, saw her. According to his
evidence he found a small discharging ulcer on the
site of the inoculation. The axillary glands were
enlarged and tender. Her condition deteriorated
and the child died on April 20th. An autopsy
by Dr. W. J. O’Donovan, lecturer in clinical
pathology at University College, Cork, showed
generalised tuberculous infection without meningitis. -
According to Dr. O’Donovan the inflammation on the
right arm could not be recognised as tuberculous.
Dr. McCarthy stated that he had got the material used
from Dr. O’Farrell, county medical officer of health.
He had inoculated 44 children at St. Augustine’s
College on Nov. 3rd, 10th, and 18th, 1936, and no
illness resulted. He inoculated 38 children at Ring
College on the dates given above, and 24 of them were
affected. He believed that these 24 were injected
in sequence. He gave in detail the precautions which
he took for sterilising the instruments with which he
carried out the injections, and stated that he had
the attendance of a nurse on each occasion. He had
no case of tuberculosis in his general practice or in
the district hospital at the time. The child, when ill,
had been seen in consultation by Dr. Casey of Dun-
garvan and Dr. P. Kiely of Cork, and bacteriological
examinations had been made by Dr. O’Donovan. He
notified the deputy coroner of the child’s death. The
child’s father stated that he had given his consent
to the inoculation, that he knew that two of Dr.
McCarthy’s children had been inoculated at the same
time, that three of his other children had also been
inoculated, and that they had sore arms. Dr. H. J.
Parish, bacteriologist to Messrs. Burroughs Wellcome
and Co., who attended the inquest, gave detailed
evidence as to the manufacture of T.A.F. and went
minutely into the different processes. He contended
that their system was error-proof.. Prof. J. W.
Bigger of Dublin also described Messrs. Burroughs
Wellcome and Co.’s laboratories at Beckenham. He
was of the opinion that the precautions taken in the
manufacture of T.A.F, made it impossible for a live
culture of tuberculosis to contaminate the product.
The inquest was held by Dr. C. J. Walsh, coroner for
East Waterford, since Dr. McCarthy himself was
coroner for West Waterford and his deputy was also
debarred as he was acting as legal adviser to Dr.
McCarthy. At the conclusion of the hearing on
May 21st Dr. Walsh adjourned the inquiry sine die
to the Register may drop, but has nothing but a, for advice as to his jurisdiction.
1306
THE LANCET]
AN INDIAN LEPROSY HOSPITAL
(FROM A CORRESPONDENT)
ALTHOUGH in one of the healthiest parts of India,
at Coonoor, which is situated in the Nilgiris at a
height of 6000 ft. over sea-level, one may see on the
outer wall of a chemist’s shop a large and reassuring
announcement to the effect that it sells “ the house-
hold remedy for all aches and pains,” there are
other parts of India that
have cause to be less happy.
In the largest of the
native states, Hyderabad,
there is a good deal of
leprosy and much is bemg
done under Colonel Nor-
man Walker, director of the
Nizam’s medical service, to
combat this affliction. The
annual report of the well-
known leprosy hospital
at Dichpali makes very
interesting reading. In
the year ending November,
1936, 903 new patients
were admitted, compared
with 764 the previous year,
while 557 patients passed
out of the institution;
for lack of space, however,
1209 applications for
admission had to _ be
refused. Sir Leonard Rogers
wrote in 1933 that ‘‘ some
two-thirds of the lepers
in the asylums of India are
uninfective nerve cases
whose isolation does nothing to reduce infections.
Yet the public, in their ignorance, still evince the
greatest dread of the perfectly harmless crippled
lepers with loss of fingers and toes, although they are
mostly suffering from the scars of an old ‘ burnt-out’
infection.” It is because the verdict. of scientific
opinion is quite clear that the general policy which
has been operative in Dichpali since its foundation
has been maintained, and only such patients are
admitted to the hospital as are likely to respond to
treatment. It is felt that the ‘ burnt-out’”’ cases
are fit subjects not for a hospital but for an asylum,
for they cannot face the battle of life unaided. At
Dichpali they try to prevent the patients ever reach-
ing the state of mental anguish and physical suffering
that is the lot of the victim of advanced leprosy.
“ We hope,” says the report, “ that the patients here,
after a course of treatment, will be able to return to
normal life, and become useful members of society,
and we are glad to say that this is generally the case.”’
During the year treatment was carried out along
routine lines—i.e., with hydnocarpus oil and its
esters by injection, supplemented by regulated diet
and occupational therapy. Gingerly, coco-nut and
ground-nut oils, as well as copper sulphate solution,
were tried, but it is too early to give an opinion on the
permanent therapeutic value of these drugs.
Dichpali is maintaining its reputation as one of the
finest leprosy hospitals in India. The Nizam’s
Government, the King’s Silver Jubilee Fund, the
British Empire Leprosy Relief Association, and many
other friends have been generous in their support
so that it has been possible to undertake a heavy
building programme. Provision is made at Dichpali
AN INDIAN LEPROSY HOSPITAL.—AUSTRALIA
Sister from Dichpali Leprosy Hospital treating patients out in the villages.
[may 29, 1937 —
for both work and play. The latest and best methods
of farming are taught, while the adult patients undergo
elementary education in the adult schools which are
held every afternoon. For the children also there
are schools where they learn reading, writing, and
arithmetic; their gardens provide an outlet for
useful manual activity. In the afternoons the boys
may be seen playing football, hockey, or badminton
with great zest, while in the evenings the time passes
pleasantly in dramas, concerts, or at the cinema.
Leprosy is now one of the classes attended by students
of Osmania University—in the capital of the State—
proceeding to their. M.B., and the State medical
department also has continued its usual practice of
sending twelve medical officers for post-graduate
instruction. As a result of this policy, which has
been in operation for some years, almost all the medical
officers in the Nizam’s Government Medical Service
are skilled in the diagnosis and treatment of leprosy.
AUSTRALIA
(FROM OUR OWN CORRESPONDENT)
AUSTRALASIAN COLLEGE OF PHYSICIANS
THE Australasian College of Physicians, which is
being formed, includes in its scope both the Common.
wealth of Australia and the Dominion of New Zealand,
and it is proposed to model it as far as possible along
the lines of the Royal College of Physicians of England.
Amongst its objects is the management of post-
graduate study in medicine, requiring of candidates
for admission to the College evidence that they have
given intensive study to advances in knowledge in
medicine. Regular scientific meetings will be also held.
It was unanimously determined, at a meeting of
representative physicians from New South Wales,
Victoria, Queensland, and South Australia, that
Sydney should be the site of the building of the
College. The Government of New South Wales
offered to provide £25,000 towards the foundation of
the College and the University of Sydney offered a
site on which the building could be erected within
the precincts of the University. It was, however,
THE LANCET]
subsequently decided by the Committee of Physicians
that it would be more suitable to have the College
situated in a more central position in the city. A
committee appointed has purchased a building in
Macquarie-street, the old home of the Warrigal Club.
Certain Victorian donors have signified their
intention to provide at least £20,000 to initiate a
fund for the permanent endowment of the College
when completed. Considerable progress has been
made in raising further sums of money for alterations
OBSTETRICS IN GENERAL PRACTICE.— PERNICIOUS ANÆMIA IN AN INFANT
[may 49, 1937 1307
to the building and for the maintenance of the
College when its activities begin.
INFANT MORTALITY IN SOUTH AUSTRALIA
Vital statistics for 1936 show that during the year
infantile deaths in South Australia have decreased
to the record low rate of 31-08 per 1000 births. In
1935 the rate was 34:95 per 1000. The present
death-rate is less than half the rate of twenty years
ago and about a third of the rate in 1900.
, | CORRESPONDENCE
MEMORIAL TO THE LATE PROF. E. H.
KETTLE, F.R.S.
To the Editor of THE LANCET
Sir,—By the death of Edgar Hartley Kettle in
December last, pathology, in this country, lost one
of its most distinguished exponents, and all who
' knew him were deprived of a personal friend. We
feel sure that those who were associated with him,
as colleagues or students in his professional work,
or in any other of the activities in which he took part,
would desire that his memory should be perpetuated
in some suitable form. .
Kettle’s devotion to his subject, and to all that
concerned it, including particularly the interests of
his students and younger colleagues, was evidenced
throughout his professional career. As an original
` worker, as a director who stimulated the work of
others, as a teacher, as a senior member and treasurer
of the Pathological Society, and as an active member of
numerous committees, he played a part that will not
be forgotten. In each of the four university schools
in which he directed the teaching of pathology,
St. Mary’s, Welsh National School of Medicine,
St. Bartholomew’s, and the British Postgraduate
Medical School, he won the admiration and affection
of his colleagues and his students. We feel that a
fitting tribute to his memory would be the foundation
of a Kettle Memorial Lectureship in Pathology, and
that this lecture might appropriately be given
annually, in each of these schools in turn.
An endowment fund is being collected for this
purpose, and we are sure that his colleagues and
friends, including many who, though not pathologists,
were associated with him in connexion with his
pioneer work on silicosis, or in other ways, would wish
to be given the opportunity of contributing. It is
suggested that individual contributions should not,
in most cases, be more than two guineas, and smaller
sums will be welcomed.
Contributions should be sent to The Treasurer,
Kettle Memorial Fund, British Postgraduate Medical
School, Ducane-road, W.12. Cheques should be
drawn in favour of the Kettle Memorial Fund and
crossed Barclay & Co.
We are, Sir, yours faithfully,
BALFOUR OF BURLEIGH, G. HADFIELD,
W. GIRLING BALL, JAMES MCINTOSH,
A. E. Boycott, RosBErT Murr,
S. LYLE CUMMINS, J. A. MURRAY,
DAWSON OF PENN, A. J. ORENSTEIN,
H. R. DEAN, . A. H. PROCTOR,
J. HENRY DIBLE, Joun A. RYLE,
J. B. Ducuip, A. W. SHEEN,
HERBERT L. EAson, BERNARD SPILSBURY,
Francis R. FRASER, SQUIRE SPRIGGE,
G. E. GASE, M. J. STEWART,
M. H. GORDON, W. W. C. TOPLEY,
W. E. GYE, C. M. Wi1son.
May 24th.
OBSTETRICS IN GENERAL PRACTICE
To the Editor of THE LANCET
Sır, —Those who sincerely desire an improvement
in our maternity services will be grateful to Prof.
Munro Kerr for his letter in your last issue which
brings out just the essential points. Most practi-
tioners with experience of general practice realise
that, owing to the greatly increased demands made on
their time since the introduction of the National
Health Insurance Act, they can no longer give
adequate attention to midwifery. Midwifery is
now full-time work and if we are to avoid the
criticism, which appears again and again in the
Maternal Mortality Report of the Ministry of Health,
that antenatal work is defective, we must have one
practitioner with time at his or her disposal respon-
sible for each patient, before, during, and after her
confinement.
I was particularly pleased that Prof. Munro Kerr
mentions the need for institutional treatment for
primigravids because public health authorities
responsible for the provision of maternity hospitals,
while most anxious to do what is right, are too
often advised that midwifery in the home is safer
than midwifery in hospital, with the result that in
most counties maternity hospital accommodation is
totally inadequate.
Prof. Munro Kerr is a recognised leader in his
profession ; will he lead the general public to achieve
-better maternity services ?
I am, Sir, yours faithfully,
Station-road, New Barnet, May 21st. JOHN ELAM.
PERNICIOUS ANAEMIA IN AN INFANT
To the Editor of THE LANCET
Str,—Dr. Hawksley’s letter in your issue of
May 15th in which he supports the diagnosis of
pernicious anzmia of infancy in the case recorded
by Langmead and Doniach raises several points
that are of interest. First, he emphasises the
presence and importance of achlorhydria in Lang-
mead’s case, yet it is well known that during infancy
the gastric acidity is extremely variable, that it is
frequently low, and that in association with ill health,
especially infectious disease, achlorhydria is commonly
found.
In answer to my letter of May 8th, Dr. Hawksley
suggests that if at a later date the infant is able to
thrive without liver therapy it may be presumed
that the so-called ‘‘ pernicious ansmia’’ was caused
by a temporary cessation of ability either to elaborare
or to absorb the anti-pernicious anæmia factor. This
may or may not be the explanation, but it is hardly
justifiable to label a temporary upset in secretion of
intrinsic factor true pernicious ansmia—a disease
that occurs almost exclusively during the second
half of life and in which inability to elaborate the
1308 THE ioei
anti-anæmic factor is permanent. Dr. Hawksley men-
tions the analogous situation which may arise in cceliac
disease, but he will I think agree that we do not label
that condition pernicious anzemia.
Among the cases investigated by me, of hemolytic
anemia of infancy and childhood which showed
macrocytosis, the case in which the macrocytosis
was most marked and which recovered with the
greatest rapidity with liver therapy had a high
gastric acidity. In view of this finding it was
thought possible that, as a result of prolonged
hemolysis and increased red cell production, the
‘liver factor was temporarily exhausted and that
consequently a macrocytic anemia developed which
responded to liver therapy.
I am, Sir, yours faithfully,
Birmingham, May 22nd. W. CAREY SMALLWOOD.
CARCINOMA OF THE STOMACH
To the Editor of THE LANCET
Sir,—In his article on gastric and duodenal ulcer,
which appeared in your last issue, Dr. Duncan Leys
states that ‘‘ carcinoma of the stomach is mercifully
a relatively uncommon disease.” But relative to
what ? Ifit be a cold in the head or measles in children
the answer may be “ Yes,” but if it be to gastric
disorders of middle age—or indeed to any disease of
middle age for that matter—the answer is most
emphatically ‘‘ No.” I submit that a truer statement
would be that carcinoma of the stomach is mercilessly
a common disease, whether the word relatively be
used or not.
I have to hand the notes of 25 cases which I saw at
King’s College Hospital during the first eleven months
of 1936 alone. Analysis of these cases speaks for
itself. No less than 9 of them were clinically -
inoperable, and of the remaining 16 which were
explored, the radical operation was practicable only
in 5. The average duration of symptoms in these
cases was one year and eight months—another
eloquent fact.
Dr. Leys’s unhappy experience of surgery in this
disease is, however, by no means a fair representation
of surgery as a whole. He writes: “in six years
of busy hospital practice, I have not seen a single
patient with carcinoma of the stomach whose life has
been usefully prolonged by surgery.” Most surgeons
can claim at least that “lives have been usefully
prolonged ” by the radical operation in proven cases
of carcinoma of the stomach. In a comparatively
short experience I can from my own series quote one
case alive and well four years and eleven months
after operation, and several of shorter duration.
Length of history, as is well known, is not always an
indication of operability. None the less, surgery
could do far more did the cases reach the surgeon
earlier, As regards differential diagnosis from other
disorders of the stomach—not only peptic ulcer but
also chronic gastritis—I would commend the use of
the gastroscope as a most helpful adjuvant to
radiology.
Figures from the gastric clinic at King’s College
Hospital, where the cases are primarily seen by my
colleague, Dr. Charles Newman, bear out the experi-
ence of Dr. Leys as regards the relative frequency of
gastric and duodenal ulcer. During the first eleven
months of 1936 there attended 82 new cases of
gastric ulcer and 61 new cases of duodenal ulcer,
including 2 of duodenal stenosis. During the same
period there were 21 cases of gastritis.
I am, Sir, yours faithfully,
London, W., May 25th. HAROLD C. EDWARDS.
CARCINOMA OF THE STOMACH
[may 29, 1937
‘“ POPULAR ” NAMES OF DISEASES IN DEATH
CERTIFICATES
To the Edttor of THE LANCET
Sır, —The extract from THE LANCET 100 years ago
(May 27th, 1837) in your last issue is of much interest,
Probably the letter signed by the medical grandees
was composed by Farr and the explanatory statement
(which is printed on p. 211 of the volume of excerpts
from Farr’s writings published by the Royal Sanitary
Institute in 1885 under the title ‘‘ Vital Statistics ’’)
is pure Farr. The leader writer scores a good debating
point enough, but Farr might probably have retorted
that his proviso ‘‘ whenever the popular name will
denote the cause of death with sufficient precision ”
met the real objection. The development of Farr’s
policy in the matter of registration can be followed
very well in the volume of excerpts quoted above.
Remembering that Farr himself had any amount of
intellectual courage verging, as his successor Ogle
evidently thought, on temerity, it is noteworthy -
how cautious he was in imposing rules of nomen-
clature. As late as the Sixteenth Annual Report he
flatly declined to put an official ban on dropsy.
“ The permission to use vague terms in these cases,
it is objected, encourages negligence ; but the refusal
to recognise those terms that express imperfect
knowledge has an obvious tendency to encourage
reckless conjecture.” I stoutly resist the temptation
to display my King Charles’s head on a charger
with the label status lymphaticus, and content myself
with remarking that Farr’s conservatism was a great
virtue. I am, Sir, yours faithfully,
Loughton, May 22nd. MaJOR GREENWOOD,
THE PATELLA
To the Editor of THe LANCET
Sir,—Many surgeons must have had their former
conceptions of the functions of the patella rudely
shaken by Mr. Ralph Brooke’s article in the current
number of the British Journal of Surgery. That the
patella can be removed and the power of the knee
increased seems to go against all that was taught us
in our anatomy studies ; yet this is what Mr. Brooke
has now demonstrated. The explanation of this
anomaly is brought out by Prof. Hey Groves’s
paper in the same journal, and it would appear
that we must now look upon the patella as
a rudimentary structure, a back-number like
the appendix. Surely this new conception of the
mechanics of the patella is aptly to be stated by saying
that the patella is a sesamoid bone, not in the tendon
of the quadriceps but deep to it, or underneath it.
When one dissects back the quadriceps expansion
in the new operation of removal, one is surprised at
the thickness of the tendon over the patella compared
to the lateral expansions—the capsule that one cuts
through in the removal of a semilunar cartilage.
The surgeon is sometimes surprised that a patient
with a comminuted fracture of the patella due to
direct violence is still able to use the knee. The
reason for this is now made clear, as the following
case brings out.
A clerk, aged 50, slipped on some railway stairs, hitting
his knee-cap several times as he fell downwards. He was
able to get up, catch his train, and do a day’swork. Next
day as the knee was swollen he consulted his own doctor
and was advised to rest for a few days till the fluid went
down. However, when he started to use the knee again the
fluid returned, with a little discomfort, though he was able
to walk a mile or so to the station each day. After nearly
a fortnight he was advised to come up to hospital. When
THE LANCET]
he came into the out-patient room he walked with a slight
limp, but was able to flex and extend the knee to nearly
its full range. The tenderness of the patella suggested a
chip off this bone. Radiography however showed a com-
minuted fracture. As he seemed a suitable case, operative
removal was decided upon.
When I exposed the patella I found that the prepatellar
aponeurosis and the lateral expansions were intact. On
incising this I was surprised at the cuff of aponeurosis
nearly a quarter of an inch thick which I had to reflect
back over the patella to reveal the fragments beneath.
This was very different from the frayed ends which one
endeavours to sew up in operating to wire a transverse
indirect violence fracture. After. removal of the bone
this aponeurosis came together with ease, and when sewn
up was certainly as strong as the tendo Achillis. One
saw how with this aponeurosis intact, the mechanical
power of the quadriceps was but little impaired, once there
was some power of adhesion between the fractured
surfaces and the surrounding hematoma, so that a pulley
action was again possible round the lower end of the
femur.
It would be interesting to know the experience of
other surgeons with this new operation ; both in the
case of comminuted and in transverse simple fractures.
I am indebted to Mr. Alan Todd for kindly allowing
me to operate on this patient.
| I am, Sir, yours faithfully,
Devonshire-street, W., May 23rd. G. O. TIPPETT.
THE LIMITED FIELD OF CANCER RESEARCH
To the Editor of THE LANCET
SIR,—A perusal of the thirteenth annual report
of the British Empire Cancer Campaign leaves one
with the feeling that, as far as treatment by radiation
is concerned, too large a share of the available workers
and resources is being concentrated on the use of °
radium and super-voltage X ray therapy, a share
altogether out of proportion to any reasonable
expectation of what can be achieved by these agents,
to the detriment of other lines of research. I doubt
whether the most optimistic of radium therapists
ever hope for so much as a 50 per cent. five-year
cure of all cases of cancer referred to them for treat-
ment. All experience so far recorded of the use of
super-voltage X ray therapy indicates that the most
to be expected is possibly slightly better results
in a very limited class of cases.
The construction of such costly forms of apparatus
as radium bombs and super-voltage X rays generators
would only be justified, beyond one or two sets for
experimental purposes, if there were substantial
reasons for believing that if would lead to a great
advance on all previous methods in controlling
cancerous growths. There is no convincing argument
in favour of such an expectation. The only justifica-
tion for this outpouring of treasure and effort is an
assumption that the gamma rays of radium possess
a greater therapeutic value than X rays, which is
due to their shorter wave-length, and hence the
shorter the wave-length of X rays the greater their
usefulness.
That radium has been used with more success than
X rays in the treatment of malignant disease in
certain situations no one will deny; but, in these
cases, besides the difference of the wave-length of the
radiation, there are other important variant factors
which are known to exert a powerful influence on the
results. To assume that the shorter wave-length is
the only factor responsible for the better results, or
even that it is a contributory cause, is illogical. `
. The cavities of the body are the situations in
which radium can be used with the greatest advantage,
because it can be placed in contact with the growth
THE LIMITED FIELD OF CANCER RESEARCH
[may 29, 1937 1309
and its radiation is diminished in intensity before
reaching the subjacent healthy tissues. This alone
might account for better results, but there is also the
time-intensity factor. For a dose of equal intensity a
much longer time is required when using radium
than when using X rays. This dissimilitude can be
lessened by splitting the X ray dose into a number
of small daily doses and this practice has been followed
by greatly improved results, proving that the time
during which the growth is under the influence of
radiation is of great importance. By means of the
Chaoul technique, brilliant results have been obtained
with X rays of long wave-length by bringing the
source of radiation very close to the growth—further
strong evidence against the assumption that wave-
length is a factor of importance, `
It would be neither a very difficult nor a very
costly experiment to compare the action of X rays
and gamma rays with the time-intensity factor
eliminated. By means of a long shield—say any
length up to ten feet—the X ray tube could be used
at such a distance from the patient and the current
could be so adjusted that the mtensity of the radiation
would be the same as that received from a radium
pack ; in short, with X rays the time-intensity factor
is entirely under our control.
The assumption that the gamma rays of radium
have a therapeutic value that can only be equalled
by X rays of equally short wave-length, when they
can be generated, is based mainly, if not entirely,
on impressions; they are the impressions of those
working with radium, and we know quite well that
there are very few workers who are free from a strong
bias in favour of their own methods. The arguments
against this assumption is based on facts. Experi-
ments with drosophila eggs and other test materials
go to show that biological reaction is independent of
wave-length. Then there is the brilliant success of
the Chaoul technique, in which the X rays are
generated with a voltage of only 60,000. And there is
also the fact that the results obtained at Erlangen,
by treating uterine carcinoma with X rays only,
compare very favourably with the results obtained
by the combined use of X rays and radium.
And the claim that super-voltage X ray therapy is
an advance of any value was, to my mind, finally
disposed of at the thirty-sixth annual meeting of
the American Roentgen Ray Society in September,
1935, At this meeting, after the reading of papers
recording poor results of this method, Dr. Carter
Wood of New York City said “it would be well
to confine the construction and operation of these
very expensive forms of apparatus to those now
installed in the institutions in various parts of the
country.” Dr. Ruggles, whose name is well known
also in this country, speaking of a year’s experience
with 800 kv. X rays, said: “From what can be
observed in the routine of a clinic they (the patients)
do about as well as those treated at 200 kv.”
Neither theoretically, nor from practical experience,
have we any reason to expect any outstanding advance
in the treatment of cancer by the use of X rays of
very short wave-length.
At the same meeting of the American Roentgen
Ray Society, an account of which is well worth the
study of those controlling research in this country,
a paper was read by three radiologists, reporting
three cases, two of advanced carcinoma mamma,
one of which had widespread bone metastases, and
one of lymphosarcoma involving the lymph nodes
of almost the entire body, all well and clinically free
from disease five years after treatment. The treatment
1310 THE LANCET]
MIDDLE-EAR DISEASE IN INFANCY.—VITAL STATISTICS
e
[may 29, 1937
was X radiation of the whole body and endocrine glands
extending over a year. In view of the uncertainty
of the effects of whole-body radiation only these
three cases had been treated up to two years ago.
Here is a method by which there is some possibility
of a great advance, yet there is nothing in the report
of the British Empire Cancer Campaign about research
in this direction, nor the radiation of large areas of the
body with a view to increasing the patient’s resistance
to the cancerous invasion and increasing the radio-
sensitivity of malignant growths.
I am, Sir, yours faithfully,
Dower, May 22nd. WILFRID GARTON.
TRACHOMA IN REFUGEE CHILDREN
To the Editor of THE LANCET `
‘Srr,—Lord Lloyd in the House of Lords last
night performed a public service by asking a question
as to the incidence of trachoma among the refugee
children from Spain who have arrived in this country.
It is known that in many of the provinces of Spain the
disease is practically universal. Lord Lloyd was
informed that a voluntary body called the National
Joint Committee for Spanish Relief sent out some
doctors to examine the children before they left
Bilbao. Itis not reported that any of these gentlemen
had any experience of trachoma or even any special
knowledge of ophthalmology. The examination of
the eyes of 4000 children by port medical officers on
arrival at Southampton was an absolute impossibility.
It is therefore still unknown what proportion of the
children if any is trachomatous. The difficulty in
making a diagnosis in the early stages of the disease,
its contagious nature, the long period required
for treatment, and its devastating effects on visual .
acuity make it important to decide the matter.
If the children are to be kept segregated in a camp
no danger will accrue to the surrounding inhabitants.
On the other hand, if a few of them are trachomatous
and are temporarily placed in Salvation Army or
other homes in contact with other children there is
every expectation of a recrudescence of the disease
in this country. In this matter the responsibility
of the Ministry of Health is very great.
I am, Sir, yours faithfully,
A. F. MACCALLAN,
President of the International Organisation
London, May 26th. against Trachoma.
MIDDLE-EAR DISEASE IN INFANCY
To the Editor of THE LANCET
Sır, —I was very interested in the leading article
in your last issue. At the Hospital for Sick Children,
Great Ormond-street, it has been recognised for some
years that pus in the middle ear and mastoid is a
frequent autopsy finding, especially in infants dying
of gastro-enteritis. I have just looked through the
post-mortem records of the past two years and
observe that out of the 170 autopsies in which the
middle ears were examined, just over 50 per cent. had
pus in one or both. This agrees closely with Dr. Ebbs’s
figures for a much larger series. All but a small
proportion of these positives were in children under
two years of age. Another fact that emerges is that
a much higher proportion of children dying from
gastro-enteritis have pus in their middle ears than
those dying from other diseases. Thus 33 (65 per
cent.) out of 43 cases of gastro-enteritis had one or
both ears infected whereas of 100 children under two
dying of some other disease only 44 had pus in one
or both middle ears.
From these figures it seems that the infant suffering
from gastro-enteritis is particularly liable to a middle-
ear infection.. The gastro-intestinal infection is, I
think, undoubtedly in some cases secondary to the
otitis media; but, in my view, in the majority of
cases the otitis supervenes during the course of the
gastro-enteritis and, as Dr. Ebbs suggests, may
contribute to the fatal issue.
All who have to deal with these patients know how
difficult of diagnosis the otitis media may be. Not
only are there no symptoms but frequently the
appearance of the drum is normal. It must be a
common experience for the ears to be pronounced
normal only to find them full of pus at the autopsy
a day or two later. One should never hesitate to
incise a drum should there be any suspicion, such as
a sudden unexplained rise of temperature would
provoke, that the middle ear has become infected.
The ventilation of this difficult subject at the
Royal Society of Medicine discussion should stimulate
both otologists and pediatricians to codperate in
investigating this widespread malady.
I am, Sir, yours faithfully,
G. H. NEWNS.
Hospital for Sick Children, Great Ormond-strect,
May 25th.
A REMEDY FOR HÆMORRHOIDS
To the Editor of THE LANCET
Sir,—In your issue of May 22nd (p. 1261) you
refer to a very recent paper in the Revista sud-
americana de endocrinologia immunologia y quimio-
terapia in which an oily solution of an extract of the
earthworm Microscolex dubius (Fletcher) is recom-
mended as a remedy for piles. It may perhaps interest
your readers to learn that this is a very ancient
treatment. Stephenson, in his monograph on the
Oligocheta, quotes Damiri, the author of an Arabic
treatise on the life of animals, written in A.D. 1371,
as saying that suppositories made from earthworms
fried in olive oil and powdered are highly beneficial
to persons suffering from piles.
I am, Sir, yours faithfully,
C. C. A. MONRO
British Museum (Natural History), Cromwell-road,
. May 22nd.
INFECTIOUS DISEASE
IN ENGLAND AND WALES DURING THE WEEK ENDED
MAY 15TH, 1937
Notifications.—The following cases of infectious
disease were notified during the week: Small-pox, 0 ;
scarlet fever, 1440; diphtheria, 781; enteric fever,
24; pneumonia (primary or influenzal), 798; puer-
peral fever, 26; puerperal pyrexia, 108; cerebro-
spinal fever, 30 ; acute poliomyelitis, 5 s acute
polio-encephalitis, 2; encephalitis lethargica, 5;
continued fever, 1 (Nuneaton); dysentery, 16;
ophthalmia neonatorum, 76. 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 May 21st was 2967 which included: Scarlet
fever, 783; diphtheria, 856; measles, 76 ; whooping- -cough,
496; puerperal fever, 17 mothers (plus 12 babies) ; encephalitis
lethargica, 283; poliomyelitis, 0. <At St. Margaret’s Hospital
there were 20 babies (plus 12 mothers) with ophthalmia
neonatorum.
Deaths.—In 123 great towns, including London,
there was no death from small-pox, 3 (0) from enteric
fever, 13 (0) from measles, 3 (0) from scarlet fever,
20 (6) from whooping-cough, 19 (3) from diphtheria,
57 (13) from diarrhoea and enteritis under two years,
and 36 (5) from influenza. The figures in parentheses
are those for London itself.
The fatal cases of enteric fever were at Portsmouth,
Southampton, and Southend-on-Sea. Liverpool reported 3
deaths from whooping-cough. Diarrhea was fatal in 3 cases
each at Liverpool and Nottingham.
The number of stillbirths notified during the week was
277 (corresponding to a rate of 43 per 1000 total
births), including 51 in London.
THE LANCET]
[say 29, 1937 131]
OBITUARY
FREDERICK EDGE, M.D., M.R.C.P. Lond.,
F.R.C.S. Eng.
Dr. Frederick Edge, who died at Wolverhampton
on May 17th, was born in Russia in 1863, the son of
William and Mary Pollitt Edge. He was educated
at Owens College, Manchester, and St. Thomas’s
Hospital, London, qualifying in 1886, and taking
higher diplomas after further study at Munich,
Vienna, and Dresden. Five years after qualifying he
settled in Wolverhampton and was shortly appointed
honorary surgeon to the Women’s Hospital, then in
St. Mark’s-road. A few years later he joined the
staff of the Birmingham and Midland Hospital for
Women, and on both these hospitals he served for
thirty years or more. Later he was attached to the
Birmingham Maternity Hospital and examined for
the Central Midwives Board. Before his hospital
appointments became too pressing he was a member
of the Wolverhampton town council. He married
the daughter of Isaac Bradley of Codsall House,
Staffordshire, and leaves two sons and a daughter.
J. H. S. writes: “ In the week that Frederick Edge
died there appeared in THE LANCET an article entitled
‘Perspective and Poise in Practice. These words
epitomise the whole personality of Dr. Edge, for he
possessed these qualities in relation not only to
practice but to the art of living itself. Endowed
with an unusual facility for friendship, which found
no difficulty in bridging a disparity of years amounting
often to half a lifetime, the love and veneration in
which he was held is no matter for surprise. His
passing touches many of us deeply. To these
qualities was added a certain flavour of individuality
—pboth in point of view and its expression—which
derived perhaps from the mixture of Slav and Saxon
temperament in his veins, and added point to his
personality, marking him off from the mean of the
normal man. His professional life was spent in
Birmingham and Wolverhampton. To the latter
town (from which these notes have been written) his
services were immense. To mention but one point
from the many that spring at once to mind: the
fusion of two hospitals is rarely accomplished without
friction between the numerous personalities involved,
but the amalgamation between the Royal Hospital
and the Women’s Hospital at Wolverhampton was
saved from this very largely through the presence of
Dr. Edge in our midst. He was made the first
chairman of the medical committee of the new
hospital, and so rare a power did he show of smoothing
difficulties, and of keeping us all not only happy and
agreeable but—so rare in such committees—to the
point as well, that what had invariably been a yearly
tenure was in his case by unanimous desire made
into a triennium. Whether in practice, at the bridge
table, at the deciding putt on the 18th green, or
in the presence of some administrative or other
difficulty, Frederick Edge was a connoisseur of life
with a zest—and a sagacity—all his own. We shall
not easily see his like again.”
JOHN POLAND, F.R.C.S. Eng.
Wit the death of Mr. Poland at his home at
Seal, Kent, on May 22nd medicine loses a distinguished -
orthopedist and London a distinguished citizen.
Mr. Poland was grandson of a sheriff of London, he
was himself a Master Skinner, and one of his sons
is City Marshal. Born at Blackheath in 1855, he
qualified from Guy’s Hospital in 1879, taking the
F.R.C.S. Eng. three years later. He- was demon-
strator of anatomy and surgical registrar at the
hospital, going on to the Queen’s Hospital for
Children where he was registrar and anesthetist. He
. attached himself to the Miller General Hospital at a
time when it was emerging from the Royal West Kent
Dispensary, and became its senior surgeon, holding
also similar positions at the Royal National Ortho-
pædic and the City Orthopedic Hospitals. He edited
and brought up to date the collected lectures on
“ Bodily Deformities,’’ delivered at the latter by his .
predecessor, E. J. Chance, adding two lectures of his
own on club-foot, and he was for many years surgical
secretary of the Hunterian Society, delivering the
Hunterian oration in 1901 and becoming president
in 1906. Mr. Poland was 81 years of age. His wife,
a daughter of James G. Denham, predeceased him
in 1932.
RICHARD THOMAS WILLIAMSON, B.Sc. Vict.,
M.D., F.R.C.P. Lond.
Dr. R. T. Williamson, who died on April 28th at
his home in Surrey, had retired twenty years ago
from his position as physician and neurologist in
Manchester, and the announcement of his death
will recall to the older generation the memory of
a wise clinician, a stimulating teacher, and an ardent
seeker after truth. Williamson was a Lancashire
man by birth and education. He did his schooling
at Burnley and Owens College, Manchester, qualifying
in 1884 when he was
only 22 years old. He
was house physician
at the Infirmary,
went on to demon-
strate physiology at
Birmingham, and to
take a house appoint-
ment at the National
Hospital, Queen-
square. Having there
gained a taste for
neurology, it remained
his primary interest
in medicine when he
returned to Man-
chester to work his
way up *'to staff
appointments at
Ancoats and the
Royal Infirmary. His
earliest publication, however, was a monograph on
diabetes. Dreschfeld, in his lecture course of medicine,
left to Williamson the whole department of neurology.
In 1908 Williamson published his ‘‘ Diseases of the
Spinal Cord,’ a book which was illustrated more
profusely than almost any medical book of that time,
and its success was such that a second edition was
called for within a few years. None of his colleagues
at the Infirmary used the ophthalmoscope in diagnosis
of disease to anything like the extent he did, and he
was the first one of them to examine the fundus
by direct vision, using an unenclosed candle as his
means of illumination. He did a great deal of
practical laboratory work, fixing, cutting, staining
his own specimens and drawing illustrations from
them for use in papers or book. His health was
never robust, and in 1917, when 55 years of age,
he was obliged to give up his active professional life.
Retirement to the south gave him the opportunity
DR. WILLIAMSON
1312 THE LANCET] OBITUARY.—ROYAL INSTITUTE OF PUBLIC HEALTH & INSTITUTE OF HYGIENE [may 29, 1937
for historical writing, the taste for which dated from
a visit to Vienna in his student days. Many stories
and short sketches appeared in a New York journal,
and in 1927 he embodied some of his own experiences
in a book entitled “ The Log of an Old Physician.”
A colleague writes: ‘‘Many students of the
Manchester Medical School will have friendly and `
happy memories of the work they did with R. T.
Williamson, He was ever ready to help in the
difficult paths of medicine and though his lectures
might go beyond the understanding of his audience
his bedside help—freely given—was always of the
greatest use and benefit. He delighted in tackling
a difficult case and in the end his opinion was usually
right. Though he was unimpressive on first acquain-
tance and retained the speech and mannerisms
of his native county to the end, his kindliness and
his knowledge made a deep impression on those who
knew him. Medically his chief interests were in
neurology and in diabetes mellitus. In both of these
subjects he did keen research work, relying on his
own examinations and estimations in all that he did.
His published books are full of original observations,
pictures, and diagrams. The treatment of diabetes
brought him a large practice. Later in life he took
a keen interest in school hygiene and after his retire-
ment from practice, when he had settled in Barnes,
he turned to history, spending long hours at the
British Museum.
“ There was much that was tragic in his life.
Naturally of an introspective nature he was saddened
by two events—the death of his mother, who was
killed in a street accident, and that of his wife—who
was of Thuringian birth—who died with thrombosis
after a minor surgical operation. His later thoughts
often turned on the ways these two deaths might
have been avoided.” À
The picture is from a photograph in the Manchester
University Medical Library taken before his retirement.
JAMES ADAMS, M.D. Aberd., F.R.C.S. Eng.
THE death at Eastbourne on May 10th of Dr. James
Adams removes the elder of two brothers, both
of whom qualified from $t. Bartholomew’s Hospital
in the early ‘seventies. James was born near
Salcombe, Devon, in 1850, and was educated at the
University of Aberdeen. After qualification he was
resident at the West London Hospital and at the
Brooke House Asylum, Clapton, before returning
to Devon to practise at Ashburton, where he was
surgeon to the local hospital and became chairman
of the West Country Association. In 1888 he took
the F.R.C.S. Eng. and moved to Eastbourne, where
he spent the remaining 50 years of his life. He was
attached for many years to St. Mary’s Hospital,
where he had the reputation of being a specially
skilled. operator. Many short contributions to our
own columns indicate the wide range of his surgical
interest. For some time he was deputy medical
officer of health. In private life he was a man of
social gifts, keen on gardening and skilful at chess,
presiding over the Eastbourne Chess Club. His
wife predeceased him, and his only son is senior
surgeon at Penang. His brother, Mr. John Adams,
F.R.C.S., is still living in London.
ROYAL INSTITUTE OF PUBLIC HEALTH
AND INSTITUTE OF HYGIENE
Lord Horder presided over the inaugural meeting
of the Congress of the Royal Institute of Public
Health and the Institute of Hygiene which was
opened at Margate on May 25th. In his address
on health education, Lord Horder pointed out that
the healthiness of the individual was bound up with
the art of living and was inseparable from the conduct
of life. He emphasised the importance of the forma-
tion of sound habits, which must of necessity be first
inculeated by the parent. Touching on the relation
of medicine, first in its study and then in its applica-
tion, he maintained that:the function of the doctor
should be more educative than corrective; healthi-
ness is a positive concept, not merely the absence
of disease. Lord Horder summarised the rôle of
local authorities and their staffs in combating
‘infectious disease, in protecting foodstuffs, in secur-
ing satisfactory shelter for the individual and the
provision of fresh air and pure water, all powerful
factors in promoting health. Nevertheless he
submitted that to aim at extending life was not
everything—not even the main thing—the chief
problem being how to live more happily. He
considered that just as we can organise for defence,
we can organise for health and happiness.
While admittedly great strides had been made
much more remained to be done. Although adultera-
tion of food was controlled, we had not yet begun
to tell the people what foods they required for health.
Though occupational disease had been reduced,
occupational fitness had also diminished. In a list
of conditions calling for remedy he included crowding,
fatigue, the conditions of railway travel, and the
prevalence of preventable noise; the maternal
mortality-rate, the high incidence of tuberculosis
in young women, and the appalling ravages of minor
illnesses which result in loss of time and wages must
also be reduced. He advocated the extension of
insurance to the families of the workers and urged
the care of the pre-school child, pointing out that
preventive medicine was most active when it concerns
itself with those matters on which public opinion and
attention have already been directed.
At the conclusion of the meeting two presentations
were made by Lord Horder. The first was the
Harben medal, given by the Institute of Hygiene
every third year as a reward for eminent services,
The recipient this year was Sir Gowland Hopkins,
F.R.S. The other was the Smith award, given
triennially by the terms of the trust to the medical
officer of health who was deemed to have performed
the most noteworthy work in the department of
preventive medicine. This (second) award was made
to Dr. Charles S. Thomson, medical superintendent
officer of health, City of Belfast.
THE LANCET 100 YEARS AGO
May 27th, 1837, p. 351.
ROYAL MEDICAL AND CHIRURGICAL SOCIETY
From a contribution made by Dr. J. JOHNSON to a
discussion on nervous affections peculiar to young women,
causing contraction of the muscles of the extremities, accom-
panied by increase, diminution, or absence, of sensation, or
motion, held at the Royal Medical and Chirurgical Society
on May 23rd, 1837.—Dr. Brieut, President.
The cases of Dr. Wilson proved that hysterical affections,
particularly in young women, might simulate organic
disease occurring in every part, from the head to the
foot, even taking on the character of white swelling, loss
of vision, &c. He thought the author had acted wisely
in advancing no theory on the subject; the idea of the
uterus wandering from one part of the body to another,
was as good as any that had been adduced.
THE LANCET |
[may 29, 1937 1313
PARLIAMENTARY INTELLIGENCE
THE House of Commons reassembled on May 24th
and the House of Lords on May 25th, after the
Whitsuntide Recess.
SPANISH REFUGEE CHILDREN AND
TRACHOMA
IN the House of Lords on May 25th Lord LLOYD
asked H.M. Government what, if any, arrangements
were being made for the segregation of refugee
children from Spain. He said that his solicitude in
this matter resulted from correspondence which he
had had with Dr. Andrew MacCallan, an ophthalmic
‘surgeon who had. done so much to relieve blindness
right through the Nile Valley, where his name would
be long remembered. Dr. MacCallan and the president
of the Royal Society of Medicine had written to the
Minister of Health pointing out to him how grave
was the danger of introducing these Spanish children
unless careful examination and segregation were
carried out. The fear was that these children might
introduce trachoma, a contagious eye disease, which
was very obstinate to treat and which led ultimately
to blindness. We only rid ourselves of this scourge
of trachoma by a rigid application of the Aliens
Act of 1920. In its early stages the disease was
very hard to detect, except by experts, and it was
a disease which was known to ravage the whole of
Northern Spain. He saw it reported that the Basque
children were not to be kept in one camp but were to
be distributed about the country. Owing to our
comparative immunity from trachoma it was doubtful
whether there were many oculists in this country
capable of detecting the disease in its early stages and
since the necessary examination was a long and
difficult process he wished to know whether the
Government were satisfied that the necessary pre-
cautions had been taken. He hoped the Government
would give an assurance that greater precautions were
being taken than any that had yet been referred to in
the Press.
The MARQUESS OF DUFFERIN AND AVA, Lord-in-
Waiting, replying on behalf of the Home Office,
said that all the arrangements for bringing these
children to England were made, not by the Govern-
ment, but by: the National Joint Committee on
Spanish Relief, a voluntary body which had accepted
all financial responsibility for the children. The
committee had also accepted the principle that the
selection of the children to be evacuated from Bilbao
should be made without reference to creed or class
or political beliefs. The committee sent out doctors
to examine the children before they left Bilbao.
He was glad to be able to tell Lord Lloyd that in
the opinion of the British medical officers appointed
by the committee to go to Bilbao trachoma was very
uncommon in the Basque country and the only cases
discovered were in children from other parts of
Spain. Among all the children who were selected to be
evacuated the doctors had found only two cases
of this admittedly very dangerous contagious disease,
and those two cases were ruthlessly excluded from the
sera The committee had made every effort to
make sure that no child should be admitted to England
suffering from any contagious or infectious disease.
The committee had also taken full responsibility
for the care and maintenance of the children in this
country, and it was fully understood by the Committee
and all responsible’for this evacuation that the
presence of these children here would be, they hoped,
of short duration. The interest of the Government
in this matter was limited to securing that practical
plans had been made by the committee for the
maintenance of these children in institutions and
homes, and to making sure that on arrival the children
were medically examined. The committee had
furnished, particulars showing that the majority of the
children were already provided for, while plans were
being rapidly advanced for the care of the remainder
For the moment the children had been placed in a
temporary camp at Southampton, but this camp was
not accessible to the general public. Nobody could
get in without a special pass and the children were
not allowed out without special permission. When
the children did leave the camp it would be on the
advice of the medical officers in charge and the local
health authorities. When that permission had been
obtained the children would go in fairly large units to
various places where they would be supervised by
Basque priests and teachers taking no part in propa-
ganda while they were in England. On arrival the
children were all submitted to a medical examination
more searching than would have been the examination
if. they had arrived individually. The medical
officers in charge were surprised to find how little
their experiences in a beleaguered city had affected
the health of the children.
QUESTION TIME
MONDAY, MAY 24TH
Inter-departmental Committee on Abortion
Mrs. TATE asked the Minister of Health whether he
was now in a position to give the terms of reference and
the personnel of the Inter-departmental Committee
on Abortion, the decision to appoint which by the
Secretary of State for the Home Department and himself
was announced when the recent report on: maternal
mortality was issued.—Sir KINGSLEY Woop replied:
Yes, Sir. The terms of reference of the committee are :
“To inquire into the prevalence of abortion, and the
present law relating thereto, and to consider what steps
can be taken by more effective enforcement of the law
or otherwise to secure the reduction of maternal mortality
and morbidity arising from this cause.”
The members of the committee will be: Mr. Norman
Birkett, K.C. (chairman); Mrs. Stanley Baldwin, Lady
Ruth Balfour, M.B., Sir Comyns Berkeley, Mr. H. A. de
Montmorency, Dr. T. Watts Eden, Lady Forber, M.D.,
Sir Rollo Graham-Campbell, Dr. G. C. M. M’Gonigle
Sir Ewen Maclean, M.D., Capt. M.P. Pugh, Mr. W. Bentley,
Purchase, Mr. C. D. C. Robinson, Mrs. Thurtle, and
Lady Williams. Communications relating to the work
of the committee should be addressed to the secretary,
Committee on Abortion, Ministry of Health, Whitehall,
S.W.1.
Tests for the Prison Service
Mr. MontaavuE asked the Home Secretary if he was
aware that a recent candidate for the prison service,
F. H. L., of Barnsbury, London, N., who passed a strict
medical examination and other scrutinies as to character,
was failed at an interview by an assistant commissioner
because he failed to remember with absolute certainty
the number of halls in Leeds prison through which he
passed only about once; and whether, seeing that in
view of the prospect of joining the prison service the
candidate gave up a good position he had held for ten years
and was now unemployed, his application could be
reconsidered.—Mr. GEOFFREY LLoyp, Under-Secretary,
Home Office, replied: The suggestion that this candidate
was rejected merely because he failed to answer a particular
question is mistaken. The decision was reached on a
review of his qualifications as a whole, after he had been
under instruction for some four weeks, and after full
consideration of reports by the governor and of others
responsible for the instruction of probationers. Like all
other candidates who are accepted for training, he was
warned beforehand that his engagement was provisional
only in the first instance and might be terminated at any
time during the training course if he were found to be
unsuitable. My right hon. friend regrets that the question
of his engagement cannot be reopened. In the selection
of candidates for training, every effort is, of course, made
to choose only men who appear likely to make good
officers, but some men who make a good impression at the
original interview are found after a period of trial not to
be suitable for the duties.
1314 THE LANCET]
MEDICAL NEWS
[may 29, 1937
TUESDAY, MAY 25TH .
Officers Invalided Out of the Army
Mr. CHORLTON asked the Secretary of State for War
the number of officers invalided out of the Army as
a result of accident or sickness during their first 10 years
of service in the years 1933, 1934, and 1935 or the latest
convenient dates.—Mr. Durr Cooper replied: The
numbers for 1933, 1934, 1935, and 1936 were 6, 6, 4, and
6 respectively.
Housing in Scotland
Mr. Barr asked the Secretary of State for Scotland
what was the total number of houses completed in Scotland -
with State assistance from 1919 till March 31st, 1937, or
the last available date; and the total amount of State
subsidy paid in respect thereof.—Mr. Error replied: ©
The total number of houses completed in Scotland with
State assistance from 1919 till March 31st, 1937, is
215,537. The total amount of State subsidy paid up to
that date is £23,549,148.
Treatment of Tuberculous, Crippled, and
Orthopedic Cases
Mr. Witson asked the Secretary of State for Scotland
the annual cost for the treatment of tuberculous, crippled,
and orthopedic cases.—Mr. Exuiot replied: Local
authorities in Scotland incurred a net expenditure of
£640,670 on the treatment of tuberculosis in the year
1934-35, the latest year for which information is available.
Orthopsedic and cripple cases are dealt with by local
authorities under their tuberculosis, child welfare, and
school health schemes, but I regret that a separate figure
for this expenditure is not available.
A Factory Code
Mr. Ruys Davies asked the Home Secretary whether,
in view of the complexity of the Factories Bill, he would
issue from his department, when the Bill became law, a
Factory Code as a plain guide to the new Act, somewhat
similar in character to the Highway Code.—Mr. R. S.
Hupson, Parliamentary Secretary to the Ministry of
Health, replied: It will clearly be necessary to issue same
kind of explanatory statement. I cannot anticipate
now what form it may take, but the’ hon. Member’s
suggestion will be borne in mind. |
Staffordshire Hospital Arrangements
Mr. MANDER asked the Minister of Health the present
position with regard to the Staffordshire county council
scheme for dealing with invalids and old persons which
came into operation on April Ist in Wednesfield, Willen-
hall, and other districts ; whether a reply from the council
to his letter had now been received; and whether there
was yet a resident medical officer at the Wordsley institu-
tion.—Mr. Hupson replied: I understand that the
position remains as stated in the reply given to the
hon. Member’s question on this subject on April 8th,
and that the county council will not have an opportunity
of submitting a report to my right hon. friend until after
their next meeting in July. As regards the last part of
the question, I am informed that there is now a temporary
medical officer resident at the Wordsley institution
pending the making of a permanent appointment,
MEDICAL NEWS
University of Oxford
Dr. A. G. Gibson, reader in morbid anatomy in the
University, has been constituted Nuffield reader in morbid
anatomy while holding the office of honorary pathologist
at the Radcliffe Infirmary. He will receive a stipend of
£500 a year. Dr. B. G. Maegraith has been appointed
university demonstrator in pathology from May Ist, 1937,
to Sept. 30th, 1941. .
University of London
Mr. John Kirk has been appointed from Oct. Ist to the
S. A. Courtauld chair of anatomy tenable at the Middlesex
Hospital medical school.
Mr. Kirk is 55 years old. He graduated M.B. at the University
of Edinburgh in 1904 and after holding hospital appointments
was engaged in medical missionary work in China from 1907
to 1928. Inthe East he continued his studics in human anatomy,
and when the new buildings at the Kung Yee Medical College
Canton, were opened in 1924, he was invited to organise and
take charge of the department of anatomy, which was the first
of its kind in South China. During the first of his two periods of
furlough (1913-14) he was admitted a fellow of the Royal
College of Surgeons of Edinburgh and during his second furlough
(1921-22) he was a full-time demonstrator in the University
of Birmingham. - For six years he was a member of the council
of medical education of the China Medical Association, was
chairman of the Association during the biennium 1927—28, and
president from 1925-27; and he acted as chairman of the joint
conference of the Chinese Association and the Hong-Kong
and South China branch of the British Medical Association
held at Hong-Kong in 1925. In 1920 he visited Canada and the
United States as a member of a delegation financed by the
Rockefeller Foundation for the purpose of reorganising support
in these countries for the Canton Hospital as a centre of medical
education in South China. He returned to England in 1928
and since then ho has becn on the staff of University College
London, from1928-—30, asa full-time demonstrator ofanatomy and
since, 1930 as senior demonstrator. For the past six years he
has also had charge of the class of anatomy preparing students
for the primary F.R.C.S. examination. He is also sub-dean
of the faculty of medical science of University College and for the
past four years has had the additional duties of senior tutor in
the faculties of medicine, science, and engineering.
The title of professor of morbid anatomy in the
university has been conferred on Dr. W. D. Newcomb
in respect of the post held by him at St. Mary’s Hospital
medical school.
Society of Medical Officers of Health
Dr. James Fenton, medical officer of health for the
Royal Borough of Kensington, has been elected president
of this socicty for the session 1937-38. Dr. Fenton is
chairman of the Central Council for Health Education,
and is a past-chairman of the Royal Sanitary Institute.
University of Egypt, Cairo
Dr. A. Cecil Alport has been appointed professor of
clinical medicine and director of the medical unit of the
university.
Dr. Alport graduated in medicine at the University of Edin-
burgh in 1905 and during the war worked in the 28th and 4lst
General Hospitals and at the Royal Herbert Hospital, Woolwicb.
He also acted as specialist in medicine to the latter hospital and
as consultant in tropical diseases to the Ministry of Pensions.
In 1919 he took his M.D. degree at Edinburgh and in 1920 he
became a member of the Royal College of Physicians of London.
He was elected to the fellowship this year. Dr. Alport at present
holds the position of assistant to the director of the medical unit
of St. Mary’s Hospital. He published a text-book on nephritis
in 1929 and has also written on malaria and splenic anemia.
Commonwealth Fund Fellowships
Commonwealth fellowships in medicine have been
awarded to Dr. D. M. Douglas and Dr. J. D. Spillane.
Dr. Douglas intends to work at the University of Minnesota
and Dr. Spillane at Columbia University.
International Faculty of Sciences
On May 3lst, at 7.30 P.M., at the Gaumont-British
Theatre, Film House, Wardour-street, London, W.,
Dr. S. Monckton Copeman, F.R.S., will give a lecture
on experimental work bearing on the treatment of cancer ;
it will be illustrated with a film and lantern slides. Those
who wish to attend should notify the hon. secretary,
Hazlitt House, Southampton Buildings, W.C.2.
British Association of Radiologists
The third annual general meeting of this association
will be held at the British Institute of Radiology,
32, Welbeck-street, London, W., on Friday, June llth,
and on Saturday, June 12th. On the first day of the
meeting Dr. F. Hernaman-Johnson will deliver the Skinner
lecture on the after-care of patients suffering from cancer
of the breast. A paper on wavé-length as a factor in
radiotherapy will be read by Mr. G. F. Stebbing, and
Prof. J. M. Woodburn Morison and Dr. S. B. Adams will
open a discussion on low-voltage near-distance X ray
therapy. On the second day the following will speak :
Dr. E. Lysholm (radiological experience in ventriculo-
graphy), Dr. H. W. A. Post (salpingography), Dr. E.
Rohan Williams (urography in pregnancy), Dr. H. M.
Worth (the use of lipiodol in the localisation of spinal
tumours), and Dr. M. H. Jupe (some observations on cases
of suprarenal tumour).
THE LANCET]
Dr. L. W. Dryland and Dr. Josiah Walker have
been appointed doputy-Meutenants for the county of
Northampton.
London Hospital
On Tuesday, July 6th, at 3 P.M., Sir Kingsley Wood,
the Minister of Health, will distribute the prizes to students
of this hospital in the college library.
Tuberculosis Association
The annual provincial meeting of the Tuberculosis
Association will be held at the Central Library, Manchester,
on,June 10th, llth, and 12th, under the pig aeney. of
Dr. S. Roodhouse Gloyne.
Royal Eye Hospital
The clinical society of this hospital will hold a meeting
on Wednesday, June 2nd, at 5.30 P.M., at which a number
of cases will be shown and discussed. All medical practi-
tioners are invited, and further particulars may be had
_ from the hon. secretary at the hospital, St. George’s-
circus, London, S.E.
Demonstrations of Contraceptive Technique
On Wednesday, June 2nd, at 2.30 P.M., a practical
_ 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. Medical -practitioners
and senior students should apply for tickets to the hon.
secretary of the Society for Constructive Birth Control,
108, Whitfield-street, London, W.1. ’
Society for the Provision of Birth Control Clinics
A lecture on the theory and practice of contraception
will be given to medical practitioners and medical students
by Dr. Greta Graff on Friday, June llth, at 6 P.M., at
the Walworth Women’s Welfare Centre, 153a, East-
street, London, S.E. Practical demonstrations will be
given on Friday, June 18th, at 6 P.M. and at 7 P.M.
Further information may. be had from ane secretary at
the clinic.
Wellcome Chemical Works, Dartford
Mr. Sydney Smith, Ph.D., has been appointed works
manager at the Dartford works of Messrs. Burroughs
Wellcome and Co in succession to Mr. H. A. D. Jowett,
D.Sc., who met his death in a car accident last August.
Dr. Smith has been associated with Messrs. Burroughs
Wellcome and Co. for 23 years and has made many
contributions to the study of the alkaloids of ergot and.
the glucosides of digitalis.
Fellowship of Medicine and Post-Graduate Medical
Association
The following all-day courses will be held during tke
summer .months: gynecology, Chelsea Hospital for
Women (June 14th to 26th); proctology, St. Mark’s
Hospital (July 5th to 10th); dermatology, Blackfriars
Skin Hospital (July 12th to 24th, afternoons only) ;
urology, All Saints’ Hospital (July 12th to 31st). Week-
end courses will be held as follows: obstetrics, City of
London Maternity Hospital (June 12th and 13th); general
surgery, Prince of Wales Genera] Hospital (June 19th and
20th); diseases of heart and lungs, Victoria Park Hospital
(July 3rd and 4th); medicine and surgery, Miller General
Hospital (July 10th and llth). Courses to be held in
preparation for the M.R.C.P. examination are: clinical
and pathological course. at the National Temperance
Hospital (8 p.m. Tuesdays and Thursdays, June lst to
17th); course in chest diseases at the Brompton Hospital
(twice weekly, 5 P.M., June 7th to July 13th); course in
diseases of the heart and lungs, Victoria Park Hospital
(Wednesdays and Fridays, 6 P.M., June 9th to July 3rd);
course in neurology, West End Hospital for Nervous
Diseases (afternoons, June 2lst to July 3rd); fundus
oculi demonstration, 8.30 Pr.M., July 6th; pulmonary
tuberculosis demonstration at Preston Hall, July 3rd.
Full particulars of all courses and demonstrations can be
had from the secretary of the fellowship at 1, Wimpole-
street, London, W.
THe address of the Institute for the Scientific
Treatment of Delinquency has been changed from 56,
Grosvenor-street to 8, Portman-street, London, W.1.
MECICAL NEWS.—VACANCIES
[may 29, 1937 1315
Memorial to Young and Noguchi
The government of the Gold Coast is erecting a memorial
to William Alexander Young and Hideyo Noguchi who
died from yellow fever in 1928 while working at the
Medical Research Institute at Accra where Young was
the director. In their memory & bronze tablet will shortly
be placed in a room at the Institute and a small drinking-
fountain in front of the out- potons block of the Gold
Coast Hospital.
International Union against Tuberculosis
` The executive committee of the union has placed at the
disposal of the governments and ‘associations belonging
to the union a biennial prize of a value of 2500 French
francs, in memory of the late Prof. Léon Bernard, who
was founder, and, for fourteen years, the secretary-
general of the union. The prize will be awarded for the
first time in 1938 to the author of an original essay on
the social aspect of tuberculosis, in French or in English.
The essays must be typewritten or printed and must
not exceed 10,000 words. They must be forwarded by
a government or an association belonging to the union
to the secretariat, 66, Boulevard Saint-Michel, Paris
(VIe), not later than May Ist, 1938.
International Union against Cancer
Twenty-one different countries sent delegates to a
meeting of the general committee of the International
Union against Cancer which took place in London over
the week-end. They were entertained to luncheon on
Saturday by the executive committee of the British
Empire Cancer Campaign, and on Saturday evening they
were invited by His Majesty’s Government to a dinner
at Lancaster House, at which Sir Kingsley Wood, presided.
The chief business discussed by the delegates was the
programme for the next international cancer congress,
which it was decided should be held in Atlantic City in
September, 1939. The two official British representatives
` on the general committee are Dr. W. Cramer and Mr. Cecil
Rowntree, from whom any further information can be had.
Society for Relief of Widows and Orphans of Medical
en
The annual general meeting of this society was held
on May 19th, with Mr. V. Warren Low, the president, in
the chair. During 1936 21 new members were elected,
9 died, and 1 resigned; the membership on Dec. 3lst
was 275. The total income for the year was £5392 and
£5275 was distributed in relief to the 59 widows and
9 orphans in receipt of grants. This is an increase of
£1000 over the previous year. Special grants, amounting
to £217 10s., were made from the Brickwell fund to
orphans, to enable them to study for some business or
professional careers. The president announced that
in 1938 the society would be celebrating the 150th
anniversary of its foundation. Membership of the society
is limited to registered medical men who at the time of
their election reside within twenty miles of Charing Cross.
Further information may be had from the offices of the
society, 11, Chandos-street, London, W.1.
V acancies
For further information refer to the advertisement columns
are. Royal Infirmary.—Sen. Cas. O. for Out-patient Dept.
Altrincham General Hosp.—Sen. and Jun. H.S., at rate of £150
and £120 respectively.
Aylesbury, Royal Buckinghamshire Hosp.—Sen. Res. M.O., at
rate of £200.
Barnsley, Beckett Hosp. and Dispensary.—H.P., £200.
manna AA Hosp., Battersea Park, S. W.—Hon. Radio-
ogis
Belfast” Royal Maternity Hosp.—Res. M.O., at rate of £52.
Birmingham, Dudley-road Hosp.—Jun. M. O., at rate of £200.
Birmingham General Hosp.—Res. Surg. Reg., £100-£120.
PURUT omy Borough.—Asst. School "M.O. and Asst.
Blackburn F Rowel Infirmary.—Res. H.S., £175.
Bradford Children’s Hosp.—H.S., £150.
Bradford Royal Infirmary.—Hon. Asst. Physician.
Brighton, Royal Sussex County Hosp.—Office of Hon. M.O.,
Dept. for Treatment of Early Nervous Disorders. Hon.
Surg. Reg. H.P., £150. Also Cas. H.S., £120.
British P Pest praduule Medical School, WwW. —Three H. S? s to
Surgical Unit, at rate of £105.
1316 THE LANCET]
VACANCIES.—BIRTHS, MARRIAGES, AND DEATHS
[may 29, 1937
E E General Hosp.—Jun. Res. M.O., at rate of
Cardiff, King Edward VII Welsh National Memorial Assn.—
Asst. Res. M.O.’s for Spec. Hospitals, each £200.
Central London Throat, Nose, and Ear Hosp., Gray’s Inn-road,
W.C.—Hon. Assts. to Out-patient Dept.
Central Middlesex County H osp., Willesden.—Visiting Ear, Nose,
and Throat Surgeon, 3 guineas per session. Two Res. Asst.
__M.0.’s, each £400. Also Res. Cas. M.O., £350.
Children’s Hosp., 30, College-crescent, Hampstead, N.W.—Res.
. M.O., at rate of £150.
City of London Hosp. for Diseases of the Heart, &c., Victoria
, Park, E.—H.P., at rate of £100.
City of London Maternity Hosp., City-road, E.C.—Asst. Res.
M.O., at rate of £80.
Connaught Hosp., Oxford-road, E.—Sen. Res. M.O., at rate of
£175. Also H.P., H.S., and Cas. O., each at rate of £110.
Coventry and Warwickshire Hosp.—Res. H.S., Cas O., and Res.
H.S. to Aural and Ophth. Depts., each £150.
Coventry, City of —Asst. M.O. (Woman), £500.
Croydon Mental Hosp., Upper Warlingham.—Asst. M.O., £400.
Derbyshire Hosp. for Sick Children.—Res. H.S., at rate of £130.
Derbyshire Royal Infirmary.—Cas. O. and Orthopeedic H.S., £150.
Dreadnought Hosp., Greenwich, S.L.—Receiving Room Officer,
at rate of £200. Also H.P. and H.S., each at rate of £110.
Dudley, Guest Hosp.—Second H.S., £120.
Gloucestershire Royal Infirmary.—H.S., at rate of £150.
Gloucestershire Royal Infirmary and Eye Institution.—H.P.,
at rate of £150.
Golden-square Throat, Nose, and Ear Hosp., W.—House Anms-
thetist and H.S., £150 and £100 respectively.
Guildford, Royal Surrey County Hosp.—H.S., at rate of £150. —
Halifax Royal Infirmary.—Third H.S., at rate of £150.
Hampstead General and North-West London Hosp., Haverstock-
rat N.W.—Cas. Surg. O. for Out-patient Dept., at rate of
Hawkmoor Sanatorium, near Bovey Tracey.—Res. Asst. M.O.,
at rate of £250.
M kai Medical Service.—Vacancies for M.O.’s, £600-—
Holland (Lincolnshire) County Council.—Asst. M.O.H., £600.
Hoen: Jor Jropical Diseases, Gordon-street, W.C.—H.P., at rate
_ Hosp. of St. John and St. Elizabeth, 60, Grove End-road, N.W.—
i Ophth. Surgeon.
Huddersfield, St. Luke’s Hosp.—Res. M.O., £200.
Hull Royal Infirmary.—H.S. to Ophth. and Ear, Nose, and
ter Dept. Second H.P. and Second Cas. O., each at rate
oO ;
Institute for the Scientific Treatment of Delinquency, Portman-
street, W.—Med. Reg., £300.
Ipswich, East Suffolk and Ipswich Hosp.—Cas. O., H.S. to
Orthopsedic and Fracture Dept. Also H.S. to General
Surg. and Genito-Urinary Surgeon, each £144.
Kettering and District General Hosp.—Res. M.O. and Second
_ Res. M.O., £160 and £140 respectively.
Kingston and District Hosp.—Res. Asst. M.O., at rate of £375.
Lancashire County Council.—Asst. County M.O.H., £800.
Leeds, Menston Mental Hosp.—Asst. M.O., £350.
Leicester City Isolation Hosp. and Sanatorium.—Res. M.O., at
, rate of £300. À
Leicester. Royal Infirmary.—Res. Radiologist, at rate of £200.
Liverpool University.—Research Asst.in Dept. of Medicine, £600.
Also Demonstratorship in Anesthesia, Part-time, £100.
London County Council.—Asst. M.O.’3 (Grade I), each £350.
Also Asst. M.O.’s (Grade II), each £250.
London Jewish Hosp., Stepney Green, E.—Res. Cas. O., £100.
Manchester, Ancoats Hosp.—Res. Surg. O., £200.
aren and Salford Hosp. for Skin Diseases.—H.S., at rate
o ;
Manchester, Booth Hall Hosp. for Children.—Res. Surg. O., £400.
Manchester Ear Hosp., Grosvenor-square.—Res. H.S., £120.
Manchester, St. Mary's Hosps.—H.S.’s, each at rate of £50.
Manchester, Victoria Memorial Jewish Hosp., Cheetham.—Jun.
H.S. and Res. M.O., at rate of £125 and £150 a ,
Marie Curie Hosp., 2, Fitzjohn’s-avenue, N.W.—Res.
Ministry of Health, Whitehall.—Staft M.O.’s, £847.
National Temperance Hosp., Hampstead-road, N.W.—Cas. O.,
at rate of £120.
A ewo ie upon- Tyme; Barrasford Sanatorium.—Res. Med. Asst.,
Newport, Mon., Royal Gwent Hosp.—Two H.S.'s, each at rate of
Norwich, Jenny Lind Hosp. for Children.—Res. M.O., £120.
Tortie A as and Norwich Hosp.—Two General H.S.’s,
each 4 :
pillar nel County Council.—H.S. for City Hosp., at rate of
Nottingham General Hosp.—H.S. for Ear, Nose, and Throat
Dept., at rate of £150.
Oldham Royal Infirmary.—H.S. Also Cas. O. and H.S. to
Fracture Dept., cach at rate of £175.
CHLOE: BAREIS College.—Hulme Lectureship in Physiology,
50.
Oxford, Wingfield-Morris Orthopedic Hosp., Headington.—
Lord Nuttield Scholarship in Orthopedic Surgery, £200.
Plymouth, City General Hosp.—Jun. Asst. M.O., at rate of £250.
Plymouth, Prince of Wales's Hosp., Greenbaunk-road.—H.P.
and H.S., each at raie of £120.
Pontefract General Infirmary.—Jun. Res. M.O., at rate of £150.
Preston and County of Lancaster Royal Infirmary.—Res. H.S.
and H.S., each £150.
Preston County Borough.—Asst. School M.O., £500.
Princess Elizabeth of York Hosp. for Children, Shadwell, E.—
. H.P., H.S., and Cas. O., each at rate of £125.
Princess Louise Kensington Hosp. for Children, St. Quintin-
avenue, W.—H.S., at rate of £120.
Queen Charlotte’s Maternity Hosp., Marylebone-road, N.W.—
Hon. Gen. Surgeon. Also Obstet. Surgeon to In-patients.
wu Koya Hosp. for the East End, Stratford, E.—Clin. Asst.
o Skin Dept.
Queen’s Hosp. for Children, Hackney-road, E.—H.P. and Oas.
O., each at rate of £100.
Reading, Royal Berkshire Hosp.—Cas.O., at rate of £150.
Rochester, St. Bartholomew's Hosp.—H.P., at rate of £150.
Rotherham Hosp.—Cas. H.S., £150. Also H.S. for Ophth. and
Ear, Nose, and Throat Depts., £120.
Royal Air Force Medical Service.—Commissions.
Royal London Ophthalmic Hosp., City-road, E.C.—Out-patient
Officer, £100. tg
Royal Naval Medical Service.—M.Q.’s.
Salford Royal Hosp.—Two H.S.’s, each at rate of £125.
St. John’s Hosp., Lewisham, S.E.—Orthopeedic Registrar.
St. Mark’s Hosp. for Cancer, &c., City-road, E.C.—H.S., at rate
of £65. a
St. Peter’s Hosp. for Stone, d-c., Henrietta-street, W.C.—Clin.
Assts. to the Hon. Staff. f
St. Thomas’s Hosp., S.E.—Physician.
Sheffield Children’s Hosp.—H.S., £100.
Sheffield, Jessop Hosp. for Women.—Asst. in Hosp. Labs., £300.
Res. M.O. and Sen. Res. O., each at rate of £150. Also Three
H.S.’s, each at rate of £100.
Sheffield Royal Infirmary.—Ophbth. H.S., at rate of £120. Also
H.S. and Aural H.S., each at rate of £80.
Southampton, Royal South Hants and Southampton Hosp.—
Cas. O., and Res. Anesthetist and H.S. to Kar, Nose,
and Throat Dept.,at rate of £150.
South London Hosp. for Women, Clapham Common, S.W.—
H.P. and H.S., each at rate of £100.
elo. Prestwood Sanatorium.—Jun. Asst. M.O., at rate of
Stockport, Stepping Hill Hosp.—Res. Asst. M.O., at rate of £200.
Stoke-on-Trent, Burslem, Haywood, and Tunstall War Memorial
Hosp.—Res. H.S., at rate of £175. |
Stoke-on-Trent, Longton Hosp.—H.S., £160. i
Stoke-on-Trent, North Staffordshire Royal Infirmary. —H.S.
; for Auraland Ophth. Dept., £150.
Sunderland Royal Infirmary. —HĦH.S., £120. |
Surrey County Council.—Jun. Asst. M.O. for County Sanatorium,
at rate of £350. ` 5
Surrey County Hosp., Redhill.—Res. Asst. M.O., at rate of £375.
Sutton and Cheam Hosp.—Second Ophth. Surgeon.. Also
Physician-in-Charge of Physio-Therapeutic Dept.
Swansea County Borough Mental Hosp.—Asst. M.O., £400.
Swansea General and Eye Hosp.—H.S., at rate of £150.
Pano. ones and Bath Mental Hosp.—Res. Second Asst.
Tilbury Hosp., Essex.—H.S., at rate of £140.
Tunbridge Wells, Kent and Susser Hosp.—H.S.to Ear, Nose, and
- Throat Dept., £150.
Warrington Borough General Hosp.—Part-time Visiting M.O., at
rate of £300.
Weir Hosp., Grove-road, Balham, S.W.—Jun. Res. M.O., £150.
West London Hosp., Hammersmith-road, W.—Jun. Asst. M.O,
Uy Dept., £350. Also H.P. and Two H.S.’s, each at rate
of £100.
baer eral Royal Hampshire County Hosp.—H.P., at rate of
£
125.
mingor ne Edward VII Hosp.—Two H.S.’s and Cas. O.,
eac :
rores ahire Mental Hosp., Barnsley Hall.—Deputy Med.
Supt. :
Worksop Victoria Hosp.—Jun. Res., £130.
York, Bootham Park Mental Hosp.—Med. Supt., £800.
York County Hosp.—Second H.S. and Res. Anesthetist, £150.
The Chief Inspector of Factories announces vacancies for
Certifying pec Surgeons at Invergordon (Ross), South
Cave (Yorks, E.R.), Whitland (Carmarthen), Newton-le-
Willows (Lancs.), Lydbrook (Glos.), Milborne Port
(Somerset), Holborn and St, Pancras (London).
Births, Marriages, and Deaths
BIRTHS
AORES.—On May 9th, at the Baptist Mission, Bolobo, Belgian
Congo, the wife of Dr. Ian Acres, of a son.
BEAcH.—On May 17th, at Oxford, the wife of Surg. Lieut.-
Comdr. W. V. Beach, R.N., of a daughter.
CovE-SMITH.—On May 22nd, the wife of Dr. R. Cove-Smith,
of Stanhope-place, W., of a daughter.
Kay.—On May 21st, at Mill Hill, the wife of Dr. James Kay,
Elstree, of a daughter.
McDowa.Lu.—On May 22nd, at Emsworth, Hants, the wife of
Dr. Edward Benson McDowall, of a son.
OWEN.—On May 14th, the wife of Mr. C. Langley Owen,
F.R.C.S., of Ross-on-Wye, of a daughter.
PEGGE.—On May 16th, the wife of Dr. George Pegge, of Chepstow-
place, W., of a daughter.
STEADMAN.—On May 16th, at Devonshire-place, W., the wife
of Dr. Brian St. J. Steadman, of a son.
_Wass.—On May 17th, at Church-crescent, N., the wife of
Mr. S. H. Wass, F.R.C.S., of a son.
DEATHS
MARTIN.—On May 21st, at Churchill, near Bristol, Theodore
Martin, M.R.C.S., in his 82nd year. -
May.—On May 18th, at Bath, Colonel William Allan May,
C.B., R.A.M.C. (retd.), aged 86.
POLAND.—On May 22nd, at Seal, near Sevenoaks, John Poland,
F.R.C.S. Eng.
N.B.—A foe of 78. 64. is charged for the insertion of Notices of
Births, Marriages, and Deaths.
THE LANCET]
[may 29, 1937 1317
NOTES, COMMENTS, AND ABSTRACTS
LEGAL, CLINICAL, AND COMMERCIAL ASPECTS
OF BIRTH CONTROL |
AN important Bill concerned with contraception
and abortion became effective in Iceland in January,
1935.1 Its provisions are remarkable because they
impose upon doctors an actual obligation to give
advice on contraception in certain conditions; also
because they regard the woman’s economic circum-
stances as forming part of the therapeutic indications
for terminating pregnancy. The first sentence of the
` first section reads as follows :—
“If a woman consults a doctor and suffers from a
disease the nature of which is such that the doctor would
deem it dangerous to the woman to become pregnant or
to bear a child, it shall be his duty to warn her in this
matter and to direct her how to prevent conception. ...
The physician shall be bound to give her the information
required, but no one who is not a physician shall be allowed
to give such directions. The Minister of Health shall
publish and the Chief Medical Officer shall distribute among
physicians ‘Directions for women how to prevent
pregnancy ’.”
Section 9 ends with the following paragraph :—
“ When estimating how far childbirth may be likely to
damage the health of a pregnant woman, as mentioned
under sub-section 1] hereof, it may among other things
be taken into consideration whether the woman has
already borne many children at short intervals and a short
time has passed since her last confinement, also whether
her domestic conditions are difficult, either on account of
a large flock of children, poverty or serious ill-health
of other members of the family.”
CONTRACEPTIVE SUCCESS AND FAILURE
Reports on the data at birth control clinics have
been accumulating in the last fifteen years and a
valuable precedent as to how they should be presented
was set four years ago by Dr. Hannah Stone.? The
information collected has social and medical aspects,
and the scientific reports should therefore give
consideration to the economic status of the woman as
measured by her husband’s occupation and earnings,
to her age and religious affiliation, to her previous
reproductive history and her previous use of contra-
ception. It is always found that the clinics lose
touch with a proportion of patients and the exact
number should be stated; the earlier in the clinic’s
history a patient is seen, the greater is the chance
of the clinic losing touch. Of the women with whom
the clinic maintains touch, some discontinue the
method, either because it is not needed (in cases of
sterilisation, menopause. death of or separation from
husband), or because the method is found unaccept-
able. The number in each of these categories should
be given. Finally, a proportion of women use the
method successfully; and another proportion
experience failures—i.e., they have unwanted
pregnancies when using the method advised by the
clinic—which have been classified in various ways.
A report on 4000 cases by Dr. Ruth Robishaw °?
of Cleveland, Ohio, covers the six-year period 1928-34,
and gives much valuable information ; but it is not
clear on all these points. The reader is left to deduce
that, of the patients seen during this period, the
clinic maintained touch with 2083—yjust over half
the total; as is to be expected, the proportion of
women seen each year with whom the clinic main-
tained touch increased steadily from 1928 to 1933.
Thus, by 1934, it had retained contact with only 16
per cent. of the cases seen in 1928; whereas it main-
1 Hodann, M., Marriage Hygicne; Bombay. November, 1936
(English translation of the Act).
2 Stone, H. M., and Hart, H., Medical Health apd Contra-
a Study of the Social and Medical Data of 2000
The social data were published by the New Jersey
Birth Control League; the medica] data (by Stone) in the
Medical Journal and Record, April 19th and May 3rd, 1933.
3 Robishaw, R. A. (1936) Amer. J. Obstet. Gynec. 31, 426.
ception :
Patients.
tained touch with 96 per cent. of those seen in 1933.
But particulars of all 4000 women are given by
Dr. Robishaw in her report, so it is to be presumed
that,in 1917 cases, the records of the women’s experi-
ences stop short when contact with them was lost,
and thus do not cover the whole interval which elapsed
between the date of their first attending the clinic and
the year 1934 when the six-year period ended.
In 3514 of the recorded cases the method advised
was a combination of a diaphragm pessary and a
lactic acid jelly. In the remaining 486 patients,
12 other methods were advised. Of the total of
4000 women, 1760 successfully used thea method
which had been advised; 1353 discarded it because
they found it unsatisfactory ; and 151 gave it up
for reasons that had no connexion with its. merits
or demerits. One hundred and twelve women were
pregnant before they began to use the method. Of
357 women who became pregnant after it had been
used, 331 experienced unwanted pregnancies; only
26 pregnancies appear to have been planned. The
smallness of this proportion is remarkable in view of
the fact that the average age of the women was
between 25 and 30 and of the fact that, in this country
at least, birth control clinics are used largely by
women who want to space their children. Of the
failures, 41 were unaccountable—i.e., were not attri-
buted to defects in the appliances provided or to
omissions of part of the procedure. The unaccount-
able-failure rate of 1 per cent. over a period of about
two years accords closely with the findings of previous
investigations in America and in this country.
Assuming a coitus-rate of once a week, the risk of
failure at each act works out at 1 in about 4000,
provided that the method is properly carried out.
THE COMMERCIAL SIDE
In an account of the birth control industry in
America Harrison Reeves ‘ givessome striking figures.
It is said that 5,000,000 sheaths are sold daily and
that 275 million dollars a year are spent upon them.
But in addition to this, 300,000,000 dollars are annually
spent on other contraceptive appliances such as
jellies, suppositories, caps, rings, and compounded
prescriptions. The birth-control industry, while not
yet comparable in volume to the petroleum industry
or to the industry in cosmetics and beauty appliances,
is one upon which is being increasingly focused the
principles of scientific salesmanship. Thus we are
told that the use of slot-machines in garages and
public lavatories, and of placards for advertisement,
are being discouraged ; but schemes are favoured for
installing vending machines on battleships, in army
barracks, in police headquarters, and in country clubs.
“ Successful installations of this sort,’’ says Mr.
Reeves, ‘‘ would give class to the business, speed word-
of-mouth advertising and break down one barrier
after another.” Since the author does not quote
the sources from which his computations are drawn,
his figures should be accepted with caution; but
they suggest the desirability of obtaining accurate
data in this country with regard to a trade that
now has a noteworthy sociological influence.
THE NUTRITIONAL POLICY OF THE
LEAGUE OF NATIONS
AT the twenty-fifth session of the Health Committee
of the League of Nations, held at Geneva during the
last days of April, a programme was discussed and
approved for the next three years. Consideration
was given to the report of the Technical Commission
of Nutrition set up in 1935, which held its first session
in London in November of that year (see Lancret,
1935, 2, 1434). This report has, it seems, created
an impression not only in Europe but also overseas ;
thus the agenda of the Intergovernmental Conference
on Rural Hygiene in the Far East includes items
eS eaa
4 Reeves, H., American Mercury, October, 1936.
1318 THE LANCET]
such as the composition of dietaries, the nutritive
value of the principal foods, deficiency diseases and
their method of investigation, all of them inspired
by the Commission’s report. In Chile a study of
popular nutrition by Profs. Dragoni and Burnet is
now in the hands of the government. Nutritional
problems will also figure prominently in the agenda
of the Conference on Rural Hygiene in American
Countries and in that of the European Conference on
Rural Life, both of which, it is presumed, will be
held during the mandate of the present Health
Committee. It was felt at this session that the
procedure adopted for the study of nutrition has
produced valuable results in a comparatively short
space of time and, having thus proved its worth, is
not in need of modification at present. The report
of the Technical Commission will thus remain the
pivot of activity.
LE PLAY SocIeTY.— Sir John Russell, F.R.S., of the
Rothamsted Institute, Harpenden, is to lead a group of
mem bersandfriendsof thissociety to Soviet Russiain August.
The visit will afford an opportunity for seeing something of
what is being done in the application of science to everyday
problems in Russia, particularly in regard to farming.
The general geographical features of the country, its
geology, vegetation, and various social experiments will
also be studied. This group will leave -London on
August 6th and will go via the Black Sea to Erivan in
Soviet Armenia, returning via Moscow and Leningrad
by boat to London. Finnish Lapland is to be visited by
another Le Play group, who will stay for a short time on
the Arctic coast. For geographers, botanists, and
geologists, this presents a particularly interesting area for
vacation study. The party will leave London on
August 4th. Similar arrangements ‘are being made for
visits to Yugoslavia (Old Serbia), where there will be
special interests for the geologist and the botanist; to
Czechoslovakia; to the Dalmatian coast; and to the
Outer Hebrides. Full details of these vacation visits
can be had from: Miss Margaret Tatton, director of the
society, 58, Gordon-square, London, W.C.1.
CorricENDUM.—In the article on the Action of Trypsin
on Diphtheria Toxin by Brandwijk and Tasman in our
last issue, p. 1228, the reference in line 7 should be to
various strains of t typhoid bacteria.
Appointments
Brown, D. G. W., M.Ch. Orth. Liverp., F.R.C.S. Edin., Ortho”
predic Surgeon to the Royal Infirmary, Sunderland.
GIBSON, ROBERT, M.B. Glasg., Assistant Medical Officer at
the Bristol Mental Hospital, Fishponds.
GORDON, W. H., M.B. Glasg., D.O. M.S., Refractionist to the
Queen Mary’ s Hospital for the East "End.
HALDANE, F. P., M.B. Glasg., Assistant Physician to Runwell Hos-
pital ‘for Nervous and Mental Disorders, Wickford, Essex,
HOPE, EDITH, M.R.C.S. Eng., D.M.R.E., Radiologist in Charge
of Dingnostic Work at the Elizabeth Garrett Anderson
ospita
HOSFORD, JOHN, M.S. Lond., F.R.C.S. Eng., Consulting Surgeon
to the Bethiem ee Hos no London
HULBERT, N. G., M.B. Camb., P. Lond., Medical Registrar
to the Royali Chest oroita, Lonin
JoHNSON, J. F. M.B. Manch., Assistant Medical Officer at
Wooley E ie. N orthumberland.
LEDERMAN, M.B. Lond., Resident Medical Officer at the Radium
Institute, London.
MCCARTHY, Rita, L.R.C.P. Irel., Clinical Assistant to the
Ophthalmic Depart ment, Sheffield Royal Hospital.
MILLs, J. P. TYNAN, L.R.C.P. Edin., Temporary Assistant
School Medical Officer and’ Assistant Medical Officer of
Health for Excter.
PRICE, MARGARET R., L.R.C.P. Lond., D.C. H., First Assistant
in the Children’s "Department of the Royal Free Hospital.
SAVEGE, RONALD, M.B. Aberd., F.R.C.S. Edin., D.L.O., Hon.
Assistant Surgeon to the Ear, Nose, and Throat Depart-
ment of the Croydon Generi Hospital.
SMITH, C. M., M.D. Glasg., D.P.H., County Medical Officer
of Health and Chief School Medical Officer for Northampton-
shire
THOMAS, A. R., B.Chir. Camb., D.M.R.E., Radiologist to the
Bethlem Royal Hospital, London.
City Infectious Diseases Hospitals, Liverpool.—The following
appointments are announced :
HURST, Mary M., M.B. Liverp., Assistant Resident Medical
Officer ;
DoDD, ARCHIBALD, M.B. Liverp., Assistant Resident Medical
Officer ; and
CONCANNON, A. B., M.B. Liverp., Assistant Resident Medical
Oficer. i
, APPOINTMENTS. —MEDICAL DIARY
[may 29, 1937
Medical Diary
Information to be included in this column should reach us
tn proper form on Tuesday, and cannot appear tf at reaches
us later than the first post on Wednesday morning.
SOCIETIES
ROYAL SOCIETY OF MEDICINE, 1, Wimpole-street, W.
WEDNESDAY, June 2nd.
Surgery. °2.30 P.M. Summer meeting at the British
Postgraduate Medical School, Hammersmith Hospital,
Ducane-road, W.
BIOCHEMICAL SOCIETY.
FRIDAY, June 4th.—2.30 P.M. (Institute of Physiology
the University, Glasgow), cemmunications an
demonstrations.
LECTURES, ADDRESSES, DEMONSTRATIONS, &c.
ROYAL COLLEGE OF PHYSICIANS, Pall Mall East, S.W.
TUESDAY, June 1st.—5 P.M., Dr. Edwin Bramwell : Clinical
Reflections upon Muscles, Movements, and the Motor
Path. (Last Croonian lecture -)
MATERNITY AND CHILD WELFARE CONFERENCE.
TUESDAY, June lst, WEDNESDAY, and THURSDAY.—English-
speaking Conference on Maternity and, Child Welfare
at B.M.A. House, Tavistock-square, W
ea W. POSTGRADUATE MEDICAL SCHOOL, Ducane-
roa
TUESDAY, June lIst.—4.30 P.M., Dr. D. Hunter:
tional Diseases.
WEDNESDAY.—Noon, clinical and pathological conference
(medical). 2. 30 P. M., Prof. M. Greenwood, F.R.S.:
Experimental Epidemiology. 3 P.M., Clinical and patho-
logical conference (Gurgical).
THURSDAY.—2.15 P.M., Dr. Duncan White: Radiological
Demonstration. 3 P. M., operative obstetrics. 3.30 P.M. j
Mr. A. K. Henry: Demonstrations of the Cadaver of
Surgical Exposures.
FRIDAY.—2.30 P.M., Mr. Russell Howard: Diseases of
the Breast. 3 P. M., ges a ae pathological conference
(obstetrics and gynecol ogy).
Daily, 10 a.m. to 4 P.M., medical clinics, surgical clinics
and operations, obstetrical and gynæcological clinics
ene operations. Refresher course for general prac-
itioners.
WEST LONDON HOSPITAL POST-GRADUATE COLLEGE,
Hammersmith, W.
MONDAY, May 31st.—10 A.M., Dr. Post: X ray film demon-
stration, skin clinic. 11 A. M., surgical wards. 2 P.M.,
operations, surgical and gynecological wards, medical,
surgical, and gynecological clinics.
TUESDAY, June 1st.—10 A.M., medical wards.
surgical wards. 2 P.M., operations, medical, surgical,
and throat clinics. 4.15 P. M., Dr. B . Coden : *Choice o
Aneesthesia.
WEDNESDAY.—10 A.M., children’s ward and clinic. 11 a.™.,
medical wards. 2 P.M., gyneecological operations,
medical, surgical, and eye clinics. 4.15 P.M., Dr.
Redvers Ironside: Subarachnoid Hemorrhage.
THURSDAY.—10 A.M. , neurological and gynsecological clinics.
Noon, fracture "clinic. 2 P.M., Operations, medical,
surgical, genito-urinary, and eye clinics. 4.15 P.M.,
Mr. Simmonds: surgical lecture.
FRIDAY.—10 A.M., medical wards, skin clinic.
iecture on treatment. 2 P.M.,
surgical, and throat clinics. 4.15 P.M., Dr. Owen:
Artificial Feeding in Infants.
SATURDAY.—10 A.M., children’s and surgical clinica.
11 A.M., medical wards.
The lectures at 4.15 P.M. are open to all medical practitioners
without fee.
FELLOWSHIP OF MEDICINE AND POST-GRADUATE
MEDICAL ASSOCIATION, 1, Wimpole-street, W.
* MONDAY, May 31st, to SUNDAY, une 6th.—ST. PETER’s
HOSPITAL, Henrictta- street, W.C., all-day advanced
course in urology. —PRINCE OF WALES GENERAL
HosPITAL, Tottenham, N., Sat. and Sun., course in
Occupa-
11 A.M.,
Noon,
operations, medical,
general medicine.
ST. MARY’S HOSPITAL, W.
TUESDAY, June Ist. —5 P.M. (Institute of Pathology and
Research), Mr. F. T. Ridley : The Intraocular Pressure.
no oo FOR SICK CHILDREN, Great Ormond-street,
THURSDAY, June 3rd.—2 P.M., Dr. E. A. Cockayne:
Jaundice. 3 P.M., Mr. Charles Donald: Goitre in
Out- patient clinics daily at 10 A.M. and voro visits at 2 P.M.
LONT ON SCHOOL OF DERMATOLOGY, -5, Lisle-street,
MONDAY, May 31st.—5 P.M., Dr. G. B. Dowling : Occupa-
tional Dermatitis.
TUESDAY, June 1st.—5 P.M., Dr. H. W. Barber: Lichen
Planus.
THURS E= P.M., Dr. Hugh Gordon: Treatment of
cne. $
FRIDAY.—5 P.M., Dr. J. E. M. Wigley: Napkin Area
Eruptions.
SOUTH- WEST LONDON POST-GRADUATE ASSOCIATION,
St. James’ Hospital, Ouseley-road, S.W.
WEDNESDAY, June 2nd.—4 P.M., Dr. C. E. Lakin : Demon-
stration of Medical Cases.
MANCHESTER ROYAL INFIRMARY.
FRIDAY, June 4th.—4.15 P.M., Dr. P. B. Mumford: Demon-
stration of Skin Cases. ‘
THE LANCET]
[June 5, 1937
ADDRESSES AND ORIGINAL ARTICLES
THE TREATMENT OF DIABETES
CLINICAL AND EXPERIMENTAL
OBSERVATIONS WITH NEW INSULINS
By T. Izop BENNETT, M.D., F.R.C.P. Lond.
PHYSICIAN WITH CHARGE OF OUT-PATIENTS, MIDDLESEX
‘HOSPITAL, LONDON
T. M. Davis, B.M. Oxon., M.R.C.S. Eng.
OLINICAL ASSISTANT AT THE HOSPITAL ;
DOUGLAS GAIRDNER, B.M. Oxon.
HOUSE PHYSICIAN AT THE HOSPITAL ; AND
A. Morton GL, M.D., M.R.C.P, Lond.
‘ MEDIOAL REGISTRAR AT THE HOSPITAL
(From the Wards and the Diabetes Clinic, Middlesex Hospital)
THE evolution of the modern treatment of diabetes
is marked by certain stepping-stones of fundamental `
importance. These are :—
1. “ Ladder ” diets devised by Dr. George Graham.
The introduction of gradually increasing and balanced
diets after a period of initial starvation began a new epoch
by which the mortality of diabetes was greatly diminished
and the general welfare of the diabetic patient notably
increased.
2. Discovery of insulin.—This has enabled us to diminish
the mortality of diabetes to a very low level even in cases
of great severity; it has also reduced the mortality of
diabetic coma, ae was previously 100 per cent., to a
relatively low fi
3. Introduction of high-carbohydrate diets.—Several years
ago observers in many countries discovered, almost
simultaneously, that in severe cases of diabetes, controlled
by diet and insulin, it often becomes possible to increase
the daily ration of carbohydrate, with benefit to the
patient, and without increase in the daily dose of insulin ;
it was even found that it was often possible to diminish the
daily dose of insulin. This advance has been less funda-
mental than the others and has occasionally had the dis-
advantage of encquraging patients to eat unwise amounts
of carbohydrate ; it has however, when properly employed,
brought increased liberty to the diabetic patient.
To these three advances must now be added a
fourth in the form of certain new insulin preparations
which act more slowly and over a longer period than
does insulin in its original form. The parent of these
insulins is the protamine insulin invented by Prof.
H. C. Hagedorn of Copenhagen, and marketed in
this country under the name of Retard Insulin.2
The other new insulin marketed in Great Britain by
a group of British chemical firms is known as Protamine
Insulin (with Zinc) Suspension?; its composition
may broadly be described as ‘being Hagedorn’s
protamine insulin with minute amounts of zinc added
to it.
A further new insulin has been widely used in
North America under the name of “crystalline
insulin”; this product is not at present on the
British market but our observations include some
made with an insulin of this type and provisionally
called Zine Crystalline Protamine Insulin; this
composition may be described as being ordinary
insulin crystallised by zinc and subsequently combined
with protamine.
1 Leo, made by Nordisk Moulin Laboratorium, Copenhagen,
and obtainable from C. L. Bencard Ltd., Londo
2 Allen and Hanbur pf Ltd., Boots Pure Drue Co., Ltd., The
British Drug Houses Ltd., Burroughs Wellcome and Co.
5936 3 Made by Organon Laboratories, Oss, Holland.
BASIC PRINCIPLES OF TREATMENT
igenséion of the value, and of certain disadvantages,
of these new insulins can be clarified. by a brief
recapitulation of the basic therapeutic principles
which have governed the majority of physicians
when treating diabetes during the last twenty-five
years, At first, when the immense significance of the
“ starvation ” treatment and ‘“‘ladder’’ diets was
appreciated, it was believed that if a patient with
diabetes was kept constantly sugar-free the pancreas
was placed in a condition of rest, deterioration was
checked, and the possibility of regeneration secured.
With the introduction of insulin attention became
concentrated upon the sugar in the blood but the
principle of pancreatic rest still governed treatment ;
it was often laid down that the optimum dose of
insulin was that which would prevent hyperglyca#mia
at any time in the twenty-four hours. The astounding
success of insulin gradually brought with it the
conviction that this substance had a wider effect
‘than mere chemical control of the sugar circulating
in the blood; patients properly treated with insulin
do not only cease to lose weight, and regain strength,
they exhibit far wider physiological restoration, as
may be exemplified by the disappearance of pro-
longed amenorrhea in women and the reappearance
of virility in men. In fact, it becomes clear that
successful insulin therapy is a true “replacement ”
therapy akin to the treatment of Addison’s disease with
adrenal cortical extract. It might almost be said to-day
that the correct dose of insulin in any patient with
diabetes is the maximum dose that can be adminis-
tered without the production of unpleasant. symptoms,
But recent years have taught us that certain
unpleasant symptoms resulting from hypoglycsmia
form a very important factor in the lives of many
patients suffering from severe diabetes. We can
recall the case of a medical man who set out on his
morning round in a new car and remembered nothing
until he awoke in a London hospital with a badly
cut head, to receive the news that his car had been
found smashed to pieces in a quiet suburban road.
We were recently asked. to report on a bank clerk,
who had at one time attended the diabetes clinic
at the Middlesex Hospital, and who had just achieved
notoriety by entering the manager’s office in the
middle of the morning where he smashed the furniture
and assaulted his superior. Another bank clerk,
who had been perfectly controlled with insulin in
1926, consulted us again in 1932 because he found
that on several days a week he tended, at about
11 A.M., to throw the ledgers all over the office and
then retire to sulk in the w.c. for half an hour. In
children a condition of pronounced nervousness,
irritability, and fear is often apparent at times when
the effect of a previous dose of insulin is at its maxi-
mum, and almost any diabetic patient who has been
on insulin for a long time will, if his confidence be
secured and his very proper desire to avoid grumbling
be subdued, tell his medical adviser of the dread
he has of these mild hypoglycemic attacks. The
new insulins, with their slower and more prolonged
action, hold promise of making it easier to reproduce
the continuous secretion of natural insulin which we
believe to be the physiological condition, and to diminish ,
this risk of frequent hypoglycemia, mild or severe,
which is so much dreaded by the diabetic patient.
Comparison with Ordinary Insulin
Table I sets out briefly the varieties and times of
action of the insulins at present available in Great
Z
1320
Britain. From this it is clear that the essential differ-
ence between the various insulins lies in their rate of
action. All of the new insulins here are, when used,
suspensions of ordinary insulin combined with prota-
THE LANCET]
TABLE I
‘ Types of Insulin
Commence-
Type of insulin. Synonyms. ment of sr a
action. era
Ordinary insulin. — 20—40 min. 3 hrs.
Insulin retard. Protamine 1-3 hrs. | 6-8 hrs.
l sulin ;
Hagedorn’s
l insulin
Zinc insulin. Protamine 9-11 hrs. | 15—20 hrs.
insulin (with
zinc) suspension.
Zinc crystalline pro- Protamine- 8-12 hrs. | 12-20 hrs.
tamine insulin. insulin Organon.
mine, the zinc insulins containing zinc in addition.
All these insulins act much more slowly than ordinary
insulin, and it is believed that this is due to the
fact that they remain for a long time in the sub-
cutaneous tissues, where they are broken up and slowly
absorbed into the blood stream as ordinary insulin.
The zinc products are far more slowly absorbed than
the pure protamine insulin. Whether there is any
further distinction between the action of the English
zinc protamine insulins and the Dutch crystalline
protamine insulin. we are not yet in a position to say
with certitude. Table II sets out briefly the advan-
tages and disadvantages of the different products.
In this table it has been necessary to place all the
zine insulins together, though later observations
may make it necessary to separate them as regards
their effects.
TABLE II
Advantages and Disadvantages of Different Types
a Ags Advantages. Disadvantages.
Ordinary Constant in effect, Transient effect, multiple
insulin. invaluable’ in doses often needed,
coma, available in liable to produce fre-
many strengths. quent brief hypo-
glycemia.
Insulin More prolonged Effect somewhat oan,
retard. effect, painless on occasional severe hy
injection, controls glycæmic effects, ba
early morning to administer in es
hyperglycemia, doses, occasional dift-
never more than culty in controlling
two doses required glycosuria before lunch.
daily.
Zinc insulin | Stillmore prolonged | Effect somewhat erratic,
and crystal- effect, will often may produce unex-
line prota- control even a pease and very pro-
mine in- severe case with nged hy ypogiy comia,
sulin. one injection bulky to administer in
daily. large doses.
It remains to be said that of the new insulins,
insulin retard is supplied in boxes containing five
bottles of the insulin and one bottle of buffer solution,
a small amount of the latter having to be added to
each bottle of the insulin before it is used; the
addition of the buffer throws down a precipitate and
until this is done the product acts exactly as ordinary
insulin. A buffer solution is also supplied with
crystalline protamine insulin, but in this case the
buffer is attached to each bottle of insulin in a
separate chamber from which it can be mixed with the
insulin before the bottle comes into use. This has
the advantage of obviating an essential but not
DR. IZOD BENNETT AND OTHERS : NEW INSULINS IN DIABETES
-into a vein.
‘saline with glucose quickly restored him and he was.
[sone 5, 1937
altogether trivial measurement by the patient. The
English protamine insulin (with zinc) suspension is
supplied mixed as a suspension which, it is claimed,
remains potent for six months. Each bottle is dated
and it remains to be seen whether the claim of the
manufacturers that their product remains stable for
so long a period is justified.
HAGEDORN’S PROTAMINE INSULIN (INSULIN RETARD)
In a previous communication two of us (Bennett.
and Gill 1936) reported the excellent effects obtained
by means of protamine insulin in the treatment of
severe diabetes in children. Further experience
enables us to confirm all that was said in that paper ;
the children are more easily kept sugar-free, often only
require one daily dose of insulin, rejoice in the painless-
ness of the injections, and are observed to be in better
health and less subject to attacks of mild hypo-
glycemia. We have seen no ill effects from the use of
this product except that one of these children was
brought into hospital in hypoglycemic coma as the
result of having accidentally given his injection direct.
The administration of intravenous
in his usual health within a few hours. It is to be
8 0
IN HOURS
6
TIME
FIG. 1.—Comparison between ordinary insulin and protamine
(retard) insulin in a normal man. Inthe ee he curves
show rapid recovery from effect of ordinary ins but
proremine (retard) insulin still acting 6 hours after the
Phere and producing py pols cole attack. On a
e effect of ordinary insulin
“* Peen ” by lunch, but „protamine insulin continues to act
strongly until its action is ‘‘ buffered ” by tea.
d diet the curves show
noted that all the new products, if administered
intravenously, act with the same speed and in the
same degree as a corresponding dose of ordinary
insulin. An attack of hypoglycemia arising in this
manner will therefore be exactly similar to one arising
from the result of such an accident when ordinary
insulin is used. Severe hypoglycemia following the
subcutaneous administration of one of the new insulins
may, however, be more serious than the hypoglycemia
of ordinary insulin. We have not met with such an
event with protamine insulin but further reference
will be made to the subject when discussing the zinc
insulins.
Fig. 1 illustrates the effect of protamine insulin
on the blood-sugar. It shows the curves of
blood-sugar in a normal man, in one fasting, in
the other on a fixed diet, after an injection of this
substance,
This effect is seen in the fasting subject after the
injection of 30 units, and it will be noted that at the end
of a few hours the effect of the ordinary insulin has quite.
passed off whilst the protamine insulin is acting more and
more strongly at the end of six hours; sweating, giddiness,
and general mental disturbance proclaimed the advént
of pronounced hypoglycemia and glucose had to be
rapidly administered to the patient, the blood-sugar having
now fallen to 45 mg. per 100 c.cm. The curves with a.
fixed diet show the comparative effect of the pwo insulins
given before a series of small spaced meals. Two hours
after breakfast the ordinary insulin has produced the
greater effect but lunch soon counteracts this, whereas
THE LANCET]
the protamine insulin is only reaching its maximum at
fave hours after its first administration.
We have now been using retard insulin for many
months, both for children and for serious cases of
diabetes in adults. In a certain number of cases we
have been able to establish stability with a single
daily injection given before breakfast, but in the
Majority it has been necessary to give a dose at night
as well, and as the effect of this second dose has almost
entirely ceased by breakfast next morning, when the
LTS
B : 100
Š ITLI Š
% 30UNITS $
S80 80
$ $ JansaT =
> 60 Ì 60
9
S 0 4 2 20 O10 4 2 20
TIME IN HOURS TIME IN HOURS
2 3
FIG. 2.—Comparison between oroinary insulin and protamine
insulin (with zinc) suspension, tbe latter acting powerfully
18 hours after injection. (Normal man on a fixed diet.)
FIG. 3.—Comparison between ordinary insulin and zinc pro-
tamine crystalline insulin. Zinc protamine crystalline insulin
aching de nen 18 bours after injection. (Normal man on a
fixe et. i
morning dose has not yet begùn to act, it is not
unusual to observe a transient glycosuria for one or
two hours after breakfast. For this reason certain
observers have advocated the addition of a little
ordinary insulin to the morning dose, but we feel that
any possible advantage of this procedure is probably
outweighed by the danger of obliging a patient
to employ two different brands of insulin, each
requiring careful measurement. It must also be
noted that some of the chemists responsible for the
manufacture of the new insulins stress the importance
of great accuracy in the pH of the substances when
t
used, and mixture of two products will tend to upset
this. Wbile it is perhaps doubtful whether such
extreme exactness is of great importance we have no
evidence that any real ill effect follows a transient
hyperglycæmia which is only present for a very short
period after breakfast.
The following illustrative cases may be cited :—
CasE 1.—Dose unchanged. Reactions abolished. Female
aged 29. Severe diabetes of eleven years’ duration.
Sugar-free on 32 units of ordinary insulin morning and
28 unitsevening. Frequent and rather severe hypoglycemic
reactions. Result.—Now sugar-free on protamine (retard)
insulin 32 and 28 units. Only two mild reactions in many
weeks.
Cast 2.—Dose reduced to one a day. Male aged 36.
Mild diabetes for two years. Sugar-free on ordinary
insulin 14 and 10 units. No reactions. Result.—Now
sugar-free on one daily dose of 26 units protamine (retard)
insulin
Case 3.—Failure to secure stabilisation. Female aged
39. Severe diabetes for eleven years. Sugar-free on
20 units ordinary insulin for each of three main meals.
Frequent hypoglycemic attacks. Changed to protamine
(retard) insulin, 40 units morning, 20 units evening.
Result.—Reactions abolished but has frequent glycosuria
both morning and afternoon.
Case 4.—Morning glycosuria abolished. Male aged 37.
Severe diabetes ten years. Complicated by pulmonary
tuberculosis now quiescent. Constant early morning
glycosuria on ordinary insulin 40 and 25 units. Result.—
Now continuously sugar-free on protamine (retard)
insulin 44 and 30 units. Comment.—The pulmonary
complication made it important to secure complete control
DR. IZOD BENNETT AND OTHERS: NEW INSULINS IN DIABETES [JUNE 5, 1937 1321
in this case; it is, however, to be noted that with active
pulmonary tuberculosis, and with varying and very low
tolerance, ordinary insulin, with its rapid and constant
action, is to be preferred to the slower insulins.
Case 5.—Constant glycosuria abolished ; ‘total dosage
reduced. Male aged 66. Severe diabetes five years.
Glycosuria never properly controlled on ordinary insulin
40 and 36 units. Occasional hypoglycsmic reactions.
Result.—Now continuously sugar-free on protamine
(retard) insulin 38 and 20 units. Occasional slight
hypoglycemia.
PROTAMINE INSULIN (WITH ZINC) SUSPENSION AND
ZINC CRYSTALLINE INSULIN
Both these insulins act more slowly and for a longer
period than does protamine insulin (retard). Figs. 2
and 3 show the effect of an injection of 30 units of
these insulins on the blood-sugar of normal individuals
taking four fixed meals ; it will be seen that the normal
increase in blood-sugar is converted into a sharp
decline which begins to be apparent only after eight
hours and is approaching its maximum at about
eighteen hours after the administration of the insulin.
Owing to this extreme delay it is often possible to
achieve stability even in severe cases of diabetes
by employing a single daily dose of one of these
substances ; the following are illustrative cases :—
CasE 6.—Incipient coma ; stabilised with a single daily
dose. Female aged 16. Severe diabetes, two months’
duration. Admitted to hospital in incipient coma,
relieved by massive doses of ordinary insulin. She was
+ placed on a ladder diet and gradually built up to 120C,
100 P, 150 F, discharged on this diet, with 26 units of
protamine insulin (with zinc) suspension before breakfast.
Result.—She has remained well and stable for two months.
CasE 7.—Heavy ketosis; stabilised with single small
evening dose. Female aged 11. Admitted with heavy
ketosis and uncontrolled glycosuria. Six weeks’ history.
Controlled with ordinary insulin; gradually built up on
ladder diet with substitution of protamine insulin (with
zinc) suspension. After fourteen days in the ward she
N : 100
Š §
g 8
N pe 160
= =
Š i20
Š Š
Š Š
S 40 = 80
0 4 2 20 26 “4 2 20
TIME IN HOURS TIME IN HOURS
4 5
FIG. 4.—Blood-sugar observations from Case 7 taken when
stability was first achieved.
FIG. 5.—Blood-sugar curves from a case somewhat similar to
Case 8. Female aged 53. Zinc protamine crystalline insulin
40 units given at 9 p.M.—i.e., two hours after supper. Only
fair control of blood-sugar and total daily carbohydrate low
(60 g.). Distribution of carbohydrate: breakfast 35 per cent. ;
lunch 35 per cent.; tea 20 per cent.; supper 10 per cent,
was sugar-free and symptomless on a single evening
(9 P.M.) injection of 40 units (Fig. 4). During the next
week this dose was reduced to 32 units and the patient
was discharged from ward. Result.—Now attending out-
patients and dose is only 16 units. There have been
three slight reactions at about 2 a.m.
But against apparently brilliant successes of this
kind must be set a number where this is qualified
by the necessity to employ more than one type of
insulin,
CasE 8.—<Stability on two doses of ordinary insulin ;
failure to control with single dose of zinc insulin. Female
aged 55. Severe diabetes of two years’ duration. Sugar-
free on 18 units of ordinary insulin night and morning
1322. THE LANCET]
DR. IZOD BENNETT AND OTHERS: NEW INSULINS IN DIABETES
[JUNE 5, 1937
but subject to occasional severe hypoglycemic attacks when
taking much exercise in the mornings. Very desirous to
get on to a single dose of insulin. Three weeks’ careful
treatment in hospital failed to achieve this but at the
present time she is well on 36 units of protamine insulin
(with zinc) suspension, given every evening at 8.30 P.M. ;
on this she usually shows glycosuria between 10 a.m. and
l P.M., which can be controlled by giving 6-10 units of
ordinary insulin before breakfast. It is felt that the present
position is probably preferable to the previous situation,
because this patient is not very intelligent and was
irregular in her meals and times of administration of
ordinary insulin; there is now much less risk of hypo-
glycemia and she has greater liberty in that the exact
hour of the evening dose does not very much matter ;
it remains to be seen whether it is necessary for her to
take the morning dose of insulin.
Risks of Hypoglycemia
The risks of severe hypoglycemia owing to cumu-
lative or to delayed effect must be borne carefully in
mind. When a patient on one of the very slow insulins
develops hypoglycemia, it is apt to appear only when
the blood-sugar has fallen to a very low level. With
ordinary insulin a hypoglycemic attack is the result
of a sharp and rapid fall in the blood-sugar level;
with zine insulins the advent of hypoglyczmia is so
gradual that it sometimes produces symptoms only
when the blood-sugar has reached a dangerously
low level. Further, it must be noted that hypo-
glycæmia with ordinary insulin tends to be a transient
phenomenon from which the patient often emerges
without special treatment, and is susceptible to rapid
correction by an injection of adrenaline or the admini-
stration of a little glucose. With the zinc insulins,
. on the other hand, hypoglycemia will tend to be
prolonged and treatment may have to be continued
over several hours before safety is re-established.
CasE 9.—Severe hypoglycemia threatening life. Female
aged 23. Severe diabetes for three years, stabilised and
well on ordinary insulin 25 units morning, 10 units
evening. Twelve months ago married, neglected her
diet and omitted evening insulin. Recently admitted
to the Middlesex Hospital, pregnant three months,
incipient coma and uncontrolled diabetes. She became
practically stable with occasional positive urine tests
on 1750 calories, including 100C, with 66 units zinc
crystalline insulin at 6 a.m. One slight hypoglycemic
attack at 11 a.m. (blood-sugar 68) on 70 units. On 66
units there were no signs of hypoglycemia until she had
been taking this dose for seven days ; on the seventh day
she was given her 66 units at 6 a.m. and ate her usual
meals; twenty-two hours later, at 3.30 A.M., a night
nurse reported that she was noisy and incoherent and
disturbing the ward. The night nurse erroneously
interpreted this as hysteria, and half an hour later she
was quiet because of deep coma and was found to be cold
and almost pulseless. Adrenaline was administered
without effect and 10 grammes of glucose given intra-
venously ; she became partly conscious and vomited,
glucose was administered by mouth, but vomiting con-
‘tinued and the patient was dangerously ill until 5.30 a.m.,
when recovery gradually became complete. The blood-
sugar at 3.30 a.m. was 38 mg. per 100 c.cm.
The patient is now being treated with protamine insulin
(retard), and is approaching stability on 16 units in the
morning and 22 in the evening.
This case illustrates the potential dangers of the
new insulins. We are strongly of opinion that great
caution must be observed in their use when a dose
exceeding about 30 units ts required. When protamine
insulin (with zinc) suspension was first put on the
market one of us (T. I. B.) wrote a warning in the
-medical press, and subsequent experience convinces
us that this warning was more than justified. A
death from hypoglycemia after the administration
of a large dose of one of these insulins has occurred in
Great Britain, and although we have no personal
experience of such a catastrophe the case recorded
above was one causing great anxiety for some hours.
Case 10.—Severe diabetes controlled with single injection
of 88 units of zinc insulin ; treatment changed on account
of danger. Female aged 17. Severe diabetes of 18
months’ duration. On ordinary insulin 32 and 28 units
showed variable glycosuria with frequent hypoglycemic
reactions. On protamine insulin (retard), 40 and 32 units,
reactions were abolished but glycosuria constant. Next
on 38 units of ordinary insulin in the morning and 36 of
protamine insulin (retard) in
the evening she was sugar- §
free but still had rather fre- =
quent hypoglycemic attacks. S$
She dreaded multiple injec- ~ 20
tions. She was _ re-stabilised- 9
on zinc protamine crystalline XŠ
insulin, 88 units before break- S 180
fast. Only. very small hypo- ¢
glycemic reactions occurred, 3
usually in early morning before 140 0 4 12 20
breakfast. Blood-sugar estima- ° TIME IN HOURS
tions showed constant hyper- FIG. 6.—Severe diabetic
glycemia without glycosuria with high renal thres-
(Fig. 6). Single doses were hold, sugar-free on one
abandoned on account of maJeotion of 95 una o
potential danger. Result. — line insulin, aoe
Now sugar-free and without
hypoglycemic attacks on -32 units of ordinary insulin
before breakfast and 60 units. of zinc’ protamine crystal-
line insulin before tea. This patient is being kept under
“very careful observation.
Psychology of the Patient and its Bearing
on Treatment
Patients with diabetes mellitus fall into two broad
but important classes—young diabetics in whom
diabetes is the predominant feature of the situation
and is severe, and middle-aged or elderly diabetics
in whom the disease is complicated by the presence
of arterial degeneration and in whom this latter
feature is usually the dominating factor, the diabetes
being easy to control. In both these classes psychology
plays an important part in that the patient is the
victim of an incurable disease that can almost
invariably be kept under control, provided that the
patient has the intelligence and knowledge necessary
for proper collaboration with his medical attendant.
But the knowledge that the disease is incurable and
that the patient is obliged to exercise perpetual
discretion concerning diet is a heavy handicap, and
until discipline has merged into habit this must have a
depressing effect. A further psychological burden is
imposed upon the diabetic patient by the well-meant
advice which he or she is constantly receiving from
friends, who advocate changes of diet, patent foods,
changes of medical attendant, and other things which
are so easily urged upon someone other than one’s self.
The introduction of a series of new insulins may
prove a curse to a large number of diabetics who are
at present being successfully treated without the use
of these innovations. It must be clearly stated that
the diabetic patient who has for some time been
maintained in excellent health, without alarming
variations in weight, and without much glycosuria or
attacks of hypoglycemia, should be advised to keep
to his present treatment. The new insulins offer him
no great advantage. When, on the other hand, such a
patient finds the administration of multiple doses
a serious burden, or when he has been subject to
frequent hypoglyczemic attacks, the substitution of one
of the slower insulins may prove to be a very real boon.
It must not be assumed, however, that it is a simple
matter to change a patient over to one of the slower
U
THE LANCET] MR. R. PILCHER : PERICARDIAL RESECTION FOR CONSTRICTIVE PERICARDITIS [JUNE 5, 1937 1323
insulins. In milder cases where the total daily dose of
ordinary insulin does not exceed 30 or 40 units it can
often be achieved in the out-patients’ department
without great difficulty, but when the case is more
severe the change must be carried out in a hospital
or nursing-home, with most careful control of the diet
and daily observations of the urine. When stabilsa-
tion is accomplished or approaching great care should
be taken to see that the patient is taking plenty of
exercise, and a few estimations of the blood-sugar,
specimens being secured at an appropriate time after
the administration of the insulin, should be made in
order to be sure that “ masked hypoglyc#mia ” is not
_ present. i
In cases where an evening dose of zinc insulin renders
the patient sugar-free except for a brief period after
breakfast it is often easy to control the morning
specimen by a small injection of ordinary insulin ;
but we are not satisfied that such a patient has
derived real benefit because he is still receiving two
injections daily and carries the risks inherent in the
employment of two very different substances.
A survey of recent publications dealing with the
treatment of diabetes reveals the interesting fact
that many American observers have joined their
British colleagues in believing that the successful
treatment. of diabetes must be simple. Complicated
diets and the employment of more than one type of
insulin in any patient are the antithesis of simplicity
and we remain convinced that the requirements of
the diabetic patient cannot be met by a complex
treatment.
Conclusions
(1) Extensive clinical trial has now been made with
protamine insulin (retard) and protamine insulin
(with zinc) suspension. Experimental trial has been
made with zinc crystalline insulin.
(2) These observations confirm the slower action
of the néw insulins as compared with ordinary insulin,
the maximum effect of protamine insulin being
usually 6 hours after administration, whist that of
the zine
T S$ prepara-
l tions, in-
12 3OUNITS cluding the
t crystal-
line” pro-
duct,is
often about
8L000 SUGAR Mg PER 100 cem.
©
8 18 hours.
(3) The
effect of
0 4 2 20 2 36 44 the zinc in-
TIME IN HOURS sulins wears
FIG. 7.—Repeated blood-sugar observations on Ê ff co eae
& normal man on a fixed diet, before and Pletely in
after injection of 30 units of zinc protamine 18-24 hours
crystalline insulin, showing return of blood-
near to its pre-injection level in about 24
ours.
Weare
unable to
i ; confirm the
suggestion that cumulative effects may occur—
i.e., the prolongation of action beyond 24 hours
(Fig. 7).
(4) It is often possible to reduce the number of
daily injections of insulin from multiple doses to a
single dose when these slower products are employed.
(5) The protracted action of the new products
carries with it the danger of prolonged hypoglycemia,
unless great care is observed.
(6) It is unwise, in the present state of knowledge,
to substitute one of the new insulins for ordinary
insulin unless there is valid objection to multiple doses
or frequent tendency to hypoglyczmic attacks owing
to the too rapid effect of ordinary insulin. :
(7) The new insulins, owing to variation in the
rate of absorption or other causes, tend to vary in
their effects from day to day, and even if this variation
is not of cardinal importance it is liable to have a bad
psychological effect on the patient.
(8) At the present time, in cases where it is desirable
to employ one of the slower insulins, protamine insulin
(retard) is probably the safest preparation available.
Our thanks are due to our colleagues in the Courtauld
Institute of Biochemistry for blood-sugar analyses here
recorded. We also wish to thank the manufacturers of
Leo Insulin and the proprietors of the Organon Labora-
tories for supplying us with insulin for experimental
purposes. We would further acknowledge the constant -
help we have received in our work from Miss V. Scott-
_ Carmichael, the lady dietitian to the Middlesex Hospital.
BIBLIOGRAPHY
Alahu: S. S., and Leiser, R. (1936) J. Amer. med. Ass. 107,
Bennett, T. I., and Gill, A. M. (1936) Lancet, 2, 416.
Himsworth, H. M. (1937) Brit. med. J. 1, 547.
Jacobi, H. G. (1937) N.Y. St. J. Med. 37, 1.
Lawrence, R. D., and Archer, N. (1937) Brit. med. J. 1, 487.
Rabinowitch, I. M., Fowler, A. F., and Corcoran, A. C. (1937)
Canad. med. Ass. J. 36, 111. -
Richardson, R., and Bowie, M. A. (1936) Amer. J. med. Sci.
, 164.
Wilder, R. M. (1937) Arch. intern. Med. 59, 329.
PERICARDIAL RESECTION FOR
CONSTRICTIVE PERICARDITIS
REPORT OF A CASE APPARENTLY CURED
By Rosin Pitcuer, M.S. Lond., F.R.C.S. Eng.
FIRST ASSISTANT IN THE SURGICAL UNIT, UNIVERSITY
COLLEGE HOSPITAL
(WITH ILLUSTRATIONS ON PLATE)
Churchill in 1929 collected 36 cases of pericardial
resection for constrictive pericarditis, and added
one of his own. More recently (1936) he has published
9 others. Paul White (1935) published a full account
of the disease in his St. Cyres lecture, giving clinical
details of some of the cases operated on by Churchill.
Most of Churchill’s collected cases came from Germany,
notably those reported by Volhard, Schmieden, and
Fischer. In 18 of the 36 the result was excellent, in
4 there was transitory improvement, in 2 there was
no improvement,.and in 7 the operation was fatal,
In the remaining 5 the operation was not completed.
Among Churchill’s own 10 cases there were 6 cures
and 1 death, the remaining 3 showing marked improve-
ment. In the discussion on Churchill’s later paper
Blalock reported 8 operations with 3 cures, 2 improve-
ments, and 3 deaths. Other surgeons in America
have reported single cases, some successful, some not.
The only case reported in this country which I have
found is that of Roberts and Wilson (1936). The
absence of others suggests that either the disease
is not being diagnosed or the value of surgery is not
recognised, The results that have been published
show that about half the patients are cured. This
is at least encouraging in view of the severity of the
disease and the magnitude of the operation.
The following is an account of a case in which, as
in others on record, diagnosis and treatment were
long delayed. That operation should have succeeded
completely some seven years after the onset of
ascites seems to show that the very long period
during which its activity was severely restricted
had left the heart mnderniec’:
Z
1324 THE LANCET] MR. R. PILCHER: PERICARDIAL RESECTION FOR CONSTRICTIVE PERICARDITIS [JUNE 5, 1937
HISTORY OF ILLNESS
The patient, a female, was first admitted to
University College Hospital in September, 1929.
She was then aged 13 and gave a history of pro-
gressive enlargement of the abdomen for three
months. There was no preceding illness and no
other symptoms except slight discomfort from the
swelling. She had had measles at the age of 8 and
whooping-cough at the age of 6, neither illness being
attended by any complications. She had never had
rheumatic fever or chorea; there was no family
history of tuberculosis.
At the time of her first admission she was a normally
developed, well-nourished girl, 7 st. in weight. The
abdomen was distended with fluid, the girth 2 in. above
the umbilicus being 34:5 in. The liver was enlarged to
three fingers-width below the costal margin, its surface
being smooth. The spleen could not be felt. Distended —
veins were noted in the flanks and axille. Nothing abnormal
was found on clinical examination of the heart. Percussion
note was impaired and breath sounds weak at both bases.
There was no cedema of the legs or face. The blood count
was normal and the Wassermann reaction negative.
The radiologist reported that both sides of the diaphragm
were high, appearing to compress the heart, and there
were increased shadows through both lung fields.
Abdominal paracentesis yielded 10 pints,of clear brown
fluid which contained leucocytes, lymphocytes, and
endothelial cells, and was sterile on culture. A guinea-pig
was inoculated with the fluid and six weeks later showed
no evidence of tuberculosis. Paracentesis was repeated
after four weeks, 8 pints being withdrawn. During her stay
in hospital of 107 days the temperature varied from
97° to 99° F., the average being subnormal. The pulse-
rate at first varied from 99 to 100, but later fell to 80
to 90. The blood pressure varied between 100 and 120
(systolic). The daily output of urine varied from 16 to
56 oz., but was seldom more than 30 oz. No diuretics
were given. Blood and albumin were found on admission,
but subsequently disappeared. The blood-urea was 14 mg.
per 100 c.cm. The diagnosis made at this time was cirrhosis
of the liver, and at the time of her discharge the patient
was much relieved.
The subsequent history of the patient is one of
repeated admission to hospital until September, 1935,
when the diagnosis of constrictive pericarditis was
made by Dr. L. P. E. Laurent. Some idea of her
disability may be gained from the following facts.
During six years she had been admitted to hospital
thirty times, spending in all nearly three years
there, She has been tapped forty-two times, a total
of 402 pints of fluid having been withdrawn. The
maximum girth attained was 40 in. The following
observations are extracts from the notes made
during her various periods in hospital.
In May, 1929, the tip of the spleen was palpable and
remained so; no progressive enlargement was observed.
In Octobor, 1930, the legs began to swell. Subsequently
there was a variable amount of cedema sometimes so much
that the knees could hardly be flexed.
In January, 1932, there was said to be no pulsation
in the cervical veins. Previous observations on this
point are not recorded.
In June, 1933, omentopexy was performed. At operation
the liver edge was felt to be smooth and there was some
thickening of the root of the mesentery. A small umbilical
hernia was present at this time.
In December, 1933, the swelling of the legs was less
troublesome, but repeated abdominal paracentesis was still
necessary.
In November, 1934, venous pulsation was observed in
the neck to 7 cm. above the manubrium.
In January, 1935, the umbilical hernia was repaired.
The site of the omentopexy was examined and the omentum
was found to be atrophic, the adhesions consisting of a few
strands only about } in. in diameter. During this admission
the urine output was recorded over a long period. A
tendency to diminish had been noted on previous admis-
sions. During 98 days the lowest daily output recorded
was 3 oz., the highest 28 oz. Urea, 6 grammes three
times a day, made no appreciable difference.
In September, 1935, the patient complained that
in addition to her previous symptoms her eyelids
were puffy in the morning. X ray examination of
the chest was repeated and the radiologist reported
as follows: ‘* Diaphragmatic movements free,
diaphragm high on both sides, costophrenic angles
clear. Increase in transverse diameter of heart,
perhaps due to high diaphragm. Right supracardiac
shadow increased. Normal pulsation. Some increase
in vascular markings in lung fields. Large calcified
plaque on left side near left border of cardiac shadow,
? calcification in pericardium ” (Fig. Ion Plate). Subse-
quently it was shown in oblique radiograms that
the calcification surrounded the heart in the form of
a ring (Fig. II on Plate). An electrocardiogram showed
inversion of T wave in lead 3 but was otherwise
normal, The diagnosis of constrictive pericarditis
having been made operation was advised, but was
postponed on account of respiratory infection at
the suggestion of Dr. J. W. McNee, under whose care
the patient then was.
At the time of the patient’s transfer to the Surgical
Unit the following observations were made.
She was a well-developed healthy looking girl aged 20,
5 ft. l in. in height, and 9 st. 14 lb. in weight. The maxi-
mum circumference of the abdomen was 36} in., this and
the weight being measured shortly after paracentesis. There
was no cedema of the face, legs, or sacrum, but the abdomen
was distended and contained free fluid The liver was
palpable three fingers-width below the costal margin.
It was smooth and did not pulsate. There was no recur-
rence of umbilical hernia. No apex-beat was palpable,
but there was systolic retraction of the precordium,
with a sharp diastolic recoil. The left limit of cardiac
dullness was 7-5 cm. from the midline in the fifth space,
the right limit was in the midline. The heart sounds
were normal and no adventitious sounds were heard.
There was distension and pulsation of the veins of the
neck to the level of the angle of the mandible when the
patient was sitting upright in bed. The pulse was regular
in rate, its volume diminished on inspiration. The
pulse-rate varied from 80 to 95. Since the first admission
the rate had always been a little above normal. The
daily output of urine was still low.
OPERATION
Pericardial resection was performed on Jan. 7th,
1936.
Anesthetic, intratracheal nitrous oxide, oxygen and®
ether. Incision T-shaped (see Fig. III). The sternum was
divided transversely at the second intercostal space and
the lower part was split longitudinally, the xiphisternum
being excised. The second intercostal space was opened
on either side of the sternum as far as the internal
mammary vessels. The two sides of the sternum were
retracted and a few adhesions between the pericardium
and the chest wall were divided. The pleure were
stripped from the pericardium without much difficulty,
the left being opened by a small tear which was sutured
forthwith. The surface of the pericardium was white and
glistening, except where adhesions to the pleura and
chest wall had been divided. The pericardium appeared
thick and inelastic and many calcified plaques were
palpable, the largest being round the base of the heart.
The pericardium was opened anteriorly and a plane of
cleavage between the visceral and parietal layers was
easily found. Stripping in this plane was carried over the
left border of the heart and then to the right, then up
to the. base, and finally round the apex on to the posterior
surface. As soon as the pericardium was widely opened the
heart began to fill better and bulged through the opening.
The constricting effect of the pericardium was shown by
a few fibrous bands left after the main stripping; these
‘
THE LANCET] MR. R. PILCHER : PERICARDIAL RESECTION FOR CONSTRICTIVE PERICARDITIS [JUNE 5, 1937 1325
made deep furrows in the bulging heart, which expanded
still further after their removal. At the base of the heart
there was a dense ring of calcified material closely adherent
to the auricles. On the right side this ring was severed
and a segment about 1 cm. square was excised. On the
left side the pericardium was stripped to a higher level and
another segment of the calcified ring about 2-5 x 1 cm.
was excised piecemeal. Access to the base of the heart
was a little difficult and was obtained by traction on the
reflected flap of pericardium which was not cut away
until the stripping at the base had been carried as far
as seemed safe. The greater part of the calcified ring
was left but two complete gaps were made in it, one on
each side. The inferior caval opening was next exposed
and all adhesions round it divided. A sickle-shaped
band running backwards from the front of the heart
to the diaphragm appeared to pull the caval opening
forward. This was divided and partly excised. There was
calcification round the orifice apparently in the wall of the
vein itself, and it was thought unwise to attempt its
removal. Stripping was next continued round the apex
and posterior surface of the heart until the ventricles
were quite free. Two strong bands fixed the apex to the
diaphragm. On the posterior aspect could be felt the
continuation of the calcified ring in which two gaps had
been made anteriorly. Only the anterior part of the
pericardium was actually excised.
At no time did the procedure appear to embarrass
the heart, even when strong downward traction was made
to-obtain access to the base. The pericardium was washed
out with saline and the wound closed with drainage
at the lower end, the two halves of the sternum being
held together with encircling sutures of catgut passing
through the intercostal spaces. The operation lasted
2} hours, and at the end the pulse was 108, regular and of
good volume.
The largest piece of excised pericardium is shown in
Fig. IV. It was in places as much as § mm. thick. Micro-
scopic examination showed fibrosis and calcification, but
- no evidence of tuberculosis.
POST-OPERATIVE COURSE
The patient recovered rapidly from the operation.
The tube was removed after 24 hours. The wound
was painful for several days, pain being aggravated
by movements of the divided sternum. A week
after operation there was observed a strong diffuse
systolic impulse in the precordium, the divided sternum
allowing more movement than normal. No spon-
‘taneous diuresis occurred and the distension of
the abdomen remained unchanged. For six weeks
the daily output of urine only once exceeded 20 oz.
On Jan. 23rd, 1936, paracentesis was performed,
17 pints being withdrawn. This was repeated on
Feb. 4th, 94 pints being withdrawn. On Feb. 19th,
in view of the continued low urinary excretion,
6 grains of Theocin was given and this dose was
repeated on three succeeding days. There followed
a marked increase in excretion. Administration of
theocin was therefore repeated and continued until
nine weekly courses had been given.
Paracentesis was performed for the last time on
March 3lst, 2 pints only being withdrawn. The
girth was now 33} in. A light rubber belt was fitted
and the patient was discharged on April 17th, 1936,
since when she has remained well and able to work.
Her girth remains fairly constant, being 32} in. on
March Ist, 1937. Her weight at this time was 9 st. As
Fig. III shows, there is redundancy of the skin of the abdo-
men, and irregularity due to the scars of the previous
operations. At the present time, a year after operation,
there has been no recurrence of abdominal distension
or edema of the feet. The manubrium and body of the
sternum have not united, being separated by a gap of
about 1 cm. Free movement occurs at this point with
respiration and with the heart beat. The two halves of the
sternum are also apparently ununited and are slightly
depressed in the midline. The precordium moves with the
heart beat as if it were floating on the heart, the upper
part coming forward in diastole, the lower in systole.
A feeble venous pulsation is visible in the neck to 2 cm.
above the manubrium when the patient is sitting upright,
but the veins are not visibly distended. The blood pressure
is 140 systolic, 60 diastolic. There are many previous
observations on the blood pressure, but it is doubtful
whether they are reliable. The highest pressure recorded
before operation was 128, the average being about 110,
“g.
d
FIG. III.—Patient after operation showing scar of the
incision for pericardial resection.
o
Further X ray examinations have been made
since operation. On Feb. 26th, 1936, there was little
change, except that the breach in the ring of calcifica-
tion was visible. The diaphragm was still elevated.
On Sept. 10th the diaphragm was one space lower
on each side, the heart shadow being correspondingly
increased in vertical diameter and slightly diminished
in transverse diameter (Fig. V on Plate). On Feb. lst,
1937, no further change was apparent, and there has
been no visible increase in the calcification.
COMMENTARY
In spite of the long period during which severe
symptoms were present in this case, operation has
given the patient complete relief. It has been thought
that in long-standing cases the heart might suffer
from the extra strain suddenly thrown on it by
increased filling in diastole following removal of the
pericardial constriction. No evidence of this has
appeared in my case.
With regard to operative exposure of the heart
there is a difference of opinion as to the best approach.
Churchill and Schmieden (1926) both recommend
resection of anterior ends of ribs, costal cartilages,
and part of the sternum on the left side. The sternum-
splitting method has been little used and the American
surgeons are disposed to reject it as apt to cause
shock, Beck and Griswold (1930) from an experi-
mental study of constrictive pericarditis in dogs
concluded that exposure and liberation of the inferior
caval opening is very important, and in a case which
they reported expressed dissatisfaction with the
left-sided exposure. Should there be extensive
extrapericardial adhesions a rib resection over the
heart might be of value, as in the Brauer operation,
‘but for actual exposure of the heart the sternum-
splitting method seems more satisfactory. A possible
objection to this method is suggested by the depres-
sion of the sternum that has recently developed in
my case. In the discussion on Beck and Griswold’s
paper Alexander reported two cases in which depres-
sion of the sternum following injury was associated
with severe pain and dyspnea, which he attributed
1326 THE LANCET]
to pressure on the heart. Both were relieved by
operation, in one the sternum being elevated, in the
other partly excised.
The removal of the constricting pericardium
presented no great difficulty except at the base of the
heart and round the inferior caval opening, where
there was calcification. As recommended by Schmieden
FIG. I1V.—Largest piece of pericardium excised at
operation (cm. scale),
the left ventricle was cleared first. He states that
liberation of the right before the left may result in a
sudden overburdening of the former, and he attri-
buted one operative death in his series to this accident.
Some disappointment was felt at the failure to deal
with the calcified plaques round the base of the
heart and the inferior caval opening, but the danger
of tearing the heart seemed too great if more were
attempted. It was clear, moreover, that liberation of
the ventricles had already increased the filling of
the heart and it was therefore possible that in spite
of the calcification there was no serious constriction
of the venous inlets. It must always be difficult
to decide how much liberation of the heart is neces-
sary to give relief. Lilienthal (1930) reported a case
in which he was unable to strip the pericardium
and did little more than make two incisions into
it, one of which entered an auricle. In spite of this
limited procedure the patient was relieved.
After operation further disappointment was felt
at the persistence of ascites. There was no spontaneous
diuresis such as occurred in the six successful cases
reported by Paul White, and it was several weeks
before the benefit of the operation was apparent.
Schmieden mentions the difficulty that may occur
in ridding the patient of the excess of fluid, especially
from cedematous lower limbs. Theocin appeared to
give the necessary stimulus in this case, and after
its administration only one small paracentesis was
necessary. Since her discharge from hospital the
patient has had no treatment.
The important factor in this case seems to have
been the constriction of the ventricles by the thickened
pericardium preventing adequate filling of the
heart. The band holding the heart down to the
diaphragm may have narrowed the inferior caval
opening by distortion. The persistence of calcification
round the caval opening and the base of the heart
does not seem to have detracted from the value of the
operation.
REFERENCES
Alexander, J., Discussion of Beck and Griswold.
Beck, C. S., and Griswold, R. A. (1930) Arch. Surg. 21, 1064.
(Continued at foot of opposite column)
MR. BOWDLER HENRY : CYSTS OF THE NASOPALATINE CANAL
[JONE 5, 1937
CYSTS OF THE NASOPALATINE CANAL
By C. BowpLeR HENRY, M.R.C.S. Eng., L.D.S.
DENTAL SURGEON AND LECTURER IN ORAL SURGERY AT THE
ROYAL DENTAL HOSPITAL, LONDON
(WITH ILLUSTRATIONS ON PLATE)
Synonyms :— Median Anterior Maxillary Cyst ;
Supernumerary Paranasal Sinus.
ROvuTINE skiagraphic examination of the teeth
has brought to light the prevalence of cystic enlarge-
ment of epithelial remnants in the nasopalatine
canal, For the most part, unless they become
infected, these cysts are symptomless, for they cause
no local pain and only occasionally become large
enough to bulge through the surface of the bone.
The etiology is unknown. They are commonly seen
in apparently healthy mouths, and they are distinct
from dental cysts originating from the epithelial
rests in the periodontal membranes of the incisor
teeth, with which in fact they have no connexion.
INCIDENCE
Although these cysts are seldom recorded they are
not uncommon, Mayer, who in 1914 first reported
one of them, subsequently (1931) dissected 600
cadavers and found an incidence of 1 in 66, and in a
skiagraphic study of living adults found 1 in 100.
It is probable that the cysts are often seen but not
recognised, especially when small. Their main import-
ance lies in the risk of subsequent infection, when
they cause both pain and focal toxemia, or in mis-
diagnosis resulting in needless extraction of perfectly
sound central incisor teeth. When small, they may
be overlooked entirely, or may be mistaken for
merely large anterior palatine fossæ. Their patho-
genic importance—if any—when uncontaminated has
not been assessed.
MORBID ANATOMY AND HISTOLOGY
In their simplest form these cysts appear in the
skiagram as ovoid or spheroidal cavities in the bone,
above and between the apices of the central incisor `
teeth, which are often overlapped by the shadow
(Figs. I and II). Commonly, extension occurs on
either side of the median line so that a characteristic
bilobed appearance is produced (Fig. III); or some-
times the cyst may be located upon one side only ;
or two separate cysts may develop side by side.
The outline of the bony cavity is always clearly
defined. The fibrous wall consists of loose connective
tissue lined with epithelium which may be squamous,
transitional, or ciliated columnar.
Kronfeld (1933) described an early cyst in the
edentulous jaw of an adult cadaver. Sections showed
the anterior palatine canal filled with a large mass of
stratified epithelium which was solid except for a
central part where cystic degeneration had occurred.
He also illustrates histological sections of a larger cyst.
Histological sections are illustrated by Stafne, Austin,
and Gardner (1936), who suggest that the type of epi-
thelial lining depends upon whether the cyst arises from
(Continued from previous column)
Blalock, Aa Dibrani of Churchill (1230);
Churchill, E (1929) Arch. Surg. 19, 1457.
— (1 36) ae Surg. 104, 516.
Lilienthal, H., Discussion of Beck aaa Griswold.
Roberts, J. J. E. H., and Wileon, A. J. (1936) Proc. R. Soc. Med.
219
Schmieden Victor (1926) Surg, Gynec. Obstet. 43, 89.
White, P. D. (1935) Lancet, 2, 539 and 597.
THE LANCET]
the nasal or stomal epithelium. These writers discuss
the daughter cysts, first noted by Congdon (1920) con-
taining mucoid material and found in the wall of
the larger cyst, and they describe mucous glands.
The nasopalatine blood-vessels and nerves were also
seen within the connective tissue wall.
SIGNS AND SYMPTOMS
When the cyst is large attention may be called to
the area by swelling on the palate behind the front
teeth, or on the gum high up over the incisor teeth
_ and deep to the attachment of the frenum labii.
The protuberance is smooth, rounded, painless and
hard, unless there has been absorption of the bony
covering, when typical springy fluctuation may be
elicited. Sometimes the cysts erode through both
the palatal and the labial plates of bone and the
impulse of palpation may be felt across from labial
to palatal. Sometimes the patients detect some
shght chronic discharge. In these circumstances
examination of the dried surface of the palate with a
ma
the fistula (Fig. IV), but the orifices of those which I
have seen have been capillary and only traced with
difficulty. Growth is slow, and patients may be
unaware of the swelling until an artificial denture is
fitted and causes discomfort or blocks up a fistula
so that tension causes neuralgia, referred first to the
glabellar region of the frontal bone and subsequently
to the maxilla.
The patient whose radiogram is shown in Fig. V was an
edentulous female over 60. She had suffered for 10-12
years from frequent and repeated headaches which were
ascribed to toxemia originating in the gall-bladder,
which she refused to have removed. The cycle of symp-
toms was typical. Without warning she would suffer
rapidly increasing pain over the bridge of the nose extend-
ing up on the forehead between the supra-orbital sinuses.
This would be supplemented two hours later by tenseness
and eventual pain in the cyst, and subsequently, unless
discharge occurred, there would be slight pyrexia and the
malaise of toxic absorption which always induced a
painful neurofibrositis of the neck. The patient treated
herself by fomenting the premaxillary region and estab-
lishing discharge. She refused a radical operation, but,
having had great relief from evacuation of the contents
with a fine (lacrymal) cannula on a syringe and the
instillation of acriflavine emulsion, she consented to
having a window made on the palate side large enough
to allow permanent free drainage and permit irrigation
with a dental water syringe. All her local and general
symptoms disappeared. Bacteriological examination of
the evacuated contents of the cyst showed: “ A purulent
specimen containing streptococci and diphtheroid bacilli.
Culture grew Streptococcus viridans and a few diphtheroid
bacilli ” (L. Whitby).
OPERATIVE TREATMENT
The simplest treatment of the larger cysts is to
make, under Novocain, a circular aperture in either
the palatal or the labial wall sufficiently large for
permanent drainage and for irrigation. A more satis-
factory operation is radical removal, which should
be done from whichever aspect is most convenient.
If the cyst presents on the labial surface above, the
central incisors the operation will naturally be done
by this route, but there is always a chance of injuring
the nerve supply to these teeth, with resulting degene-
, ration and infection of their pulps. The “teeth, if
conserved, should be tested for vitality from time
to time. If the cyst presents on the palate, it should
be removed by reflecting the palatal mucosa, as for
the extraction of a buried supernumerary tooth ;
this is simpler, and the innervation of the central
incisors is not so gravely threatened. The cyst
DR. ANGUS SCOTT: ANGINAL SYNDROME IN PNEUMOMEDIASTINUM [JUNE 5, 1937
gnifying mirror and a fine dental probe may reveal |
- Sexes,
1327
shells easily out of the bony chamber, but is usually
attached to the cords in the upper (nasal) portion
of the ducts and found to have been adherent to the
deep surface of the palatal integument below.
REFERENCES
Congdon, E heer (1920) Anat. Rec. 19, 367.
Hronteld, (1933) Histopathology of pret and their Sur-
ee Structures, T hiagelph'a, ae ai
Meyer, ac Ae (1914) J. Anat., Lond.
(1931) J. Amer. dent. ASS. 18, 1851. :
Stafne, a sce Austin, L. T., and Gardner, B. S. (1936) bid,
THE SIGNIFICANCE OF THE
ANGINAL SYNDROME IN ACUTE
SPONTANEOUS PNEUMOMEDIASTINUM
By Aneus M. Scott, M.D. Glasg.
ASSISTANT PHYSICIAN TO THE VICTORIA INFIRMARY,
GLASGOW
(WITH ILLUSTRATIONS ON PLATE)
THE solution of the anginal puzzle has attracted
most clinicians at one time or another, and we would
agree with Allbutt (1915a) that ‘“‘in this secret
and fell disease there is a fascination to which no
physician is a stranger, a fascination in its dramatic
events and in the riddle to be read.” That pain,
indistinguishable in character and intensity from
true stenocardia, may occur when for any reason
there is a sudden increase in mediastinal pressure,
is not I think widely appreciated. Wassermann
(1920) noted severe stenocardia in a patient suffering
from influenzal pneumonia complicated by interstitial
emphysema, and this after discussing the possibilities,
he attributed to the sudden onset of mediastino-
pericardial emphysema.
While spontaneous pneumothorax, whether the
so-called benign or that secondary to hypertrophic
emphysema or other disease of the lungs, is a relatively
common condition, mediastinal emphysema must
surely be rather rare. This is perhaps surprising
when one considers, first, the widespread use during
the past decade of artificially induced pneumothorax
as a therapeutic measure in chronic pulmonary
disease, and secondly, the present-day popularity
of strenuous athletics with young people of both
In the cases it has been thought worth while
to record here, occurring as they did in young healthy
adults, the condition is so analogous to acute benign
spontaneous pneumothorax that similar terminology—
with the omission of the word “ benign,” since its
benignity is at least doubtful—seems desirable.
ETIOLOGY
Mediastinal emphysema may be a complication
of many diseases of the lungs. For example, Kelman
(1919) and Wassermann (1920) have recorded its
occurrence during the influenza pandemic of 1918-
1919, as a complication of broncho-pneumonia,
and they are in general agreement about the origin
and spread of the antecedent interstitial emphysema.
Small areas of lung tissue which had not been involved
in the pneumonic process were the seat of considerable
emphysema, and the strain of severe cough or urgent
dyspnoea was enough to rupture the damaged and
distended alveoli, and to allow air to escape into the
interstitial tissues and so reach the mediastinum
by way of the lung root, following the reflexion
of the pleura and the pericardium along the great
vessels.
1328 THE LANCET]
Air may also reach the mediastinum by the exten-
sion of a subcutaneous emphysema along the endo-
thoracic fascia or the deep fascia at the jugulum,
by the direct sucking of atmospheric air through
wounds in the apertures of the thorax, by injury
to the trachea and main bronchi, by openings in the
mediastinal pleura so that air produced by pneumo-
thorax is admitted, and by extension of retro-
peritoneal emphysema through the crus of the
diaphragm.
With this in mind, it is not surprising that medias-
tinal emphysema may occur in widely differing
pathological conditions, and the majority of cases
reported have been, as one would expect, secondary
to pulmonary tuberculosis. It has also been observed
as a complication of pertussis and in the new-born,
as the result of strangulation by the umbilical cord.
It „has occurred as a complication of parturition,
where the condition must be due to excessive pressure
on the alveolar walls while the patient is straining
during full inspiration. Surgical operations on the
neck and thorax, tonsillectomy and irrigations of the.
accessory air sinuses, and stab wounds are some
of the less common causes. Congenital cystic disease
of the lung, whether of the diffuse so-called honey-
comb type or of the commoner poly- or uni-cystic
type, is another very possible source of pneumo-
thorax and mediastinal emphysema.
But in the spontaneous type of which the cases here’
cited are examples, strenuous exertion alone may be
the determining cause, and as in the cases occurring
in parturient women, there may be no coexistent
disease of the lungs.
SYMPTOMS AND SIGNS
Cyanosis of varying degree is usual, but if the
quantity of air is small, this may not be a prominent
feature. Dyspnoa or perhaps more correctly an
alteration in the character of the respiration has
been noted in the majority of cases, and congestion
of the superficial veins of the neck will be dependent
on the amount of extravasated air. The presence of
subcutaneous emphysema may mask the character-
istic auscultatory signs which consist of curious
metallic sounds having the rhythm of pericardial
friction and of similar origin to the bruit de moulin
' that occurs in pneumo-pericardium. This sound,
' which has been likened to the “rattle of dried peas
on taut canvas,’ may be audible both to patient and
observer during the act of deglutition, if the air lies .
in contact with the cesophagus in any part of its
course in the mediastinum. Finally, pain, and pain
of a very distinctive character, is so striking a feature
of any serious increase in mediastinal pressure from
whatever cause, that I think it merits a very full
investigation. :
My own interest in the subject was aroused when I
was called on to deal with the following patient.
CASE REPORTS
A boy, aged 16, was first seen in the early hours of
May 28th, 1935, complaining of excruciating pain behind
the sternum and radiating down both arms, particularly
the left.
Family history—There is no record of pulmonary
disease in the family, and there is nothing of significance
in his own history. He has always enjoyed good health
and has taken part in all school games.
Present illness,—On the evening of May 27th he took
part in a half-mile foot-race trial, with a view to competing
at his school sports a week later. On completing tke
course, he coughed once, dropped down, and immediately
experienced a curious sensation in his chest. After resting
he was able to make his way home without assistance,
and retired early to bed without complaint. During the
DR. ANGUS SCOTT: ANGINAL SYNDROME IN PNEUMOMEDIASTINUM
[JUNE 5, 1937
night he was restless, could not sleep, and in the small
hours of the morning, sat bolt upright in obvious distress
but was unable to utter a word.
Examination.—When seen a little later the boy looked
desperately ill, sitting rigidly in bed, clutching the bed-
clothes tightly with both hands, unable to speak, and
with a very anxious expression. The pulse was small
and thready, his respirations were now suspended, now
shallow and restrained, and he was perspiring profusely.
While his face was very pale, there was evidence of acro-
cyanosis, and when he could relax for a second, he pointed
to the upper end of the sternum as the site of his distress.
His temperature was 97-6°F., the pulse-rate 130; his
respiratory rate very variable, ranging between 10 and 40,
and his pupils were widely dilated. He was given gr. 4
of morphine hypodermically, and when this had taken
effect, it was possible to proceed with the examination of
his chest. While his whole aspect at once recalled the
classical picture of angina pectoris, his clinical story was
so strongly suggestive of spontaneous pneumothorax
that I was surprised to find no evidence in support of this
diagnosis. After the acute distress passed off, he was
able to say that his pain was deep-seated behind his
sternum, and radiated down his arms, occasionally shooting
up behind his ears producing a sense of constriction, and
at times running along the rami of the lower jaw into his
teeth. He was also conscious of some movement behind his
sternum, where the severe pain took origin, sometimes
from its upper, sometimes from its lower end.
A provisional diagnosis of air in the mediastinum
suggesting itself, he was shortly afterwards admitted to
hospital, where he was examined under the fluoroscopic
screen and the diagnosis confirmed. Examined in the
dorsal decubitus, no abnormality could be made out, but
while lying in the left lateral position, a moderately large,
single, lenticular-shaped bubble of air couJd be seen in the
posterior mediastinum, and is shown clearly in Fig. I.
Progress.—While in hospital the boy had several further
attacks of stenocardia, none of which was quite so severe
as the original, but during one of these his systolic blood
pressure fell from 120 to 85 mm. Hg, and he complained
of pain running down the left arm, interrupted at the
elbow, to resume at the wrist and continue into the left
little finger. For several hours before the onset of this
attack he had been conscious of some pain in the left thumb,
and on examination there were areas of paresthesia in this
arm. He was discharged from hospital on June 15th,
1935, and was advised to avoid strenuous exercise for six
months.
In March, 1936, he had a similar but milder attack
after a game of football, and again in July while playing
tennis he felt a sudden acute. pain in his chest, but radio-
logical examination, which was carried out 48 hours later,
failed to reveal the presence of air in the thorax, and it is
probable that it had been absorbed in the interval. On
this third occasion the characteristic auscultatory signs
were still present 24 hours after the accident but had
disappeared by the following day.
For particulars and the radiogram of the second
case, the clinical details of which are unfortunately
lacking, I am indebted to Dr. Richard Schatzki,
assistant radiologist to the Massachusetts General
Hospital, Boston, who has kindly consented to its
publication.
A healthy youth, aged ‘20, collapsed at the end of a
hundred-mile cycle race, complaining of severe pain in his
chest, in the region of the sternum, but unfortunately
details as to its radiation are not available. He was
examined radiologically some hours after the onset,
and Fig. II shows the mediastinal emphysema on the
left side, and considerable subcutaneous emphysema in
both supraclavicular areas, with no sign of pneumo-
thorax, if we restrict the use of that term to denote the
presence of air in the pleural cavity. The air was com-
pletely absorbed in a few days. -
COMMENT
While the question of a cardiopathy did not arise
in the case of the first boy, there is no doubt that the
occurrence of similar symptoms in a person twenty
nae aa an othe aaay
THE LANCET]
years older would ‘have given rise to considerable
difficulty, and in this connexion it is interesting
to note that Hamman (1934), dealing with the
differential diagnosis of coronary occlusion, cites
three cases of interstitial emphysema of the lungs
that came under his personal observation and where,
following the escape of air into the mediastinum,
the pain was similar in type and distribution to that
seen in coronary disease.
Inspection of the lateral view of the thorax in
Fig. I shows the collection of air to be in the posterior
mediastinum, in close contact with the tissues
surrounding the aorta, and the increased pressure must
have exerted its greatest effect on these structures.
The fact that the air was not distributed loosely
through the tissues but remained circumscribed
may have accounted for the great severity of the
reaction, and in my view it seems difficult to escape
the conclusion that this sudden alteration of pressure
was responsible for the initiation of the anginal
attack. That alteration in mediastinal pressure,
particularly if it be sudden, may have alarming
and even fatal results is well known. More than
ten years ago Lord (1925) noted that death apparently
due to “deep emphysema” had been observed in
3 instances after the induction of artificial pneumo-
thorax, and Ballon and Francis (1929) quote a series
where mediastinal emphysema as a complication of
artificial pneumothorax occurred 15 times in 9 of
63 patients, so that the work of these two on the
consequences of variations in mediastinal pressure
is of some practical importance. They conclude that
the initial change in blood pressure after the inflation
of a balloon in the rabbit’s mediastinum is always
a fall, and that some of the results of increased
pressure in the mediastinum are: (a) pulmonary
emphysema, (b) wdema of the tracheo-bronchial
mucous membrane, (c) pericardial effusion, (d) dis-
ordered heart action, and (e) acute cdema of: the
lungs. Normally the mediastinal pressure is round
about minus 4 mm. of water, and there are no notice-
able changes until it reaches zero, when changes do
occur and progress rapidly, depending on the amount
of pressure and the rapidity of increase. When the
pressure is raised beyond plus 35, death takes place
from acute pulmonary oedema.
DISCUSSION
Many will recall with interest the lively debates
of twenty years ago as to whether anginal pain was
aortic or myocardial in origin. Allbutt (1915b), at
great pains to prove by masterly and convincing
argument that angina pectoris is a disease sui generis,
rails. at one of his contemporaries who dares to
prefer the more popular “syndrome” or “symptom
group ” concept, and accuses him of propounding
the theory “that a similar series of events can have
dissimilar causes.’ He himself (1915c) finds an
excuse for this reluctance to accept angina as a
disease ‘‘ in the shifting explanations of the pathology `
of the anginous process,” and surely there is some
justification for such hesitation, if it be taken as
proved that “ this dynamic procession of symptoms ”
may result from such vastly different pathological
conditions as coronary thrombosis and mediastinal
emphysema. Such an admission would not necessarily
imply that the mechanism responsible for the
‘‘dynamic procession” was different in the two
conditions, but would certainly suggest that it may be
set in motion by very different pathological factors.
Ewart (1912) quotes a case from Perez that has
evoked much comment, where the patient, an elderly
phthisical subject suffering from tuberculous medi-
DR. ANGUS SCOTT: ANGINAL SYNDROME IN PNEUMOMEDIASTINUM [JUNE 5, 1937 1329
astinopericarditis, experienced typical anginal pain,
and Allbutt (1915d) mentions the remarkable case
of angina recorded by Haygarth of Chester, “‘ which
proved on autopsy to be one of mediastinal suppurative
inflammation, apparently involving the base of the
heart and the great vessels.” Hare (1906) considered
that angina was “due to painful distension of the
mediastinum, and this to intense vasomotor con-
striction in very large areas elsewhere,” but Allbutt
points out that vasomotor changes although relatively
common in angina are not essential, and, propounding
his well-known ‘“‘ pressure tambour ” theory in which
the suprasigmoid portion of the aorta is regarded
as the mainspring of the attack, he adduces valuable
evidence in its support. There can be little doubt,
I think, that true angina may occur in the entire
absence of any pathological lesion in the coronaries,
and conversely, gross disease in these vessels does not
necessarily predicate attacks of angina. It seems
reasonable to suppose therefore that they play no
part in the actual mechanism of the anginal syn-
drome. That disturbance of their function however,
particularly if it be sudden—spasm or thrombosis
—may set the anginal mechanism in motion seems
more than probable, and if so, must we not assume
the presence of a “knot of exalted sensibility ”
somewhere in the circuit? Most physiologists are
now agreed that there is an important vasosensory
area in the first part of the aorta, and Spiegel and
Wassermann (1926), by injecting saline into a part
of the aorta that had been ligatured off, were able to
produce pain in dogs (as registered by movements
of the animal’s lower jaw) after vagal section and
sympathectomy. This proof of pain as a result of
stretching of the investment of the aorta is in complete
accord with the views of Allbutt and Wenckebach,
and the former (1915e) cites a number of cases of
rupture of the aorta, where the vessel coats were
split asunder by dissecting hemorrhage, and where
this accident was associated with intense anginal pain.
Sutton and Lueth (1930), who are on the side of the
“ coronarians,” state that “the nerve fibres respon-
sible for conducting the pain sensations from the
heart are those fibres in the adventitia of the blood
vessels or the adjacent tissues.”
It seems reasonable to postulate the existence
of a complex and highly specialised centre controlling
the anginal mechanism when one considers the
analogy of a similar control of the important lung
reflexes by just such a centre or centres situated at
the lung root, and of whose existence the thoraco-
plastic surgeon is only too well aware. Remembering
the course of the sensory fibres, which accompany
_veins as well as arteries, it seems likely that this
centre—or the more important station of this centre
—is situated in the integuments of the aorta, and that
a lesser or substation may be similarly related to
the pulmonary artery, which might account for the
dramatic results of embolism of that vessel. Further,
from some interesting observations of Wassermann
(1931) on forced respiration and apnea in angina,
it seems that there may be a very close liaison between
these cardiac and respiratory control stations ;
indeed, according to Anrep (1936), there are some
physiologists who maintain that the aorta and the
carotid sinus are the chief regulators of respiration.
Fortunately the vexed question of the pathway of
impulses to the sensorium and their various reflex
arcs does not come within the scope of this discussion.
| SUMMARY
Two cases of acute spontaneous pneumomedi-
astinum are reported and the occurrence of the anginal
1330 THE LANCET]
DRS. CRAMER AND HORNING: MALE GONADS AND ADRENAL GLAND
[JUNE 5, 1937
syndrome in one of these is noted and discussed.
~ A plea is put forward for a reconsideration of Allbutt’s
well-thought-out ‘“‘ sensitive tambour” theory of the
initiation of anginal pain. 7
REFERENCES
Allbutt, C. (1915a) Diseases of the Arteries, including Angina
Pectoris, London, vol. 2, p. 211.
— 1815D) Zid, D. 213.
TAE Ibid ae
Ibid, p. -4
— (oteey Ibid, p ea,
Anrep, G. V. (1936) rane Medical Lectures: Studies in Cardio-
vascular Regulation, Tonton,
Balon, H. C., and Francis, . (1929) Arch. Surg., Chicago,
19, 1627.
Ewart, Ww. eT ae med. J. 1, 771.
Hamman, L (1934) Ann. intern. Med. 8, 417.
Hare, F. (1906) Med. Rec. 70, 601.
Kelman, S. R. (1919) Arch. intern. Med. 24, 332.
Lord, F. T. (1925) Diseases of the Bronchi, Lungs, and Pleura,
London, 2ED., p. 736.
Spiegel, Boa , and Wassermann, S. (1926) Z. ges. exn. Med.
Sutton, D. C., and Lueth, H. C. Vin a 33, intern. Ma 45, 827.
Wassermann, S. (1920) Wien. klin. Wschr 12
— (193 1) Z. klin. Med. 117, 321.
—
‘ON THE RELATIONSHIP BETWEEN THE
MALE GONADS AND THE ADRENAL
GLAND
By W. CRAMER, Ph.D. Berlin, D.Sc. Edin.,
M.R.C.S. Eng.
AND
E. S. Hornine, M.A., D.Sc.
BEIT MBMORIAL FELLOW
(From the Imperial Cancer Research Fund, London)
(WITH ILLUSTRATIVE PLATE)
THE adrenal of the adult male mouse consists of a
relatively large medulla and a relatively narrow
cortex. It has been described and figured by Cramer
in his book “ Fever, Heat Regulation, Climate and
the Thyroid Adrenal Apparatus.” When adult male
mice are castrated the volume of the medulla charged
with adrenaline undergoes a marked diminution and
a broad ring of tissue appears between the central
medullary core and the cortex (Fig. II on Plate).
This ring of tissue when examined by the routine
histological methods is seen to consist of cells which
have neither the appearance of cortical cells nor of
medullary cells. The appearance of this ring of
tissue after castration was first described by Deanesly
and has now been confirmed by us. It is identical
in appearance with the ring of tissue seen in normal
young female mice and described in the literature as
boundary zone or X-zone. This zone is not present
in the adrenals of male mice of mixed strains. In
the adrenals of female mice it gradually disappears
as the animals get older.
When the male sex hormone testosterone is injected
into castrated male mice the volume of the medulla
increases, the X-zone rapidly dikappears, and the
adrenal resumes the appearance of the gland seen in
a normal adult male mouse (Fig. I). The same result
is obtained when testosterone is injected into young
but sexually mature female mice, in which this zone
is almost always present. This applies to intact and
to spayed female mice (Fig. IV). In such mice the
injection of testosterone also leads rapidly to the.
disappearance of the boundary zone, with an increase
in the volume of the medulla (Fig. III). None of the:
anterior pituitary hormones that we have applied:
produces this effect, which appears, therefore, to be:
caused by a direct action of testosterone on the;
adrenal gland. The estrogenic hormones also fail
to bring about a disappearance of the X-zone in
normal female and in spayed female mice.
The testosterone preparation used was testosterone
propionate, which had been very generously put at
our disposal by Messrs. Schering-Kahlbaum. It was
injected three times weekly in doses of 1 mg. dissolved
in oil for periods varying from 12-28 days. The first
injection was given two weeks after castration.
These observations demonstrate a close functional
relationship between the adrenal gland and the male.
sex hormone. In the absence of the latter the number
of the medullary cells fully charged with adrenaline
and available for the functional activity of secreting
adrenaline is greatly diminished. The X-zone or
boundary zone which appears after castration consists
mainly of medullary cells which have temporarily
been inhibited from forming adrenaline, That this
is so can be demonstrated conclusively by examining
the ‘adrenal gland of castrated mice after fixation in
osmic vapour. By this method the adrenaline of the
medullary cells is rendered visible as osmophil
granules. In the gland of a normal male mouse alk
the medullary cells are fully charged with adrenaline,
and the medulla has a regular outline sharply
delimited from the cortex by a leash of blood-vessels.
After castration the adrenaline granules have partly
or completely disappeared from the peripheral part
of the medulla. There is still a central core of
medullary cells fully charged with adrenaline, but
this central core is diminished in volume and its
outline has become irregular. Passing outward from
this there is a gradual transition from these fully
charged cells to cells only partly charged with
adrenaline granules, and in the peripheral part quite
free from them, but even when the cells are free from
Ėė
LEGENDS TO ILLUSTRATIONS ON PLATE
MR. PILCHER
Fic. I.—Antero-posterior view showing high diaphragm,
increased transverse diameter of heart, and calcified
plaque near left border.
Fia. II.—Oblique view showing ring of calcification.
Fic. V.—After operation showing lower diaphragm,
decreased transverse and increased vertical diameter of
heart.
MR. BOWDLER HENRY
Fic. I.—Skiagram of a dry specimen of the palate of an
Australian aboriginal showing cyst of the cere aera
canal. (Specimen given to the writer by Dr. W. E. Fish.)
Fics. II and III.—Skiagrams of nasopalatine cysts
showing typical variations of shape.
Fic. IV.—Skiagrams of a nasopalatine cyst with silver
probe passed through sinus opening into the mouth.
Fie. V.—Skiagram of a nasopalatine cyst in an edentulous
patient, causing intermittent frontal neuralgia and
symptoms of toxsmia.
DR. SCOTT
Fic. I.—Lateral view of thorax showing bubble of air
in posterior mediastinum in a boy aged 16 with anginal}
attacks.
Fie. II.—Antero-posterior view showing subcutaneous
emphysema in supraclavicular regions and mediastinal
emphysema on left side,
THE LANCET, June 5, 1937
20.1X.35 26.1X.35 10.1X.36
MR. PILCHER : PERICARDIAL RESECTION FOR CONSTRICTIVE PERICARDITIS
MR. BOWDLER HENRY : CYSTS OF NASOPALATINE CANAL
te
I N I :
DR. SCOTT: ANGINAL SYNDROME IN ACUTE SPONTANEOUS PNEUMOMEDIASTINUM
THE LANCET, June 5, 1937
P
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ar o
Fic. III
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FIG. V
DR. CRAMER AND
DR. HORNING :
MALE GONADS
AND THE ADRENAL GLAND
Digitized by Google
THE LANCET]
adrenaline they still show the arrangement in alveoli
characteristic of the medulla. Such an alveolus may
sometimes consist half of cells still containing
adrenaline granules, while in the other half the cells
are free from them, or an alveolus of cells fully charged
with adrenaline may lie like an islet among cells
deprived of adrenaline. In the peripheral part of the
X-zone the cells are often indistinguishable from
cortical cells deprived of lipoids, so that the peripheral
part of the X-zone may consist of cortical cells.
Even the leash of blood-vessels which normally
delimits the medulla can sometimes be seen at the
peripheral end of the X-zone. The same phenomenon
of an ebbing-away of adrenaline from the peripheral
part of the medulla can be demonstrated in the
adrenals of young female mice, where the X-zone is
almost always present (Fig. V). The phenomenon
was described and figured in greater detail than is
possible in this communication by Cramer in his
book, although he did not recognise then that it was
essentially a sex difference.
A number of other observers (Tamura, Howard-
Miller, Deanesly, and Whitehead) have since inter-
preted the X-zone or boundary zone as representing
a separate anatomical entity, distinct from either
cortex or medulla and disappearing as the result of
a process of degeneration. Grollman in his book
calls it a third tissue, and ascribing to it on purely
speculative grounds masculinising properties has
called it “ androgenic tissue.” The rapid appearance
of this zone in adult male mice after castration and
its rapid disappearance after the administration of
testosterone shows that this view is untenable and
that the term ‘androgenic tissue” is, in any case,
a singularly inapt misnomer.
CONCLUSION
_ The experiments with testosterone show that the
X-zone is the morphological expression of a func-
tional change in the adrenal gland, and in so far as
this functional change consists in a marked diminution
in the number of cells charged with adrenaline and
available for the secretion of adrenaline, this functional
change may logically be described as-an inhibition.
The action of testosterone on the adrenal gland thus
affords a satisfactory explanation of the phenomenon
of the X-zone in normal mice. It is absent in male
mice, because under the influence of testosterone the
medullary cells maintain their full load of adrenaline
throughout the whole extent of the medulla. The
X-zone is present in young female mice, even when
sexually mature, because in the absence of the male
sex hormone the peripheral cells of the medulla do
not maintain their load of adrenaline. The fact
DR. BUTTLE & OTHERS : DIAMINOSULPHONE IN STREPTOCOCCAL INFECTIONS [JUNE 5, 1937
1331
that the X-zone disappears in female mice as they
grow older seems to indicate that there is an increased
formation of the male sex hormone in female mice as
age advances.
REFERENCES
(1928) Fever, Heat Regulation, Climate and the
yroid Adrenal Apparatus, London. .
Deana R . (1928) Proc. roy. Soc. B. 103, 523.
Grollman, A. (1936) The Adrenals, London.
Howard- -Miller, E. (1927) Amer. J. Anat. 40, 251.
Tamura, Y. (1926) Brit. J. exp. Biol. 4, 81.
Whitehead, ae (1931) Tid, 12, 305.
(1 933) J . Anat. , 387.
a
THE TREATMENT OF
STREPTOCOCCAL INFECTIONS IN MICE
WITH 4:4’DIAMINODIPHENYLSULPHONE
By G. A. H. BurTTLE, M.A. Camb., M.R.C.S. Eng.
DORA STEPHENSON, Ph.D. Leeds |
OF THE WELLCOME PHYSIOLOGICAL RESEARCH LABORATORIES,
BECKENHAM, KENT
S. Smitu, Ph.D. Kiel, T. DEwiInc, M.Sc. Lond.
AND
G. E. Foster, Ph.D. Lond.
OF THE WELLCOME CHEMICAL WORKS, DARTFORD
AFTER Domagk’s initial discovery (1935) of the
therapeutic value of Prontosil in streptococcal
infections of mice, and the further discovery by
Tréfouél, Nitti, and Bovet (1935) that p-amino-
benzenesulphonamide (commonly called sulphanil-
amide or sulphonamide P) was also active, a number
of other compounds of this series have been tested
(Buttle et al. 1936, Fourneau et al. 1936, Goissedet
et al. 1936, Tréfouél et al. 1937, Gray et al. 1937),
but in no case was there a striking increase in
activity over sulphanilamide.
The present communication deals with two com-
pounds of a different chemical structure. The first,
4:4’diaminodiphenylsulphone, is considerably more
active than sulphanilamide in curing streptococcal
infections of mice but is more toxic to mice; the
second, 4:4’dinitrodiphenylsulphone, is as active
as sulphanilamide but is less toxic. 4:4’diamino- -
diphenylsulphone, NH,< » 80, > NH,
(Fromm and Wittmann 1908), occurs in very long
colourless rectangular plates, m.p. 176°C. It is
sparingly soluble (0-01 per cent.) in water at room
temperature, but more soluble (0:05 per cent.) in
LEGENDS TO ILLUSTRATIONS ON PLATE
DR. CRAMER AND DR. HORNING
All sections are of adrenal glands of mice fixed by the
osmic vapour method. Figs. I-IV are photomicrographs,
and Fig. V is a camera-lucida drawing. In Figs. I-IV
C=cortex; Z==zona reticularis; X= boundary zone or
X-zone; and M—medulla.
Fic. I.—Section through adrenal gland of a castrated
male mouse showing the disappearance of the X-zone
after administration of testosterone propionate.
Fic. II1.—Adrenal of castrated male mouse with a broad
X-zone.
Fic. III.—Section of. adrenal of a spayed female mouse
illustrating complete disappearance of the X-zone
following treatment with testosterone.
Fic. IV.—Adrenal of a spayed female mouse showing
a broad X-zone.
Fie. V.—X-zone of female mouse adrenal showing on
the left the medullary core of the gland (CA) with
its cells fully charged with adrenaline and on the right
the inner end of the zona fasciculata (ZF) of the cortex
with its cells containing lipoid globules. Between
them lies the broad X-zone. It is composed of cells
partly charged with adrenaline (C) lying next to the
medullary core and of cells with large clear nuclei
free from adrenaline but still arranged in alveolar forma-
tion (B). Among them there are islets of cells fully
charged with adrenaline (A). This part of the X-zone
becomes completely charged with adrenaline after
testosterone and belongs to the medulla. The peri-
pheral part of the X-zone in this figure consists of
irregularly arranged cells free from cell inclusions
(D), and it is cortical in eae
Z
1332 THE LANOET]
DR. BUTTLE & OTHERS : DIAMINOSULPHONE IN STREPTOCOCCAL INFECTIONS
[JUNE 5, 1937
TABLE I
COMPARISON OF SULPHANILAMIDE, 4:4’DINITRODIPHENYLSULPHONE, AND 4:4’DIAMINODIPHENYLSULPHONE
Hemolytic| Approx. Number of mice ae ai ape ed of 10) dying on each Mice
Treatment (by mouth) streptococci! number of SY Giver Infection. surviving
y 3 “ Richards ”| organisms. 10 days.
I.P. 1 2 3 4 5 6 7 8 E
c.cm.
Controls untreated. 10-9 2| 0 2 2 0 0 0 0 0
10-7 130 | 3 5 0 0 0 0 1 0
AETAT ces 10-5 13,000 | 7 3 0 |- 0 0 0 0 0
p Ta
40 mg. : 1, 2, 3, & 4th day. 10-5 13,000 | 0 0 0 0 0 0 0 0
4 mg. = 10-5 13,000 | 1 2 0 0 0 0 2 1
0°4 mg. H 10-5 13,000 | 1 4 0 1 0 2 0 0
4:4’ ty ae een ea phone
.: 1,2, 3, & 4th day. 10-9 13,000 | 1 0 1 0 0 1 0 0
o a 10-9 13,000 | 0 1 0 0 0 0 0 0
0°4 mg. 3 10-5 13,000 2 0 0 0
4: 4’diaminodiphenylsulphone—
4mg.: 1, 2, 3, & 4th day. 10-5 13,000 | 2 2 0 0
0'4 mg. X 10-95 13,000 | 0 0 0 0 0 0 0 0
0°04 mg. i 10-5 13,000 2 0 1
Sulphanilamide—
50 mg. daily, 10-3 1,300,000 | 6 2 1 0 0 0 0 0
4:4’diaminodiphenylsulphone—
2 mg. gaily t or 6 days, 1 mg. 10-3 1,300,000 | 0 2 1 0 0 0 0 2
aily for ays.
Mice weighed 25 g.
hot water. 4:4 ‘dinitrodiphenylsulphone (Fromm first 6 hours. Blood counts were normal the day
and Wittmann 1908) is an amorphous yellowish
powder, insoluble in water.
TOXICITY
Sulphanilamide is tolerated in 50 mg. doses given
. by mouth to mice of 20 gramme weight ; these doses
can be repeated daily in 25 g. mice infected with
streptococci (Buttle et al. 1936). The 4:4’dinitro-
diphenylsulphone is tolerated in 200 mg. doses
given by mouth, but a 400 mg. dose is lethal; doses
of 40 mg. can be given repeatedly to infected mice.
The 4:4’diaminodiphenylsulphone is tolerated in
5 mg. doses given by mouth; 2 mg. can be given
daily to normal or infected mice, but daily doses of
5 mg. kill some of the animals. The drug is slightly
more toxic in infected animals.
Although the diaminosulphone is about ten times
_ as toxic as sulphanilamide when a single dose is
‘given to normal mice (and about twenty-five times as
toxic when the doses are given daily to infected
animals), it is not more toxic to normal rabbits and
monkeys. Single doses of 2:0 g. per kg. of either of
the drugs produce slight symptoms in the rabbit but
not in the monkey. (The dinitro compound has
not yet been tried in these animals.) A single dose of
0:3 g. of the diamino compound was taken by a
healthy human individual and caused no symptoms ;
five hours after the administration of the drug, how-
ever, the blood contained a very small quantity of
methæmoglobin. A monkey which had received
much larger doses of the drug (1:0 g. per kg.) had a
much larger quantity of methæmoglobin in the blood,
but this was not associated with any respiratory
embarrassment or other change. A similar dose of
sulphanilamide when given to another monkey did
not produce methæmoglobinæmia.
We are indebted to Mr. G. Discombe, St. Bartholo-
mew’s Hospital, for demonstrating the presence of
small quantities of methemoglobin in the blood (see
Discombe 1937). The urine of the individual men-
tioned above was examined for the presence of the
sulphone using the diazo reaction with thymol.
There was a considerable quantity in the 12- and the
18-hour specimens, but very little was excreted in the
after taking the drug.
Toxic doses of these sulphones have an action on
the nervous system in mice which is somewhat
different from that of sulphanilamide. With the new :
drugs the mice appear excited and often run con-
tinuously round their cages; if they are taken from
the cages and placed on the table, they move about
without any apparent purpose, sometimes running
straight over the edge; when lethal doses are given,
they become paralysed and have difficulty in
respiration. With sulphanilamide, on the other hand,
the mice rapidly become paralysed and move their
limbs continuously in an incoérdinate manner. The
symptoms produced by the new drugs are much more
persistent than with sulphanilamide; they may last
for 48 hours or longer, whereas with sulphanilamide
the mice either die or recover within 6 hours. Lethal
doses of the new drugs cause intense dilatation of the
stomach and small intestine in mice, and slight
swelling of the belly may be observed in rabbits
which receive large doses, but it is not great in
proportion to the size of the animal. These changes
are not produced by sulphanilamide.
THERAPEUTIC EFFECTS
In hemolytic streptococcal «infecttons.—Mice were
infected with streptococci (“‘ Richards”) intraperi-
toneally and treated with the various drugs, adminis-
tered orally (Buttle et al. 1936). Table I shows a
comparison between the therapeutic effects of sulph-
anilamide and of the dinitro- and diamino-sulphones,
The dinitrosulphone is as effective as sulphanilamide
when similar doses are used. In the case of the
diaminosulphone, doses of 0-4 mg. are as effective as
40 mg. of sulphanilamide, and doses of 0-04 mg. are
only slightly inferior; owing to the toxicity of the
drug, however, doses of 4 mg. of the sulphone do not
give such good results. The second part of the Table
shows that a better degree of protection is obtained
against a large dose of culture with 2 mg. of the
diaminosulphone than with 50 mg. of sulphanilamide.
(Approximately 2000 mice have been used in this
investigation, but hitherto no more than one strain
of hemolytic streptococci.)
THE LANCET] -
As the.diaminosulphone is not more toxic for rabbits
than sulphanilamide, it would be interesting to know
how the two drugs compare in therapeutic activity
in this animal. Unfortunately we have not been able
to obtain a Lancefield Group A strain or any human
strain which is virulent for rabbits. Preliminary
experiments have been done with a Group C strain,
P.230, which was isolated from a guinea-pig epidemic
by Dr. Theobald Smith and was sent to us by
the courtesy of Dr. Homer Swift. Although the
diaminosulphone is more active than sulphanilamide,
the difference between the drugs is not so great as
in the mouse experiments. It appeared from the
rabbit experiments that daily doses of 15 mg. per kg.
of the sulphone by mouth are not quite so effective
as 150 ‘mg. per kg. of sulphanilamide; on the other
hand, doses of 150 mg. per kg. of the sulphone are
more effective than doses of 150 mg. per kg. of
sulphanilamide.
The bactericidal effect of the blood of a (3-1 kg.)
monkey (Silenus rhesus) was studied at intervals
after the administration of (a) 4 g. of sulphanilamide,
and (b) 1 g. of the diaminosulphone given by mouth
(Table II). The rotating-tube technique (Colebrook
TABLE II
Bactericidal effects induced in the blood of a monkey by the
l administration of (a) 4 g. of sulphanilamide and
(b) T g. of 4:4’diaminodiphenylsulphone.
r
a Number of organisms
£ .| implanted in 0°5 c.cm.
EE of blood (rotating-
Treatment. z E tube technique).
5
a 200 |2000] 20,000
(a) Sulphanilamide 4 g. 0 ee zs
(Feb. 23rd, 1937.) l —0 |-0 H
5 —0 |-0 | -+
24 H ee ee
7 48 . æ ee
(b) 4:4’ diaminodiphenyl- 0 Sa a
sulphone 1 g. (April 16th, 13 Sa ats
1937.) 5 —0 ;-0 | -+
24 —0 R + ee
48 Ea ee ee
96
120
—0=no hemon HE of blood, and no streptococci found on
su
— +=no hemolysis of blood, but streptococci grown on sub-
culture
H =hemolysis of the blood with full growth of streptococci.
Controls with normal blood from another animal were
put up on each occasion and the cocci grew freely from the
smallest inoculum.
et al. 1936, Todd 1927) was used in these experiments.
The maximum bactericidal effect was of the same
order in both cases; the effect of sulphanilamide,
however, disappeared within 48 hours, whereas that
of the diaminosulphone, which was not quite so
rapid in its onset, lasted for 96 hours. This experi-
ment was repeated: another monkey, weighing 2:5 kg.,
received 200 mg. of each drug on two separate occa-
sions, and it was again found that the maximum
bactericidal effect obtained was of the same order for
the two drugs; 300 cocci were killed in 0°5 c.cm.
samples after treatment, whereas 3 cocci grew freely
in normal samples. The effect of the diamino-
sulphone was again more persistent than that of
the sulphanilamide.
The bactericidal effect in the blood of man after
the administration of the drug by mouth has not
been sufficiently determined, but in one experiment
in which a dose of 0:3 g. was given, 0-5 c.cm. samples
DR. BUTTLE & OTHERS :. DIAMINOSULPHONH IN STREPTOCOCCAL INFECTIONS [JUNE 6, 1937
1333
of blood (G. A. H. B.) withdrawn six hours after the
administration destroyed 400 cocci and inhibited the
growth of 40,000, whereas 400 cocci grew in a
specimen of blood taken before administration, and
40 cocci were destroyed.
When 0-001 per cent. of the diaminosulphone was
added to 0:5 c.cm. quantities of monkey blood in
vitro a bactericidal effect was obtained which was
greater than that with sulphanilamide in equal
concentrations ; but it was not quite so great as
that with 0:01 per cent. of the latter. With 0-001 per
cent. of the sulphone 80 cocci were completely
destroyed, and the growth of 800 was slightly delayed ;
with sulphanilamide, on the other hand, 0-001 per
cent. only delayed the growth of 8 cocci for 48 hours,
while 0:01 per cent. delayed the growth of 800 cocci
for 72 hours and destroyed 80 completely. The
results with 0:01 per cent. of the sulphone were
slightly better than those with 0-01 per cent. of the
sulphanilamide.
In another experiment with human blood (N. McL.),
120,000 cocci were destroyed by 0-01 per cent. of the
sulphone, whereas with a similar concentration of
sulphanilamide 12,000 were destroyed and the growth
of 120,000 delayed for 48 hours; 120 grew freely
in the control, and 12 were destroyed.
In non-streptococcal infections.—Preliminary experi-
ments indicate that the diaminosulphone (2 mg. doses)
is considerably. more -effective than sulphanilamide
(40 mg. doses) in prolonging the lives of mice infected
with pneumococci, but it is as yet uncertain whether
mice can be completely cured. In the treatment of
typhoid infections, the diaminosulphone is less effective
in doses of 2 mg. than sulphanilamide in doses of
25 mg. These differences in therapeutic efficiency
appear to be associated with the fact that a prolonged
action of the drug is required for protection against
pneumococcal infections in mice, and a rapid action
is necessary for protection against typhoid infections
(Buttle et al. 1937). The diaminosulphone is also
effective in staphylococcal infections. |
DISCUSSION
When patients are treated with sulphanilamide
it is necessary to give large doses by mouth. This
is sometimes inconvenient or difficult. It would,
therefore, be of interest if a compound could be
discovered which, even when given in smaller doses,
would be as efficient as sulphanilamide in treatment.
The results presented in this paper show that
4:4’diaminodiphenylsulphone is much more active
than sulphanilamide in curing streptococcal infections
of mice, and that, while it is more toxic for mice than
the latter compound, it is not more toxic for rabbits
and monkeys, except that it causes methzemo-
globinemia more readily in the monkey. When the
diaminosulphone is added directly to monkey or
human blood in vitro it appears to be slightly more
effective than sulphanilamide. Further, when the
drugs are given by mouth to normal monkeys the
maximum bactericidal effects obtained in the blood
are of the same order in each case, although the action
of the diaminosulphone is more persistent. In view
of these facts it is somewhat difficult to understand
why mouse infections are cured by doses of the
diaminosulphone so much smaller than those required
with sulphanilamide. The latter is absorbed and
excreted very quickly by the mouse, the concentration
in the blood falls to about one-tenth of its initial value
in 7 hours, and to one-hundredth of this value in 13
hours ; it seems probable, therefore, that there is not
a uniformly high bactericidal effect. The experiment
e
1334 THE LANCET]
with the monkey suggests that the bactericidal
effect of the sulphone, on the other hand, is main-
tained. This persistence of the bactericidal effect
may account, in part, for the difference between the
drugs, but it seems unlikely that it is the only factor
concerned. It is highly improbable that either the
diamino- or the dinitro-sulphone could give rise to
p-aminobenzenesulphonamide in the body, and their
activity is of special interest since it indicates that
streptococcicidal activity is not confined to drugs
which contain, or could easily produce, substances
containing a sulphonamide group.
SUMMARY
1. 4:4’diaminodiphenylsulphone (diaminosulphone)
is active in curing streptococcal infections of mice in
doses of about one-hundredth of those required with
p-aminobenzenesulphonamide (sulphanilamide) ; it is,
however, twenty-five times as toxic. The drug is
not more toxic than sulphanilamide in normal rabbits
or monkeys, except that it is more active in producing
methzemoglobinzemia in the latter animal.
2. The corresponding dinitro compound (dinitro-
sulphone) is not so toxic to mice as sulphanilamide
and its antistreptococcal activity in mice is not
inferior to that of the latter substance.
We have to thank Mr. W. H. Gray for the prepara-
tion of the dinitrosulphone, Dr. J. W. Trevan
for his help and criticism, and Mr. H. Proom for
estimating the sulphone and sulphanilamide in the
specimens of urine and blood.
Note.—Since the above paper was written Dr.
F. Nitti of the Pasteur Institute, Paris, has kindly
written to us saying that he has been working inde-
pendently with the dinitro compound, and that his
results are in general agreement with ours.
REFERENCES
Buttle, G. A; H.,
Gray, W. H., and Stephenson, D. (1936)
Lancet, , 1286.
— Parish, H. J.,
wa McLeod, M., and Stephenson, D. (1937)
Colebrook, t, „Buttle, G. A. H., and O’Meara, R. A. Q. (1936)
Discombe, í G. (1937) Ibid, 1, 626. f
Domagk, (1935) Deut. med. Wschr. 61, 250.
epr a n E., Tréfouël, J. and Miia Ss Nitti, F., and Bovet, D.
(1936) C. ’ R. Soc. Biol. Paris, , 652.
A enn: y (1908) Ber. dtsch. chem.
ee iar oe Des oF Pa R., HETT Os and Mayer, R. (1936)
Soc. Bio
. Path. 8, 1.
J, and SA Mer ieh F., and ort, D. (1935) C. R. Soc.
' (1937) Ann. Inst. Pasteur, 58, 30.
TEHTDY SANATORIUM, CAMBORNE.—Mrs. Bolitho,
wife of the lord-lieutenant of Cornwall, opened a new
orthopædic unit costing £5000 at this hospital on
May 19th. It provides accommodation for an eight-
bed ward, five double-bed ward, and three single-bed
wards, and has been designed to give the maximum
of air and sunshine. It is to be used entirely for surgical
orthopædic tuberculosis cases.
BIRTH-RATE IN SOVIET UNION.— According to
official reports, the birth-rate in Soviet Russia is
steadily increasing. Last January the number of births
registered was 21°7 per cent. higher than in January,
1936, and in the first quarter of this year it was
about 30 per cent. higher than in the corresponding
quarter of 1936. Of the Union republics, the Ukraine
records the largest increase for this quarter—namely,
70 per cent. Up to April Ist the local authorities had
effected transfers of 566 million roubles for the payment
of allowances to mothers of large families. The number of
mothers in the country receiving these allowances is
given as 270,000.
DRS. BREEN AND TAYLOR: ERYSIPELAS TREATED WITH PRONTOSIL
[JUNE 5, 1937 »
ERYSIPELAS TREATED WITH
PRONTOSIL
By G. E. BREEN,
AND
Ian TAYLOR, M.B., M.R.C.P. Lond., D.P.H.
SENIOR ASSISTANT MEDICAL OFFICERS AT THE NORTH-
EASTERN FEVER HOSPITAL, LONDON
M.D. N.U.I.
EACH of the preparations of the Prontosil group
has been used in the treatment of erysipelas as it
appeared. Of the early publications on this subject
mention may be made of the work of Meyer-Heine
and Huguenin (1936) who treated 150 cases of
erysipelas, beginning in May, 1935. They found
that apart from rare exceptions a fall of temperature
and local amelioration took place with impressive
similitude. Eight of their cases were infants under
a year, all of whom were successfully treated.
Tonndorf (1936) reports 22 prompt successes with
one relapse.
The route of administration of these preparations
may be varied to suit individual cases. The use of
the oral route has received strong support from the
recent experimental work of Marshall, Emerson, and
Cutting (1937) with para-aminobenzenesulphonamide.
These workers found that the concentration in the
blood of dogs does not mount quicker or higher after
subcutaneous injection than after oral administra-
tion. Absorption by the gastro-intestinal tract is
complete in four hours ; and two or three days elapse
after discontinuation before the body is free of the
drug.
RESULTS
The present consecutive series consists all told of
46 cases. Of these all but 5 were examples of the
facial variety. The diagnosis was made on purely
clinical grounds. No bacteriological confirmation
was sought or considered necessary. Prontosil in
one or other form was given to 35, and various other
forms of therapy to 10. All cases were in addition
painted locally twice daily with a mixture of glycerin
and ichthyol. In the whole series there were 2
deaths. One was a man aged 71, who was admitted
in a moribund state with gangrene of the nose, cheeks,
eyelids, forehead, and scalp (at sight of which an
attendant fainted). He was obviously beyond the
reach of any therapeutic measure or agent and died
within 48 hours; he is omitted from either series.
The other was also a man aged 71, admitted with
sharp erysipelas of the left hand and forearm, which
responded promptly to treatment with Prontosil
Album. Unfortunately five days after admission
a cerebral hemorrhage supervened, and death
occurred within 24 hours.
An analysis of the records of the remainder of the
patients is illuminating. Admittedly 10 controls
are much too few for even so small a series as this one ;
nevertheless the evidence they afford cannot be
disregarded, especially when it is considered that
clinically they were the milder cases and were
purposely selected for that reason. Summarised
the results are as follows :—
Of 35 cases treated by prontosil from admission, 33 had
regressed, 1 had spread, and 1 was stationary 48 hours
later. There was one subsequent relapse. Of 10 cases
not treated with prontosil 4 had regressed, 5 had spread,
and 1 was stationary 48 hours later. There were no
relapses (Fig. 1). Of the five no-prontosil cases which
had spread 3 were subsequently treated with prontosil,
and within 48 hours they had also regressed.
r
THE LANCET]
The effect on the temperature is shown by the
composite graph in Fig. 2, and on the pulse by the
graph in Fig. 3. It will be seen that the average
temperature of the prontosil cases fell to normal
or below in 48 hours, whereas the average of the other
cases remained above normal. As regards the pulse,
the advantage lies with the no-prontosil group,
but it has to be remembered that they were regarded
clinically as milder cases, and this is reflected in the
lower temperature and pulse-rate on admission.
The cases are given in age-groups in the Table.
It will be noticed that of 6 cases in the 50—65 no-pron-
tosil group 3 spread, while of a similar number in the
prontosil group all regressed. Of 9 cases in the over-65
prontosil group none spread and only one was
Fico
za SPREAD OR
ZA STATIONARY
C REGRESSED
PRONT6SIL
OTHER
CASES 38
CASES
FIG. 1.—Effect of pronfosil on
the progress of the disease.
stationary, the other 8 having subsided ; whereas the
solitary no-prontosil case in the same age-group was
noted as stationary.
Turning to the prontosil group as a whole a
further noteworthy fact emerges. The drug was
administered by mouth in all but 2 cases. Two five-
grain tablets of prontosil album three times daily
COMPARISON OF RESULTS
Age-group | 0-5 | 5-15 | 15-30 | 30-50 | 50-65 | Over 65
PRONTOSIL CASES
Cases .. 2 3 | 8 7 6 9
Regressed 1 3 | 8 7 6 8
Stationary = — |; — = = 1
Spread 1 —_ — — — —
Relapse — — | 1 — — —
OTHER CASES
Cases ee = ee, 3 —" 6 1
Regressed — — 1 — 3 —
Stationary — — — — — 1
Spread — — 2 ` — 3 —
Relapse — — — — — —
was the ordinary adult dose, smaller doses propor-
tionately to body-weight being given to children.
In two cases, however—one a baby of 7 months who
objected to the inclusion of the powdered tablets
in his feeds, and the other an adult female of 69
who was comatose on admission and for some days
later—the drug had to be administered intra-
muscularly in doses of 5 c.cm. The baby was the only
case of spread after 48 hours recorded in the prontosil
24
HOURS AFTER ADMISSION
FIG. 2.—Average temperature chart.
DRS. BREEN AND TAYLOR: ERYSIPELAS TREATED WITH PRONTOSIL [JUNE 5, 1937 1335
series, and the spread was slight and of short duration ;
the adult was the only prontosil case reported as
stationary after the same period. She subsequently
developed lung abscesses on both sides; that on the
left cleared up, that on the right persisted. (A report
of this case is to appear elsewhere. ) |
The single relapse recorded occurred in a young
adult female. The attack was a moderate one and
her response to treatment by tablets was so prompt
. that the drug was discontinued after three days.
She was about to be discharged on the tenth day
when the relapse occurred. This yielded so promptly
to a resumption of treatment that she was actually
discharged a week later. In this connexion Tonndorf
cites a similar case ‘following five days medication.
100
90
48 24 48
HOURS AFTER ADMISSION
FIG. 3.—Average pulse-rate char! s
The average length of stay in hospital in the
prontosil cases was 184 days, which compares
favourably with the figure of 23-8 days in the other
series.
Both series were remarkably free from complica-
tions. A moderate degree of cervical adenitis was
noted on admission in a number of cases. One in
particular already referred to presented in addition
corneal ulceration with much cedema of the lids, a
severe stomatitis, laryngitis, and pneumonia. Pul-
monary abscesses subsequently developed. There
was a notable absence of toxemia, and her general
condition improved so much that she was transferred
to a thoracic unit for further treatment.
DISCUSSION
With the small number of cases and controls at
our disposal it would be folly to dogmatise; neverthe-
less a few tentative conclusions may be offered.
Prontosil is of undoubted value in the treatment of
erysipelas. The drug is best administered by mouth.
It is necessary for the patient to receive repeated
doses in order to maintain the requisite concentra-
tion, and these are more easily administered by mouth
than by repeated injections.
The dosage in our series appears to be adequate.
It may be expected to produce a favourable result
in about 48 hours—i.e., when about 60 grains have
been ingested. No obviously untoward results
followed from this dosage or mode of therapy. The
drug ought to be persisted in for about a week.
(Tonndorf suggests ten days.)
It has little or no effect on local septic lesions which
may have been the starting point of the attack.
1336 THE LANCET]
Finally, we would draw attention again to the
quite remarkable results in the age-group 50-65
and over, and to the fact that no spread or relapse
occurred in any patient while actually taking prontosil
by mouth.
We are greatly indebted to Dr. E. H. R. Harries, medical
superintendent of the North Eastern Hospital, for his
MEDICAL
ROYAL SOCIETY OF MEDICINE
~ SECTION OF UROLOGY
AT a meeting of this section on May 27th, with
Mr. BERNARD WARD, the president, in the chair, a
paper on
Genito- -urinary Tuberculosis
was tead by Mr. James CARVER. It was based on
46 cases under his care in the last four years, most of
which had been sent from sanatoriums, where they
were having treatment for tuberculosis of urinary
tract, lungs, or joints. Jn 28 cases the lesions were
renal and in 10 they were genital. Renal tuberculosis
was commonest during the second, third, and fourth
decades; 1225 of 1571 cases in a recent series were
between twenty-one and fifty years of age.
Genital tuberculosis occurred at the period of
maximum sexual activity. Half the cases in which
the disease was in the seminal tract had bilateral
epididymitis, the second epididymis becoming involved
within a year of the first; in three the testis was so
diseased that castration was necessary, while in one
bilateral castration had to be performed.
In tuberculosis of the kidney, said Mr. Carver, the
earliest symptom was frequency of micturition; the
next most common was burning and scalding and
hematuria. No one would wait nowadays for night-
sweats and hoarseness before sending sputum for
examination; but in non-sanatorium cases a sur-
prisingly long period often elapsed before genito-
urinary tuberculosis was suspected. There was
need for wider recognition of the earlier symptoms,
and all patients whose bladder symptoms did not
improve within a reasonable time should have a
complete bacteriological and urological examination.
It was unwise to rely on smears alone for diagnosis ;
on the other hand guinea-pig Inoculation and
cultures had proved reliable in 24 out of 26 cases of
renal tuberculosis Occasionally negative laboratory
reports might lead to a wrong diagnosis—e. g., when
renal occlusion was present. “Braasch, of the Mayo
Clinic, reported that of 621 cases of tuberculous
kidney 69 had renal occlusion. Uroselectan was
valuable as a diagnostic aid, but its use should be
preceded by ordinary radiography of the renal tract
to find any calcareous deposits. Often excretion
urography indicated which side was diseased. For
cystoscopy the speaker always employed a low spinal
anesthetic. Where there was much contraction, and
where it was difficult to obtain a clear medium,
an operating cystoscope should be used. Operation
for tuberculosis of the kidney was rarely required
very urgently, and everything possible should be done
to raise the patient’s resistance and general health
beforehand, even by sanatorium treatment when this
could be arranged. Patient and staff should be on
the best of terms for a considerable period before
operation. As an anesthetic, cyclopropane was now
largely used in place of gas-and-oxygen ; it had the
- ROYAL SOCIETY OF MEDICINE: UROLOGY
[JUNE 5, 1937
permission to published details of these cases and for his
help and advice in presenting them.
REFERENCES
Marshall, E. KE ; Emerson, K., and Cutting, W. C. (1937) J. Amer.
med. A88. 10 953.
eee A., and Huguenin, P. (1936) Pr. méd. 44, 454.
Tonndorf (1936) ' Med. Klin. 32, 1307.
SOCIETIES
advantage that no chest complication followed its
administration, and also that breathing was very
quiet during the operation, and there was sufficient
relaxation. The only drawback to cyclopropane in his
experience was a tendency to nausea and vomiting in
the 24 hours after it was given.
In his Bradshaw lecture Hugh Lett spoke of the
advantages of removing the ureter when the kidney
had to be removed for tuberculosis, and the speaker’s
choice was the same procedure. After the vascular
pedicle had been divided, the kidney was pushed
down towards the pelvic brim, and the wound was
sewh up and drained. Then the patient was put
into the Trendelenburg posture, and a subumbilical
midline incision made. The kidney was delivered
to the assistant, who held it vertically upwards while
the ureter was being stripped down to the bladder.
The ureter was clamped flush with the bladder and
divided. The cut end was sealed with pure carbolic
and embedded. The pelvic wound was also drained.
Several writers had emphasised the importance of
removing the perinephric fat, so as to avoid con-
tamination of the operation field and subsequent
breaking-down of the wound. But Carver
thought the perinephric fat played little part in this
catastrophe; in his view the causes of it were
rupture of the kidney owing. to rough handling, and
contamination of the wound by the ureteric stump
when the kidney had alone been removed. : All his
loin wounds healed by first intention. Urologists
who did not practise nephro-ureterectomy declared
that the ureteric stump was able to look after itself.
But it was impossible to judge of the condition of
the lower third of the ureter from a loin incision.
The portions of the ureter which were most seriously
involved were the upper and lower thirds.
A condition that was almost as trying to the
surgeon as to the patient was tuberculous cystitis in
association with bilateral renal tuberculosis, or other
condition rendering operation on the kidney impos-
sible. Diathermy had proved very successful in one
case in which ulceration and hypertrophy of mucous
membrane was present. Mr. Carver had had no
experience of such methods as injections of 6 per
cent. carbolic, as recommended by Rovsing, or of
chloride of mercury as suggested and used by Guyon,
nor of Holland’s method of giving potassium iodide
internally, and calomel emulsion in oil into the
bladder. In carrying out epididymectomy, every
effort should be made to preserve the testicle,
especially in young men; small abscesses in it should
be curetted in preference to castration. When,
however, the testicle was severely involved, castration
was necessary. In the presence of sinuses there was
great danger of wound contamination, and A. B. Cecil’s
extrusion operation was worth employing. The
sinuses were treated with pure carbolic and a circular
incision was made around them; then the incision
was deepened and the tunica opened. Barney
advised removal of the tunica also if it was diseased.
Bumpus and Thompson reported 68 cases of genito-
THE LANCET]
urinary tuberculosis, in only one of which seminal
vesicle disease was present. In 16 the opposite
epididymis was also infected, but the seminal vesicle
on that side was clear. Of a large series of fatal cases,
44 per cent. were found to have died of tuberculosis of
the other kidney, 35-5 per cent. of tuberculosis of the
lungs, and 13-3 per cent. from miliary tuberculosis ;
in other words, 93 per cent. of the deaths were due
to tuberculosis. Mr. Carver considered that the
poorness of the results was largely due to an insuff-
cient building-up of the patient’s resistance after
operation. . Patients were very reluctant to submit
to prolonged sanatorium treatment, especially if
they had already had sanatorium régime. They
disliked being away from family life, and they feared,
with good reason, loss of employment. Lett had
stated that 80 per cent. ofthe well-to-do recovered
‘completely, whereas in those less fortunately circum-
stanced, workers and others, the proportion sank to
55-60 per cent., which showed how large a part was
played by physieal vigour and resistance. Finally,
genito-urinary tuberculosis should not be regarded
as a localised disorder but rather as a manifestation
of a generalised disease. Hence the prognosis should
be guarded,
DISCUSSION
Mr. F. E. FEILDEN said many denied that a renal
tuberculous focus ever. healed, and that might be
true. Nevertheless eight years ago he had a patient,
aged 22, with a definitely diseased left kidney and
a grossly diseased right kidney, who was passing
urine 32 times per night. A right nephrectomy
was done and when he saw her six months ago she
was very fit—her weight having increased by 3 st.—
and apparently comfortable, never rising at night.
All he had hoped, in operating, was to give some
relief. In removing a tuberculous kidney he would
insist on real sanatorium treatment for at least six
months.
Mr. H. P. WINSBURY-WHITE said that in the cases
of tuberculous epididymitis he had seen he had
always found evidence of prostatic infection, though
he could not always prove it was tuberculous. Often
such patients did not show symptoms which directed
attention to the urinary tract—i.e., they might have
prostatic infection but no great disturbance of
micturition. A large proportion of cases of renal
tuberculosis had genital infection also, and this
suggested that there must be an easy pathway by
which the infective material could wander casually
from one part of the genito-urinary apparatus to
another. It was not easy to regard the infection as
blood-borne. |
Mr. Hucum Lett thought that in tuberculous
epididymitis the infection was usually hzemato-
genous. Often the testicle showed no obvious sign
of tuberculous disease. It was very probable that there
was a definite infection of the lymphatics of the vas.
In his view, once there was a closed renal tuberculosis
and the other kidney was sound it was unwise to
leave the infected kidneys, no matter how well the
patient might appear. By removing the ureter with
the kidney it was possible to prevent the many
distressing cases with a persistent sinus in the lumbar
region and a breaking-down wound. In taking away
the ureter one removed an important focus of infec-
tion which was in direct communication with the
bladder. In many patients who ultimately died,
having had one kidney removed, there was found to
be tuberculous disease of the dpposite kidney. It
was also known that there were many patients who
ROYAL SOCIETY OF MEDICINE: UROLOGY
(i
[JUNE 5, 1937 1337
died from disease of the opposite kidney which was
not necessarily tuberculous disease ; it might be a
condition of hydronephrosis. Either the ureter was
dilated along its whole extent or there was a stricture
at its lower end. In the former case the cause was
thought to be persistent contraction of an inflamed
bladder. In that way the kidney might become the
seat of tuberculosis. Even more important was the
development of tuberculous disease in the lower end
of the ureter on the sound side. He emphasised the
importance of sanatorium treatment for these patients
before as well as after operation. In recent cases the
importance of bed could not be overstated.
Mr. E. W. RICHES agreed about the advisability of
removing the ureter as well as the kidney. On
several occasions he had had to remove ‘a ureter by
a secondary operation to clear up either a persistent
cystitis or a persistent sinus. He thought that if
clinical and bacteriological examination and excretion
urography were carried out there was seldom need
for pyelography. He was a believer in tuberculin ;
its use often brought improvement in the condition
of the second kidney when the first had been removed
by operation. It was valuable. to remembér this,
seeing that many patients could not have sanatorium
treatment. As to prognosis, he felt. that unilateral
tuberculous renal disease had a reasonably good
prognosis.
Mr. H. V. WELLS said that in prostatic trouble the
infection travelled along the lumen of the vas. In a
case with prostatic infection the passage of an instru-*
ment might be followed in 24 hours by acute epi-
didymitis. In a considerable proportion of cases of
tuberculous epididymitis there was no demonstrable
renal lesion. A tuberculous bacilluria might be
determined by a focus in the kidney, which might
afterwards heal. : | | |
Mr. R. OcIer Warp thought the general outlook
on renal tuberculosis unduly pessimistic. Mr. Carver’s
series, largely composed of sanatorium cases, was
notable for the proportion in which there were other
tuberculous lesions in the body. It was his own
custom, in both hospital and private practice, to
ask patients whether they had had disease of bones
or joints, and he was surprised at the small number
who had. He did not often perform nephro-ureterec-
tomy. When should it be done? If the patient had
a golf-hole ureter, or if it was grossly diseased, the
ureter should come out. If a ureteric orifice moved
with respiration, it meant it was a rigid ureter and
that the kidney was stuck to the diaphragm, and the
surgeon should be prepared to perform nephro-
ureterectomy; and similarly if the ureter could be
felt per abdomen. oO E
Mr. A. E. RocHE agreed about the general undesira-
bility of ascending pyelography for the diagnosis of
renal tuberculosis. He had never tied the vas on
the apparently sound side in cases of unilateral
epididymal tuberculosis; his mind always ran on
the possibility of a legal action, for one could not
swear that a particular patient was not one of the
40 per cent. in whom the disease would not have
spread to the fellow testicle.
The PRESIDENT said that if there was tubercle in
any other part of the body—particularly lungs,
bones, or joints—he held his hand until, under
sanatorium or other treatment, the active lesions
had become quiescent or cured. Even a kidney with
advanced disease was doing. a considerable amount
of work ; if it was removed, the whole of that work
had to be done by the other kidney, and its chance
of infection was increased. As kidney operations
|
1338 THE LANCET]
were not urgent, there was every opportunity for
careful preparation of the patient. Moreover, tuber-
culosis of the kidney was not necessarily a progressive
disease ; it would be curious if the kidney were the
only organ in the body that did not show resistance
to tubercle. Once the calyces were ulcerated and the
pelvis was involved, the lesions were progressive ;
but even cases of this type could in certain circum-
stances undergo cure. He did not often do pyelo-
graphy ; sometimes it did not teach as much as did
careful examination of urine drawn off by ureteric
catheter. If such urine showed pus—whether with
or without tubercle bacilli—the kidney should be
regarded with suspicion. If a ureter was thickened
he removed it, almost throughout its length.
Mr. CARVER, in reply, agreed that in established
renal tuberculosis infection could spread to the
epididymis, prostate, and vesicle from the urethra.
He believed the infection often travelled by the
blood stream ; often the primary lesion was in the
epididymis. When in doubt about a kidney sinus
he used ascending pyelography.
BRITISH PSYCHOLOGICAL SOCIETY
Dr. H. CrRIcHTON-MILLER took the chair at a
meeting of this society held at the Tavistock Clinic
on May 25th, when Prof. Witt1am McDOUGALL
delivered an address on the relations between
Dissociation and Repression
These relations, he said, constituted one of the funda-
mental problems in psychology. Both words were
widely used and both were doubtless needed; they
probably stood for phenomena of two different
orders requiring at least two quite distinct theories
for their interpretation. This view was, however,
not generally accepted. The followers of Janet had
as a rule no use for the concept of repression, while
most of the followers of Freud, Jung, and Adler
admitted no need for the word “ dissociation.”’
This continuing division of opinion might, thought
Prof. McDougall, be properly regarded as a symptom
of the sickness of psychology—a dissociative symptom,
or a disorder due to conflict and repression. It was
in any case a notable instance of lack of integration
of the science of human nature. Many of the more
eclectically minded psychologists—who were fortun-
ately more numerous in Great Britain than in any
other country—used both words as descriptive
terms and recognised the need for two corresponding
theories.
Study and experience had led Prof. McDougall
to treat repression as a dynamic factor which in many
cases prepared the way for and led to dissociation.
Assisted by various friendly but vigorous opponents
of his views he had gradually come to realise that
he was confounding, under the single term “‘ dissocia-
tion,’ at least two factors which ought to be
distinguished—dissociation and disintegration. The
first step towards a solution of the problem must be
to distinguish the various meanings of the word
“ dissociation ” as used by various authors. Here
one must bear in mind the distinguishable conditions
of mental integrity or unity, expressed by the
harmonious functioning of mind in its normal healthy
instances. The study of the normal had been too
much neglected in psychology.
A psychologist who regarded the structure of the
developed mind as the product of the operation of
BRITISH PSYCHOLOGICAL SOCIETY
[JUNE 5, 1937
a single powerful principle, that of association,
naturally saw in dissociation the one abiding principle
of mental disorder. Some such logical principle
seemed to have invaded Janet’s doctrine of dissocia-
tion. Though few workers nowadays accepted the
old associational doctrines, much uncertainty was
felt concerning the principles which must replace
or accompany association as the organising processes
by which the sane mind became a harmoniously
working entity. In his “ Outline of Psychology ”
Prof. McDougall had described three principles
which governed his doctrine of the mind’s structure.
He had distinguished two great aspects of the mind’s
organisation. The first of these was the logical
structure, corresponding to the logical relations
of the cosmos in general. It grew in two ways:
mainly by differentiation of germs of mental structure
—mental dispositions—achieved by innumerable
acts of analytical discrimination, and secondly by
acts of synthetic apperception. The other aspect
of mental organisation was the historical aspect, the
total structure of the mind. This was built up hy
innumerable acts of association resulting in the
formation of associative bonds between those units
of structure which grew up by discrimination and
apperceptive synthesis.
BREAKDOWN OF THE HISTORICAL STRUCTURE
There were therefore three distinct processes of
growth and three corresponding modes of failure of
development and perhaps of breakdown of the
products of those three processes. The principal
mode of failure for Prof. McDougall’s present purpose
was, he said, the breakdown of the historical structure.
This was what he understood by dissociation in the
strict sense: an undoing or weakening of the links
of association. It was illustrated by cases of complete
absence of memory for all concrete facts but complete
retention of the use of language and the understanding
of things, so that the patient could conduct himself
like a perfectly normal person, his chief trouble being
that he did not know the names of things, which were
attached to the things themselves by associative
process. There were also cases in which the function
of the logical structure of the mind was arrested.
These were the cases of extreme regression in which
the patient became like an unborn babe, understanding
nothing. The mind was regarded, according to
this view, as built up of distinguishable units of
structure or mental dispositions, cognitive and
conative, which underwent differentiation in various
conjunctions and became smaller and larger systems,
linked to one another by a multitude of associative
bonds. It was a fair assumption that the structure
of the mind could be validly translated into terms of
neurones and cerebral structure, the mental disposi-
tions being regarded as functional groups of neurones
or systems of such groups. It was also a fair assump-
tion that the associative links between such systems
were represented in the structure of the brain.
Further, mental dissociation might be assumed to
involve some kind of impairment of these neural
cross-connexions. A further and much more question-
able and speculative assumption was, however, that
neural continuity was the ground of the unity of
consciousness ; or, in other words, that one condition
of unity of consciousness was continuity of the field
of energy changes going on in the brain at any one
moment. In the latter form this assumption was
confidently made by the representatives of the
Gestalt school of psychology, and was carried to an
extreme in the very questionable doctrine of
isomorphism.
wR
THE LANCET]
DYNAMIC RELATIONS OF THE MIND
In writing his “ Outline of Abnormal Psychology ”’
Prof. McDougall had, he said, found it necessary
to recognise a fourth kind of functional relations
between various parts of the total structure of the
mind: relations of dominance and subordination.
These relations made of the total structure not merely
a vast complex system of units all so connected that
they might reciprocally influence one another, but
also a unity in a further and a higher sense, an
hierarchical system. They integrated the whole
organisation of the mind and made of it a
harmoniously working unity. They could not be
translated, like the other relations, into terms of
neural or cerebral structure, They were strictly
dynamic relations. It was very difficult to suggest
any adequate picture of corresponding relations
between neural systems. These dynamic relations
were essentially moral relations, or at any rate mainly
relations which perhaps had no neural equivalents.
For this reason Prof. McDougall had felt compelled
to describe the mind as made up of monads, in the
sense of relatively independent psychic units. He
regarded the integration of the human personality
as consisting in the main, and most importantly,
of its maintenance as one harmonious whole by this
system of dynamic relations of dominance and
subordination. The other structure relations he
regarded as adjuvant, as instrumental aids to or
conditions of. integration. This system was even
more important in psychotherapy than the other three.
At this point he had begun to connect the theory
of dissociation with the theory of repression. To
reconcile and combine the first three systems with
the fourth was a fundamental problem, and the
difficulty of doing so was the chief barrier which still
divided psychologists into those who thought of a
neurotic disorder chiefly in terms of dissociation, and
those who thought of it chiefly in terms of repression.
Both ways of thinking were right, and to combine
‘them only required that certain assumptions should
be boldly and consistently carried through. A
great army spread over a wide front consisted of many
units,
organised in turn within larger units. These units
corresponded to the mental systems or dispositions.
Connexion between the units of an army was main-
tained by a multitude of field telephone wires ;
these represented the historical associative structure
of the mind, which linked up all the mental disposi-
tions. So long as the military units maintained their
normal internal organisation and the telephone
system was in good condition, the various parts of the
army were in touch with one another and the army
was a whole. A general failure of the telephonic
system through a weakening of the electrical supply
‘would correspond to the general relative dissocia-
tion of cerebral hemispheres which took place in
sleep, hypnosis, fatigue, and intoxication. Serious
impairment of the lines or receiving instruments
of one unit would represent local cerebral dissocia-
tion cutting out one special function or group of
functions.
DISINTEGRATION WITHOUT DISSOCIATION
The mere effective functioning of the telephonic
system did not, however, make the army a whole
in the -higher sense. The telephone wires might
carry. information about the activities of each unit,
but they might also carry mere gossip or argument.
The higher form of unity in a vastly complex system
was best and perhaps only attained and maintained
by the organisation of an hierarchical system of
BRITISH PSYCHOLOGICAL SOCIETY
each with its own internal organisation,
[JUNE 5, 1937 1339 |
dominance and subordination over and above all
the telephonic intercommunication. The telephone
system might be working perfectly while the whole
army was in a state of complete anarchy. Similarly,
the associative mechanism of the mind might be
unimpaired while the mental integrity was broken
down through a failure of the dynamic relations of
dominance and subordination. There was dis-
harmony without dissociation. |
Relations of this sort were fundamental in the
social system, even in that of animals. Their extreme
and true prototype was the relation between the
hypnotist and his subject. There was no physical
compulsion but a purely moral compulsion or influence,
which nevertheless was highly effective. Prof.
McDougall did not think that the dynamic relation-
ship was maintained by the mechanisms of associa-
tion. Two other possibilities suggested themselves.
In an army, headquarters might control all sub-
ordinate systems by a special set of telephone wires
or by wireless. Similarly, these dynamic relations
might be maintained in the mind by means of special
associational links or by a telepathic or direct
connexion. Critics who found this hypothesis too
speculative might be able to entertain that of special
nerve paths or fields of energy not confined to the
substance of the neurones. :
The next question which. arose was how the
authority of one part of the mind over the others
was attained. : The status of a warrior king depended
only in small measure on his own qualities, and much
more on tradition, heredity, or custom. He symbolised
and controlled the energy of the whole system and
could bring it to bear in or against any part. The
organisation of an army, which rested ultimately
on the same principles, provided a close analogy
with the hierarchical organisation of the mind.
Dissociation, therefore, resulted from failure of the _
associative mechanism or structure of the mind.
Conflict and repression were disorders of the dynamic
or moral relations between dominant and subordinate
parts of the mind, and led not merely to dissociation
but to disintegration. It might be better to use the
term ‘‘disharmony’”’ ta describe the disorder of the
dynamic relation, and to reserve the term “ dis-
integration ”? for cases in which both the structural
and the dynamic systems of relations were disordered,
when conflict and repression had led to severe dis-
sociation perhaps amounting to multiple personality.
In many of the graver disorders these fundamental
forms of breakdown were certainly combined. In
an army a single unit might lose touch with the
main body through breakdown of its telephonic
communication ; this was simple dissociation, as
in simple amnesias, anesthesias, and paralyses.
Secondly, the unit might refuse to obey orders ;
this was conflict. Thirdly, the Opposition of the
unit might be overwhelmed and nullified by superior
force ; this was repression. Fourthly, the rebellion
might result in breakdown of communications so that
the rebels were isolated. In the body .a rebellious
unit might be isolated physically as well as morally ;
here repression had led to dissociation with con-
sequent disintegration. The isolated unit might
continue to struggle against the superior force as
best it could from time to time.
In conclusion, Prof. McDougall said that he accepted.
the eoncept of general relative dissociation of the
brain. and of localised cerebral dissociations under-
lying various functional defects. He distinguished,
however, between disharmony and disintegration,
the latter of which in many cases involved dissocia-
tion as a secondary result of conflict and repression.
1340 THE LANCET]
[JUNE 5, 1937
REVIEWS AND N OTICES OF BOOKS
The Facial Neuralgias
By WitFrReD Harris, M.D., F.R.C.P., Consulting
Physician to St. Mary’s Hospital, and Physician
to the Hospital for Epilepsy and Paralysis, Maida
Vale. London: Humphrey Milford, Oxford
University Press. 1937. Pp. 105. 7s. 6d.
IN this little book Dr. Wilfred Harris surveys his
vast experience which now extends over nearly
30: years in the treatment of the many varieties of
pain in the face. The style of writing, which amounts
almost to a collection of aphorisms, will prove to be
of the greatest value and delight to those who already
know something about the difficulty of interpreting
and treating facial neuralgia; the uninitiated may
find it necessary to revise their knowledge not only
of anatomical landmarks but of nerve distributions
before they seek clinical information from this book
and even then may fail to appreciate the significance
of the brief comments made on the various kinds of
pain. The great clinician often makes up his mind by
intuition rather than by reasoning, and it may be
difficult or even impossible for him to explain exactly
how he assesses certain factors, especially the psycho-
logical ones, in any given case. This difficulty is
greatest when symptoms are all he has to go upon,
and the book shows how even the very elect may
sometimes be. deceived. |
However vague may be our conception of their
underlying pathology we must recognise Dr. Harris’s
outstanding contribution to the treatment of the
facial neuralgias, of which only trigeminal tic is
described in detail. He gives many examples of the
beneficial effect of alcohol injection for other condi-
tions besides true trigeminal tic, and he also mentions
contra- indications to its use. It is not possible to
teach in writing the master’s touch, and though we
can find from. Dr. Harris’s directions the point on
the face at which the needle should be inserted, it
is only by practice that we may hope to know where
it ought to go. The book necessarily shows us what
can be done rather than how to do it, and it leaves
us deeply impressed.
Accidents and Their Prevention
By H. M. Vernon, M.A., M.D., Member of Tech-
nical Advisory Board, National Institute of Indus-
trial Psychology. London: Cambridge University
Press. 1936. Pp. 336. 15s.
THE earliest studies of the incidence of accidents
in industry showed that some persons were more
liable than others to have accidents, and to this
phenomenon Eric Farmer applied the term “ accident-
proneness.”” Accident-prone people make up about
25 per cent. of the population, and this group accounts
for about 75 per cent. of all accidents. Another
25 per cent. of the population are considered to be
accident-free, whereas the remaining 59 per cent.
account for about 25 per cent. of all accidents. The
doctrine of accident-proneness is still contested by a
number of practical works managers in charge of
large groups of workmen, but from a statistical
point of view it is becoming almost an axiom. Dr.
Vernon’s method of approach to the problem of
accident prevention is largely a statistical one. His
book contains among other things a comprehensive
review of the work and reports of the Industrial
' Health Research Board to which he has himself
made valuable contributions. As he says, ‘‘ everyone
must be acquainted with persons who are clumsy
with their hands, and are liable to break almost every
article they touch . . . it is generally assumed that
their accident liability is due to sheer carelessness
and lightheartedness, and that they could easily
avoid it by taking more thought and care.” But
some persons retain this liability to accidents under
all circumstances; it is associated with a greater
tendency to stay away from work on account of
illness, and is observed more often amongst unskilled
than among skilled workers. In industry a reduc-
tion in the “frequency of accidents has resulted from
the removal from dangerous occupations of persons
judged to be accident-prone, but it is not always
easy to identify them. Psychological tests devised
for the purpose have not proved entirely satisfactory,
and Dr. Vernon does not seem hopeful that they ever
will be; but it is encouraging to learn that accident-
proneness can be largely overcome by instruction
and training.
The practical man is more ready to accept the view
that any factor which lowers the general health
tends to increase the liability to accidents, though
it is difficult to obtain tangible evidence in its support.
Fatigue and the taking of alcohol tend definitely to
increase accident liability. Good environmental con-
ditions, such as comfortable air temperatures, well-lit
workrooms, and a reasonable rather than rushed
speed of production, all influence the accident rates
favourably. The influence of night work on the
accident rates is less obvious, but Dr. Vernon cannot
doubt that night work is less suited than day work
to the physiological rhythm of the human organism.
He discusses road accidents at some length in the
light of analyses of their incidence, and this section
of his book is worthy of serious study by ‘those
interested in the preservation of their own lives and
those of their fellow men. His main conclusion in
relation to the prevention of accidents in general is
that the most important measure is to educate the
people of all ages and classes and to instil in bem a
safety habit of mind.
The Lung
By Wu11am S. Murer, D.Sc., M.D., Emeritus
Professor of Anatomy, University of Wisconsin.
London: Bailliére, Tindall and Cox. 1937. Pp. 210.
348,
Durine his long and ET career as an
anatomist, Dr. Miller has perhaps done more to
elucidate the finer architecture of the lung than any
other investigator. His own contributions, embody-
ing work published during five decades,. bulk large
in this monograph, but they are modestly woven into
accounts of other people's work in such a way as to
provide a complete and well-proportioned story.
Probably Dr. Miller’s greatest single contribution to
the subject has been in demonstrating the morphology,
topography, and function of the intrapulmonic
lymph channels and depdts. This vastly important
system of delicate lymphatics is here delineated in
amazing detail, The finer divisions of the air passages,
the ramifications of bronchial musculature, and the
terminations of pulmonary blood-vessels and nerves
are also effectively represented. The structural
obscurities of the lung have not even now been finally
cleared up. The author is, indeed, at pains to show
the need for further research in several subdivisions
of his subject. He has himself set down a few con-
clusions which may not escape challenge. Most
THE LANCET]
readers will probably accept his dictum that the
. “ interalveolar pore” is only an artefact, and will
regard as conclusive his demonstration of a con-
tinuous lining membrane within the alveoli, but they
“may not agree that this membrane is necessarily
epithelial. Some will be disappointed that greater
attention has' not been given to cytological detail ;
for instance the common mononuclear phagocyte
is barely mentioned. Unquestionably, however,
the work as a whole will meet with widespread
appreciation. It is a monumental treatise, unique
in its field. j
British Encyclopædia of Medical Practice
Vol. III. By Various Authors. Under the general
editorship of Sir Humpury RorLesroNn, Bart.,
G.C.V.0., K.C.B., M.D., D.Sc., Emeritus Professor
of Physic, Cambridge. With the assistance of
Prof. F. R. Fraser, M.D., F.R.C.P.; Prof. G.
GREY TURNER, M.S., F.R.C.S.; Prof. JAMES
Youne, D.S.0., M.D., F.R.C.S.E.; Sir LEONARD
Rocrrs, K.C.S.I., F.R.C.P., F.R.C.S., F.R.S. ; and
F. M. R. Warsa, O.B.E., M.D., D.Sc., F.R.C.P.
London: Butterworth and Co. 1937. Pp. 681.
358.
CONTINUING its exhaustive survey of the entire
field of modern medical practice, the third volume
of this work opens with an article on cataract by
Sir Stewart Duke-Elder and ends with one on diseases
of the diaphragm by John D. Comrie. Some of the
articles dealing with rare, obscure, or tropical diseases
will be of interest mainly to the specialist, but others
provide plenty of material useful to the general
practitioner. In the forefront of these is Sir Arthur
Hurst’s article on constipation wherein he continues
to fight the good fight against the widespread habit
of taking purgatives. His wise words might well
“be taken to heart by those inside as well as outside
the profession: “ The vast army of hypochondriacs
who are never happy unless their stools conform to
an ideal which they have invented for themselves,
can be cured only by making them realise that
feeces have no standard size, shape, consistence or
colour ; they may then be ready to follow the example
of the dog rather_than that of the cat and never look
behind them.”’
coma by Sydney Smith and W. Ritchie Russell, and
one on concussion and compression by L. R. Broster
‘should help in many a situation where differential
diagnosis is both vital and difficult. H. W. Gordon
writes on the less momentous subject of chilblains ; he
summarises the modern methods but offers no royal
road to success in the treatment of this tiresome and
common minor malady. Discussing the treatment
of the common cold A. H. Douthwaite does suggest
a new remedy, unfortunately not yet available to
the many—to fly for half an hour at a height of
8000 ft. In his article on coliform bacillus infections
Clifford Morson details the uses and limitations of
mandelic acid therapy. Chassar Moir’s article on.
pelvic cellulitis, however, must have been written
before prontosil was introduced in the treatment of
cases streptococcal in origin.
An interesting and significant innovation in a work
of this kind is the inclusion of a sound and well-
tabulated article on contraception by C. P. Blacker
and Joan Malleson, who point out (1) that lactation
offers very poor protection against pregnancy, and
(2) that pregnancy may occur after the menopause,
even several months after menstruation has ceased.
The only contraceptive methods recommended are
those in use at recognised birth-control clinics, and
REVIEWS AND NOTICES OF BOOKS
Miller on coeliac disease.
Two other important articles, one on `
[JUNE 5, 1937 1341
to protect himself against the extravagant claims
made for proprietary contraceptives the practitioner
is urged to write to the National Birth Control
Association for a list of the more efficient productions
on the market. Pediatrics is represented by several
articles ; Kenneth H. Tallerman and Alice Campbell
Rose write on child health and welfare, and Reginald
Writing on child guidance
William Moodie, in discussing importance to children
of a sympathetic environment, observes drily that
when dealing with cases of child-delinquency it is
sometimes among the parents rather than among the
children that the real patient is to be found. In the
sphere of gynecology M. J. Stewart and Alan
Brews write on chorionepithelioma and hydatidiform
mole and James Young collaborates with the general
editor in an article on the climacteric and its disorders.
Various dermatological conditions common and
uncommon receive attention ranging from the homely
corn and bunion by W. J. O’Donovan, through
various types of dermatitis by Arthur Whitfield
and P. B. Mumford, to the redundant craw-craw by
Sydney Thomson. F. M. R. Walshe contributes
three articles on cerebellar disease, cerebral diplegia,
and cranial nerve affections, and F. W. Watkyn-
Thomas two on deafness and deaf-mutism. There
are also two valuable articles on teeth, one by Alan
Moncrieff on dentition and one by Sir Norman G.
Bennett on dental sepsis in relation to systemic disease.
The volume, which contains in all 68 articles by
recognised authorities, is well up to the high standard
set by its predecessors.
Practical Orthoptics in the Treatment of
Squint -
By Kerru LYLE, M.A., M.D., F.R.C.S., Assistant
Surgeon, Royal Westminster Ophthalmic Hospital ;
Ophthalmic Surgeon, Metropolitan Hospital,
London; and Sytvia JACKSON, S.R.N., Senior
Orthoptist, Royal Westminster Ophthalmic Hos-
pital London: H. K. Lewis and Co. 1937.
Pp. 212. 128. 6d.
THE comparatively recent institution of a diploma
in orthoptic training for squint (conferred by the
Council of British Ophthalmologists on the advice
of a specially appointed board of examiners), has
created a demand for text-books dealing with this
subject. The volume under review has been written
with a view to meeting this demand, and on the whole
it fulfils its purpose in that it supplies an elementary
introduction to orthoptic training suitable especially
for students. The book is easy to read and gives
straightforward and comprehensible descriptions of
instruments and methods of examination and treat-
ment; if these are somewhat lacking in detail they
_ are no doubt intended to be supplemented by practical
work on the part of the student. In spite of their
disclaimer in the preface, the authors have not
altogether succeeded in avoiding the introduction
of controversial matter, and it seems regrettable, from
the point of view of the student at any rate, that
other principles of treatment besides those approved
of at the Royal Westminster Ophthalmic Hospital
have not at least been mentioned. The allocation of
40 pages—nearly a fifth of the book—to tabulated
results is perhaps rather out of keeping with the
character of the work; nor does the evidence supplied
by these tables always seem to bear out the generalisa-
tions in the text. The final chapter on ocular torti-
collis is the most interesting section in so far as
ophthalmologists as distinct from students of orthoptic -
training are concerned,
1342 THE O
GENERAL MEDICAL COUNCIL
SUMMER SESSION, MAY 25TH-29TH, 1937
On Tuesday, May 25th, the Council commenced
the hearing of cases in which certain registered
dental and medical practitioners were alleged to
have committed infamous conduct in a professional
respect, or to have been convicted of criminal offences
by courts of justice. In accordance with custom, the
Council heard these cases in public and deliberated |
upon their decision in camera; the public were
readmitted to hear the decision announced,
Penal Cases reported by the Dental Board
The Case of Willtam Laird, registered as of
40, Gray’s-hill, Bangor, Co. Down, Dentists Act,
1921..
Mr. Laird was reported by the Dental Board of
the United Kingdom for systematically canvassing
for patients in November, 1936. He did not appear
in answer to his notice and was not represented.
The Council directed the ` Registrar (Mr. Michael
Heseltine) to erase his name from the Dental Register.
The Case of James Sharples Hopwood, registered
as of 75, Flixton-road, Urmston, Lanes, Dentists
Act, 1921.
Mr. Hopwood was reported by'the Board for
wrongfully obtaining payment from two approved
‘societies of £4 3s., and £4 11s. 8d., by means of untrue
and improper certificates in dental letters falsely
stating that certain dentures had been supplied and
remade. He did not appear and was not represented.
Mr. Harper, the Board’s solicitor, read a statement
forwarded by the respondent in mitigation of his
offence and pleading severe domestic trouble. The
Council directed the erasure of his name,
The Case of Albert Edward Lloyd, registered as of
~The Bungalow, North Drive, Cleveleys, Blackpool,
Dentists Act, 1921.
Mr. Lloyd had also been found guilty by the Board
of obtaining £3 6s. 6d. in 1934 from an approved
society by means of untrue and improper certificates
for a denture which he had not handed to the member ;
this case was reported by the Minister of Health.
He had moreover been found by the Board to have
undertaken in 1936 the repair of an insured person’s
denture although he was not qualified to do dental
benefit work, and to have retained the denture until
- the member should pay him the sum which the society
would have paid him if he had been so qualified.
He did not appear and was not represented. The
Council ordered his name to be erased.
The Case of John Kennedy Scotland, registered.
as of 15, Millbrae-crescent, Langside, Glasgow,
L.D.S. R.F.P.S. Glasg., 1923.
The. Board reported that Mr. ‘Scotland had been
convicted on Oct. 20th, 1936, before the Sheriff
Court of Lanarkshire at Glasgow, of presenting to
various chemists on 20 occasions between May 26th
and Sept. 29th, 1936, fabricated prescriptions and
obtaining from them quantities of morphine sulphate,
which he had not been duly authorised to procure,
contrary to Regulation 2 of the Dangerous Drugs
(Consolidated) Regulations, 1928, and had been fined
£10 or 60 days’ imprisonment in default.
Mr. Scotland did not appear and was not
represented, but Mr. Harper read a statement which
he submitted in extenuation of his offence. The
Council ordered the erasure of his name,
GENERAL MEDICAL COUNCIL ,
- R.U. Irel. ;
[JUNE 5, 1937
The Case of Edwin Spencer Tebbutt, registered as of
30, Finsbury-square, London, E.C.2, L.D.S. R.C.S.
Eng., 1905.
Mr. Tebbutt had been convicted three times of
drunkenness. He did not appear, but a personal
friend applied for permission to be heard on his
behalf, and was allowed to address the Council and
lay before it his statement in mitigation, pleading
prolonged ill health and financial loss. The Council
directed the Registrar to erase his name.
RESTORATION TO DENTISTS REGISTER
After deliberation in camera the President
announced that the name of Thomas Ross Graham
had been restored to the Register.
Charges against Medical Practitioners
referred from Previous Sessions
The Case of William Mervyn Crofton, registered
as of 22, Park-square, London, N.W.1, M.B., B.S. 1904,
M.D. 1911, N.U. Irel., who had been
summoned to appear before the Council in 1935 on `
charges of advertising based on press interviews and
speeches eulogising the Antigen Laboratory with
which he was connected. The Council had found
some of the facts proved but had postponed
judgment until this session.
Dr. Crofton appeared, accompanied by Mr. G. W.
Pritchard, solicitor. The Medical Defence Union,
which had complained, was not represented. The
Council considered the testimonials produced by
respondent and decided not to erase his name.
Dr. Crofton then accused the Council of heinous
and unprofessional bias and put in a formal written
complaint of their conduct of the case.
The Case of William Douglas, registered as of
282, Goldhawk-road, Shepherd’s Bush, London,
W.12, M.B., Ch.B. 1921, U. Edin., who had been
summoned on charges of driving a car while under
the influence of drink. The Council had found the
charges proved in May, 1936, but had postponed
judgment for a year. Dr. Douglas appeared, and
had submitted the required testimonials. The Council
decided not to erase his name.
The Case (adjourned from May 26th, 1936) of
David Davidson Watson, registered as of c/o Haigh,
21, King-street, Wakefield, M.B., Ch.B. 1926,
U. St. And., who had been summoned to appear
as a result of convictions for driving a car while
under the influence of drink. Dr. Watson attended,
having submitted testimonials. His name was not
erased.
The Case (adjourned from Nov. 25th, 1936) of
Walter Campbell, registered as of 59, Jeffrey-street,
Edinburgh, L.R.C.P. Edin., 1927; L.R.C.S. Edin.,
1927; L.R.F.P.S. Glasg., 1927, who had also been
convicted of motoring offences and of being under the
influence of drink. Dr. Campbell had not appeared
and the Council’s solicitor had not been able to trace
him. Dr. Campbell again did not appear. Mr. Harper
outlined the steps he had taken to trace him. After
deliberation in camera the Council decided to proceed
with the case. The charges were as follows :—
That you were convicted of the following offences:
(1) on Dec. 12th, 1931, at the Sheriff Court, Cupar, of
being in charge of a motor-car whilst under the
influence of drink, and were fined £5 or thirty days’
imprisonment; (2) on Dec. 17th, 1931, at Dunfermline
Police-court, of causing a motor-car to stand longer than
was necessary for loading or unloading goods or for taking
up or setting down passengers, and were fined 25s. or tep
THE LANCET]
GENERAL MEDICAL COUNCIL
[JUNE 5, 1937 1343
days’ imprisonment ; and of the following misdemeanours :
(3) on August 29th, 1935, at the Hull City Police-court,
of driving a motor-car without due care and attention, and
were fined £15 and £3 13s. 6d. costs, or fifty-one days’
imprisonment, and were disqualified from holding a
driving licence for one month; and (4) on Sept. Ist,
1936, at the Leeds West Riding Court: (a) of driving a
motor-car whilst under the influence of drink (date of
offence August 16th, 1936), and were fined £15 and
£5 16s. costs, or two months’ imprisonment in default,
and were disqualified for holding a driving licence for
twelve months; (b) of driving a motor-car in a manner
dangerous to the public (date of offence August 16th,
1936), and were fined £10 or one month’s ‘imprisonment in
default.
Mr. Harper described the cases in detail and after —
prolonged deliberation in camera the President
announced that the charges had been found proved,
but judgment had been postponed for six months
subject to the usual proviso; Dr. Campbell woul
be well advised to attend next session.
The Case (postponed from Nov. 25th, 1936) of
Ernest Stanley O’ Sullivan, registered as of 12, Dunowen-
gardens, Cliftonville, Belfast, L., L.M. 1928,
R.C.P. Irel.; L.. L.M. 1928, R.C.S. Irel., who had
been summoned to appear before the Council on the
following charge :—
That you were convicted of the following misdemeanours,
—viz.: (1) on June 12th, 1933, at the Stockton Borough
Police-court, of being under the influence of drink whilst in
charge of a motor-car, and were fined £5 and £1 1s. doctor’s
fee (date of offence June. 9th, 1933); (2) On May 14th,
1936, at the City Police-court, Newcastle-on-Tyne, (a) of
driving a motor-car whilst under the influence of drink,
and were fined £10 and £9 7s. 6d. costs (date of offence
May 13th, 1936); (b) of driving a motor-car in a manner
which was dangerous to the public, and were fined £2
(date of offence May 13th, 1936); and (c) of using a motor-
car when the brakes were not in good and efficient working
order, and were fined £1 (date of offence May 13th, 1936) ;
to all of which you pleaded guilty.
At the meeting of the Council on Nov. 25th, 1936,
the solicitor to the Council had stated that he
had been unable to establish communication with
Dr. O’Sullivan, or to serve the notice of inquiry upon
him. The solicitor had accordingly applied for the
adjournment.
Dr. O’Sullivan now attended, accompanied by
Mr. Oswald Hempson, solicitor, on behalf of the
Medical Defence Union. Mr. Winterbottom, solicitor
to the Council, put in reports of the convictions and
gave details. Mr. Hempson addressed the Council,
giving it Dr. O’Sullivan’s assurance that he now was
and would remain a total abstainer. Respondent had,
he said, been extremely worried and unfit at the
times of the convictions. He put in a number of
testimonials. Judgment was postponed for a year.
New Penal Cases
The Case of David Willtam Jones, registered as of
10, Belsize-lane, London, N.W.2, M.R.C.S. Eng.,
1914; L.R.C.P. Lond., 1914, who had been summoned
to appear before the Council on the following charge :—
That you were on Oct. 23rd, 1936, convicted at the City
of Birmingham Police-court of the following misde-
meanour—viz., of obtaining credit to the amount of
£29 5s. 6d. from the London Midland & Scottish Railway
Company by fraud, and were sentenced to four months’
imprisonment in the second division, and that your appeal
on Dec. Ist, 1936, against the conviction to the Birmingham
Quarter Sessions was dismissed.
Mr. Harper explained that the offence had consisted
of allowing a lady with whom respondent was living
to issue a “ dud ” cheque in payment of a hotel bill ;
the lady had been sentenced to a month’s imprison- -
ment at the same time and had said in cross-examina-
tion that respondent had had nothing to do with the
cheque. Both she and respondent had persistently
stated that she had assets.
Dr. Jones asked if the lady’s evidence might be
heard in camera. Mr. Harper suggested calling
her “ Mrs. Jones.” Dr. Jones said he could not call
her unless she were heard in camera. The Council
then went into camera, after which the President
announced that the Council would postpone judg-
ment until May, 1938, subject to the usual testimonials.
ALLEGED CARELESS CERTIFICATION
The Case of Joseph Shtbko, registered as of 5, Prince
of Wales-road, Swansea, L.M.S.S.A. Lond., 1926,
who had been summoned to appear before the Council
on the following charge :— `
That being a registered medical practitioner, you on each
of the following dates, namely, Jan. 24th, April 11th,
May 6th, and Dec. 17th, 1936, signed and issued a certificate
of incapacity for work for a person described as William
Ward, whereas you had not seen or examined the said -
William Ward on any of such dates or at all, which certi-
ficates were untrue, misleading, and improper. And that
in relation to the facts so alleged you have been guilty of
infamous conduct in a professional respect.
There was no complainant in this case.
Dr. Shibko attended, accompanied by Mr. W. A.
Macfarlane, counsel, instructed by Messrs. Le Brasseur
and Oakley, solicitors, on behalf of the London and
Counties Medical Protection Society.
Mr. Harper, solicitor to the Council, said that
respondent had never seen Mr. Ward, who was in
perfect health and at work all the time his wife was
sending in certificates of incapacity supplied by
respondent. Respondent, when asked for explana-
tions, had replied by his solicitor stating emphatically
that the certificates had been given by the doctor
to Mr. Ward or to someone representing himself
to be Mr. Ward, and the doctor had never at any time
given a certificate without seeing the patient.
Mrs. W. M. Ward testified to her statutory declara-
tion stating that she had asked at the surgery for a
certificate showing that her husband was unable to
work, and had been given it without comment or
fee. The certificates were produced. She had not
mentioned any disease and had not been asked.
Her husband had never been to the surgery with
her and Dr. Shibko had never been to their house.
She had also received National Health certificates,
but had destroyed them. In _ cross-examination
she agreed that her husband was not a panel patient
of Dr. Shibko’s. She had seen the book he took the
slips from but had seen no counterfoils. The five
insurance certificates were at quite different times
from the others. The doctor had not asked for any
particulars of her husband’s number or anything.
The certificates had been used to obtain relief in
June, 1935. Her husband had never had a day’s
illness. She had been convicted of receiving £33
odd in relief and had been to prison for it. She
had not offered or been asked for any suggestion at
any time as to what was the matter with her husband ;
she had simply said she wanted a certificate for him
and Dr. Shibko had written it without a word more.
Shown a blank certificate form, she said she had
never seen such a form before. She did not know that
the other form, which she recognised, was the form
for giving to an employer. She knew that respondent
was the poor-law doctor for the district. She had
told a good many lies in her.time but this was the
1344 THE LANCET]
GENERAL MEDICAL COUNCIL
[JUNE 5, 1937
truth. She had never noticed if there was any
number on the certificates. On the one occasion
when the relieving officer had called at the house,
she had told him he could not see her husband
because the parson was in; this had been untrue.
She had not had certificates for her daughter. The
. relieving officer had read the certificates. She had
never sent anyone else to the surgery; nobody
but herself knew anything about it. She had never
paid anything.
In reply to the legal assessor, she said she had
pleaded guilty at the court. |
Sir Kaye Le Fleming asked what the National
Health certificates were wanted for; witness said
nobody had asked for them, but she had shown them
to the relieving officer until he had ceased to be
satisfied with them. :
Mr. W. Ward testified that he had not for nine
years lost a day’s employment through sickness
or been attended by any doctor. He had never
seen respondent until they met in the police-court.
He knew nothing about any certificates. After the
police proceedings respondent had come up to witness
at the bus stop and twice said he thought he had
seen witness in his surgery; witness had twice said
**'Yowre a liar.”
Cross-examined, he said he himself had obtained
poor relief in 1935 and had himself been to the relieving
officer for it. He knew his wife was on Dr. Shibko’s
list for the Public Medical Service, but did not know
how many weeks she had actually paid.
Dr. Shibko testified that he was public assistance
medical officer for Swansea No. 3 district, and had
been interested in local government work before
going there. He had a panel practice of some 1800
patients and participated in the public medical
service for non-insurable persons with an income
below £250, having some 300 families on his list.
In addition, he had a substantial private practice.
The relieving officer could aid destitution without
reference to the medical officer, but when sickness
was involved a special form was used. (This was
the form Mrs. Ward had never seen.) He invariably
used that form; there should be a query by the
relieving officer if any other form were used. The
other form (that on which the certificates had been
given) was used only for private purposes—e.g., for
a friendly society, or for an employer—and he always
used the right form for the right thing. He admitted
that the certificates in question had been signed by
him, but he had never given one to Mrs. Ward or
signed one without examining a man. He did not
know Mr. Ward personally ; 800 people might pass
through his surgery in a week and it was impossible
to call for evidence of identity. He believed he
had seen Mr. Ward and spoken to him in December,
discussing why he should visit a surgery three and
a half miles from his home. He was firmly convinced
that it was William Ward and if not, it must have
been someone strikingly like him. He was certain
‘that he had made it an invariable and inviolable
rule never to give a certificate without seeing the
patient. He well knew the consequences of giving
false or misleading certificates. When he gave
N.H.I. certificates he used a book with numbered
counterfoils, and he always filled in the counterfous,
employing a clerk to make records from them. He
had thought he had a fraud-proof system, but since
the police-court proceedings had taken steps to
tighten it up still further. He could recall nothing
about the first three certificates, but had some
recollection of the fourth. His written records of
Jan. 4th, 1936, showed that he had not seen Mrs.
Ward’s elder daughter then, for he had only issued
an infant’s cough mixture. The adult daughter had
first been seen on April 17th, 1936, for a rash on the
shoulder; she had complained of nervous trouble
in September, 1936. He also produced records of
attendance by Mrs. Ward with her children of school
age. It was not his custom to charge for certificates
of inability to work if no treatment was given.
Cross-examined, he said he knew Mrs. and Miss
Ward by sight well and had thought he knew
Mr. Ward also. He took no steps to confirm the
identity of his patients. He was certain that
Mrs. Ward had never come to the surgery with her
husband.
Witness answered questions by Dr. J. W. Bone,
saying that his recollection of his interview with Mr.
Ward in December was that he came as a panel
patient. He had no record of treatment for the
brachial neuritis and bronchitis which had then—
according to the certificate—rendered him unfit for
work. If the patient asked for a certificate for an
employer, it was now his custom, but had not then
been, to ask for the panel card or look for the record
card, and he might not give any treatment. In reply
to Mr. H. L. Eason, he said he kept no records of
patients to whom he gave such certificates ; there was
no evidence whatever that he had ever seen this man.
In reply to the legal assessor, he said he had taken
no steps to ensure that the patient really was on his
panel, Anyone could walk into his surgery and get a
certificate; if they said they were on his panel he
believed them. The certificates in question had been
made out by him during surgery hours.
In reply to Sir Robert Bolam, he said he had been in
panel practice since 1926.
Mr. Macfarlane read testimonials to character and.
called the Swansea relieving officer, Mr. Leonard
Williams, who stated that he had been there since
October, 1935. At that time, and ever since, Dr.
Shibko had been poor-law medical officer. A N.H.I.
certificate was not accepted by him, except pending
the production of the proper poor-law certificate.
The four certificates relating to Mr. Ward had been
handed to him and he had in fact paid out relief on
them. Since the police-court proceedings he always
demanded the proper certificate. He had a high
opinion of Dr. Shibko’s carefulness.
In reply to Mr. Harper, he said he would pay two
or three hundred people in two hours and he could
not give any detailed recollection of other intermediate
certificates.
In reply to the legal assessor and members of the
Council, he said similar certificates from other doctors
had been accepted and paid on without inquiry.
He had demanded no other certificate between May
and December. The average practice was for applica-
tions for relief to be made by the wife. The case had
been visited on May 13th although relief had been
paid ever since January on a certificate of Dr. Shibko’s.
His assistant might have paid other, unrecorded,
visits; he himself had never called on the Wards.
Certificates were not required weekly but only
intermittently, as required. Personation would
be quite possible and no steps were taken to establish
identity. He would accept the word of a wife that the
husband was not fit to make application; Mrs. Ward
had made such'a statement to him.
Mr. Macfarlane and Mr. Harper briefly addressed
the Council, and the President announced that the
facts had not been found proved to the satisfaction of
the Council.
THE LANCET]
ADULTERY WITHOUT ERASURE
The Case of Bardwell Ebden Tenison Mosse,
registered as of 13, King-street, King’s Lynn,
M.R.C.S. Eng., 1926; L.R.C.P. Lond., 1926, who had
been summoned to appear before the Council on the
following charge :—
That being a registered medical practitioner: (1) you
committed adultery with Ethel Gregory Johnson, a married
woman, of which adultery you were found guilty by the
decrees of the Probate Divorce and Admiralty Division
(Divorce) of the High Court of Justice dated Nov. 2nd,
1936, and made absolute on Dec. 21st, 1936, in the cases of
Johnson v. Johnson and Mosse and Tenison Mosse v.
Tenison Mosse, in which you were the co-respondent and
respondent respectively; (2) you stood in professional
relationship with the said Ethel Gregory Johnson and/or
her husband, Philip Henry Hildon Johnson. And that in
relation to the facts so alleged you have been guilty of
infamous conduct in a professional respect.
Dr. Mosse was accompanied by Mr. Macfarlane,
instructed by Messrs. Le Brasseur and Oakley on
behalf of the London and Counties Medical Pro-
tection Society. Mr. Winterbottom read extracts
from the divorce proceedings, in which it had been
stated that Mrs. Johnson was a patient of Dr. Mosse’s.
Professional attendance was admitted. In 1929
there had been six attendances on Mrs. Johnson in
November and December and there had been uninter-
rupted attendance on both Mr. and Mrs. Johnson
from then until June, 1935, ending with 26 calls on
Mr. Johnson in January, 1935, and on Mrs. Johnson
two in January, two in February, four in March,
three in April, and one in June. Three later alleged
attendances were not admitted by respondent.
Mr. J. A. Parsons, solicitor to the respondent’s
previous partnership, testified that a monthly book of
visits was in the handwriting of Dr. Mosse and found
in it entries of visits to Mr. Johnson on August lst,
1935, and Sept. 4th, 1935. He also identified a daily
record ledger and an entry in it on August 29th, 19365,
of attendance on Mr, Johnson.
Cross-examined, he said the partnership had been
dissolved by transfer from Dr, Mosse to an incoming
partner on Sept. 23rd, 1935.
_ Dr. Mosse testified that there had been no adultery
whatever before February, 1936.
Adultery before that date had never been alleged
against him, Since leaving King’s Lynn in September,
1935, he had not practised medicine but had been
selling cars. He had written to the registrar because
he was hoping to start practice again and had a
partnership in view ; he did not wish to enter partner-
ship until an inquiry had been held and the matter
settled. He had taken the initiative in the inquiry.
He had first met the Johnsons socially when doing a
locum for his brother in Norfolk; they had not been
patients of his brother, Later he had joined a partner-
ship in King’s Lynn and the Johnsons were patients
of the partnership and he had attended them. The
former Mrs. Johnson was now his wife. He had
first married in 1929 and the marriage had not proved
successful. He had never committed any kind of
misconduct or familiarity during the period when he
was practising. He had first realised his feelings in
July, 1935, and had forthwith told the lady that he
could never attend her or her husband again and that
he must see the husband about it. He had imme-
diately put’ his practice up for sale. Referring to
the entries in the daybooks, he said he had not
attended Mr. Johnson on those days but had entered
the consultations in the book because it had been
the custom to copy entries into the book from a
piece of paper. The doctor consulted did not neces-
GENERAL MEDICAL COUNCIL
[JUNE 5, 1937 1345
sarily make the entry. Until a few days ago he had not
known of the attention received by Mr. Johnson at
that time. Mrs. Johnson had needed medical attention
in September, 1935, but he had not attended her in
any way.
Mrs. Ethel Gregory Mosse, formerly Mrs. Johnson,
testified that she had been a patient of the partner-
ship and confirmed Dr. Mosse’s account of the relation-
ship. There had been no adultery before February,
1936.
Mr. Macfarlane and Mr. Winterbottom addressed
the Council and the President announced that the
Council had found the alleged facts proved to their
satisfaction but had not adjudged Dr. Mosse to be
guilty of infamous conduct in a professional respect.
\
CONVICTIONS FOR DRUNKENNESS |
The Case of Wiliam Dale Lawton, registered as
of 80, Princess-road, Moss Side, Manchester, L.R.C.P.
Edin., 1903; L.R.C.S. Edin., 1903; L.R.F.P.S.
Glasg., 1903, who had been summoned to appear
before the Council on the following charge :— |
That you were convicted of the following misdemeanours
—viz.: At the Stockport County Petty Sessions: (1) on
August 17th, 1922, of obstructing the highway by leaving
a motor-car thereon without lights, and were fined £1;
At the Manchester City Police-court: (2) on June 2nd,
1925: (a) of being drunk whilst in charge of a motor-car,
and were fined £2; (b) of driving a motor-car in a manner
dangerous to the public, and were fined £20 and licence
suspended for six months; (3) on Sept. 5th, 1927, of
driving a motor-car in a manner dangerous to the public ;
and were fined £1 and disqualified for holding a driving
(4) on Oct. 12th, 1936, of being
drunk, and were fined 5s.; (5) on Dec. 15th, 1936, of
being drunk, and were fined 10s; (6) on Dec. 31st, 1936,
of being drunk, and were fined 10s. or seven days’ imprison-
ment,
licence for two years ;
Dr. Lawton was accompanied by Mr. Oswald
Hempson, solicitor.
Mr. Winterbottom asked leave to add before
charge (2) a further charge based on a conviction
before the Manchester City Police-court on Jan. 26th,
1922, for being drunk in charge of a motor-car, with a
fine of £2. He added details of the convictions.
A Warning Notice had been sent in October, 1925.
Mr. Hempson said that his client was 75 years old
and had been in his present practice for 33 years.
He could not give an undertaking of total abstinence
as that step might be prejudicial to his health, but he
was only keeping the practice alive for his son, who
was taking his final examinations this summer and
for whom he could make no other financial provision.
Testimonials were read and the President announced
that judgment would be postponed for twelve months
subject to the usual proviso.
A CHARGE OF FALSE PRETENOES
The Oase of Alfred Edward Vawser, registered
as of Redcot, March, Cambs, L.M.S.S.A. Lond.,
1928, who had been summoned to appear before the
Council on the following charge :—
That you were on April 4th, 1936, after pleading guilty,
convicted at the Uxbridge Petty Sessions of having
obtained from Messrs. Waddington & Sons by means of
false pretences two diamond rings of the value of £52 with
intent to defraud, and were sentenced to two months’
imprisonment in the second division, and that your appeals
on May 19th, 1936, and Oct. 30th, 1936, to the Middlesex
Sessions and to the High Court ‘of Justice respectively,
were dismissed.
Dr. Vawser was accompanied by Mr. Oswald
Hempson, solicitor.
1346 THE LANCET]
Mr. Winterbottom read newspaper.accounts of the
proceedings. Respondent had taken two rings on
approval and had pawned them for £10 each. He had
pleaded guilty, expressed sorrow and offered restitu-
tion. While in the R.A.F. in Iraq he had had a severe
motor crash which had left him with a tendency to
muddle-headedness.
Mr. Hempson pointed out that the appeals had been
dismissed on the technical point that respondent
had pleaded guilty. Had he been legally advised at
the time he would not have made such a plea. From
first to last he maintained that all he had pleaded
guilty to was pawning rings that were not his property.
He had never been charged before, and was liable
to muddle-headedness ; he had failed to appreciate
the subtle legal definition of false pretences. Credit
had been given him because he was known and was
an officer in the R.A.F.; he had done nothing to
induce credit. He had given his own name and address,
and had been in uniform. He had wanted to give the
rings to his wife, who was very ill, after a miscarriage,
but he did not want to take the rings home that
night and had nowhere to put them. A pawnbroker’s
offered safe custody and a rough valuation. There-
after he was ill for four days, and was worried about
his wife and about 150 patients in bed with influenza.
He had no lack of money, and could at any time have
obtained £500 on a reversion. His confidential
reports had been first class. Hé had now had to
resign his commission and had been trying to earn a
living as a locum tenens; he had secured excellent
testimonials.
The Council did not erase his name.
ERASURE FOR ADULTERY
The Case of Douglas Chetham Pim, D.S.O., registered
as of Thornbury, Brecon-road, Abergavenny, Mon.,
M.B., B.Ch. 1915, M.D. 1920, U.Dubl., who had been
summoned to appear before the Council on the
following charge :—
That being a registered medical practitioner: (1) you
committed adultery with Mrs. Anne Alma Ferguson on
various dates during January, 1935, and on subsequent
occasions during the year 1935; (2) in August, 1933, the
said Mrs. Ferguson consulted you about the health of her
son, and during the years 1934-1936 you also stood in
professional relationship with the said Mrs. Ferguson and
her son and her maidservant. And that in relation to the
facts so alleged you have been guilty of infamous conduct in
a professional respect.
The complainant was Mrs. Anne Alma Ferguson,
who was represented by Mr. J. P. Valetta, counsel,
instructed by Messrs. Grover, Humphreys and Boyes,
solicitors.
Dr. Pim attended, accompanied by Mr. Macfarlane,
instructed by Messrs. Le Brasseur and Oakley
on behalf of the London and Counties Medical
Protection Society.
Mr. Valetta emphasised the importance of the dates
in the case. Intimacy was admitted but professional
relationship denied. Complainant said that the first
act of adultery had been in January, 1935, and there
had been no suggestion of it before. Respondent put
it first in July, 1933, and claimed to have known
Mrs. Ferguson in childhood. Complainant denied
childhood acquaintance, and said she had taken her boy
to the doctor in 1933. He had been extremely kind
at a tinte when eminent specialists had given the
gravest prognosis. He had flatly contradicted the
diagnosis and had secured further opinions.
Mr. Valetta read a letter dated September, 1934,
giving a report on the boy’s X ray appearances to
Dr. Pim, and discussing a régime for the patient.
GENERAL MEDICAL COUNCIL
-papers citing her as intervener ;
be appointed medical officer.
[JUNE 5, 1937
Dr. Pim, he said, had dissuaded the mother from
getting a London specialist’s opinion, promising to
keep an eye on the boy himself. He had done so
admirably, and the mother had felt a very great
sense of obligation. Dr. Pim had poured into her
ears a tale of domestic woe, including statements
that his wife was unfaithful and that he was in.
financial trouble. On Armistice Day, 1934, he had
introduced her to his wife for the first time and the
ladies had conversed for an hour. Afterwards Dr.
Pim had spoken of divorce and.re-marriage, saying
his wife had suggested it, and suggested also that
Mrs. Ferguson should make provision for Mrs. Pim.
Thereafter he had laid siege to complainant, saying
he had finished with his wife. Then had come a period
in which there had been no communication. In
1935 they had stayed together in Torquay for a week,
complainant thinking Dr. Pim and Mrs. Pim had
parted. Next March she had been served with divorce
this had been a
complete surprise. Adultery had been alleged on
a number of dates. A few days later the petition was
withdrawn. Then Mrs. Ferguson had discovered that
Dr. and Mrs. Pim were living together and they had
begun bombarding her for money. Scurrilous state-
ments were circulated to the effect that Mrs. Ferguson
had broken up the Pim household. In February,
1935, she had required a dental] extraction and Dr.
Pim had taken her in his car to a dental surgeon
—not her usual attendant—and had given the
anesthetic.
Mrs. Ferguson confirmed the story told by her
counsel. She had first met respondent on the beach
at Greystones in 1933 ; she had never seen him before
in her life and did not know he existed until that
morning. He had not made love to her at that time
and they had not committed adultery during that
summer. On the beach they had discussed the
boy’s education ; respondent had urged her to send
the boy to a school where he himself was about to
She had visited him
there and he had shown her over the school and been
very kind, and had suggested holiday arrangements.
Later in the year he had told her about a “‘ tremendous
row ” concerning his wife and his partner and had
said he and his wife went their own ways. In June
or July, 1934, she had met Dr. Pim again, having
moved to Cheltenham in the February, and in
August, 1934, she had been very worried about her
son and had sent the X ray report and bad prognosis
to Dr. Pim and asked for help. Later she had
telephoned to ask the best doctor to go to in
Cheltenham. The doctor recommended was on
holiday and his locum, who attended, was just going,
so next day Dr. Pim had himself called, bringing the
X ray and report. The boy was in bed and Dr. Pim
and another doctor had consulted about him ;
Dr. Pim had taken the X ray to a local radiologist
and got a second reading of it. She had had four
doctors already and had asked if Dr. Pim could not.
look after the boy, who had burst into tears at the
suggestion of yet another examination. Dr. Pim
had at first refused, as he did not practise in that
district, but had at last consented, and had been
present at the consultation with the specialist..
He had refused a fee but had taken a water colour
as a gift. Her brother had pressed her to take a
London opinion and Dr. Pim had told her not to.
He had given her a tonic for herself, some patent
medicine, and she had taken it. She had asked him
about a pain and he had asked about an operation
she had had and offered to write to the surgeon.
Instead, she had returned to Ireland and seen the
THE LANCET]
surgeon. Dr. Pim had asked her to find shooting
for him there. They had travelled over on the same
boat. Between August and November, 1934, Dr. Pim
had brought in a tonic for the boy but had not
attended any other member of the household until
the maid got influenza in December. He had
performed small operations on her hand and foot.
The maid had been on his panel. She had felt very
grateful and would have done anything she could
for him. After the dental anæsthetic in February,
1935, respondent had not attended at her house.
He had offered to but she would not have it.
Cross-examined by Mr. Macfarlane, she said she
made the complaint in March, 1937, because of the
calumny by his brother in August, 1935. In January,
1936, she had written to Dr. Pim saying that she
would go to the General Medical Council if that were’
necessary to get Dr. and Mrs. Pim to speak the
truth. The year’s delay was due to her nephew’s
grave illness. She had not heard in March this year
that Dr. Pim was doing rather well in practice now,
and had not told two gentlemen in Cheltenham that
she was taking proceedings for revenge. She denied
that Dr. Pim had recognised her on the beach at
Greystones ; she had played on the beach there as
a child. She had been for walks on the golf links in
the evening with Dr. Pim at Greystones, but had not.
had intercourse with him then. He had not done
anything professionally for the son in August, 1933.
They had discussed the school and bullying. She
had asked nothing of him ; he had volunteered every-
thing. He had sent no bill and she had not thought
of suggesting payment. She had asked why he took
so much trouble and he had said he would get a
guinea a term for him if the boy went to the school
he recommended. He had never examined the boy
with, any instrument ; being on holiday he had no
instruments. The boy had suffered from travel
‘sickness on the journey from Ireland and Dr. Pim
had given him a sedative at the hotel. The boy had
not disliked him more than any other doctor. At
no time had Dr. Pim written and refused to attend
the boy. He had written a letter to enable the boy
to be removed to the new school—as he was a ward
in chancery ; it said the boy was not in very good
health. She had never tried to see Dr. Pim or rung
him up asking for meetings. He had not proposed
to discontinue the friendship; no such letter had
been written. She had telephoned in June, 1934,
and asked him to come, but had never: previously
rung him up. The consultation about the boy was
before she ever consulted him about herself. In
March or April she had had a sort of caffeine poisoning
and her cousin had rung up a nearby doctor; she
had paid the bill. She had had a facial burn about
this time and had shown it to Dr. Pim professionally ;
` he had said it was all right. She had written to the
Irish doctor and asked for the report he had sent
to Dr. Pim; in his reply (produced) the doctor had
written that he had no record of a report sent to
Dr. Pim and had only seen the boy once and found
no clinical signs of disease. Yet she still maintained
that this doctor had said the boy might die at any
moment. The X ray had been sent to Dr. Pim, not
to her. She did not know what “consultation ”
or “ professionally ” meant, she used the terms in her
own meaning. She had paid the other doctors but
not Dr. Pim. She had written also to the doctor
who had examined the boy in Cheltenham, with
Dr. Pim, and he had replied to her solicitor that on
August 30th he had received a message from her
and had arranged to meet Dr. Pim at the house as
Dr. Pim had the X ray. He had asked Dr. Pim
GENERAL MEDICAL COUNCIL
have done that.
‘to Dr. Pim that he had suggested lines of treatment
- was not the agreed share of the expense.
[JUNE 5, 1937 1347
to get in touch with the tuberculosis officer. He
recollected Dr. Pim saying he did not want to take
on the case as he lived too far away, and did not
recall his making an examination. He had never
regarded Dr. Pim as the doctor in charge, and had
charged for ordinary visits and not for a consultation.
He had only understood that Dr. Pim would act for
him in getting hold of the tuberculosis officer. She
did not agree that she herself or any man friend could
The tuberculosis officer had written
to her; he had not made the suggestions to Dr. Pim.
Dr. Pim had shown her the letter but had not given
it to her. On the occasion when she had seen respon-
dent’s wife Mrs. Pim had said she wanted a divorce
and told all her life-history. She had never mentioned
Greystones or adultery. Dr. Pim had had a number
of meals with her and had not paid for them. He
had given her £20 but that was his mother’s money.
His mother was almost living on her. His telephone
had been switched through to her house,-but the £20
She had
not told the dentist that she would only have gas
if Dr. Pim gave it, or asked for Dr. Pim. It had been
an emergency. (The letter from the dentist stated
that Dr. Pim had rung up saying a friend of his had
a very bad tooth. He had advised immediate
extraction and gas and she had expressed desire to
have Dr. Pim.) It was not fair to say he was
practically living in the flat at the time. In March,
1934, another doctor had attended her; in April
Dr. Pim had gone to practise in Abergavenny where
she had written to him. It was not obvious that
he was in a very poor state of health and worried
to death about the situation. She had gone to live
with him in Abergavenny in May. She had lent him
a maid, as his wife had left him. Mrs. Pim had not
left in consequence of her arrival. Dr. Pim had
not cashed cheques for her. Mrs. Pim had begged
her to do something to help Dr. Pim. She had left
Abergavenny some time before Mrs. Pim returned.
Re-examined, she said she had made every endeavour
to obtain witnesses for a slander action against
Dr. and Mrs. Pim because of the scurrilous remarks
being made, and had been advised that there was
no relief to be obtained that way. Rumours were
going round both in her Irish home and in Cheltenham,
She had appealed to Dr. Pim to stop them in October,
1935. |
Mr. Hugh Richard Ferguson, son of the complainant,
testified in support of the story told by his mother.
Dr. Pim had given him some medicine for travel
sickness. After his illness in Ireland Dr. Pim had
examined his chest with a stethoscope and asked
various questions. He was in the room during the
tuberculosis officer’s examination. He had promised
to keep an eye on witness at school and had seen him
on Sundays and asked if he was keeping all right.
He had given witness some medicine as an alternative
to that ordered by the tuberculosis officer.
' In answer to the legal assessor, he said he had only
seen Dr. Pim at his mother’s flat on Sundays and
holidays. Dr. Pim had never visited him.
Cross-examined, he said he had not liked Dr. Pim
very much. The first bottle of medicine, he thought,
came from the chemists and the second direct from
Dr. Pim.
Miss Margaret Frances Cadell said she had known
Mrs. Ferguson since childhood and had been at
Greystones in August, 1933. She remembered
Mrs. Ferguson’s visit. She had noticed no signs of
intimacy between her and Dr. Pim and had heard
1348 THE LANCET]
no gossip. She had not known Dr. Pim during
childhood. |
Cross-examined, she agreed she had said some-
thing to Dr. Pim to the effect: ‘‘ You know that
person ; she used to be Alma Gamble.”
In reply to the legal assessor, she said she had
never seen them together before.
Dr. Pim gave evidence denying that of the
complainant. He said he had been born in Ireland
and had usually spent his childhood holidays at
Greystones. He had seen Mrs. Ferguson there in
1933 but had not recognised her until after Mrs. Cadell
had spoken to him. Then he had said: “Do you
remember me? I’m Douglas Pim.” . She had replied
“ Great God; we played here together as children.”
During the ten days they had been together there
she had wept and said how lonely she was as she was
being divorced in Australia. He had tried to cheer
her and had taken her to a dance; both had had
alcohol and on the way home misconduct had occurred.
He had never seen the boy except when sunbathing
on the sands and had passed casual remarks about his -
physical state and recommended his own school.
The boy had gone to that school in January but
respondent had not known of it until June. After the
journey from Ireland he had not seen the boy but
had said to the mother ‘‘ Why don’t you send him
to bed?” He had never heard of the alleged
certificate for the Chancery Division until this after-
noon and had never written any such letter. In
the summer of 1934 he had not been consulted by
Mrs. Ferguson but she had frequently rung him up
and he had refused to see her. He had given it her
in writing that he did not wish the affair to continue.
One day in June she had left a message accusing
him of getting her over to England and then letting
her down. She had complained of loneliness and
asked him to tea. She was being attended at that
time by Dr. Basil Taylor. She said she had tried to
commit suicide because of him; he had repeated
what he had said before and walked out of the house.
At no time in that year did he advise her as her doctor.
She had written again at the time of the alleged
tuberculosis (August, 1934) and he had again refused
to have anything to do with her professionally,
partly—he had said—because of the distance and
partly because of the boy’s dislike of him. He was
not clear whether the X rays had come to him direct
or not; he had known the radiologist at college.
He had never put a stethoscope on the boy in his life
and had not been in the room when the other doctor
had examined him. He had gone to the house out of
pity and because Mrs. Ferguson had asked him to
go and introduce the other doctor, a friend of his.
He had got in touch with the tuberculosis officer at
the other doctor’s suggestion because the latter was
going on holiday next day. He had never seen
the resulting X ray or a report of it and had handed
the tuberculosis officer’s letter to the mother. He had
himself played no part in treatment. Apart from the
dental gas he had never acted as a doctor to Mrs.
Ferguson or her son, At the time of the gas he had
been having all his meals at her flat; it was about a
month after she had been cited in the divorce proceed-
ings. She had refused to have gas unless he gave it.
He had paid £20 the first week in January towards
the expenses incurred for him in the flat. His wife
had joined him at Abergavenny on April lst and from
that time he had had frequent correspondence with
complainant. He had been under treatment by the
medical superintendent of the mental hospital at
Abergavenny as he had been so worried about the
state of his mind. She had lent him a maid, who had
GENERAL MEDICAL COUNCIL
„he didn’t take it.
[JUNE 5, 1937
acted as his maid; he had never treated the girl.
He had. last seen complainant in October, 1935.
In January, 1936, he had received a letter from her
which he had handed to his wife, who had torn it
up and thrown it in the fire.
Cross-examined, he maintained that complainant
had forced herself on him from May, 1933, onwards.
He had relented in June, and had regretted it ever
since. She had reproached him hysterically over the
telephone until he had said “‘ Shut up: [Pll come
round.” The housemaster was his nephew and he
saw him frequently; he might have handed the
tuberculosis officer’s letter to him as a matter of
convenience. She had offered him a picture; he
had refused it; she had said she would break it if
The petition had been withdrawn
partly because he felt he had done the wrong thing
in breaking up his home and partly because friends
in Ireland told him the type of woman Mrs. Ferguson
was.
Mrs. Pim, wife of the respondent, said in answer
to examination that her husband had brought
Mrs. Ferguson to the house in November, 1934.
She had then told Mrs. Ferguson the substance of her
husband’s confession of adultery and that she would
take divorce proceedings: She had filed a petition
-but had withdrawn it in March, 1935. She had then
become reconciled with her husband and had gone
to: live with him at Abergavenny. Mrs. Ferguson
had come to Abergavenny on several occasions.
On cross-examination she said that she had with-
drawn her petition because she considered it best
for her husband and herself. She had known nothing
about the existence of love letters. She had never
asked Mrs. Ferguson for money. She had even refused
Mrs. Ferguson’s offer to pay for the education of
her son. She may have told her relations that
Mrs. Ferguson had broken up her home. She denied
that she had discontinued proceedings because it
was hopeless to expect to squeeze any more money
out of Mrs. Ferguson. :
Counsel then addressed the Council. After delibera-
tion in camera the President announced that the
Council had found the charges proved to its satisfac-
tion and directed the Registrar to erase from the
Register the name of Douglas Chetham Pim.
Restoration after Removal at Own Request
On Nov. 30th, 1935, the Council acceded to an
application by Jean Braun, L.M.S8.8.A. Lond., 1915,
to have his name removed from the Register. On
April 25th, 1937, Dr. Braun wrote to the Council
asking that his name should be restored to the
Register, and forwarding a statutory declaration and a
remittance in accordance with the standing orders
which relate to applications for restoration after non-
penal jerasure under the Medical Act, 1858, s. 14.
The Executive Committee reported to the Council
that the standing orders did not expressly provide
for the restoration to the Register of a name which had
‘been removed at the practitioners own request,
though in 1921 the Council had been advised that they
had an implied discretion to restore such a name and
that it was for the Executive Committee to consider
the circumstances and advise the Council. In
November, 1921, the Council actually restored such
a name on the recommendation of the Committee, and
the Committee now recommended that the name
of Dr. Braun should be restored.
The Committee acceded to this request, but passed
at once to consider in camera a report from the
Executive Committee which stated that the Committee
THE LANCET]
had been advised by counsel that the standing orders
dealing with the removal of names at the request of the
practitioners themselves were ultra vires, for the
Medical Acts give the Council no power to make such
standing orders. The Committee were satisfied that the
Council should recognise that its power to remove
names of registered medical practitioners from the
Medical Register consists solely of the power of penal
erasure given by s. 29 and the power of non-penal
removal given by s. 14 of the Act of 1858. The
Council agreed with the recommendations of the
Executive Committee that the standing orders relating
to,erasure at the practitioner’s request be deleted.
CONSIDERATION: OF THE CURRICULUM
Prof. J. B. LEATHES, introducing the report of the
Education Committee, said that the committee had
now completed a full examination of the Council’s
regulations for the registration of medical and dental
students. It had been instructed to consider the
regulations with a view to the removal of discrep-
ancies in practice, and to suggest the modifications
which would be ‘necessary to bring the policy of the
Council into harmony with its resolutions passed
in May, 1936. The committee now, said Prof. Leathes,
advised the Council to rescind the regulations and
substitute for them the series of recommendations set
out in its report. Hitherto the students’ register
had been compiled from the forms of request for
registration which students filled in at the various
schools, and had never been complete. Forms
were supplied to the schools but only a portion of the
whole, sometimes a small one, was returned every year.
The method was therefore unsatisfactory. The
committee now proposed that deans should send to the
Council returns of all persons registered as medical
or dental students in order that the Council might be
in a position to compile an annual register of the
medical and dental students who had commenced
their professional studies in each academic year. The
Council would be content to rely upon these returns for
such information as they might require as to the ages
at which students commenced their professional
studies, and as to the preliminary examinations in
general education and the additional examinations
passed by students before admission. It would
relinquish the policy by which the authorities of the
schools and licensing bodies had been encouraged to
make the registration of students by the Council a
condition precedent to their admission to the schools.
The committee recommended, therefore, that the
present regulations, so far as they related to the
method of registration, should be rescinded with effect
from Sept. Ist, 1938. So far as the regulations related
to the conditions under which students were registered,
they should be rescinded from Nov. Ist, 1938. These’
two dates had been chosen, on the one hand in order
that deans entering students in October, 1938,
should send in their lists beginning with the academic
year 1938-39, and on the other hand that the new
conditions of admission relating to age, general
education, preliminary examinations and the like,
which would be affected by the Council’s new resolu-
tions governing professional education, should not
come into operation until those resolutions became
effective. The committee suggested Nov. Ist as a
suitable date. Originally the Council resolved that the
new resolutions should come into operation on
Jan. Ist, 1938, but in November last they had adopted .
a recommendation of the committee that the date
should be postponed to Oct. Ist, 1938. The com-
GENERAL MEDICAL COUNCIL
[JUNE 5, 1937 1349
mittee now recommended postponement for another
month in order to give the schools a little more time
to come into line with the new changes. It would
then be clear that the schools would be at liberty
to deal with applications for admission in the first
term of the academic year 1938-39 under the ‘1923
resolutions, and that applications for admission in
any later term should be dealt with under the resolu-
tions of May, 1936. The committee therefore recom.
mended that its recommendations, and the resolutions
of the Council adopted in May, 1936, should come
into operation on Nov. Ist next year.
NEW CONDITIONS OF STUDENT REGISTRATION
The principal changes made in the recommendations
to accord with the 1936 resolutions were that before
registration as a medical student the applicant
must be within three months of attaining eighteen
years, and must have passed a recognised preliminary
examination in general education, and an additional
examination conducted or recognised by one of the
licensing bodies. University matriculation remained
the minimum standard of general education. A
list of examining bodies whose examinations in
general education complied with the recommendations
was given in the report. The Council should also
recognise as complying with these recommendations
such examinations of universities in British India,
the British Dominions and Colonies, and foreign
countries as were accepted by any university of
Great Britain, Northern Ireland or the Irish Free State
as qualifying for entrance or matriculation.
The subjects and scope of the additional examina-
tions to be required were copied from the Council’s
1936 resolutions :—
(1) For all applicants, chemistry (theoretical and
practical), the elementary principles of general and
physical chemistry and of the chemical combination of
elements, including carbon.
(2) For all applicants, physics (theoretical and practical),
the elementary mechanics of solids and fluids, the elements
of heat, light, sound, electricity and magnetism.
(3) For applicants who have received their instruction
in chemistry and physics before entering universities,
university colleges, or medical schools, one or two subjects.
of general education other than chemistry, physics, or
biology, at a standard higher than that of the recognised
preliminary examination in general education.
The standard of the additional examination in a
subject or subjects of general education should be
approximately that required in a subsidiary subject
offered for the Higher School Certificate at the
examinations specified in the recommendations.
This phrase indicated the kind of standard the
Council had in mind. The School Certificate in
England, which could be taken at sixteen or under,
might under certain conditions exempt from uni-
versity matriculation, but provision was made at the
schools for an examination at a higher standard—
the Higher School Certificate—for boys in later
years. This certificate could be obtained by taking
either three full subjects, or two full subjects and two-
others at a somewhat less exacting standard, called
subsidiary subjects. This latter standard might well
have been in the mind of the Council as a standard
for the additional examinations.
This change, which was perhaps the most difficult
of all the new changes, had not been proposed without.
due cause. Since 1923 English schools had been
teaching chemistry and physics to boys who intended
to take up medicine, and a pernicious tendency had
developed of allowing boys to pass their test in
general education at sixteen, and sometimes even.
1350 THE LANCET]
before, and then setting them to study nothing
but the principal medical subjects for the rest of their
time at school. The present suggestion was an effort
to combat that tendency and to draw the attention
of masters and parents to the necessity of continuing
the general education of students after they had passed
the comparatively low standard of the School Certi-
ficate. Applicants should be able to offer themselves
for examination in biology either before or after
they were registered as students.
The committee had met in conference all the deans
of the London medical schools except three, and they
had unanimously agreed that this method could be
‘worked so far as they were concerned.
THE CASE AGAINST DELAY
Sir HENRY BRACKENBURY said that he was not
convinced that the postponement of the operation
of the new conditions from Oct. lst to Nov. lst was
either necessary or desirable. In May, 1936, the
Council had prescribed the new curriculum, both
preliminary and clinical, and all members had regarded
it as a considerable improvement. It should not,
therefore, be postponed longer than was fair and
necessary to those who had already embarked upon
some portion of their medical education, either
at school or at a medical school. The effective date
had already been postponed once in order to give the
public and secondary schools from which most
medical students were recruited two full school
years’ notice of the alterations that might be neces-
sary for the guidance of their senior boys and girls in
the kind of curriculum they: should take while at
school or immediately afterwards. This notice had
been ample. The only effect of postponing the change
from Oct. lst to Nov. lst, 1938, would be to enable
the authorities of medical. schools to train the whole
body of medical students who joined in. 1938 (for
nearly all medical students entered in October) under
the old instead of the new curriculum, The recruit-
ment of medical students under the improved con-
ditions would be postponed for a year. The postpone-
ment would even embarrass the schools themselves,
for they might be conducting two different kinds
of curriculum simultaneously, according to whether
a student registered in October or November.
Prof. R. J. JOHNSTONE also inquired the reason
for the change. His own faculty, he said, had spent
a very strenuous winter session preparing for the
change, and now would not encounter it for another
year. He suggested that the same effect would be
produced by a postponement to Jan. lst, 1939,
or even Oct. Ist, 1939.
Prof, LEATHES replied that when the new resolutions
came into operation they would, so far as they dealt
with clinical years, affect not only students who
entered after Nov. Ist but all students. Only
the conditions of entry after Nov. Ist would be affected.
The committee had been advised that two years was
not enough notice and had thought it advisable to
give what amounted practically to an additional
year.
Sir H. BracKENBURY asked whether a student
who entered in October, 1938, and therefore under
the old conditions had not a right to claim registration
five years afterwards because he had satisfied the old
conditions though not the new.
Sir ROBERT BOLAM suggested that this question
must be put to the licensing bodies. Sir Henry
was not fully aware of the difficulties that beset the
officers of medical schools when a new set of regula-
tions was announced. The faculty at his own school
GENERAL MEDICAL COUNCIL
[JUNE 5, 1937
had been bombarded by headmasters and parents
with questions whether the pupils who had been under
preparation for two or three years could sit in October,
1938, under the old regulations, or whether they must
prepare for the new. To upset the whole of the
medical curriculum meant years of work for a
licensing body in readjusting its arrangements.
The postponement meant that medical schools
could but need not insist on pupils coming in under
the new recommendations. If they gave sufficient
notice in their calendar they could alter the succeeding
years of the curriculum. He doubted, however,
whether the schools had yet got everything ready for
the later years. He hoped that the Council would not
embarrass the public and the medical schools by
bringing the new conditions into force in October
and forcing them to deal with many applications for
exemption.
Prof. L. P. GAMGEE said that such difficulties were
not felt in all schools. His own school was quite ready
to adopt the new regulations on Oct. Ist. If the
change was postponed for a month it would probably
cause trouble in the shape of applications from
students who had entered under the old regulations
to undergo the whole of the old curriculum. If
the extra month were given the Council should
recommend that all students who entered during
October, 1938, should, for the remainder of their
course, go under the new regulations.
Dr. D. J. COFFEY, however, spoke in favour of the
extra month. The raising of the age to eighteen had
been unexpected and the students who came up
from schools after doing chemistry and physics might
not have done extra subjects, but would have an
opportunity of coming in without them, A student,
however, who had passed in chemistry and physics
by Nov. Ist under the old system was in an ambiguous
position. Under the old regulations he would have had
at the end of the year to pass an examination in
chemistry, physics, and zoology, but under the new
regulations he would begin on his anatomy and
physiology at once. Had he to pass the old examina-
tion at the end of the first year and the new at the
end of the second ? He would have to be exempted
from the heavy first examination in chemistry and
physics required under the existing curriculum.
Dr. Coffey also suggested that printed forms should be
supplied to each school.
Prof. GAMGEE also opposed the postponement to
November, but Sir R. BoLam pointed out that the
contract into which the new student entered with his
medical school gave the school liberty at any time on
due notice to alter the syllabus and examination
subjects. No school could be run on any other lines.
Prof. J. W. BIGGER thought that great confusion
would be caused and students would go to the schools
which gave them the most generous exemptions.
If the notice given to the schools was not enough the
correct procedure would be to hold back the new
conditions until October, 1939. November, 1938, was
either too soon or not soon enough.
Afterfurther debate a motion bySir H. BRACKENBURY
to put the date forward until Oct. lst, 1938, was lost
by 20 votes to 6.
REGISTRATION OF DENTAL STUDENTS
The committee advised the Council to require that
every dental student (subject to occasional exceptions)
should be registered in the same manner and under the
same conditions as a medical student, but that
applicants for registration might commence their
professional studies as pupils of a registered dental
practitioner instead of at a recognised dental hospital
THE LANCET]
or school. Under the regulations at present in force,
said Prof. LEATHES, a student who took his dental
mechanics in his apprenticeship might deduct half
the time from his curriculum. In consultation with
dental authorities, including the dental committees
of the Council, the Education Committee had decided
to recommend that an applicant who, after reaching
seventeen, had served two or more years as a bona-fide
apprentice in dental mechanics with a registered dental
practitioner should, if the licensing body thought fit,
be allowed to antedate his registration by not more
than six months. A year was too much to allow
out of a dental curriculum of four years. A dental
student could not do all that was required of him in
three, for he had to go to a dental clinic for two
years and could not pass his biology, anatomy, and
physiology in one only. The change would bring no
hardship, as applications for exemption on this
ground were very rare. |
Many persons would like to see the recognition of
outside dental mechanics done away with, but there
were always a certain number of deserving men who
had earned their living for several years as dental
mechanics, done very good work, and also educated
themselves and passed their preliminary examinations.
They deserved encouragement and made excellent
practitioners. The committee had therefore recom-
mended what they considered a fair allowance.
Mr. Bishop HARMAN urged that dental mechanics
should still be allowed one year’s exemption from the
dental curriculum if they had served two years as
apprentices, but although the Council agreed that
these students were exceptionally deserving people
he could not find a seconder for his amendment
to substitute twelve months for the six months
recommended by the committee.
PUBLIC HEALTH
Sir GEORGE NEWMAN, chairman of the Public
Health Committee, referred, in introducing its report,
to the new resolutions and rules submitted by the
Committee for diplomas and degrees for public health.
Formerly, the rules had provided that candidates
should produce evidence of having devoted so many
hours to the study of specified subjects, but the
new rules laid down that a candidate should produce
evidence that he had regularly attended a course
lasting not less than a stated number of hours. This
change would, said Sir George, be more convenient
to the licensing bodies. The earlier provision that
candidates must ntake 24 daily attendances of not
less than two hours each at a fever hospital had been
deleted as too difficult to work. Candidates would
now be required to show that they had attended for
three months on the clinical practice of an approved
hospital for infectious diseases. Of the twenty
licensing bodies who had seen the draft rules, three
only had criticised them substantially. The Royal
Army Medical Corps found difficulty in Rule 2,
which provided that the curriculum could not be taken
in less than a year. The Committee had felt that the
old rules had to be strengthened to shut out the
part-time or somewhat transitory kind of training
sometimes contemptuously known as “ night school ”
education.
Dr. H. L. TIDY suggested that this rule might be
relaxed for R.A.M.C. candidates. The rules were
adopted without dissent. .
Indian Medical Diplomas
The Executive Committee reported that in
February last they had passed a resolution that holders
of diplomas granted by the Punjab University
BRITISH HOSPITALS ASSOCIATION
[JUNE 5, 1937 1351
on or after Feb. 25th, 1930, should be entitled to
registration in the Colonial List. The Committee
passed a similar resolution on May 24th recognising
the diplomas of the University of Calcutta granted
on or after Oct. 16th, 1936. Sir NORMAN WALKER
(President), chairman of the Committee, referred to the
work of the recently established Medical Council
of India in maintaining the standard of Indian
university examinations. The three universities
already on the list were, he said, those of Bombay,
Madras, and Patna.
The Pharmacopeia
The report of the Pharmacopeia Committee was
‘presented by Prof. DAvip CAMPBELL, its chairman.
He said that 43,276 copies of the British Pharma-
copæœia 1932 had been sold up to date, 1066 of them
in the last half year. Of the Addendum 1936 the
number of copies sold since its publication at the end
of last year had been 5557. The British Pharmacopoia
Commission had reported to the Committee that its
principal concern had been the scope of the next
Pharmacopoeia. It had reviewed the monographs
of the present work and had made a survey of drugs
which had been recently introduced or which were
attaining increased use in therapeutics. It had
compiled a list of those drugs which through decreased
use or doubtful therapeutic value might be regarded
as no longer worth inclusion in the Pharmacopeia.
The lists of proposed omissions and additions had
been sent to the appropriate Government Departments
and medical bodies, to the Governments of India and
the Dominions, and to various branches of the Colonial
Medical Service, with requests for criticisms and
suggestions. Information had been interchanged
with the United States Pharmacopewia Committee
of Revision, which had sent the Commission a report
on its plan for the revision of the U.S. Pharmacopeia
by means of annual supplements. The Commission
proposed to watch the plan with interest.
BRITISH HOSPITALS ASSOCIATION
THE weather collaborated with the Mayor of
Torquay (Councillor A. Denys Phillips) and his
fellow townsmen in providing a welcome to the
members of the British Hospitals Conference for their
annual conference last week. Miss M. G. MILNE, matron
of Leeds General Infirmary, spoke at the first meeting
upon the status and rôle of the nursing profession
in the hospital system. Contrary to the generally
accepted idea she expressed the opinion that salaries
paid to nurses in training were adequate and in some
cases excessive in an endeavour to tempt an increased
number of candidates. More freedom might be
allowed, however, to the trained staff and it might
soon be necessary to undertake the additional expense
of allowing senior sisters to be non-resident. On the
controversial question of the matron’s position in
respect to the supply of food. Miss Milne was content
to leave the control to the lady housekeeper with
direct access to the house governor, while arranging
for close collaboration for which she made a powerful
plea among all branches of the staff with the nurses.
Hospital publicity was the subject of a paper read
in the afternoon by Mr. C. E. A. BEDWELL, house
governor of King’s College Hospital. Based upon
a resolution passed at the last International Hospital
Congress he considered the relationship of hospital
publicity to health education propaganda. In
particular he urged that .the voluntary hospitals
should be given a proper place in the campaign now
being organised for next autumn under the egis
of the Ministry of Health. Mr. Bedwell directed
1352 THE LANCET]
attention to the admirable paper by Dr. Homer
Wickenden, of the United Hospital Fund of New
York, for the forthcoming congress in Paris, published
in the current issue of Nosokomeion and discussed
the relationship of the press to hospital publicity
a well as the contribution of broadcasting and the
S.
VOLUNTARY HOSPITALS COMMISSION
Lord SANKEY made a great impression upon his
audience on the following morning in presenting
the report of his commission. He based his argument
on the contention that there is a general agreement
that the voluntary hospital system cannot go on as
it is and that something must be done and that had
been the opinion of all the witnesses who came before
the commission. There was no proposal whatever
in the recommendations of the commission to pool
funds, but they had endeavoured to create an
organisation by which it might be possible to pool
experience. In order to deal with’ the financial
difficulties and to provide a means by which the
State could assist with grants in aid the commission
proposed the appointment of a committee similar
to the University Grants Committee as, said Lord
Sankey, “the analogy between the universities an
hospitals is almost perfect.” l
Provost SHEEN, in dealing with some of the details
of the report from a medical point of view, strongly
urged the substitution of auxiliary hospitals for
convalescent homes and the abolition of the ‘‘ process
of canvassing masses of people ” on making appoint-
ments to the staffs of hospitals,
Sir REGINALD POOLE, another member of the
commission, said that he had come to its deliberations
with an entirely open mind and was in full agree-
ment with the recommendations. He added a
personal expression of his interest by offering to
contribute to any fund raised to carry them into
operation.
The effect of Lord Sankey’s speech upon the
audience, in which at the outset there was a some-
what critical atmosphere, was seen in the afternoon
when at the annual meeting a resolution was passed,
almost without discussion, to appoint a special
committee to implement the first three resolutions
of the commission—namely, the division of the
country into hospital regions, the formation in each
region of a voluntary hospitals regional council to
correlate hospital: work and needs in the region, and
the formation of a central council to codrdinate the
work of the regional councils,
It is announced that the first meeting of the special
committee will be on June 9th.
THE SERVICES
ROYAL NAVAL MEDICAL SERVICE
Surg. Comdrs. E. B. Pollard to Arethusa, and G. S.
Rutherford to Pembroke for R.N. Hospl., Gt. Yarmouth.
Surg. Lt. F. Bush transferred to Emergy, List.
Surg. Lt. B. O’Neil to Ramillies.
Surg. Lts. transferred to Permanent List: H. J.
Bennett, J. W. Caswell, L. G. Yendoll, D. B. Jack, J. G. V.
Smith, G. S. Thomas, W. B. Taylor, J. E. Davenport,
W. D. Gunn, E. J. Littledale, G. D. Wedd, E. James, and
W. A. S. Grant.
Surg. Lt. (D) W. L. Mountain to Ramillies.
The following have been appointed Admiralty Surgeons
and Agents: Mr. L. A. Hiscock, of Southbourne, Emsworth
(Emsworth); Mr. J. R. J. Beddard, of Frome (Frome) ;
` and Mr. T. Sharp, of Rothesay, Bute (Rothesay).
ROYAL NAVAL VOLUNTEER RESERVE
Surg. Lt.-Comdr, D. M. Craig to Revenge.
Surg. Lt.-Comdr. (D) G. A. O. White to Victory for
R.N. Hospl., Haslar.
Surg. Lt. C. M. Lamont to Caledonia.
Proby. Surg. Lt. J. Ronald to Iron Duke.
THE SERVICES.—THE LANCET 100 YEARS AGO
. J. F. Sandow to No. 1
[JUNE 5, 1937
ROYAL ARMY MEDICAL CORPS
Lt.-Col. G. H. Dive, D.S.O., having attained the ag
for retirement, is placed on ret. pay. l
Maj. W. E. Tyndall, M.C., to be Lt.-Col.
REGULAR ARMY RESERVE OF OFFICERS
Capt. J. B. Murray (Army Dental Corps), having attained
the age limit of liability to recall, ceases to belong to the
Res. of Off.
TERRITORIAL ARMY
Lt. B. B. Hosford to be Capt.
ROYAL AIR FORCE
Squadron Leader F. P. Schofield to R.A.F. Genera}
Hospital, Palestine and Transjordan, Sarafand.
Flight Lts. R. F. Wynroe to R.A.F. Hospital, Cranwell ;
(Indian Wing) Station Kohat,
India; J. L. Walsh to No. 20 (Army Codperation) Squadron,
Peshawar, India; and A. W. Callaghan to R.A.F. Station,.
Biggin Hill.
Flying Offrs. J. H. L. Newnham, P. A. Wilkinson to-
special duty list on appointment to short service
commissions, and J. H. Preston to R.A.F. Station,
Debden.
Short service commissions as Flying Officers for three
years on the active list and all to Medical Training Depôt,.
Halton: C. D. Clements, F. V. Maclaine, J. R. McWhirter,.
A. Muir, J. P. Brazil, and A. W. St. C. Greig.
Dental Branch.—Non-permanent commissions as Flying
Officers for three years on the active list and all to Medical
Training Depét, Halton: A. J. Clegg, F. V. Franks, T.A.
Gray, and J. F. M. Sampson.
Flying Offr. H. B. Shay to Special Duty List, on appoint-
ment to a non-permanent commission.
INDIAN MEDICAL SERVICE
Indian Medical Department.—Asst. Surgs. (lst Cl.)
to be Lts. (Sen. Asst. Surgs.): D. H. J. Nicholas and.
J. W. C. Lopez.
THE LANCET 100 YEARS AGO
June 3rd, 1837, p. 370.
From a summary of the report for 1836 from the
Morgue, Paris.
Causes of suicide which were identified :—
Male. Fem. Total.
Mental alienation .. oe es .. 10 12 22
Bad conduct ra zx a si 9
Disgust of life ae is
Misery ;
Robbers ‘8 is ie os
Disappointed love .. a gas Or oH
Loss of money ni i i si
Quarrels and domestic disappointments
Loss at play : sXe a sy
Drunkenness Ss ie
Result of quarrels .. iy
Incurable disease .. g os T
Departure from, or separation of, family
Brain fever : ge ahs we
Loss of wife ;
Embarrassed affairs
Result of remonstrance
eas She es tO eS Sa ea Uses ae Os
ee eer ee rere ore
bet mt em BD BD 69 09 09 09 OR I Or Rt OD
3
From the section on deaths from drowning in
same report :—
Accidents leading to submersion :—
Bathing sa E h NA su a -- 1l
Drunkenness sis a Pe ne yA
Boating, or sailing .. zx si
Falling from horses, while drinking
Playing on the shore š Pe
Fishing S ká
Leaping near the river ci T a
Washing feet, saving others, storm blowing
individual into water, &c. zá w%
mR BD 09 00 69
THE LANCET]
THE LANCET
LONDON: SATURDAY, JUNE 5, 1937
THE CAPITATION FEE
THE national health insurance system, in the
twenty-fifth year of its age, is again faced with
the problem of making an equitable adjustment in
the capitation fee paid to the practitioners respon-
sible for the medical care of the 18 million insured
persons in Great Britain, a number which it is
proposed to increase by the addition of approxi-
mately 1 million juveniles entering insurable
employment between leaving school and reaching
the age of 16. As on previous occasions, the
Insurance Acts Committee of the British Medical
` Association, representing the practitioners, and the
Government have been unable to reach agreement,
and the question has, with the consent of both
parties, been referred for determination to an
independent court of i inquiry. The present inquiry
is simplified in that it is not to consider the question
ab initio. It starts with the assumption that the
capitation fee of 9s., awarded by a similar court
in 1924, is to be taken as the proper remuneration
at that time ; and the task of the present court
is to ascertain what changes, if any, should be
made in the capitation fee to meet the changes
that have taken place since 1924 in the conditions
under which insurance medical practice is carried
on. The court of inquiry began its deliberations
on May 26th, and the Ministry of Health and the
Insurance Acts Committee have exchanged memo-
randa of evidence and rejoinders, all of which are
reproduced in the supplement to the British Medical
Journal of May 29th.
The Committee contends that the changes
affecting insurance practice since 1924 justify an
increase in the capitation fee from 9s. to 12s. 6d.,
and bases the contention on three main grounds.
First, it is pointed out that recently, and especially
within the last ten years, there has been a
“ reorientation of medical thought and a widening
of the basis of medical practice,” which now seeks
not only to remove diseased conditions but to
promote positive health. The increased responsi-
bility and skill involved in such preventive work
is not fully expressed in the increase in the number
of the items of services rendered, but it is of definite
value to the community and should be taken into
account in assessing the remuneration of insurance
practitioners. Moreover, the advance of medical
science has increased the complexity of diagnosis
and treatment and therefore the amount of time
necessarily spent with individual patients.
Secondly, the Committee produces evidence of an
increase in the average annual number of attend-
ances made to each person on a doctor’s list. In
1924 the number was estimated by the Minister
THE CAPITATION FEE
. [JUNE 5, 1937 1353
at 3:5, and by the Committee at 3:75. Since 1924
the Committee has arranged for the keeping of
special records by practitioners in nearly all
insurance committee areas, and has thus obtained
particulars of over 3000 practices, which, it is
contended, show that the average annual number
of attendances per person on a doctor’s list in the
years 1930-36 was 5-02. Thirdly, it is put forward
that the ratio of practice expenses to gross receipts,
which was taken by the 1924 court to be 25 per
cent., is now 33 per cent. The Committee accepts
the view of the Ministry that the fall in the cost
of living would, other things being equal, justify
a reduction of 5d. in the capitation. fee, and that
there has been some decrease in motoring costs
—not more, however, than 4:6 per cent., corre-
sponding to a reduction in the capitation fee
of 4d.—but it is contended that these reductions
are far outweighed by the increased costs under
other headseand by the increased responsibilities
and efforts now required in insurance practice.
The Committee emphatically rejects the Ministry’s
view that the young workers proposed to be
brought within the health insurance system will
need less medical care than = general body of
insured persons.
The most important point at issue between the
Ministry and the Committee is the extent of the
increase in the work devolving upon insurance
practitioners, and especially in the average number
of services rendered to each person on a doctor’s
list. According to the records specially kept at
the instance of the Committee the number in
1930-36 was, as already stated, 5-02, but an
examination made by the regional medical officers
of the insurance medical records kept in 600
practices during 1936 showed that the number in
those practices was 3-66; and it was found that
while the nuraber of surgery attendances had
increased by 10-7 per cent. as compared with the
results of a similar examination made in 1924, the
number of visits had fallen by 3-8 per cent. To
estimate the net effect of these changes, the visits
and attendances were weighted in the ratio of
14 to 1 respectively, the average fee in private
practice for a visit being usually about half as much
again as the fee for a surgery attendance. The
figures were corrected for the omission of records
of persons dying during the period under review in
each of the years in question; and when the
weighting is applied to the figures so corrected
the totals become 3-99 in 1924 and 4:12 in 1936,
showing a net increase in services rendered of about
34 per cent.—which would be met by an increase
of rather less than 4d. in the capitation fee, as
against the 3s. 3d. claimed under this head by the
Committee. In considering the contention that
scientific advances have made insurance practice
more exacting, the Ministry expresses the view
that the improved methods have mainly affected
specialist practice, and that such methods as have
been adopted in general practice, for example the
injection of varicose veins, have tended to reduce
the total services required. The Ministry gives
statistics drawn from insurance medical records
and hospital reports which, it is suggested, afford
1354 THE LANCET]
evidence that “ insurance practitioners have been
relieved of some of the more onerous part of their
work by recent developments of health services.”
As regards motoring costs, the estimate in the
Committee’s memorandum assumes the use of a
15-h.p. model, which it is stated, ‘‘is perhaps
typical of the car most commonly employed in
general practice,” and a running cost based on
petrol consumption at the rate of 20 miles per
gallon. The Ministry’s figures are based on a car
of 9 to 10 h.p. consuming Pea at the rate of
32 miles per gallon.
There is an acute difference of opinion on the
question of the work that would devolve upon
practitioners by bringing persons under 16 years
into insurance on their entering insurable employ-
ment. The Committee presses the view that
though in providing medical care for these young
people a practitioner’s duties will be to a con-
siderable extent preventive and advisery—that he
will be concerned less with incapacity than with
positive instruction in health and in the early
detection and treatment of disease—they will be
none the less onerous. For such persons the
practitioner’s services though different in kind
will be more rather than less important than those
rendered to other members of the insured popula-
tion. It is urged that the period of “ transition
from the sheltered years of school life to the early
years of wage-earning is very commonly a difficult
and trying one, when the friendly supervision of
the family doctor is of paramount importance,”
and that therefore the new responsibilities it is
proposed to entrust to insurance practitioners will
be specially important, not only from the point of
view of the individual patients but from that of
the community of which they form part. The
Ministry agrees that the period of young adolescence
is important for future health, but holds that it
does not follow that persons of the age in question
require more treatment than older persons, or
“that in practice they will demand or receive
more treatment”; and from evidence drawn
chiefly but perhaps not very appropriately from
mortality-rates, incapacitating sickness experience,
and insurance medical records, it is submitted
that the claims which this new class of insured
persons are likely to make on the time and energy
of insurance practitioners may reasonably be
assessed at about half those made by an equivalent
number of older insured persons. The Ministry
concludes, however, that there should be one
uniform capitation fee for all insured persons,
including the juveniles, and that the fee should be 8s.
The chief impression left by the study of the
four able documents now published is that the court
of inquiry has still a good deal of ground to explore.
The discrepancies between the estimates made by
the Ministry and the Committee respectively of
the services to be rendered by insurance prac-
titioners, and of the costs that will be entailed in
rendering the services, are so great that further
information seems needed of the data on which
the estimates were based, and the methods employed
in handling these data. In the arguments put
forward there appears to be some difference of
NOVEL METHOD OF ADMINISTERING HORMONES
he shoulders.
_ [JUNE 5, 1937
outlook and emphasis. The Ministry seems to
consider the question of remuneration in terms of
separate items of service—from a strictly quanti-
tative point of view. The Committee, on the other
hand, rightly emphasises the importance of ¢on-
sidering also the kind and degree of the responsi-
bility assumed. This is in harmony with the
general principle on which the capitation system of
payment is based; for in that system the doctor
is paid, not—as in the attendance system—for
work done but in proportion to the responsibilities
The court was instructed to have
regard in its inquiry to “ other relevant factors ”
and not the least of these is the attainment of the
willing coöperation of insurance practitioners in
the greatest of national services.
NOVEL METHOD OF ADMINISTERING
HORMONES
In our issue of April 11th last year experiments
were recorded showing that the effectiveness of
testosterone could be much increased by aug-.
menting the volume of oily medium ‘used for —
injection or by adding fatty acid to the solution.
The effect was probably due to retardation of
absorption and decrease of wastage of the hormones.
In an annotation we then drew attention to the
parallelism between these experiments and earlier
work on increasing the effectiveness of cestrone
and oestradiol by subdivision of the total dose or
by esterification. Soon afterwards the preparation
and biological examination of a long series of
aliphatic esters of testosterone led to the selection
of the propionate as giving the optimum com-
bination of intensity and duration of action,’ and
it was shown that, on castrate rats, a constant
total dose of testosterone was more efficient given
as propionate once weekly than given as free
hormone twice daily.’
More recently further tests have been carried
out with the esters of cestrone and cestradiol, both
on rats? and on the feather response of brown
Leghorn capons.4 By the latter test it can be
shown that whereas 1 mg. of free cestradiol in one
dose has an effect lasting barely one day, 1 mg. as
3-benzoate has an effect lasting ten days, and
1 mg. as 3-benzoate-17-acetate one lasting fifteen
days. It seemed likely that this effect of esterifica-
tion depended on either alteration of the solubility
of the compound, resulting in slower absorption
from the site of injection, or prolonged liberation
of free hormone from slow hydrolysis of the esters.
Some interesting experiments now reported by
DEANESLY and PARKES ® have a bearing on these
alternatives. It was found that with andro-
stanediol and trans-androstanediol an increase in
the volume of oily medium actually decreased the
effectiveness. These compounds are relatively
insoluble, and the more concentrated solutions
2 Ruzicka, L., and Wettstein, (1936) Helv. nee
19, 1141; Miescher, K., Wettgteln, and Tschopp, E 100
Biochem. J. 30, 19
ie
* Parkes, A. S. (1936) Lancet, 2
*Miescher, Schulz, C., and Tschopp CE Schweiz. med.
Wschr. 67, 268.
4 Parkes (1937) Biochem. J. 21 579.
¢ Deanesly, R., and Parkes (1937) Chem. and Ind. 56, 447.
THE LANCET]
readily crystallise out to form a mush of oil and
solid matter. It seemed therefore that the greater
effectiveness of the concentrated solutions might
be due to slow absorption of the crystal mush.
‘This possibility was investigated by administering
testosterone to rats and cestrone to capons by the
subcutaneous implantation of a solid crystal or
compressed pellet. The results were remarkable.
A single implantation of a 2 mg. crystal of free
cestrone feminised the growing plumage of capons
for 2-3 months, four times as long as a similar
amount of the most effective ester. A single
implantation of a 2 mg. pellet of free testosterone
to castrate rats caused greater development of the
accessory glands at the end of ten days than the
daily injection of a corresponding amount of the
propionate in oil.
In view of the increased response in such experi-
ments where absorption of the free hormone was
inevitably slow, converse experiments were carried
out; the esters were administered in such a way
that absorption into the circulation was inevitably
rapid (intraperitoneal injection) or instantaneous
{intravenous injection). Given in this way, neither
cestradiol benzoate nor testosterone propionate
showed any prolongation of action, indicating that
hydrolysis is rapid once the compound gets into
the circulation. Hence it is concluded that the
alteration of hormone effectiveness by esterifica-
tion depends on a change in the solubility of the
compound in body fluids and consequent alteration
in the speed of absorption from the injection site.
DEANESLY and PARKES also point out that since
the method of administration has such a profound
influence on the effectiveness of a compound, and
since the optimal conditions differ for different:
compounds, a valid quantitative comparison of two
substances can only be carried out after a thorough
study of the conditions necessary for maximum
efficiency.
A NEW USE FOR ETHYLENE
ENCEPHALOGRAPHY, a valuable method of investi-
gation which is often employed in neurosurgical
clinics, has the one great drawback of producing
intense headache, vomiting, and malaise in nearly
all of those subjected to it. Headache may disable
the patient for several days ; the other disturbances
usually subside after a few hours. Any method
which would give equivalent radiological results,
but without these unpleasant though not dangerous
accompaniments, would clearly be welcomed. It
has been assumed by some surgeons that the air
itself has an irritating effect upon the brain and
meninges. Others suggest that a more readily
absorbable gas would cause less discomfort ;
oxygen, carbon dioxide, nitrous oxide, and helium
have all been used as substitutes for air, but there
has been no unanimity of opinion that they are
any better and air is still used in most clinics.
Dr. Henry Newman’ of California has used
ethylene for encephalography in thirty cases.
In water at 20° C. this gas is about seven times
as soluble as air. Nitrous oxide—possessing a
1 J. Amer. med. Ass. 1937, 108, 461.
A NEW USE FOR ETHYLENE
[JUNE 5, 1937 1355
solubility nearly forty times that of air—was used
in a few cases, but the gas was absorbed so quickly
that the radiograms were unsatisfactory. The
pictures obtained when ethylene was used showed
good definition, provided that the exposures
were made within fifteen minutes of the insufflation.
The gas disappeared much more rapidly from the
subarachnoid space than from the ventricles.
Dr. Newman thinks that the headache experienced
during the injection was not less severe than when
air was used, but that it lasted a much shorter
time. Patients were usually quite comfortable
within three or four hours, and were able to get
up the following day. The average stay in hos-
pital following air injection was three days; the
use of ethylene reduced the average to 1-85 days.
The author does not believe that the anzsthetic
. property of ethylene has any significance, but
that its free solubility and consequent more rapid
absorption is the reason for its usefulness in these
cases.
The removal of cerebro-spinal fluid and its
replacement by a gas must profoundly affect the
dynamics of the intracranial structures. Indeed;
it is surprising that in the absence of a space-
occupying lesion or abnormally fragile blood-
vessel, the central nervous system can sustain
such an insult without apparent damage. The
withdrawal of the cerebro-spinal fluid which affords
support to the meninges and arteries by reason
of its density and pressure, and its replacement
by a medium of such vastly different density,
even under a considerable pressure, can hardly take
place without gross alteration in the tension of the
various intracranial structures. This effect will
be most pronounced upon the relatively unpro-
tected vessels coursing over the pia in the sub-
arachnoid space, and is probably responsible
for the immediate severe headache and shock-
like reaction. A pleocytosis of the cerebro-spinal
fluid subsequently develops, and the pressure
may remain unduly low, or rise above the normal.
Various pieces of apparatus have been devised
in order that the displacement of the fluid by gas
may be gradual and may lead to a minimum of
disturbance of the intracranial structures. It is
probable, however, that whatever method be
adopted, there will of necessity be a “ basal”
degree of headache, which will be noticeably
severe if the method involves sudden, violent
fluctuations in the intracranial pressure. This
immediate reaction will clearly be unaffected by
the nature of the gas employed. The prolongation
of the disturbance for two or three days is to be
related to the meningeal reaction; it is possible
that if the gas be rapidly absorbed from the sub-
arachnoid spaces, the pia-arachnoid reaction may
resolve more quickly. .This was certainly the
clinical observation in Dr. NEWMAN’S cases. -
Dr. Robert Hutchison has accepted an invitation
to serve on the committee to review the use of
corporal punishment in the penal system of Great
Britain. The constitution of the committee is given
in our Parliamentary column,
1356 THE LANCET]
a
[JUNE 5, 1937
ANNOTATIONS
PROGRESS IN THE HYGIENE OF INDUSTRY
Last week the committee stage of the Factories
Bill was completed in the House of Commons under
the able guidance of Major G. Lloyd George and the
Bill was ordered to be reported to the House. It
may be well to take stock of the present position and
to inquire in what respects the Bill has been amended
from the point of view of industrial health during
such exhaustive discussion. They may be briefly
summarised thus.
The Adolescent.—Young persons between 14-16
years are not to work more than 42 or 44 hours a
week. That is a welcome move in the right direction.
We have ourselves consistently advocated a 40-hour
week for young persons of these ages. The public-
weal démands that adolescent men should be
both encouraged and enabled to live a full and
healthy life during the second physiological period of
rapid growth, and we have recently indicated the
support given to this demand from many sources.!
Welcome also is the withdrawal of the clause per-
mitting boys of 14-16 to be employed in certain
trades for 56 hours a week between 6 A.M. and 10 P.M.
The Home Secretary is to be given power to forbid
overtime for young persons up to 18 where ‘‘ detriment
to health ” can be shown and also to reduce overtime
for women and young persons if it be proved that
that overtime is ‘‘ unnecessary”’ in a particular
industry. The practical value of these concessions
is lessened by the well-known difficulty of proving
detriment to health or the presence of necessity.
Only a strong executive could get good value out of
these and other vague clauses in the Bill. The
number of weeks in the year during which a woman
may work overtime is reduced from 30 to 25, and
here again the Secretary of State is empowered,
under certain circumstances, further to reduce the
hours of work.
General Hygiene and Safety—Washing facilities
and accommodation for outdoor clothing are now to
be provided in all factories; we must recall how
wide is the new definition of a factory to realise the
extent of this advance. The safety clauses in the Bill
were so well drawn at the outset that little alteration
has been required ; it is good that all old hoists and
lifts must be fitted with automatic locking gates.
It is still, however, too early to measure accurately
the extent of the improvements in industrial hygiene
which the Bill will ultimately contain ; a number of
amendments were withdrawn in committee upon the
understanding that the Home Secretary would
reconsider them and, if possible, reintroduce them
during the report stage. Some provision has been
made for the re-examination of young persons but it
is too early also to be sure whether certain important
amendments which appeared to be very desirable on
medical grounds and which were not incorporated in
the Bill have been irrevocably lost—e.g., the setting
up of a standard of available floor space in work-
rooms in order that overcrowding may be avoided.
Standards of dir-space are laid down, in the estima-
tion of which only 14 feet of the height of any work-
room may be taken into account. Experience
suggests that under certain circumstances the avail-
able floor space per person is the more important
consideration. In corners of a workroom in which a
conveyor-belt is working there may be gross over-
crowding, which may ‘result in severe epidemics of
1 Lancet, Feb. 20th, 1937, p. 451.
-to secure conviction in a court of law.
influenza or sore-throat, while the air-space of the
room is well above the specified standard.
There remains one vital point in the Bill to which
constructive criticism, both medical and lay, ought to
be directed—viz., to provide effective means to assist
the Secretary of State and the Home Office inspec-
torate in the discharge of the onerous responsibilities
which are laid upon them. The Bill, as it is now
drawn and amended, is capable of being made a
charter of industrial health. Or it may leave things
much as they are. Sound and progressive advance in
industrial hygiene will depend more than anything on
the treation of a strong, representative, and lively
advisory council to the Minister. It may be more
important now to make sure that the Minister’s
powers to make special regulations and orders are
neither abused nor allowed to remain unused, than
it is to obtain an alteration in specific clauses in the
Bill. Many of the orders issued under the authority
of the Act of 1901, open as they may be to criticism,
have been potent instruments for health in so far as
they were the expression of medical needs and of
practical possibilities as they existed within the
several industries.
THE OLD FARMER ANO THE RABBIT
THE practice of dentistry is protected by law far
more effectively than is that of general medicine.
Under the Dentists Act 1921 no person whose name
does not appear on the Dentists’ Register may
practice dentistry or hold himself out either directly
or by implication as practising or as being prepared
to practice dentistry ; and the penalties for contra-
vention of the Act are severe. Nevertheless it is not
easy for the Dental Board to obtain specific evidence
of practice by an unregistered person which is likely
In his address
at the opening of the thirty-second session of the
Board, Sir Francis Acland mentioned one instance
in which the difficulties had been surmounted. A
person whose name had been penally erased from the
register had opened a business described as a dental
repair company and had advertised it repeatedly in
the local press. The advertisements included a
variety of ingenious phrases designed to convey to
the uninitiated that the advertiser was a registered
dental practitioner, and as such was entitled to
practise. In testimony to the ingenuity of these
phrases Sir Francis regarded it as inexpedient to
recite them, but the Board obtained a conviction
on charges of holding out and of practising, penalties
amounting to £61 being inflicted. Five months
later when further evidence of practice became
available the same person was again convicted and
was fined £25 with costs. This was a case in which
the Board had been pressed for some time by a pro-
fessional organisation to take action but had waited
patiently for evidence sufficient to justify prosecution.
Sir Francis added: ‘‘ In this connexion I am reminded
of a story of an old farmer in my county who was wont
after finishing milking to go up to a field on the farm
where, looking over the bank, he could see a large
rabbit quietly feeding outside its hole, and after
taking careful aim at it to miss it. And on turning
away sorrowfully he would console himself by saying
‘That ther rabbutt ’ll come out of that there hole
wance tu often.’ One may hope that his perseverance
was ultimately rewarded, but his practice is not one
which I can recommend to the Board for their
imitation. It is better in most cases that we should
~
THE LANCET]
not shoot unless our armament is so powerful that
missing is extremely unlikely. I find, too, that
most rabbits will come within extremely short range
if given a little time.”
CHEMOTHERAPY OF STREPTOCOCCAL
INFECTIONS
THE consequences of the discovery of Prontosil
are increasing rapidly in complexity. When it was
shown that this drug acts by liberating in the body
a substance (p-aminobenzenesulphonamide) now
known as sulphanilamide, and that sulphanilamide
itself could be administered with equally good effect,
much that had been obscure became plain ; and when
the authors of this secondary discovery reported 1
they had synthesised over a hundred similar com-
pounds without finding any of equal therapeutic
efficiency, it seemed as if the first shot had struck the
bull’s-eye and nothing further remained to be done
in this direction. Nevertheless sulphanilamide has
at least one rival, known under the name of Prosepta-
sine, a report on which by Dr. B. A. Peters and Dr.
R. V. Havard appeared in our last issue. Their
experience with it in the treatment of erysipelas has
been favourable, and this is in accordance with many
previous reports on prontosil itself, to which another
is added by Dr. G. E. Breen and Dr. J. Taylor on
p. 1334. Meanwhile Dr. G. A. H. Buttle and his
colleagues at the Wellcome Laboratories, who have
previously widened the scope of this inquiry enor-
mously by showing that sulphanilamide has a
remarkable effect on a variety of experimental
infections other than those produced by Streptococcus
pyogenes, now enter the field with two freshly
synthesised compounds, diaminosulphone and dinitro-
sulphone, the calculated therapeutic value of which
is even greater than that of sulphanilamide, this
being deduced from a comparison of their bactericidal
activity in vivo and their toxicity. Study of the
details in Dr. Buttle’s paper (p. 1331) will show that
the question of toxicity is by no means simple,
since this appears to vary distinctly in different
animal species. Another important difference is that
the action of diaminosulphone, at least in the blood
of a monkey, is strikingly persistent.
There is no knowing where these investigations
may lead, either in the direction of improving the
present treatment of streptococcal infections, or of
broadening the scope of the treatment to include
other bacterial infections altogether. It is now quite
clear that sulphanilamide is one of a number of
chemically related substances able to destroy certain
bacteria in the blood and tissues, even when present
in very small concentration, provided that the
numbers of bacteria to be accounted for are also
_ reasonably small. This is beyond dispute, but its
significance is by no means generally understood.
A disgruntled writer to a transatlantic contemporary ?
- regards the American equivalent of prontosil as a
manufacturers’ “ stunt,” and observes: ‘‘I do not see
how this remedy gained such quick recognition, but
it goes to show that doctors are just as gullible to
exploitation of cures as the laity.
shall consign all ultrascientific literature to the waste
basket.” This letter is succeeded by one recounting
the unsatisfactory results of administering the drug in
a case of bacterial endocarditis due to Streptococcus
virtdans—a condition long known not to be susceptible
to the treatment. Between the incredulous and the
1 Tréfouél, J. and Mme., Nitti, F., and Bovet, D. (1937)
Ann. Inst. Pasteur, 58, 30. |
3 New Engl. J. Med. April 22nd, 193%, p. 711.
CHEMOTHERAPY OF STREPTOCOCCAL INFECTIONS
In the future I.
[JUNE 5, 1937 1357
over-enthusiastic this treatment will have a stormy
passage before it finds its true level and is properly
understood and applied. At the present time it is
being overdone in this country by indiscriminate
application regardless of the nature of the infection
and by unnecessary prophylactic use in obstetrics.
Except as an experiment, or perhaps as a forlorn
hope, it should be reserved for infections known to be
due to hemolytic streptococci or meningococci: the
dosage should be adequate and the effects carefully
observed. Only so can clinical data, which at present
lag far behind our experimental knowledge, be usefully
amplified.
A DETAILED ANALYSIS OF ROAD ACCIDENTS
THOSE chapters devoted to road accidents in the
book by Dr. H. M. Vernon, reviewed on another page,
are of especial interest in relation to the recent
survey by the Commissioner of Police for the London
area.1 The points analysed include fatalities among
different classes of persons, the accidents in relation
to various classes of vehicles, and the hourly and
weekly incidence of accidents. It is shown that fatal
. -road accidents increased by 164 per cent. between
1920 and 1930, and those in which motor vehicles
were involved by 198 per cent. over the same period.
The number of motor vehicles licensed increased by
160 per cent. Some evidence is adduced to show
that the application of the Road Traffic Act of 1930
is helping to restrain this terrible accident rate, and
the evidence is overpowering that speed is the pre-
dominating cause of these accidents. The conclusion
reached by the Commissioner for the Police that
pedestrians are at fault in about 80 per cent. of cases
of motor accidents, the innocent -motorist being
responsible only for about 7:7 per cent., is difficult to
credit. After all the increase in the number of road
accidents has kept step with the increase “in the
number of motor vehicles on the roads and not with
an increase in the number of pedestrians. Mr. A. P.
Herbert is not the only one who thinks it hardly fair
to blame the poor pedestrian for not crawling about
in the long grass at the side of the road while large
numbers of potentially lethal projectiles are being
shot up and down the fairway. One might with as
much justification blame the soldiers during the last
war for the number of casualties which occurred from
flying pieces of metal. An analysis of the number
of road traffic accidents shows that pedestrians suffer
63 per cent. of the total fatalities which occur in
built-up areas and 29 per cent.—Dr. Vernon says
only 29 per cent.—in unbuilt areas. Motor cyclists,
on the other hand, were killed more frequently in the
unbuilt than the built-up areas (28 per cent. and
12 per cent. respectively of the total fatalities),
whereas passengers, both pillion and non-pillion, and
the drivers of motor-cars and lorries, also appear to
be killed more often in the unbuilt than the built-up
areas. A graph (p. 106) shows that the drivers of
private cars are rarely killed in road accidents.
Railway accidents are responsible for about 350
fatalities a year as compared with 7000 from road
traffic. Dr. Vernon attributes the difference to the
two factors of education and compulsion. Another
explanation may be that railway trains are not
allowed to share roads with pedestrians. The rail-
ways have, however, adopted many forms of
mechanical preventive methods, with the object of
“ preventing the potential victim from incurring an
accident by his own action,” and this appears to be
the keynote of all rational safety methods of
1 See Lancet, May 29th, 1937, p. 1290.
1358 THE LANCET]
protecting the general public from accidents. It is, or
should be, the ideal aimed at in the prevention of
accidents in factories and mines, a matter to which
Dr. Vernon devotes close and reasoned attention.
HOMEWORK
EARLY last year, after a parliamentary debate.on
the harm done by homework to the health of school-
children,! the President of the Board of Education
said that the Government were determined to see
that whatever was wrong was remedied and that the
Board was actually in the middle of “a compre-
hensive inquiry into the whole question.” The
results of this inquiry have now been published ?
and throw light on the merits and demerits of home-
work as it affects three classes of schools—elementary,
secondary, and junior technical.
of the report lies in the fact that the investigators
did not include a medical man, so that the physio-
logical and neurological aspects are not as fully
considered as they might have been. From the
evidence provided it is clear that the problem of
homework is not one problem but many, for it differs -
in different localities and in different schools, The
Opinions of teachers and parents are correspondingly
heterogeneous, but it is perhaps significant that
teachers who are also parents are less convinced than
most of their colleagues that homework, as at present
understood, is a desirable institution. Parents
replying to questionnaires were almost equally
divided on whether homework has any adverse
effect on health, with a small majority in the negative ;
but when the homework had been reduced a great
majority testified to the benefit of the change.
Consciously or unconsciously, the parent is often
swayed by social or financial considerations, and the
greatest incentive to strenuous homework is
undoubtedly the desire of teachers, parents, and the
children themselves for success in examinations ;
indeed in, one area parents pay teachers to coach
pupils out of school hours, while others ask for extra
work to be provided. This practice is at its worst
in junior schools in preparation for special-place and
scholarship examinations, and could be checked if
it were known that examinations in school subjects
have been replaced by the use of intelligence tests for
which coaching is futile. But hope of examination
success is not the only factor influencing parental
wishes and opinions. In one home it may be much
easier to provide for undisturbed evening study than
in another; one parent may wish the child to have
much free time for activities beneficial to himself or
to the household, while another may prefer the child
to have *‘ something to occupy his mind ” or to “ keep
him out of mischief.’ One of the few medical
Opinions quoted in the report is that of an assistant
school medical officer, that ‘‘ during April and May
there is every year a marked rise in the number of
cases of nervous and physical disorders brought to his
notice ’’—a rise which he attributes to anxiety over
the examinations. The investigators’ own conclusion
is that no homework should be set to children under
12 years of age. In the secondary and junior
technical schools the trouble, where it exists, is
thought to be due primarily to defects of organisa-
tion and arrangement, and for these older pupils
some reservations are made; but in general it is
thought that preparation—i.e., homework or its
1 See Lancet, 1936, 1, 454.
Board of Education Educational Pamphlets
London: H.M. Stationery Office. 1937. Pp. 72.
2 Homework.
No. 110.
ls. 3d.
SURGERY OF ADHERENT PERICARDIUM
The only weakness -
[JUNE 5, 1937
alternatives—should not be done on more than five
nights a week and preferably on four only, and that
the hours per night should be limited to one for those
under 14 and to one and a half for those above that age.
The absence of medical experience is again almost
the only fault to find in a book which describes
inquiries at the City School, Lincoln, and contains a
striking chapter on the good effects of substituting
preparation at school for the ordinary work done at
home. The medical aspect becomes especially obvious
when one thinks of the needs of individual children
suffering from myopia or some other disability likely
to be increased by too strenuous a pursuit of higher
education.
SURGERY OF ADHERENT PERICARDIUM
Ir is more than thirty years since Delorme first
proposed the separation of an adherent pericardium
from the heart by open operation, and almost as
long since Rehn and also Sauerbruch first successfully
excised the pericardium; but it was not until the
comprehensive paper of Volhard and Schmieden 4
that operative indications and methods were clearly
defined. Paul White, in his St. Cyres lecture
of 1935, also gave a full clinical account and
described, among others, ten cases of resection
by E. D. Churchill, of which six were com-
pletely cured and one benefited considerably.
Mr. Pilcher’s excellent result described on p. 1323
should stimulate the more frequent diagnosis of a
syndrome which, though admittedly rare, must still
claim victims in this country as well as in America
and on the Continent. A patient showing chronic
congestive heart failure with ascites and swelling of
the legs, and with a heart that is radiologically
smaller than normal or at the most not grossly
enlarged, probably has constrictive pericarditis ; if
there is also a constant increase of the venous pressure
in both upper and lower extremities the diagnosis
may be made with confidence. In the early stages
the process may be arrested and natural compensa-
tion may be effected, but too long a delay before
operation may present the surgeon with an insoluble
problem, for the pericardium may be so adherent
that separation is quite impossible. Johnson ê has
recently written on the use of kymography—which
demonstrates the mode of contraction of the heart—
in the early diagnosis of the syndrome, and this
method of investigation would have the additional
advantage of distinguishing between intrapericardial
obstruction of the cava and that due to some process
beneath the diaphragm. Cranfield and his associates
have reported ? an interesting autopsy in which the
condition was associated with tuberculosis of the
lungs. Although they could find no active tuber-
culous foci in the pericardial scar it may be mentioned
that the onset of a generalised tuberculosis has
sometimes spoilt the good immediate results of
separation.
The risks of operation must not be iainimised: but
some of the important dangers can now be avoided
as a result of Schmieden’s work. When it is remem-
bered that he could show patients leading active
lives six years and four years after pericardectomy,
3? Experiments in Homework and Physical Education. By
A. Sute, M.A., B.Sc., Head Master, the City School, Lincoln ;
and J. W. Canham, M. A., Science Master at the School. London :
John Murray. 1937. Pp. 194. 4s. 6d.
* Volhard, P., and Schmieden, V. (1923) Klin. Wschr. 2, 5.
5 White, P. D. (1935) "Lancet, 2, 539, 597.
* Johnson, S. E. (1935) Surg. Gynec. Obstet. 61, 169.
Cranfield, H. V., Gwyn, N. B., Anglin, G. C., and Norwich,
A.C., Canad. ‘med. Ass. J. 1937, May, p. 449.
THE LANCET]
it is hard to justify the denial of surgical relief to a
patient otherwise condemned to a distressing’ period
of invalidism and to an early death.
OCCUPATIONAL THERAPY
THE value of occupational therapy in fostering
self-confidence and desire for renewed health in
patients with nervous as well as mental diseases was
emphasised by Dr. Wilfred Harris on May 26th
at a sherry party at Chester-terrace organised by the
Ladies’ Guild of the Hospital for Epilepsy and
Paralysis, Maida Vale (in future to be called the
St. Marylebone Hospital for Nervous Diseases).
Lack of occupation, he said, tends to aggravate
such conditions as depression or insomnia, and the
functions of weak muscles and mental process are
still further impaired by disuse. The provision
of occupational methods of treatment enables the
limbs and the mind to be exercised without the
patients realising that they are doing work or being
set a task. These methods have been developed and
systematised since the war in many large mental
hospitals, at some of which more than 90 per cent.
of the patients are constantly employed in various
handicrafts such as weaving, mat or rug making ;
knitting, sewing, and embroidery; bookbinding ;
making paper flowers and bags and Cellophane or
string belts; and wood-carving, basketry, and
raffiia work; apart from kitchen and laundry work and
the outdoor occupation in the gardens and farms. It
is found at these hospitals that noisy, troublesome,
and destructive patients become quiet, social, and
productive, while much less hypnotic and ‘other
sedative drugs are required. Dr. Harris said that
occupational treatment is also being used at certain
general hospitals. An Association of Occupational
Therapists is now being formed in England on the
lines of those organised in America, Canada, and
Scotland; schools are being started, such as the
Dorset House School at Clifton, and one which Miss
Tarrant, who demonstrated the work taught after
Dr. Harris’s address, and Miss Rivett have opened in
London. The educated women trained at such schools
are later employed to supervise the patients at their
work, to teach them and the nurses the various handi-
crafts, and to select occupations suitable for types
of patient requiring sedative or stimulant work, or
exercises for certain muscles. Codperation between
the medical staff and the nurses with the occupational
therapist is, of course, essential, and she should be
supplied with details of the patients’ ailments and
their special needs. Games for small classes with
- the medicine ball, and rhythmical physical exercises
done to music are of value to patients able to walk
about. The St. Marylebone Hospital for Nervous
Diseases is, according to Dr. Harris, one of the first
hospitals in England other than mental hospitals to
adopt this form of treatment, and although initial
expenses have to be met, it is hoped that once started
the treatment will more or less pay its way.
SUPPLY OF BLOOD TO THE WOUNDED
Bioop transfusion services—now a necessity in
hospital—reach their greatest importance in war,
which, as Sokolowski puts it, represents a ‘‘ traumatic
epidemic.” The steps taken by doctors in Spain
to cope with such an epidemic are described in a
contribution by one of them to an international
medical journal published in Prague.) Remarking
somewhat bitterly that for countries that can enter on
1 Internationales Ardliches Bulletin, May-June, 1937, p. 43.
SUPPLY OF BLOOD TO THE WOUNDED
[JUNE 5, 1937 1359
war when they wish to do so the adaptation of services
is comparatively simple, the author points out that the
plan now generally favoured is to ascertain the
blood group of every soldier, and when he is wounded
provide him with blood either from the slightly
wounded or from groups of voluntary donors who
can be brought up to the front line when required.
The use of cadaver blood would be very awkward
on active service because it has to be collected within
six hours of death and dealt with in a way that may
present difficulties at the front. In Barcelona, before
the civil war, there were a few hospitals with excellent
transfusion facilities, while others had none of their
own. Faced with a war which was unforeseen, without
any pre-existing army, and with no regular organisa-
tion, the doctors found it impossible to test the
blood groups of all the combatants, though much is
done by the goodwill and keenness of surgeons at
advanced posts. Instead of looking for donors at
or near the front, the medical authorities now send
up blood from Barcelona, obtained from carefully
selected volunteers (mostly young women) whose
help is invited by radio. A special correspondent ©
of the Manchester Guardian on May 7th described how
the blood is collected in sealed glass ampoules, con-
_ taining up to 300 c.cm. under a pressure of two
atmospheres. The tip of the ampoule enters a rubber
tube, and at the other end of this tube (which contains
a filter, a tap, and a glass section so that the flow of
blood can be observed) is an injection needle sealed
in glass. The blood in the ampoules is gradually
cooled to 0° C., and they are kept in refrigerators at
1°-2°C. till required. The temperature is then
slowly raised to blood heat, the tip of the ampoule
is broken inside the tube, and the needle is unsealed
and inserted into a vein in the usual way. In Aragon
transfusion is seldom done in the front-line posts,
but usually at the casualty clearing stations, and
apparently it is also done, if need be, on the latest
motor-car and railway ambulances. The daily
supply of blood in ampoules from Barcelona, which
has been organised by Dr. F. Duran, is stated as 42
litres; it goes to the front in cars fitted with refri-
gerators and keeps for a fortnight. On the central
and southern fronts, according to the Manchester
Guardian, the service is different in that the blood
is not supplied under pressure but has to be pumped
into a vein in the ordinary way. But here, as in
Catalonia and Aragon, blood is if possible sent up
to the military hospitals from donors at the base.
Elsewhere it has been necessary to look for suitable
donors in towns and villages close to the lines.
BASSINI AND HIS OPERATION
FIFTY years ago Edoardo Bassini revolutionised
the treatment of hernia by inventing an operation
which reconstructed the anatomical relations of the
inguinal canal.1 The principles of his method
were at once accepted, and so much a matter of
commonplace have they become that it is hard for
surgeons to believe that less than fifty years ago
operation for hernia was all but a complete failure.
This fact is indeed a little astonishing, for although `
reconstruction of the posterior wall of the inguinal
canal was not done before Bassini did it, ligature
and excision of the sac was a recognised procedure ;
and in young adults with good abdominal muscles
complete removal of the sac should have sufficed
to give a proportion of permanent cures. The
1 A paper on the rôle of Bassini in the development of inguinal
surgery, by Drs. L. M. Zimmerman and . Heller, appears
in Surgery, Gynecology and Obstetrics for May, 1937.
1360 THE LANCET]
VOLUNTARY REMOVAL FROM THE REGISTER
[JUNE 5, 1937
explanation seems to be that operation for hernia
was held in disrepute and that the surgical text-
books were unenthusiastic. There was a definite
mortality and an appalling percentage of failures.
Bassini was the first surgeon to report a long series
of cases with few recurrences. His record of 251
operations for non-strangulated hernia was published
in the Archiv fiir klinische Chirurgie of 1890, and it
was this paper that gained international acceptance
for his operation. In this series he had had no operative
deaths and his follow-up showed only 7 recurrences.
The first report of the operation was made before the
Italian Surgical Society in Padua in 1887. Bassini’s
approach to the problem was essentially anatomical.
‘There were three objectives in his operation: high
ligature of the sac; reconstruction of the posterior
wall of the canal; and restoration of the obliquity
of the canal, on which depended the valve-like action
of the anterior and posterior walls in closing the
passage. His original operation differs only in minor
details from that commonly practised to-day. He
dissected the posterior wall layer by layer, and sutured
fascia transversalis, transversus abdominis, and
internal oblique to the upturned edge of Poupart’s
ligament starting his row of sutures at the inner
side of the wound and working upwards and outwards
so as to push the internal ring, as it were, outwards
and away from the external ring. The external
oblique was then sutured in front of the cord. In
the other operation most commonly described in
text-books (Halsted’s operation) all layers are sutured
behind the cord, and the original obliquity of the
canal is ignored.
As mentioned in our last issue, the University
of Padua is celebrating the fiftieth anniversary of
Bassini’s operation by publishing two volumes of
“ Writings on the Surgery of Hernia”? which will
include Bassini’s original papers. Bassini was
appointed to the chair of surgical pathology at
Padua in 1882, and was made professor of clinical
surgery in 1888, so that the University of Padua can
claim much of the glory. But perhaps other countries
have some say in Bassini’s success, for he studied
abroad in Vienna under Billroth, in Berlin under
Langenbeck, and in London under Lister and Spencer
Wells, being one of the first surgeons to introduce
antiseptic surgery to Italy. British surgeons have
been invited to the special meeting of the Italian
Surgical Society on next Sunday in Padua at which
problems of hernia surgery will be discussed.
VOLUNTARY REMOVAL FROM THE REGISTER
UNDER standing orders adopted in 1887: and
amended in 1909 the General Medical Council has
allowed registered medical practitioners to have their
names removed from the Register at their own
request. Last week-end it was announced that the
Council had been advised that it had no power to
make standing orders for this purpose; the orders
have therefore been rescinded. To allow a practi-
tioner to apply himself for removal of his name is
a concession which is possibly capable of abuse,
‘inasmuch as he may take this step to avert the
Council’s disciplinary jurisdiction. Though the case
is not quite parallel, there was recent litigation in the
Court of Appeal over a police official who sent in his
resignation which was accepted as from a particular
date. After the resignation had taken effect, the
town council under which he had served purported
to dismiss him on disciplinary grounds. The court
held that there was no power to take such action
against a man who had already resigned. To return
to proceedings which are more fully comparable,
it is worth noting that the Dental Board’s regulations
provide for non-disciplinary removal from the
Dentists Register. The Dentists Act of 1921
authorised the Board to make regulations ‘* with
respect to proceedings before the Board in connection
with the removal from, or restoration to, the Register
of any name.” The regulations require that the
dentist who applies to have his own name removed
shall make a statutory declaration that he is not
aware of any reason for proceedings which might
result in his name being erased without his consent.
Although the Dentists Act does not seem specifically
to authorise such applications by dentists themselves,
the Solicitors Act has a definite section permitting
solicitors to apply. A similar clause is to be found
in the Solicitors (Scotland) Act of 1933. In England,
under Section 5 of the Solicitors Act of 1932, an
application by a solicitor to procure his name to be
removed from the roll is made to, and heard by, the
Disciplinary Committee of the Law Society. Rules
of procedure, sanctioned by the Act, require him to
set out the reasons why he wants his name removed
and to support them in an affidavit in which he has to
declare that he is aware of no cause for any applica-
tion that he be struck off the roll or suspended
from practice. Unless the committee otherwise
directs, letters from two practising solicitors to whom
the applicant is personally known must accompany
the request. The committee has power too to require
him to advertise the fact of his application and the
date of the hearing: provision is made for objections `
to be raised. These precautions seem sufficient to
prevent abuse. It is reasonable to allow a professional
man to ask that his name be taken off the professional
register for non-disciplinary reasons. The fact that
in the case of the solicitors Parliament expressly
sanctioned such a course of action presumably
creates the inference that no such rules may be made
where, as in the case of the Medical Acts, Parliament
was silent on the point. In spite of the curious
suspicion of some of our legislators who believe that
every proposal affecting the medical profession is an
attempt to bolster up monopoly, there seems no reason
why Parliament should not now expressly provide
for the registered medical practitioner the facility
already conceded to the solicitor.
In the rearrangement of the Cabinet following Mr.
Neville Chamberlain’s appointment as Prime Minister
Sir Kingsley Wood retains the Ministry of Health,
but Mr. R. H. Bernays succeeds Mr. R. S. Hudson as
its parliamentary secretary.
IN a presidential address to the seventh English-
speaking Conference on Maternity and Child Welfare
in London on Tuesday Sir Kingsley Wood announced
that it has just been ascertained that last year the
number of maternal deaths per 1000 living births in
England and Wales was 3-81, compared with 4-11
in 1935. This is the lowest rate since 1922.
THE death is announced of Sir Ernest Morris at the
age of 71. On his retirement in 1930 he had been house
governor at the London Hospital for 27 years.
Originally transferred from St. Thomas’s Hospital
as chief pharmacist, he was early associated with the
late Lord Knutsford in installing new operating
theatres and in training the theatre staff in new
methods of asepsis. He was later appointed secretary
and then house governor of the hospital and wrote
its history. In August, 1914, he was lent to the War
Office to assist in equipping hospitals at the front.
He was made C.B.E. in 1920 and knighted in 1932.
THE LANCET]
CENTENARY OF THE LIVERPOOL MEDICAL INSTITUTION
[JUNE 5, 1937 1361
SURGERY 100 YEARS AGO*
By R. E. KELLY, C.B., M.D., F.R.C.S.
PROFESSOR OF SURGERY IN THE UNIVERSITY OF LIVERPOOL
AND SENIOR SURGEON, LIVERPOOL ROYAL INFIRMARY
CENTENARIES are for remembrance, and in the
centenary year of the Medical Institution I thought
it would interest the members if I attempted a picture
of surgery a hundred years ago.
Before, however, I come to the purely surgical
aspect of 1837, it will be well to recall the unrecorded
background against which the surgeon of the time
carried on his work, and to remind you of the subjects
of his thought, his conversation, and his interests.
Starting his career as an apprentice he would have
attended one of the two anatomical schools in Liver-
pool, walked the hospital like Bob Sawyer, and
passed his qualifying examination as a Licentiate
of Apothecaries. Possibly he would have journeyed
to Edinburgh or London, taken the membership
of the Royal College of Surgeons, and then, if his
aim had been to become a surgeon, visited Paris
to see the work in the Hôtel-Dieu. He might easily
have had some war experience in the Navy, and he
would have returned to Liverpool to await an appoint-
ment at the Dispensary or the Infirmary. He would
have had a large and mixed general practice which
would have brought him into intimate contact with
all types of patients.
Standing on St. James’s Mount with a rich ship-
owner, he would have gazed through a forest of
masts at the busy scene of the Sloyne, crowded with
shipping, and watched the majestic sweep of the
latest arrival at its anchorage. The talk would be
of freights, cotton, the abolition of slavery, the
Reform Act, and the new railway. Then descending
the hill to the narrow, crooked, and noisome slums
to attend a fever case in a cellar dwelling, he would
hear of reduced wages, the difficulty of rearing
children, and the high cost of clothes, fuel, and light.
Illuminating gas had only recently emerged from
its primeval chaos to a municipal usefulness, and
was used solely for street lighting; street lighting
*From a presidential address to the Liverpool Medical
Institution on May 31st, on the occasion of its centenary. The
Tu text ers in the Liverpool Medico-Chirurgical Journal
» > $
was, indeed, necessary, as, even in towns, one-fifth
of the streets were never cleaned, drained, or even
paved. Plumbing, though Harrington had invented
it centuries before, was not extensive. Even if our
surgeon had lived in one of the Georgian mansions
fringing Everton Hill—the elegant district—he
would have inhabited a house devoid of a bathroom.
Envelopes and cigarettes were among the uninvented
necessities of life, and in the list of the newer luxuries
which had been the ruin of the country, Peacock
had to fall back on blameless tea, late dinners, and
the French Revolution.
x x x
A good idea of surgery is given by the masterly -
lectures of the famous Astley Cooper published in the
twenties. Inflammation, hæmorrhage, and ulcera-
tion occupy a disproportionate amount of space.
Bleeding was still popular, especially in head injuries.
There is a record of one patient who recovered after
130 oz. of blood were removed in the space of 11 days.
Aneurysms must have been exceedingly common.
Astley Cooper probably tied most arteries in the
body, and on one occasion actually tied the abdominal
aorta, though without success. He had seen seven
separate aneurysms in one man. Although he dealt
with hundreds of aneurysms in men, he records only
8 cases in women. He was dware of the dangers of
secondary hemorrhage when the usual long ligatures
came away, and on one occasion he actually used a
catgut ligature and cut the ends short. It was for a
popliteal aneurysm and the artery was the femoral.
No suppuration followed. He tried the same method
several times subsequently but was never again
able to prevent suppuration. What a tremendous
observation this was !—and how near to .a great
discovery ! The world had to wait for 40 years before
the genius of Lister unravelled these conflicting
results.
* * *
Astley Cooper’s chapter on hernia shows that the
only important operation for its relief was the opera-
tion for strangulation. Before any operation was
advised the unfortunate patient was given a tobacco
enema to relax the parts. He was then strung up
inverted on the back of a porter, back to back,
with the calves resting on the porter’s shoulders.
Cold water was then freely soused over him. If,
1362 THE LANCET]
CENTENARY. OF THE LIVERPOOL MEDICAL INSTITUTION
[JUNE 5, 1937
after all this, taxis failed, operation was done and
the strangulation reduced. Surgeons had a holy dread
of the peritoneum,.and the abdominal cavity was
never entered without misgivings. Should the bowel
have perforated, then the wound was merely opened
like an abscess. The few who recovered from this
operation were left with a fecal fistula which was
later treated with a Dupuytren’s enterotome, that
ingenious instrument invented a century before
Paul’s method of enterectomy.
There is an amusing description in this same
chapter on hernia of a butcher who had to be medically
examined for the militia. He produced in himself
a very large artificial scrotal hernia by nicking his
skin, applying a blow-pipe to the hole, and blowing
himself up until the surgical emphysema was large
enough to mislead the Army authorities. The method
was then in use for flaying animals, and is still used
by whalers on the harpooned whale to keep it
afloat.
Hydroceles were tapped and sometimes injected.
Astley Cooper’s favourite injection was port wine.
This reminds me of some interesting Lancastrian
reminiscences published in 1837. There is an account
of a surgeon who, whilst awaiting the effect of a
tobacco ‘clyster in a case of strangulated hernia,
consumed the best part of a bottle of port. This
gave him such courage that, with his first cut, he
sliced the integuments down to the gut and perforated
the bowel. ‘‘ Not a word or exclamation was uttered,
but everyone expressed by a vermicular movement
that the affair was desperate. The surgeon laid down
his knife—the gazers vanished, the wound was
dressed, the woman put to bed, and, in due time,
encased in her coffin.”’
The great operation for the surgeon appears to
have been the cutting for bladder-stone. The opera-
tion of lateral lithotomy, introduced into England by
Cheselden, probably from Frére Jacques’ work on
the Continent, was really an operation of fine skill.
It had to be performed on a squirming man trussed
up and supported by two or more strong assistants.
The knife had to engage the sound at a.proper depth
in a bleeding wound. The direction of the cut had
to be so exact that neither the bulb, the rectum, nor
the pudic artery was cut. The enlargement of the
prostate must have. been a common additional
complication, and perforation of the bladder by the
sharp end of the gorget often resulted in the stone -
finding its way into the abdominal cavity: and the
whole operation had to be done in seconds or minutes,
Bland-Sutton once said that the Spanish bull-fighter
had to aim at a target on the side of the bull’s neck
no larger than 4 cm. in diameter. The extremely
rapid operation of lithotomy on a sentient patient
must have entailed the same anxieties, and
demanded the same skill and accuracy as the
coup-de-grace of the matador.
* * *
The two great Liverpool surgeons of the eighteenth
century were Henry Park and Edward Alanson.
Park was the first surgeon to suggest excision of the
tubercular joint instead of amputation, and Alanson
the first to improve the method of amputation.
Alanson was well ahead of his time. As early as
1779 when only 32 he published his great work.
It is said that he always washed his hands and instru-
ments before an amputation. Many of his cases
healed by first intention, and he gave details of 40
consecutive amputations without a death, a most
brilliant record for that date. He suggested country
hospitals, iron bedsteads, clean bed linen, and open
windows. Some years ago Mr. R. W. Murray gave
us a delightful account of his life, and in the recent
history of Bickerton you may read how modern were
Alanson’s ideals,
Park, Alanson, and another surgeon called Lyon
conceived the idea of a reading club about 1770.
They proposed to buy new publications conjointly,
and divide the books at the end of each year. Before
the plan was instituted the physicians joined them ;
the books were deposited in a room in the Infirmary,
which became the nucleus of the first medical library.
3 x *
In 1833 John Rutter, a quaker, the foremost
physician of Liverpool at the time, thought that the
Medical Society and Library were in need of a better
house. He prevailed on the mayor and corporation
to give to the doctors in Liverpool a free lease on a
piece of land at the corner of Mount Pleasant and
Hope-street. This land had been a bowling green
and was valued at £557. He raised funds for the
building, which was to contain rooms for both the
library and a lecture theatre for debate. He persuaded
the corporation not only to give a lease of the land
at a peppercorn rent, but to give a grant of £1000
towards the cost of the building. Rampling was the
architect. The building cost £4000. The doctors
themselves subscribed over £1000, and the lay
public £242,
Precisely on this day, May 31st, one hundred years
ago, our building was opened. There was then a
debt of £900 on it, but this was wiped off by a bazaar
organised by Mrs. Dawson, the wife of one of the
Infirmary surgeons.
Rutter lived only a year after accomplishing this
great work. He was our first president. His ambition
was that this should be a place which would promote
the union and the interests of doctors, the health and
welfare of the community, a place for study and
mutual instruction, and a habitation for the
library.
All these aims have been accomplished, and should
Rutter, looking down from the Elysian fields, be aware
of our meeting to-day, he will, I think, be as proud
of this, his only child, as we are of honouring his
illustrious memory.
Liverpool Medical Institution
1837—1937
“ What Does, what Knows, what Is;
one man.”
three souls,
Wuat better terms of relereacs could a medical
society have than the gloss of Theotypas, in Robert
Browning’s “ A Death in the Desert,” which develops
and expands this doctrine? For medicine is not
merely the practical work of tending the sick, nor
even the intellectual excitement of studying disease ;
it is warmed and animated by humanity, in a common
human experience and endeavour. In this uneasy,
modern time of mass movements and the despising
of the day of small things, when institutions and
abstract ideologies are proclaimed in high places as
more important than persons, it is wholesome to
recall that medicine stands where it does because
of the lives and achievement, through the ages, of
a great host of individuals, some brilliant with
genius, but most of them ordinary folk—‘‘ so little
starres as have no name, no knowledge taken of
them.”
It is just a hundred years ago that the founders of
the Liverpool Medical Institution met together for
THE LANCET]
the first time in the present
dignified building which has
given a local habitation
and a name to the more
corporate activities of those
who practise the art of
medicine in and about
Liverpool. They foresaw it
as the common centre of
every useful and honourable
professional undertaking—
from the securing to medical
men of a fair and just
remuneration for their
services, to the purposes of
study and mutual instruc-
tion and an authoritative
helpfulness in all matters
affecting the health of the
town. As a necessary founda-
tion for these activities,
they hoped “that it would
be a means of uniting the
different members of the
profession in a firm and
compact body, disposed at
all times to co-operate strenu-
ously and cordially in the
prosecution of every measure which may conduce to
the interests of all.”
The idea of establishing such a common centre
grew naturally (and surely inevitably) from a small
medical reading club, which was the origin of the
present medical library housed in the Institution.
It grew inevitably, for Francis Bacon’s words are
especially true of medicine: ‘‘ Naturall Abilities are
like Naturall Plants, that need Proyning by Study ;
and Studies themselves doe give forth Directions too
much at large, except they be bounded in by
Experience.” For the physician, scientific facts
are but the food which must be metabolised if the
mind is to bring forth fruit. A man must always
-be busy with his thoughts, he must exercise his
intellectual powers as earnestly as an athlete trains
his muscles, if judgment is to mellow. It is given
to very few to live alone, and yet keep a sense of
proportion ; most of us need the criticism and help
of our fellows, and this we can get in calm, dis-
interested, and sincere discussion. In a live medical
society, men bring their knowledge and experience
into the common pool, not to display but to convey
information. It is, indeed, the tradition of our
ancient and honourable brotherhood that a man
shall gladly and honestly submit for the judgment and
approval of his colleagues anything which may help
to increase the body of medical knowledge. And
when a man reveals to his fellows what he knows, he
cannot but reveal also, to some extent, what he
is. More important even than discussion and con-
ference is the fellowship of a medical society, with
its stimulating contacts of personality with per-
sonality. Here especially may be nurtured and
realised the conception of medicine as the profes-
sion of a kindly, courteous, sincere, and cultivated
gentleman.
This centenary is, therefore, the anniversary not
only of the foundation of a building but also of
a living medical’ fellowship. Those who will meet
within its walls to commemorate the great occasion
will surely feel that they are compassed about with
a great cloud of witnesses. As they cast their eyes
back through the years, they will rejoice at all
excellence of achievement; and they will look
CENTENARY OF THE LIVERPOOL MEDICAL INSTITUTION
[JUNE 5, 1937 1363
The Orthopeedic Memorial Library. The inscription reads: ‘‘To Hugh Owen Thomas and
Robert Jones, the founders of orthopeedic surgery.”
forward with solemn resolve to maintain the fine
traditions of their forebears.
The Celebrations
The programme began on Sunday afternoon when
a service was held at the Cathedral attended by
members of the Institution in academic dress and
when members of the Guild of St. Luke, SS. Cosmas
and Damian met at the Catholic Cathedral site for
benediction. On Monday afternoon at the Institution
honorary membership was conferred on the Presi-
dents of the Royal College of Surgeons of England,
of the General Medical Council, of the British Medical
Association, of the British College of Obstetricians
and Gynecologists, and of the Manchester Medical
Society, as well as on Sir James Barr, Mr. C. Thurstan
Holland, and Mr. Frank T. Paul. The new honorary
members were introduced by Prof. John Hay. After
that Dr. Hugh A. Clarke was congratulated on the
attainment of his jubilee of membership. Prof.
R. E. Kelly then gave his presidential address. In
the evening the centenary dinner was held at the
Adelphi Hotel, On Tuesday afternoon the new
library of orthopedic surgery, commemorating Hugh
Owen Thomas and Robert Jones, was formally
opened and Mr. W. Rowley Bristow, president of the
British Orthopedic Association, gave the Hugh Owen
Thomas memorial lecture. The programme ended
with an At Home in the town hall given by the
Lord Mayor.
MANSFIELD HosPrraL. — This institution is en-
deavouring to raise £10,000 for a new women’s ward.
At present extra beds for female cases have been provided
by alterations to the balconies of two wards and accom-
modation is strained to the utmost.
TRANSFERENCE OF A CROYDON HOSPITAL. — St.
Mary’s ‘Hospital, Croydon, while remaining in trust of
the ‚Croydon mothers’ and infants’ welfare centre, had
had its administrative work transferred to Croydon
corporation and. the expenses of the institution will be
paid from the general rate fund. In order that the
hospital may qualify as a training school under the Central
Midwives Board a resident medical officer will be
appointed.
1364 THE LANCET]
PUBLIC HEALTH AND HYGIENE
A JOINT ANNUAL CONGRESS
As recorded in our last issue, the Royal Institute
of Public Health and the Institute of Hygiene met in
joint congress at Margate on May 25th under the ~
presidency of Lord HORDER.
Captain G. S. ELLISTON, M.P., president of the
section on State medicine and industrial hygiene,
pointed out that this year, a hundred years after the
passing of the Act imposing registration of births and
deaths, the Government was to sponsor a campaign to
interest the people in the maintenance of health by
increased use of the services provided by local
authorities and voluntary organisations. He approved
of this measure, for in most areas health services were
more or less complete and further progress must
come from the people themselves ; for example, only
50 per cent. of pregnant women went to antenatal
clinics, many cases of tuberculosis were diagnosed too
late, and attendance for later treatment of venereal
disease was very lax. Reminding the audience that
most services were promoted by the force of public
opinion, he passed on to the consideration of some
conditions now calling for attention. The first was
chronic rheumatism, a condition about which no
steps commensurate with its importance had yet
been taken. Others were noise, cremation, smoke
abatement, mental welfare, and child guidance.
HOUSING : THE BIRTH-RATE
Dr. J. GREENWOOD WILSON (M.O.H. for Cardiff),
in a paper on the place of the health department in
housing administration, maintained that the health
committee should be made the paramount com-
mittee for housing administration. The medical
officer of health should be encouraged to take more
interest in housing both before and after he entered
the public health service, and greater use should be
made of the health department in branches of
administration such as allocation of tenancies, dis-
infestation, and estate social work.
Speaking on the problem of the smaller authorities
in the rehousing of overcrowded families, Dr. N. E.
CHADWICK (M.0.H. for Hove) referred to some of the
difficulties arising out of the overcrowding provisions
of the 1935 Housing Act. In his district, at the time
of the survey of overcrowding in January, 1936,
96 houses were found to be statutorily overcrowded ;
by June this number had been reduced to 69, and
more recently it had fallen to 38. On the other hand,
it was fully realised that fresh crowding had occurred
at other houses. There were three ways in which
large families could be housed—by converting two
houses into one, by building new houses of sufficient
size, and by acquiring existing old large ones.
Houses built on sites far distant from the original
home of the tenants could hardly be construed as
“suitable alternative accommodation.”
Dr. CaryL Tuomas (M.O.H. for Harrow) spoke on
certain aspects of the declining birth-rate. He
reviewed briefly the general situation, pointed out
the effects both of a fall in population and of a changed
age-composition of the population, and summarised
measures taken, more particularly in some of the
continental countries, to arrest the decline.
FOOD-POISONING : MILK
Dr. E. R. JONES (pathologist to the Kent county
council), speaking on the epidemiology and bacterio-
logy of food-poisoning, restricted his definition to
CONGRESS OF PUBLIC HEALTH AND HYGIENE
[JUNE 5, 1937
acute gastro-enteritis caused by the ingestion of food
or drink that contains either living bacteria or toxic
substances produced by them. Such a definition
excluded botulism. Since Gaertner isolated Bact.
enteritidis in 1888, 26 other members of the salmonella
group had been discovered. In certain cases of food-
poisoning, however, no organisms could be found,
and the illness appeared to be due to the formation
of a heat-stable toxin in the food. Many of these
organisms were ordinarily non-pathogenic, but under
certain conditions of growth appeared capable of
elaborating highly toxic substances. Among those
incriminated were Staphylococcus aureus, S. albus
(the commonest), members of the salmonella group,
B. coli, Proteus vulgaris, P. morgagni, Streptococcus
viridans, and a micrococcus associated with milk.
It was not known whether specific toxins were
elaborated by the bacteria or whether the toxin was
formed - from breakdown products of the dead
organisms ; but presumably the bacteria multiplied
and elaborated their toxin in the food before its
consumption; the subsequent cooking destroyed
the organisms but did not materially affect the toxin.
Seasonal variation in incidence was less conspicuous
in this type of food-poisoning than in that caused by
the more common salmonella type. The morbidity-
rate was high (75 to 100 per cent.), but the fatality-
rate very low. The type of illness was similar. but
the incubation period shorter, being only half to
four hours; symptoms were severe but the course
was rapid, and the patient recovered in two or three
days. The foods most commonly affected were
canned meat, potted meat or fish, and milk products,
more especially cakes and éclairs filled with cream or
custard. Owing to the ubiquity of the organism, our
inability to distinguish toxic from non-toxic strains
and our comparative ignorance of conditions suitable
for the production of toxins, outbreaks of poisoning
of this kind were not only difficult to investigate but
also harder to control.
The subject of milk was discussed from the point
of view of the producer by Dr. L. MEREDITH DAVIES
(M.O.H. for Devon) and as it affects the consumer
by Dr. H. C. Maurice Wiriiiams (M.O.H. for
Southampton). Dr. Davies dwelt particularly on the
financial troubles of the farmer producing different
types of milk. Here he thought lay the difficulty
in obtaining a satisfactory milk-supply, and until
the margin of profit to the producer was consider-
ably increased the bare essentials for the production
of safe milk could not be realised.
CHILDREN
The MARCHIONESS OF READING, presiding over the
section of women and children and public health,
spoke on the ‘pre-school child.” She thought
that all blocks of flats should be fitted with nurseries
on the top floor or on the roof opening to a roof
garden, or that children’s homes should be attached
to each block at which mothers could leave their
children for short periods. She submitted that the
combination of a day nursery and nursery school
is the ideal provision, and referred to the many
advantages of the large unit from the standpoint
of cost and efficiency. Now that these were run on
open-air lines there was little risk of infections spread-
ing among the children. \
Colonel R. A. BLACKHAM read a paper on infant
feeding in warm climates. He strongly advocated
the use of sweetened condensed milk, as being stable,
easily transported and not easily tampered with, and
quoted many French authorities in support of this
THE LANCET]
view. He also defended the use of cane-sugar
in infant feeding.
Dr. WILFRID SHELDON (physician in charge of the
children’s department, King’s College Hospital),
speaking on diet and dietetic indiscretions after
infancy, dwelt more particularly on the period between
the child’s first and second birthday—the time, he
said, when errors both of omission and commission
are most likely. By the child’s first birthday it
should have abandoned the bottle and have its feeds
at the times of the adult. He deprecated the giving
of cream to any healthy child ; the ingestion of more
than one pint of milk daily was a mistake because it
resulted in the refusal of other food. Dr. Sheldon
preferred cod-liver oil to any of the vitamin A-
concentrates because it carries no risk of over-dosage,
because it has a food value of its own, and because
it contains the complementary vitamin D.
In a discussion on the staffing of antenatal and
infant welfare centres, Dr. C. J. HAMILTON
{physician in charge of the children’s department,
Charing Cross Hospital) envisaged the need of certain
auxiliary services as essential to the ideal functioning
of an infant welfare centre including a breast-feeding
clinic, a play centre, and an observation ward.
Dr. VYNNE BORLAND (M.O.H. for Bethnal Green)
said that the aim of the services was to make maternity
as safe as possible, and afterwards maintain good
health in mother and child.
PREGNANCY TOXZMIA
Miss MARGARET BASDEN (gynecological surgeon
to the South London Hospital for Women), speaking
on albuminuria and eclampsia, quoted Prof. F. J.
Browne’s finding that a blood-pressure reading of
over 130/70 is usually the earliest sign of toxsmia,
often preceding albuminuria by several weeks.
She would treat all cases with readings of over 130
as suspect. While it was true, generally speaking,
that the more the albumin the worse the case, the
converse did not hold, for cases with only a trace
might prove very severe. The risk in albuminuria
was not only a risk of eclampsia but also a risk. of
permanent damage to the kidneys. Such damage
depended not so much on the severity of the illness
as on its duration, and Miss Basden recommended that
toxemia should never be allowed to continue for
more than two or at most three weeks. As symptoms
rarely appeared before the thirty-second week of
pregnancy the only remaining treatment of an
obstinate case—namely, termination of pregnancy—
did not necessarily mean the loss of the child. In
any event the effect of the toxzemia is more neers
to the infant than the prematurity.
EARLY DIAGNOSIS OF CANCER
Dr. ELIZABETH HURDON (director of the Marie
Curie Hospital, London), in a paper on the diagnosis
of cancer in relation to its prevention, said that
in no other department of medical research had
so much been discovered within recent years. It
was probable that cancer did not arise in perfectly
healthy tissue, but in tissues or organs which had
been the seat of pathological change. The list of
chemical, bacteriological, mechanical, or physical
factors which operated as predisposing causes was
being extended and the public needed to be educated
to the importance of these factors, so that where
necessary they would seek medical advice as to their
removal, Dr. Hurdon was hopeful of benefits accruing
from statistical investigation, pointing out that
whereas the incidence of cancer of the non-exposed
CONGRESS OF PUBLIC HEALTH AND HYGIENE
[JUNE 5, 1937 1365
site was the same in all social classes, that of disease
in the exposed sites—the skin, larynx, and upper
alimentary tract—showed considerable increase -in
incidence on descending the social scale. This
suggested that other environmental conditions, such
as defective hygiene, might be responsible for the
greater incidence among the poorer classes.
NUTRITION AND PHYSICAL TRAINING
In the absence of the president of the section of
nutrition and physical training, Sir STANLEY Woop-
WARK (physician to Westminster Hospital), his
address was read. He pointed out that just at the
time that there was more leisure, there were more
difficulties in the way of obtaining enough healthy
physical exercise each day. While commending the
national movement towards more and better physical
training, he urged that the aim should be a supple
body with mind and muscle closely coérdinated—
a harmony of bodily function leading to perfect
rhythm and balance. This meant that the body
must be sufficiently nourished, and he thought that
attention should be paid to optimum rather than
minimum diets. Sound nourishment however did
not merely depend on a sufficient supply of food ;
there were many dietetic crimes, such as the bolting
of meals, inefficient cooking, the presentation of the
same dishes with monotonous regularity, and the
belief that the most expensive food was necessarily
the most nutritious weight for weight. Sir Stanley
looked forward to the time when every housewife,
as a result of tuition at school, will be able to buy food
economically, cook it conservatively and well, and
serve it in well-balanced physiologically adequate
meals.
Prof. S. J. COWELL (professor of dietetics in the
University of London) said that though there was not
much gross malnutrition, in the sense of semi-
starvation, faulty diets were probably responsible for
much more ill health and disease than was imagined
only a few years ago. The problem of malnutrition
in this country was much more a problem of deficiency
in essential food constituents than of deficiency in
total supply of food. He touched on the importance
of the recently discovered tests for minor degrees of
vitamin deficiency—vitamin A by impaired vision in
dim light ; vitamin B by its concentration in the blood ;
and vitamin C by its estimation in urine—and said
that these should result in the detection of sub-
optimal nutrition, not apparent on clinical examination.
He summarised the relation of nutrition to infection
by suggesting that the course of certain chronic
infections such as tuberculosis was related rather
closely to the state of nutrition, and that many
acute infections, especially in childhood, ran a more
favourable course in those whose previous diet had
been good. His conclusions on the relation of diet
and dental decay were that diets rich in protective
factors, given during the whole period of development
of the teeth and continued throughoutlife, would not
only encourage the formation of sound teeth but
would do much to prevent dental decay. There was
increasing evidence that an inadequate supply of
protective foodstuffs initiated or predisposed to some
of the disturbances of pregnancy, such as osteomalacia,
muscular cramps, and possibly some of the toxzemias.
As a practical measure it was unnecessary to instruct
the public in the exact amount of the various con-
stituents of food required, but they should get used
to the term “ protective foods”’ as being those that
are rich in mineral elements and vitamins likely
to be relatively deficient in common diets. They
must learn that a good health-giving diet should
1366
contain a large proportion of its total energy value in
the form of protective foods, the younger the person
the greater being the proportion.
Miss E. M. Wippowson (research biochemist at
King’s College Hospital) referred to the importance
of the minerals in maintaining osmotic pressure
and acid-base balance, and in regulating all chemical
processes.: Of the fifteen different mineral elements
in the body, each of which had its own part to play,
deficiency was most commonly found in calcium,
iron, phosphorus, and iodine, the two most often
lacking in diets in this country being iron and calcium.
To supplement calcium deficiency she advocated the
greater use of cheese, milk, eggs, green leaf vegetables,
and nuts; of these, milk was the most important
single source. Iron was found mostly in meat
(especially liver), eggs, brown bread, and green
vegetables. There was often a deficiency of iron during
pregnancy. It was important that it should be given
in a form in which it would be available to the body.
THE LANCET]
_ TUBERCULOSIS
Dr. R. A. Youne (consulting physician to the
Middlesex Hospital) gave a presidential address to
the section of tuberculosis. He spoke particularly
of the need for early diagnosis and for teaching the
laity to think bacteriologically.
case was dangerous to the community and he pleaded
for the more thorough examination of all patients
suffering from chronic bronchitis, from persistent
cough and phlegm, from hemoptysis however slight,
from pleurisy or from unexplained loss of weight or
condition, or evéning tiredness.. Clinical examination
should be supplemented by bacteriological tests and
radiography.
. Dr. F. G. CHANDLER (pliysisian to St. Bartholo-
mew’s Hospital) submitted that prolonged isolation
of tuberculous patients was often unnecessary ;
they could return to their homes if they and their
relatives understood how the disease was spread,
the necessity for care of the cough and the phlegm,
and of handkerchiefs, pillow-slips, and sheets, and the
importance of ventilation and fresh air.
Dr. J. G. JOHNSTONE, speaking on tuberculosis
of joints, said that the guiding principles in local
treatment were to arrest the active disease, by
stopping movement of the affected joint, and reduce
the functional disability by immobilisation in the
PANEL AND CONTRACT PRACTICE
The undiagnosed
[JUNE 5, 1937
correct position, and by preventing deformity in any
other joint.
Dr. E. L. SANDILAND (medical superintendent of the
East Lancashire Tuberculosis Colony) dealt with
the after-care and re-employment of the tuberculous
patient. The chronic tuberculous population could be
divided into the 15 per cent. of chronic invalids who
would always remain a medical problem for others,
the 50 per cent. who could return to their former
employment or some modified form of it, and the
35 per cent. who could not return to their former
employment either because it was unsuitable or
because they could not compete with healthy men.
The last group was the one for which after-care
schemes were intended. The three principal forms of
provision made were workshops set up by after-care
committees or local authorities, the employment
of ex-patients on the staffs of sanatoriums or similar
institutions, and the establishment of village settle-
ments, with industries attached, where the ex-
sanatorium patient could have sheltered conditions,
medical supervision, and a house away from his former
habitation.
RHEUMATISM
The section on rheumatism and allied diseases met
under the presidency of Sir ROBERT STANTON Woops
(physician in charge of the department of physical
medicine at the London Hospital). Dr. SINCLAIR
MILLER (medical director of the Harrogate Investiga-
tion Clinic) spoke on the etiology of chronic arthritis,
and Dr. DOUGLAS COLLINS (research fellow in rheuma-
tism at the University of Leeds) referréd particularly
to the importance of trauma and infection as sxtio-
logical factors. It was a mistake he thought to ignore
the local condition of the joint while concentrating
on the general physiological behaviour of the arthritic
patient. Dr. ForRTESCUE Fox (president of the
International League against Rheumatism) read
a paper on “ vicious spirals ”? in chronic rheumatism ;
Dr. JoHN PoYNTON (consulting physician to Univer-
sity College Hospital) opened ,a discussion on the
etiology of rheumatism in children, and Sir FRANK
Fox (organising secretary of the Empire Campaign
against Rheumatism) summarised the history of the
development of the movement. He pointed out that
insufficient attention had been paid to rheumatism,
in spite of the great suffering it caused, because it
lacked the dramatic element,
PANEL AND CONTRACT PRACTICE
What is a Partner ?
For health insurance purposes a partner must,
as prescribed by Clause 11 (8) of the terms of service,
be in the position of a principal in connexion with the
practice and entitled to a share of the partnership
profits which is not less than one third (in Scotland
one half) of the share of any other partner. An
insurance practitioner recently told an insurance
committee that he had taken into partnership another
practitioner. When asked whether the terms of the
partnership agreement conformed to the requirements
of Clause 11 (8) he said that his partner was not
entitled to any stated share of the profits but was in
receipt of a salary which, together with certain
allowances, amounted to a sum greater than one-
third share of the profits of the partnership. The
Ministry of Health expressed the view that although
there was nothing in the facts set out above which
necessarily negatived the existence of a partnership
it might be desirable for the insurance committee
to satisfy themselves as to the position by an examina-
tion of the deed of partnership if any. The practitioners
were unwilling to submit the deed for examination,
and the committee felt some hesitation in accepting
the view that the salaried partner could be considered
in the circumstances as entitled to a “share of the
profits ” and they asked for further advice. The
Ministry took the view that the word “salary ”
implied the payment of a fixed sum payable out of the
profits so long as the profits were sufficient to meet it.
Presumably the committee would also have to be
satisfied that provision had been made for the salary
of the junior partner to be increased if the profits of
the partnership should increase to such an extent as to
make his present salary and allowances insufficient
to comply with the terms of service.
Visitation of Surgeries
The Cheshire insurance committee have been
trying to arrive at agreement with the panel com-
mittee about the visitation of surgeries. They
THE LANCET]
asked the panel committee to appoint members
to meet an equivalent number of members of the
insurance committee to consider and report upon
the general question of surgery and waiting-room
accommodation, but the panel committee decided to
take no action. The Ministry of Health was then
asked what other course was open to the insurance
committee to secure the provision by insurance
practitioners of proper accommodation for their
insured patients. The Ministry suggested that the
panel committee would hardly withhold their coépera-
tion in the event of any specific cases being brought
to their notice where it appeared to the insurance
GRAINS AND SCRUPLES
[sunE 5, 1937 1367
committee that there was ground for regarding
the accommodation provided as unsatisfactory.
And this proved to be the position. The secretary of
the panel committee said that on a complaint being
made they would be glad to codperate, but they
had a strong objection to a roving commission to
examine anybody’s premises irrespective of complaints.
After some discussion it was decided that any com-
plaint as to the accommodation in a specific case,
brought in duly authenticated form to the notice
of the insurance committee, should be investigated
by a joint committee of the insurance committee
and the panel committee.
GRAINS AND SCRUPLES
Under this heading appear week by week the unfettered thoughts of doctors in
various occupations.
Each contributor is responsible for the section for a month ;
his name can be seen later in the half-yearly index.
FROM TWELFTH MAN
I
To sit in the pavilion while one’s betters are batting
can be a disintegrating experience. For a week
past I have sat in the pavilion. I have re-read all
the contributions to this Grains and Scruples series
from the very lively knock with which West-country
Practitioner opened the innings last July to the
sound and stylish display by A Medical Economist.
I have been amused, instructed, stimulated—and,
now, when it is my turn to go in I am heartened
by the knowledge that if Twelfth Man edges a lucky
ball between first and second slip to the boundary
there is a ripple of surprised applause.
x * x
These Grains and Scruples have indeed been
surprising. Here are twelve doctors (and more
apparently to come) who are willing to write from
five to ten thousand words about a broomstick or
nothing at all. There can, I think, be but one reason
for this. Many doctors have an unsatisfied desire
` for self-expression. This is the modern explanation
for ill-behaviour in the nursery and it explains equally
well these essays which have lightened for the last
eleven months the pages of THe Lancer. That
doctors lack self-expression is, I believe, true. Our
unhappy function is, too often, to listen and, too
often, when we talk it is to use “ vain repetitions
as the heathen do.” If we are having a preliminary
gossip—well, there is the weather or the films and
when we come to the real business of the patient’s
health how frequently we play the same record.
I doubt whether the practice of a first-class physician
equals in variety the practice of a leading counsel ;
it does not elicit a comparable number of mental
responses nor stimulate as complicated a series of
conditioned reflexes. The physician, for example,
whose practice has an “abdominal” bias will, in a
year, see some hundreds of patients with an ulcer,
an intestinal carcinoma, or an abdominal neurosis.
How often must these patients receive advice in
much the same terms.
For the mutual convenience of physician and
patient it is customary to have typewritten sheets
of instructions for the victim’s future regimen. At
the end of a hurried interview with a physician a
patient of mine was handed three such sheets. ‘A
guinea a sheet. Do I pay you directly or does the
money go into the slot-machine ? ” asked my patient
rudely.
And how stereotyped must the reactions of lesser
men become. I sit at a bridge table with a fat lady
as my partner, and she asks: ‘‘ What is your call,
doctor?’’ It is with difficulty that I refrain from
replying: ‘‘ Three rye biscuits. Take one potato
where three crept in. Eat as much of lean meat, of
green vegetables ae
Next to me sits a successful business man. ‘‘ Your
calling makes me giddy, doctor.” I want to reply:
“Take it easy. Avoid stress and strain. John
Hunter said he was at the mercy of any man who
made him lose his temper. Live within the limits of
your circulation. Grow old gracefully. Make your
changes of posture slow and deliberate——.”
My readers, if any, will recognise these records.
They are part of our common heritage. Hippocrates
played them. So we go through our professional
life with our small group of conditioned responses.
How worrying and how annoying it is when a patient
presents a group of symptoms and signs that refuse
to fit into a syndrome. As difficult as it was for
Pavlov’s dog when his master altered the dinner bell
by a semitone. Thus it is that our minds lack
elasticity, and our flow of ideas is constipated. Thus
it is that A Departmental Doctor wrote, “‘ Regarded,
at any rate as an interesting companion, as a desirable
neighbour at dinner, the doctor was ranked consider-
ably below the barrister and, a little more doubt-
fully, lower than the priest.” Thus it is that so many
were glad to accept the invitation to contribute
to the Grains and Scruples series. Here was a
stimulating chance for unfettered self-expression.
* * *
This unsatisfied desire for self-expression may
encourage the doctor off his guard into unwise
confession to his patient. His wish to help the
psychoneurotic may also lead him to confess a like
frailty. I remember a dramatic instance of this.
Many years ago a physician in the out-patient depart-
ment of a large hospital was examining a boy. in
front of a class of students. He took the lad
behind a screen and after a few minutes both emerged.
The physician addressed the class: ‘‘I thought so.
The boy’s a masturbator.” The boy burst out:
“ You sneak ! You said you wouldn’t tell, and anyway
you said you did it yourself when you were a boy.”
Confession may be obligatory in an Oxford Group
meeting but such sharing is out of place in a
consulting-room.
* * x
It is doubtless necessary for these Grains and
Scruples articles to be temporarily anonymous,
1368 THE LANCET]
but it diminishes their ‘“ news-value.” Did not
A Rover write that a newspaper proprietor would pay
a hundred guineas for signed articles by medical
men in the lay press but only five guineas if they were
unsigned? And would not even the readers of THE
LANCET have settled down in greater numbers to
relish the incisive wit of A Rover had they known he
was A in person; and enjoyed more keenly the
urbanity of A Departmental Doctor had they known
he was B and the author of C; and delighted more
in the mild humour of A Doctor in Retirement if they,
had known he was D and the author of E and F?
They would. For who can lay his hand on his heart
and deny that he brings a more lively expectation
to sharpen the edge of his critical faculty when he
knows himself to be looking at a Goya or a Vermeer ?
George Robey lifts an eyebrow and the house rocks
with laughter, while the innominate comedian works
desperately through a few painful moments for his
first laugh. Still anonymity has its advantages.
It seems possible that someone may glance down this
page finding Twelfth Man a more attractive superscrip-
tion than X, and I like to think that I could not have
enjoyed more keenly the sanity and wisdom, the
quintessential common sense, of A Rusticating Patho-
logist had I known who he was. He described the
town where I have lived happily for ten years as
a place where the sun seldom shines and listed it,
as an undesirable habitation, with Central Asia,
Tierra del Fuego, Arctic Canada, and Orkney.
* k *
It is difficult to guess to what extent the pro-
fessional journalist welcomes and to what extent he
resents the incursion of the amateur into his specialty.
I have no doubt that the office staff of Tur LANCET
could have written these Grains and Scruples a
great deal better than have its invited guests. The
late Lord Salisbury described a popular daily paper
at its inception as written by “ office-boys for office-
boys”! To-day it may be, written by impoverished
politicians, gossiping peers, pamphleteering clerics,
and pseudo-scientists whose standards are no more
worthy than their predecessors’, the office-boys. Not
that the amateur’s contribution to journalism has
been entirely without value. The best things in the
Times are Bernard Darwin’s weekly article on golf
(it might equally well be written on darts or tiddley-
winks), the fourth leader and the correspondence
columns. No Saturday is completely ill-spent that
starts with Bernard Darwin. Many a breakfast-
table has been rescued from disaster by the fourth
leader. What could add more relish to the eggs and
bacon than to read Winston Churchill admonishing
Lord Hugh Cecil, who had apparently expressed
at one time or another disapproval of Italy, France,
Japan, Nazi Germany, and Soviet Russia: “It
must be very painful to a man of Lord Hugh Cecil's
natural benevolence and human charity to find
so many of God’s children wandering simultaneously
so far astray. ... In these circumstances I would
venture to suggest to my noble friend, whose gifts
and virtues I have all my life admired, that some
further refinement is needed in the catholicity of his
condemnations ” ?
Or Prof. John Hilton’s strictures on certain members
of the House of Commons, “ Yet it is not altogether
a matter for mirth that elected persons should so
eagerly allow themselves to be made the butt of
informants defective in hearing, wits or veracity.
A certain amount of silliness in public life adds to
gaiety and does no harm. But in excess it might
spell our doom !” There was a long correspondence
GRAINS AND SCRUPLES
[JUNE 5, 1937
recently in the Times on the value of Family Prayers.
This dying habit received the most enthusiastic
support from clerics and retired members of the
services. A long, wearisome, and occasionally painful
experience of Family Prayers makes me certain that
the day is better begun with Bernard Darwin, the
fourth leader, and letters to the Editor.
In parentheses, why is it that every strange sect,
every exotic enthusiasm, every society of cranks
draws its chief support from retired members of the
services ? Is it because these admirals and generals
have grown tired of discipline and orthodoxy ?
Or because they have learnt that the secret of happy _
retirement is the espousal of a cause that is
predetermined to be lost ?
* * *
Medical journalism, like all trade journalism, is a
different cup of tea. Here a small group of
professionals drives a team of ill-assorted amateurs.
(If I had been the editor of THE Lancet I should
have asked A Chronicler to have completed his
fascinating history of medical journalism by telling
of its present difficulties, its pitfalls, its humours, and
its anxieties.) The job of the professional is to invite,
to cajole, and to flatter these “ expert ” contributors,
and to edit, alter, improve, or refuse their contribu-
tions. This is a difficult task. Most of these experts
would refuse with disdain the advice that a play-
wright accepts meekly from his stage-manager.
They would retire in dudgeon if they had to endure
the treatment that the scenario-writer receives at
the hands of the Hollywood producer or even the
cutting that the copy of a working-journalist gets
from his editor. They are thin-skinned, hyper-
sensitive, of an inordinate vanity. This is the first
difficulty of a medical editor. Why does not the
scenario-writer withdraw his services when his work
is mutilated ? Because he is well paid. I know nothing
of the balance sheet of the weekly medical journals.
I know, however, that they_have a circulation which
compares favourably with the circulation of other
weekly journals and they have access to an advertis-
ing field without rival. Perhaps the only way for
the editor to deal ruthlessly with his difficult team
would be to pay them for their signed contributions.
a x *
The second difficulty for the editor of a weekly
medical journal must lie in the diverse interests
of his readers. There must be much for the general
practitioner and physician but something too for
those who practise a specialty. Considering those
difficulties weekly medical journalism maintains an
extraordinary high standard. It has one fault.
Like all other forms of journalism there is a great
deal too much of it. To be presented on Friday
morning with a journal the equivalent in acreage
of a full-length novel and another of the same size
on Saturday morning must overwhelm the leisure of
the least busy doctor and fatigue the most receptive
mind. The individual articles are often of an
incredible prolixity. I find the clinicians generally
more verbose than the laboratory-workers. The
researchers produce reports that are often models
of lucid brevity. In a recent issue of THE LANCET
Dr. A. Q. Wells filled little more than a column with
his exciting discovery of tuberculosis in field-voles.
I tremble to think how some of us would have been
tempted into an access of “ windy blether” on such
an occasion. We should have begun with accounts
of the field-mouse in literature (deliciously apt
quotations from Robert Burns), the varieties of
THE LANCET]
field-mice, and their habits and diseases; proceeded
to a discussion of the Mycobacterium tuberculosis, its
identity and methods of culture; indicated in a few
modest pages the implications, the potentialities, and
the cosmic significance of our discovery and rounded
' the whole thing off neatly with a verbatim report
of the 134 post-mortems and some decorative micro-
photographs.
I realise that it is not necessary for me to read any-
thing that I do not wish to read and, indeed, it is
common enough to hear a man say “ Lifes too short
to read articles from start to finish. I only read
the summary and conclusions.” It is on behalf of
the weaker brethren like myself, that I cry mercy.
We are not so strong-minded nor so wisely economical
of our time. Too often, like a character of Aldous
Huxley’s, we “ creep, from cover to cover, like a beetle
through dung.”
* * x
I do not doubt that a living dog is better than a
DIAGNOSIS AND TREATMENT OF GASTRIC AND DUODENAL ULCER [JUNE 5, 1937 1369
dead lion, but what if the lion being dead yet roareth ?
I was told by a neurologist that one of his prized
possessions is an article by Hughlings Jackson on the
different levels of humour—the lowest level dependent
on incongruities of situation and the highest level that
of organised wit: the whole thesis, as the bookseller’s
catalogues say, embellished with numerous illustra-
tions. This may not be a subject of general medical
interest, but why should not the medical journals
reprint selections from the works of Paré, Laennec,
Trousseau, Addison, Graves, Gee, Hughlings Jackson,
and Osler? And even the “ Regimen Sanitatis of
Salerno ” so beloved of Taddygaddy. They might
be the beginnings of a liberal education for others
besides myself.
There was a distinguished Victorian who said that
every time a new book was published he turned back
to read an old one. The idea is a sound one but
difficult of execution in a day when new books, like
mugs, are born every minute.
CORRESPONDENCE
DIAGNOSIS AND TREATMENT OF GASTRIC
AND DUODENAL ULCER
To the Editor of THE LANCET
Sır, —In his paper published in your issue of
May 22nd, Dr. Duncan Leys makes a number of
statements which ought not to be allowed to pass
without criticism.
1. He says that gastric carcinoma is relatively
uncommon. This is hardly the correct term to apply
_to a disease from which no less than 16,000 individuals
die each year in Great Britain.
2. He suggests that the greater incidence of gastric
than duodenal ulcers in his series of 58 cases repre-
sents the true facts, and that all statistics showing a —
greater incidence of duodenal ulcer are incorrect
because they are founded on surgical experience.
My own series of 399 duodenal compared with 114
gastric ulcers at New Lodge Clinic and Prof. Ryle’s
of 563 to 13] seen in private prove how unfounded
is this assumption. The difference between our
statistics and those of Dr. Leys is almost certainly a
result of the difference in the social class of the patients,
gastric ulcer being relatively much more common
in hospital than in private practice. Thus whereas
the relative incidence of duodenal ulcer and gastric
ulcers in the comparatively well-to-do as calculated
from our figures is 962 to 245, or 4 to 1, combined
_ statistics from Guy’s and St. Bartholomew’s Hospitals
give 875 duodenal to 1013 gastric ulcers.
3. There must be something radically wrong with
Dr. Leys’s method of testing for occult blood. Using
Dr. Ryffel’s technique for the guaiac reaction and
the spectroscopic examination for hematoporphyrin
and acid hematin, the exclusion of blood and chloro-
phyll from the diet is essential, as otherwise a positive
result is almost always obtained. Occult blood is
present in 100 per cent. of cases of carcinoma of
the stomach and in at least 95 per cent. of gastric
and duodenal ulcer; in a large majority of cases
it is still positive for several days after the disappear-
ance of the niche seen with the X rays, and its
disappearance can be regarded as the most valuable
evidence, short of gastroscopy in the case of gastric
ulcer, of the persistence of an organic lesion.
4. Few physicians of experience would agree with
Dr. Leys that “a patient with achlorhydria and
long-standing indigestion, whatever the age” has
‘‘ gastric or duodenal ulcer.” He has either chronic
gastritis or carcinoma; he certainly has not a
duodenal ulcer and almost certainly not a gastric
ulcer, as we have never found achlorhydria in any
of our 399 cases of duodenal ulcer and only once in
our 114 cases of gastric ulcer at New Lodge Clinic ;
in the single exception free acid returned after. a
short period of dieting, which it would certainly not
have done had carcinoma been present.
5. Though I have often protested against the
excessive employment of surgery for gastric and
duodenal ulcer, I cannot but be amazed to read that
“ perforation remains the sole indication for surgical
interference.” I am, Sir, yours faithfully,
| ARTHUR F. Hurst.
New Lodge Clinic, Windsor Forest, May 26th.
SULPHZMOGLOBINZMIA AND
METHAMOGLOBINAMIA AFTER
SULPHANILAMIDE
. To the Editor of THE LANCET
Sm,—Since making our communication on
sulphemoglobinemia and methzemoglobinzmia
following administration of p-aminobenzenesulphon-
amide (published in your issue of May 15th)
a case has occurred in which methemoglobinsemia
and sulphemoglobinxsmia were found successively.
The case was one of septic abortion (cervical smear :
non-hemolytic streptococci) in a patient aged 33. No
sulphates were given and she received 36 grammes of
sulphanilamide in six equal doses during the 2nd and
3rd days after admission to hospital. By the evening
of the 3rd day she was very cyanosed and administration
of the drug was stopped. Examination of the blood at
this time revealed the presence of methemoglobin only.
The blood was again examined on the 6th day when
sulphemoglobin but no methemoglobin was found. By
this time cyanosis was slight but it persisted until the
16th day after admission. Administration of sulphanilamide
was recommenced on the 8th day and continued until the
15th day but only in doses of 3 g. daily and, in order
to minimise the risk of aggravating the sulphemoglo-
binzemia, the lower bowel was frequently washed out with
enemata. There was no apparent increase in cyanosis or
sulphemoglobinemia after recommencing administration
of the drug but the sulphemoglobinzmia could be detected
until the 29th day. The patient had received ten minims
of acid. hydrochlor. dil. before each dose of sulphanilamide.
We believe that only one case of methsmo-
globinemia and sulphemoglobinemia in the same
1370 THE LANCET]
patient has previously been recorded (R. L. Waterfield :
Guy’s Hosp. Rep. 1928, 78, 265).
These findings support our conclusions regarding
the relative persistence of methzmoglobin and
sulphemoglobin in the blood and our belief that
giving hydrochloric acid may increase the liability
of this drug to produce methzemoglobinemia, The
fact that in some cases slight sulphemoglobinemia
occurs apart from administration of sulphur or its
- compounds does not disprove that sulphur has been
responsible for many of the cases of, sulphemo-
globinemia recorded after giving sulphanilamide or
other drugs.
substances have an accelerating action on sulphemo-
globin formation (in vivo if not also in vitro) and that
when such substances are being given as drugs a
high concentration of sulphur in the alimentary tract
should be avoided as far as possible both by excluding
its administration and keeping the bowels open with
non-sulphur-containing laxatives.
In examining the blood of the case.herein described
we have, of course, made all necessary tests to
distinguish sulphemoglobin from methzemoglobin.
Sulphemoglobin and methzmoglobin did not appear
to be present simultaneously in the blood.
We are grateful to Dr. Thomas Archibald of
Belvidere Isolation Hospital for giving us facilities
to investigate this case and those previously described.
We are, Sir, yours faithfully,
JAS. C. EATON,
Glasgow, May 28th. J. P. J. PATON.
EXPERIMENTS ON THE ZTIOLOGY OF
LUNG TUMOURS
To the Editor of THE LANCET
Sir,—In the leading article in your last issue it is
pointed out that the incidence of lung tumours
in certain inbred strains of mice is increased by sub-
cutaneous injection of carcinogenic agents—e.g.,
dibenzanthracene. You ask: “But why is the
carcinogenic action of these substances focused on
one organ—in this case the lungs?” I suggest that
an extra stimulus comes from the external
environment.
Some of my results—of prolonged dusting experi-
ments with mice—which are being published next
month, indicate that there may be an extra stimulus
in the lungs—namely, some irritant or irritants
inhaled in atmospheric dust. The lung is thus
subject to constant irritation in this way even in
ordinary atmospheres, but usually the degree of
irritation is below the threshold. The subcutaneous
injection of dibenzanthracene increases the suscepti-
bility in certain strains so that the minor degrees
of irritation may suffice to start the tumour in the
lung. I am inclined to think that many of the earlier
animal experiments with dust were of too short a
duration, so that a reasonable conclusion could not
possibly be attained. Lung tumours are usually
late in development in mice as well as in man, where
the mean age at death is 55 years.
I am, Sir yours faithfully,
London, N.W., May 29th. J. ARGYLL CAMPBELL.
TREATMENT OF DRUG-ADDICTION
To the Editor of THE LANCET
Sır, —In your issue of May 22nd Dr. Vivian describes
the use of autoserotherapy for drug addiction.
I first made a note of this method when I read of
it in a League of Nations publication about two years
ago. It appeared to me that its results depended
purely and simply upon the injection of serum, and
EXPERIMENTS ON THE ÆTIOLOGY OF LUNG TUMOURS
Rather does it emphasise that certain
[JUNE 5, 1937
I therefore decided to test the effects of autohæmo-
therapy—i.e., the re-injection of whole blood removed
from the patient. My cases have been too few for
publication, but the results in two of them were
very striking. In a case of morphine addiction the
patient had twice discharged herself from the hospital
to which she had been admitted for this condition.
She consulted me to obtain supplies, but since treat-
ment two years ago, she has been completely free
from craving. In a case of severe alcoholism sent to
me by the probation officer of a police-court the
patient appears to have been cured; there has been
no relapse for over a year. I have found a dose of
4 c.cm. adequate, and the best interval between
doses seems to be four days.
I am, Sir, yours faithfully,
Camden-road, N.W., May 31st. H. SEARLE BAKER.
NZVOID AMENTIA
To the Editor of THE LANCET
Sim,—In Mr. Ralph Bates’s interesting case of
nzvoid amentia published in your last issue a radio-
gram of the skull is said to show irregular areas of
calcification in the frontal region’ compatible with
calcification in a plexiform angioma. Unfortunately
little can be learned from the reproduction of the
radiogram (Fig. 2 of Mr. Bates’s paper) as to whether
the shadow due to the calcification has the
“ festooned ’? appearance seen in other typical cases
(compare the illustrations in the Proceedings of the
Royal Soctety of Medicine, 1928-29, 22, 431).
Are plexiform angiomata in the frontal lobe more
likely to be associated with amentia than others ?
There was no amentia in Dr. C. P. Symonds’s case
(loc. cit., p. 440) in which the meningeal nævus was
mainly of the left occipital lobe. One would have
thought that those on the right side of the brain, as
in Mr. Bates’s case, would be less likely to be associated
with amentia than those on the left side; but then
in Mr. Bates’s case it is the frontal lobe which is
chiefly involved. According to K. H. Krabbe (Arch.
Neurol. Psychiat., Chicago, 1934, 22, 737) the intra-
cranial calcification is generally limited to the occipital
lobe; according to H. Bergstrand (Abstracts of the
Second Internat. Neurol. Congress, London, 19365,
p. 124) and H. Olivecrona (quoted in Lancet, 1936,
2, 752) réntgenological evidence of calcification is
obtained in only a minority of cases, and in abortive
forms epilepsy is often the only symptom,
I am, Sir, yours faithfully,
London, W., May 29th. F. PARKES WEBER,
PERNICIOUS ANÆMIA IN AN INFANT
To the Editor of THE LANCET
Sır, —Dr. Smallwood’s letter, in your issue of
May 29th, does not contain the all-important news
as to whether or not any of his cases of subacute
hemolytic anemia had histamine-refractory achlor-
hydria. The case of pernicious ansmia in an infant,
recorded by Langmead and Doniach, showed this
feature, which, when taken in conjunction with the
other findings, caused the infant’s syndrome to
resemble pernicious anæmia in every particular.
The fact that the pernicious anæmia syndrome is
almost unknown in infancy cannot alter the fact
that when it does occur, it just does. Urinary obstruc-
tion due to prostatic disease is a condition peculiar
to old men; I have seen it in a young child.
Dr. Smallwood rightly states that achlorhydria is
common in sick infants, but this is not true when
histamine is used to stimulate secretion of gastric
juice; it has been sufficiently rare in my series of
THE LANCET] GASTRIC ACIDITY AND CHRONIC ALCOHOLISM [JUNE 5, 1937 1371
cases always to raise in my mind the lurking suspicion
that the nurse, with more zeal than discretion, has
injected the histamine into the wrong baby or used a
blocked needle. He is also right in saying that I do
not call the megalocytic anemia of celiac disease
pernicious anzmia; surely he should know that no
alumnus of the Birmingham Children’s Hospital
could be guilty of such an aberration.
I am, Sir, yours faithfully,
Harley-street, W., May 29th.. J. C. HAWKSLEY.
INSULIN THERAPY IN MENTAL DISORDER
To the Editor of THE LANCET
Sir,—An Association of Insulin Therapists in
Psychiatry has been formed with Dr. G. W. B.
James as president. The objects are to hold meetings
to discuss all matters arising from insulin treatment,
to catalogue and make available the international
literature, and to discover by discussion and corre-
spondence the most efficient foundations of prognosis
and after-care, The Association welcomes all workers
in this method: I shall be able to answer any inquiries
from those interested.
I am, Sir, yours faithfully,
l EDWARD LARKIN,
Secretary, Association of Insulin
herapists in Psychiatry.
West Ham Mental Hospital, Goodmayes,
Ilford, Essex, May 27th.
TRACHOMA IN REFUGEE CHILDREN
To the Editor of THE LANCET
Smr,—As president of the International Organisa-
tion against Trachoma, Mr. A. F. MacCallan is clearly
in a position to make ex-cathedra statements as
to the dangers of introducing this disease into
England, and to warn the Ministry of Health against
so doing. It is unfortunate, however, that before
a question was asked in the House of Lords about the
matter, with its inevitable repercussions and alarms,
Mr. MacCallan should not either have got in touch
with any one of those directly concerned with the
medical examination of the children, or have made
some inquiries as to the incidence of trachoma in the
Basque district. He also appears to have assumed a
trifle uncharitably that because the “ gentlemen ”’
who examined the children before embarkation in
‘Bilbao were without special knowledge of ophthalmo-
logy, they were therefore also lacking in the elements
of common sense. We did, in fact, make it our first
duty on arrival in Bilbao to inquire from the public
health authorities as to the incidence of trachoma
in the Basque district, and found that of recent years
it has been extremely low. This was confirmed by
a Spanish ophthalmic surgeon of many years’
experience in Bilbao, who accompanied the children
to England. Mr. MacCallan’s statements as to the
high incidence of trachoma in certain provinces of
Spain, apparently based on the report of the Consilium
Ophthalmicum (1929, 13, 113), apply to the districts
of Murcia, Almeria, Valencia, and Castellon. The
suggestion however that trachoma is “ practically
universal ” is so palpably exaggerated that it is surely
based on a misunderstanding of Prof. Soria’s statistics.
The figure 90 per cent. which he gives refers not to
the incidence of trachoma in the population at large
but to the percentage of eye cases which are tracho-
matous. Actually the highest incidence of trachoma
in any province is 2 per cent. of the population. The
same source shows that the incidence in these
districts was from 25 to 55 times as high as in the
neighbourhood of Bilbao, so that Mr. MacCallan’s
whole quotation is likely to be misleading. It is
hardly realised in this country how widely different
from South and South East Spain are the circum-
stances both as regards climate and public health
in the Basque district. As to the further examina-
tion of the children, Dr. Richard Taylor (medical
officer in charge of the Eastleigh camp) is replying
to Mr. MacCallan’s letter in the British Medical
Journal. Briefly, each child who leaves the camp
will have received a minimum of three full medical
examinations. An ophthalmic surgeon with con-
siderable experience in the diagnosis of trachoma
sees all eye cases. No evidence of trachoma has been
found in any instance.
We need hardly add that all those concerned are
fully aware of their responsibility, and most anxious
to codperate in necessary measures to prevent the
spread of any infection that may occur.
We are, Sir, yours faithfully,
RICHARD W. B. ELLIS,
London, W., May 31st. AUDREY E. RUSSELL.
' GASTRIC ACIDITY AND CHRONIC
ALCOHOLISM
To the Edttor of THE LANCET
Srr,— Would it not be in the interest of future
generations to drop the phrase “ test-meal,” even if,
for some years more, patients must submit to the —
meaningless ritual of gruel or alcohol ? What evidence
is there that the mechanism of secretion in man differs
from that in experimental animals? Gruel, if intro-
duced into the resting stomach in the small hours of
the night without awakening the subject, leads to
no acid secretion. Seven per cent. alcohol under the
same circumstances usually also gives a small response
only. In other words the test-meal response is not
a response at all but is partly the result of a basal
secretion which is either continuous (pathological)
or conditioned by breakfast time, and partly the
result of various other conditioned reflexes.
The secretion of 100 c.cm. of gastric juice per hour
is quite sufficient to give a very high curve in a rapidly
emptying stomach, but it is no evidence that the
patient is capable of secreting the 300 or 400 c.cm.
per hour needed to deal with the buffering powers of a
Christmas dinner. The possessor of a normal mucous
membrane, even if he gives the,lowly normal curve,
can reduce a protein meal to a low pH in a far shorter
time than the patient with chronic gastritis, who may
incidentally give a hyperchlorhydric curve.
Chronic alcoholism and chronic gastritis are almost
synonymous but the patients referred to in your
annotation (May 29th, p. 1292) were not given a
fair trial. They had probably lost the habit of
secreting at breakfast time, and through their habit
of drinking without food had lost the conditioned
response to alcohol which better brought-up persons
tend to possess.—I am, Sir, yours faithfully,
Oxford, May 30th. DENYS JENNINGS,
B.I.P.P. TREATMENT OF ACUTE
OSTEOMYELITIS
To the Editor of THE LANCET
Srr,—I should like to add my testimony to that of
Mr. J. H. Saint as to the great value of Bipp treatment
in the prevention of necrosis after acute osteomyelitis.*
Fifteen years ago a boy, aged 6, was admitted to the
East Suffolk Hospital with acute osteomyelitis of the left
1 The case described here was reported in the Clinical Journal
(1930, 59, 90). :
1372 THE LANCET]
leg of five days’ duration. He was very ill with a
temperature of 105° F. and a pulse-rate of 160. The
leg was greatly swollen and inflamed and acutely tender.
There was no effusion on the knee- and ankle-joints.
Thinking it possible that even when the periosteum was
stripped from the shaft by pus and the medulla acutely
infected, the actual structure of the dense bone might be
still living and free from bacterial invasion, I decided
to attempt complete sterilisation of the inner and outer
walls of the shaft.
A tourniquet was applied above the knee. This is
essential in order to keep the field of operation free from
blood, and especially to avoid the danger of causing a
general systemic infection by scrubbing the inflamed
tissue during the operation. A long incision was made
down the whole length of the diaphysis over the inner
side of the tibia. The shaft was bare and bathed in pus,
the periosteum being entirely stripped off. The pus was
washed away and the surface of the bone and periosteum
thoroughly cleansed by scrubbing with gauze, first with
1 in 20 carbolic lotion, then with spirit, and, finally, with
ether. Sterile gauze was then packed between the bone
and surrounding tissue, and the medullary canal laid open
for its whole extent; the marrow which was infiltrated
with pus was scraped away and the cavity scrubbed with
carbolic lotion, spirit, and ether. The packing was then
removed and a thick layer of gauze, moistened with carbolic
lotion and soaked in Bipp (the excess of which was
removed by squeezing), was laid between the bone and
periosteum, and the medullary canal also packed with
gauze soaked in Bipp. The usual dressing was then applied
and the tourniquet removed.
On the next day the temperature and pulse were normal,
the swelling had entirely subsided, and the leg was free
from pain or tenderness. The gauze was removed on the
third day. The wound healed quickly without suppura-
tion except for a small sinus in the metaphysis at the head
of the tibia which continued to discharge a little pus
for several weeks ; finally a very small sequestrum came
away at this spot and healing was complete. Unfortunately
I did not realise at that time that the primary focus of
infection in these cases is in the metaphysis. Had this
focus been explored and sterilised, there would no doubt
have been no delay in complete recovery.
I saw the boy five years later and took a photograph
and radiogram of the leg. Both legs were of exactly
the same size and shape, and the radiogram showed a
perfectly normal shaft, except that the bone was
solid throughout, the medullary canal being filled up.
I am, Sir, yours faithfully,
Worthing, May 31st. HERBERT H. BROWN.
OBSTETRICS IN GENERAL PRACTICE
To the Editor of THE LANCET
Srr,—The general opinion certainly is that the
practice of obstetrics, like the practice of surgery,
should be in the hands of those who have specialised
in the subject. It is also desirable that in every area
there should be a medical man readily available to
attend to these cases, since many require attention
at a very short notice. Our consulting surgeons
usually reside in the larger towns and cities ; this is
quite satisfactory in the case of surgery, but would
not be as satisfactory in the case of obstetrics. Further,
many general practitioners are excellent obstetricians,
keen on the work and (what is even more important)
have the complete confidence of their patients.
Certain of these practitioners might be given the
care of the antenatal and confinement work in their
area, but it would only be fair that they should
produce some evidence to the authorities of their
proficiency in the art of midwifery. The Diploma
of the British College of Obstetricians and Gynæco-
logists and the Mastery of Midwifery of the Society
of Apothecaries would either of them furnish good
evidence of the special knowledge ; but unfortunately
OBSTETRICS IN GENERAL PRACTICE
er
\
[JUNE 5, 1937
both these examining bodies require the candidates
to have held resident appointments in hospital for
at least six months before their examination. Now
many quite able practitioners cannot afford to leave
their practices for this length of time. Would it not
be possible for some of our examining bodies to arrange
an examination for a diploma in obstetrics, &c.,
without a compulsory resident appointment? If
such an examination could be arranged in the very
near future, practitioners desiring to specialise in
the work would have reasonable opportunity to
obtain that diploma before it is decided by the
Ministry of Health to place the practice of obstetrics
in the hands of experts.
I am, Sir, yours faithfully,
May 29th. SCALPEL,
METHODS OF DESTROYING BED-BUGS
To the Editor of THE LANCET
Sir,—Research on the eradication of bed-bugs is
being mainly (and rightly) directed towards discover-
ing simple methods which are 100 per cent. efficient.
The “naphtha distillate’? method described by
Ashmore and McKenny Hughes (Lancet, Feb. 27th,
1937, p. 530) shows a real advance in technique,
but as J. M. Holborn suggests in your issue of May lst,
there is still need for contact insecticides which can
be used by the inhabitants of bug-infested houses ;
insecticides which are cheap and easy to apply and
whose use is not too obvious to the neighbours.
Experiments show that dilute methylated spirit
kills bed-bugs, A mixture of 30 parts of spirit with
70 parts of water has a low surface tension, so that
it penetrates readily into the cracks which the insects
inhabit. Practically every adult and nymph which
the liquid touches dies ; those in the cracks where the
fluid remains for some time before it evaporates are
_all killed. Small nymphs are particularly susceptible ;
in fact this stage often dies if wetted with ordinary
water. Eggs are more resistant than other stages,
but eggs in the cracks which remain wet for an hour
seldom survive. `
This insecticide is very cheap, for if duty-free spirit
can be used the mixture costs about sixpence a gallon.
It is not inflammable (50 per cent. spirit kills eggs
more readily, but is inflammable), it gives off no
noxious fumes, and, most important of all, it does
not damage furniture or bedding.
This method will not kill every bug in a house, but
if the liquid is sprayed into the crevices few bugs will
survive and the house wil be made much more
comfortable for the inhabitants. A second applica-
tion after any eggs which escaped have hatched should
leave almost none of the parasites alive. When
fumigation and other methods have been perfected,
this sort of treatment will not be necessary; but,
until then, use should be made of any practicable
means of alleviation.
I am, Sir, yours faithfully,
KENNETH MELLANBY.
The Sorby Research Laboratory, the University,
Sheffield, May 27th.
KING EDWARD’sS HOSPITAL FUND FoR LONDON.—
A second series of coronation tours of places of interest
in London is being held in aid of the Fund during June
and July. Visits will be paid to the Tower of London,
the Houses of Parliament, the Royal Naval College, and
the National Maritime Museum at Greenwich, Somerset
House, Lloyds, and Tilbury Docks. Further particulars
may be had from the secretary of the Fund, 10, Old
Jewry, London, E.C.2.
THE LANOET]:
[JUNE 5, 1937 1373
OBITUARY
ALFRED ADLER, M.D. Vienna
Prof. Alfred Adler, founder of the school of
individual psychology, arrived in Europe from
America on April 26th with a very full programme
planned for him. During the first month of his visit
he gave nearly 50 lectures in Holland, Belgium,
and France before coming to this country, where
his first public engagement was the delivery of a
course of five lectures on psycho-pathology at
Aberdeen, one on each day between May 24th and
28th. His last lecture on the 27th was on “ The
Structure of Neurosis’? and was described by a
member of a crowded and enthusiastic audience as
one of the best Adler had ever been heard to give.
‘Possibly the strain of his full Euro-
pean tour had overtaxed his
energies, but he declared to a
friend that he had found the
work easy and was apparently
in excellent spirits, delighted with
his welcome in Scotland, almost
to the moment of his sudden
death from heart failure on
May 28th.
Alfred Adler was born in 1870,
the second son of Leopold Adler,
-and was educated at the Latin
school and the University of
Vienna, where he studied psycho-
logy and philosophy as well as
medicine. He qualified in 1895
and worked in the Vienna General
Hospital and Polyclinic from 1895
to 1897, when he set up as a
general practitioner. He remained
in Vienna for 30 years as physician
and medical psychologist, and
during this long period passed
through many phases of intel-
lectual and emotional experience,
to become eventually the founder
and leader of a school of thought
which has taken hold in many
countries.
Adler played a part in the recent history of psycho-
therapy that is not easy to assess. He was a prac-
tising physician in Vienna when he became one of
the small band of supporters whom Freud drew to
himself after the period of isolation that followed
his first enunciation of psychoanalytical principles.
Adler, however, does not seem ever to have concerned
himself with the technique of psychoanalysis but
rather to have formulated general principles which
he was able to apply to individual cases, the chief
being those of “ organ inferiority,” which led to the
localisation of symptoms in the anatomically inferior
organ, and of the “‘ will to power,” which determined
neurotic behaviour with its aim of influencing the
environment and reaching a satisfaction not otherwise
attainable, the theory of the will to power giving to
our language the much abused phrase “ inferiority
complex.” These formulations could not be reconciled.
with psychoanalytical principles and after vigorous
controversy Adler. was invited in 1911 to leave the
‘Viennese Psychoanalytical Society. Since then he
showed himself to be a vigorous propagandist and
won support and popularity both in his own country
and in England, favoured by the absence from
his teaching of any special emphasis upon sexual
ALFRED ADLER
[Photograph by Universal Press
=
causes of the psychoneuroses and also by the avoiding
of the difficult conceptions associated with the theory
of the unconscious. It was characteristic of Adler
and his principles that he could expound them to an
audience in a single lecture and convey the feeling that
in them was a complete explanation of the patho-
logical vagaries of human behaviour. His clinical
methods were akin to the explanation and persuasion
of Dejerine, and his personal confidence and enthu-
siasm communicated itself to his patients as well
as to his adherents. In this country he obtained
more support from physicians and general prac-
titioners than from professed psychotherapists, who
admitted the usefulness of his approach but saw
in it an over-simplification that might lead to the
neglect of important mental pro-
cesses outside his scheme of causes.
It was in 1912, the year after
he had been asked to resign from
the Viennese Psychoanalytical
Society, that Adler began to be
specially interested in the pre-
vention of neurosis and delin-
quency in childhood, an important
branch of his interests which has
probably received too little atten-
tion in this country. He began
educating teachers to this end,
and gradually organised, with
collaborators, child guidance
centres in 30 schools in Vienna.
It is reported by his admirers
that these led to a remarkable
decrease of delinquency in
Vienna, until a change of
educational policy resulted in their
closure. His thesis was that it is
the aim chosen in early childhood
that decides the character of the
individual. The trained indi-
vidual psychologist seeks to reveal
to a child what his aim really is,
and to enable him to change
what is often a useless and
egocentric attitude—likely to lead
towards a neurotic or delinquent future—to a social
and codéperative attitude equally likely to lead
towards a normal and successful life.
There has hardly been opportunity in this country
to judge of the success of this teaching on a large
scale, but some who have watched Adler demon-
strating his method with a. child patient—such
a demonstration had been arranged for the
day of his death—are deeply impressed with its
success,
During the last ten years America has been the seat
of Adler’s activities. He was appointed lecturer in
Columbia University, New York City, in 1927, and
though he went back to Vienna for a spell as clinical
director of the Mariahilfer Ambulatorium, he returned
to the United States as visiting professor at Long
Island College in 1932. He wrote freely, his most
important works, which have been translated (but not
always very well), being on the study of organ
inferiority, the neurotic constitution, and the practice
and theory of individual psychology. |
One of his three daughters, Dr. Alexandra Adler,
who is a research reader at Harvard, is now on her
‘way to this country with the intention of carrying
through her father’s programme, :
1374 THE LANCET]
ARTHUR DOUGLAS HEATH, M.D., F.R.C.P. Lond.
Dr. Douglas Heath, who died last month at
Edgbaston, was consulting physician to the skin
department of the Birmingham General Hospital
and dermatologist to King Edward’s Schools. Born
in Exeter, the son of James Pulling Heath of
Southernhay, he retained throughout life his interest
in the west country, and just before his death had
been present at the Devonian dinner. He was
educated at Exeter Grammar School and University
College, London, qualifying M.B. Lond. with honours
in 1892 and taking the M.D. in the following year.
After holding house appointments at University
College Hospital, he settled in Birminghan, first in
general practice in Edgbaston, then as assistant
physician to the General Hospital, and as his interest
in dermatology became more pronounced taking
` charge of the skin department and of the venereal
clinic. In 1926 he presided over the British Associa-
tion of Dermatology and Syphilology, and more
recently was president of the Midland Medical
Society.
“ With the demise of Douglas Heath,” writes a
friend and colleague, ‘‘ the Midlands have lost their
acknowledged leader in dermatology. For a quarter
of a century he taught at the General Hospital and
in the University of Birmingham and many hundreds
of students were first initiated into this rather puzzling
specialty in Heath’s inimitable manner. No one
could forget his description, before a class of students,
of such a condition as psoriasis or dermatitis herpeti-
formis ; in a few words the salient points were brought
out in a way very different from a text-book
description. The Birmingham medical school has
lost a great teacher and a delightful personality.”
Dr. Heath married Annie, daughter of the Rev.
Henry Taylor of Wells, Somerset, and he leaves a
widow with one son and one daughter.
EDWARD CARMICHAEL, M.D., F.R.C.P. Edin.
Dr. Carmichael, who died on May 28th, at Bourne-
mouth, where he was living in retirement, graduated
at Edinburgh in 1884 and took the gold medal at
the M.D. two years later when he was Syme surgical
fellow. After being resident surgeon at the Edinburgh
Royal Infirmary and tutor in clinical surgery at the
University, he went into private practice in the
city and became visiting medical officer to the City
Poor House at Craiglockhart. His successor writes
of him: “ With the passing of Edward Carmichael
Edinburgh has lost one of her well-known and greatly
beloved physicians. For long years he faithfully
guided and ministered to the members of a large
general practice. He was a man wholly wrapped up
in his work, ever ready for service both in bodily
ailments and family distress. Nevertheless he found
time to keep himself conversant with the advance of
medicine, and those who worked with him will ever
be grateful for his help and the knowledge gained
through his great experience. Although he retired
some years ago his old patients still talk and think
of him as ‘Edward the Beloved.’ He was the
ideal family doctor and friend.” His son, Dr. E.
Arnold Carmichael, is director of the neurological
research unit at the National Hospital, Queen-
square.
EMILY FRANCES CAMPBELL, L.R.C.P. Edin.
WE regret to announce the death on May 20th of
Lady Campbell, widow of Sir John Campbell, the
OBITUARY.—VITAL STATISTICS
[JUNE 5, 1937
distinguished Belfast surgeon. Lady Campbell was
daughter of the Rev. William Chestnut, of Tralee,
Co. Kerry, and received her early education at the
Victoria College, Belfast. She was first married to
Dr. Fitzsimons, a medical missionary, with whom she
worked abroad for some years. After his death she
decided to return to Belfast and study medicine.
She took her degrees at Edinburgh and afterwards
engaged in private practice in Belfast, on the Antrim-
road until her marriage to Sir John Campbell some
three years later. During his lifetime Lady Campbell
identified herself closely with her husband’s work,
acting as his anesthetist and taking a deep interest
in the welfare of the Samaritan and other Belfast
hospitals. Of attractive personality she was every-
where respected for her kindly and gentle disposition.
She is survived by two sons, the elder, Robert, a
graduate in agriculture of Cambridge University,
the younger, William Stewart, a recent graduate in
medicine of Queen’s University, and a demonstrator
in the Belfast Medical School.
Dr. GEORGE HAMILTON WincH, who has died at
Penarth, at the age of 58 years, was for sixteen years
specialist officer in the treatment of venereal diseases
under the Glamorgan County Council. He qualified
M.B. Edin. in 1904, taking honours in anatomy and
surgery, was then house physician and pathologist
at the City of London Hospital and later assistant
medical officer of Oxford County Asylum. During
the late war he was bacteriologist to the Northern
Command with the rank of Captain R.A.M.C. He
is survived by his widow and two daughters.
INFECTIOUS DISEASE
IN ENGLAND AND WALES DURING THE WEEK ENDED
MAY 22ND, 1937
_Notifications.—The following cases of infectious
disease were notified during the week: Small-pox, O ;
scarlet fever, 1525 ; diphtheria, 850; enteric fever,
26; pneumonia (primary or influenzal), 787;
puerperal fever, 32 ; puerperal pyrexia, 114 ; cerebro-
spinal fever, 23; acute poliomyelitis, 3; acute
polio-encephalitis, 2; encephalitis lethargica, 5 ;
dysentery, 14; ophthalmia neonatorum, 116. 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 May 28th was 2948 which included: Scarlet
fever, 748; diphtheria, 841; measles, 68; whooping-cough,
494 ; puerperal fever, 22 mothers (plus 15 babies); encephalitis
lethargica, 282 ; poliomyelitis, 1. At St. Margaret’s Hospital
there were 22 babies (plus 16 mothers) with ophthalmia
neonatorum.
Deaths.—In 123 great towns, including London,
there was no death from small-pox, 1 (1) from enteric
fever, 16 (1) from measles, 1 (0) from scarlet fever,
14 (4) from whooping-cough, 20 (5) from diphtheria,
47 (9) from diarrhcea and enteritis under two years,
and 34 (1) from influenza. The figures in parentheses
are those for London itself.
Hull reported 3 deaths from measles, Middlesbrough and
Birmingham each 2. There were 7 fatal cases of diarrhea at
Liverpool, 4 at Birmingham, 3 at Nottingham.
The number of stillbirths notified during the week was
275 (corresponding to a rate of 40 per 1000 total
births), including 43 in London.
NEw HEALTH CENTRE AT ISLEWORTH.—Sir George
Newman has opened a health centre at Busch-corner,
Isleworth. There is a large central hall for lectures and
demonstrations capable of division into separate waiting-
rooms and a dental wing, arranged as an independent
unit. The building cost £7619.
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[JUNE 5, 1937 1375
PARLIAMENTARY INTELLIGENCE
FACTORIES BILL: COMMITTEE STAGE
CONCLUDED
THE Factories Bill was further considered by a
standing committee of the House of Commons on
May 25th and 27th.
INTERPRETATION OF ‘ FACTORY ”’
On Clause 144 Mr. SHORT moved an amendment
to provide that premises where switching operations
were performed should be brought within the Bill.
In 1935 there were 47 accidents. in stations above
650 volts and 92 accidents in stations below 650
volts.—Mr. GEOFFREY LLOYD said the Electricity
Commissioners had a statutory responsibility for
securing the safety of the public, and they were
advised that that included their employees. But
the Home Office would take up the matter again with
the commissioners.—On this understanding the
amendment was withdrawn.
DEFINITION OF ‘‘ YOUNG PERSON ”
On Clause 145 Sir J. Simon, Home Secretary,
secured amendments to make the definition of
‘‘ young person ’’ read: ‘‘ A person who has attained
the age of 14 and has not attained the age of 18,
but does not include any person whose parent is
required under, or by virtue of the Education Acts,
1921 to 1937, to cause him (unless there is some
reasonable excuse) to attend school or to attend an
alternative course within the meaning of the Educa-
tion Act, 1936.” No one ever intended that young
persons who were required to be kept at school should
be available for. factory work, and it was better to
say so in the Bill in proper terms.
On Clause 148 Mr. T. M. COOPER, Lord Advocate,
secured a similar amendment for Scotland and another
making it unnecessary to hold an inquiry under the
Fatal Accidents Inquiry (Scotland) Act of 1895 in
any case where the Home Secretary had already
held an inquiry.
WORKING HOURS FOR YOUNG PERSONS EMPLOYED
_ IN FACTORIES
Sir J. Simon moved the following new clause :—
(1) Subject to the provisions of this section, as from
the expiration of a period of two years after the commence-
ment of this Act, the foregoing provision of this Part of
this Act limiting the hours worked in any week, exclusive
of intervals allowed for meals and rest, shall have effect,
in the case of young persons who have not attained the
age of sixteen, as if for the reference to forty-eight hours
there were substituted a reference to forty-four hours.
(2) If representations are made to the Secretary of
State with respect to any class or description of factory—
(a) that the industry carried on in that class or description
of factory is, either generally or as respects a particular
process, so dependent on the employment of such young
persons and so organised that the carrying on of the
industry would be seriously prejudiced unless the number
of hours worked in a week by such young persons employed
in that industry or in that process were permitted to exceed
forty-four ; |
(b) that such increased hours would not be likely to be
injurious to the health of the young persons; and
(c) that the work in which the young persons would be
employed in that industry or process is particularly suitable
for young persons, and that their employment would
familiarise them with, and help to train them for employ-
ment in, processes in which older persons are employed in
the industry, and be likely to lead to their permanent
employment in the industry ;
the Secretary of State may direct an inquiry to be held,
and if, as a result of the inquiry, he is satisfied with respect
to all the matters aforesaid, he may make regulations
increasing the total hours, exclusive of intervals allowed
for meals and rest, that may be worked by such young
persons in any week in that class or description of factory,
or, as the case may be, in a particular process carried on
therein, to such figure, not exceeding forty-eight, as may be
specified in the regulations.
The committee were, he thought, all of one mind in
wanting to devise some plan which would not leave
48 hours for young persons under 16 as the permanent
provision of the Bill. This new clause had been brought
forward to fulfil, as far as possible, that object.
But if they were to make a reduction it could not be
done merely by a stroke of the pen. There must be
a suitable interval provided and the new clause
provided that the interval should be a period of two
years from the commencement of the Act. The
new clause was the result of very careful inquiry
in which the Home Office had had the help of trade-
union leaders and employers’ representatives..
Viscountess ASTOR said she was astonished that the
Government at this time of day proposed to allow
children under 16 to work 44 hours a week in factories.
—Sir E. GRAHAM-LITTLE said he was certain that if
the committee pressed for a 40-hour limit it would
carry public opinion with it.—Mr. LLOYD replied
that in this matter they had to secure a practical com-
promise between what should be done for the children
and what were the needs of industry. The absence
of juveniles might very seriously affect the output, and
it might be the wages, of the adult workers.,—
Mr. Ruys DAVIES secured an amendment to make
the interval after the passing of the Act before the
clause came into operation one instead of two years,
but his further amendment to reduce the number of
hours work per week for juveniles in factories from
44 to 40 was negatived by 26 votes to 16.
` Mr. LLOYD moved that a young person who works
in a factory, whether for wages or not, in collecting,
carrying, or delivering goods, carrying messages, or
running errands shall be deemed to be employed in the
factory for the purposes of this Act: provided that
the provisions of Part VI shall not apply, except as
expressly provided, to any such young person who
is employed mainly outside the factory. This was
agreed to.
WORKING HOURS FOR YOUNG PERSONS EMPLOYED
OUTSIDE FACTORIES
Mr. LLOYD moved a new clause defining the
conditions of employment of young persons employed
in the business of a factory wholly or mainly outside
the factory.
(a) The total hours worked, exclusive of intervals
allowed for meals and rest, shall, subject to the provisions
hereinafter contained relating to overtime, not exceed
forty-eight in any week,
(6) The young person shall not be employed con-
tinuously for a spell of more than five hours without an
interval of at least half an hour for a meal or rest, and
where the hours of employment include the hours from
half-past eleven in the morning to half-past two in the
afternoon, an interval of not less than three-quarters of
an hour shall be allowed between these hoursfor dinner,
(c) On at least one week-day in each week the young
person shall not be employed after 1.30 p.m.
(d) The young person, if he has attained the age of
sixteen, may, on occasions of seasonal or other special
pressure or in cases of emergency, work overtime, that is
to say, in excess of the permitted weekly hours, but his
hours of overtime work shall not exceed six in any week
or fifty in any calendar year, and where any employer
has employed overtime any young persons to whom this
section applies in twelve weeks (whether consecutive or
not) in any calendar year, neither he nor any person
succeeding to his business shall employ young persons
to whom this section applies overtime during the remainder
of that year.
(e) The young person shall in every period of twenty-
four hours between mid-day on one day and mid-day
on the next day be allowed an interval of at least eleven
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1376
consecutive hours which shall include the hours from
10 o’clock in the evening until 6:0’clock in the morning.
Sir E. GRAHAM-LITTLE protested against the
five hours’ continuous spell provided in Sub-
section (b) and the 13 hours in Sub-section (e) which.
he said he considered to be too long.—Viscountess
ASTOR concurred.
WORK BEFORE AND AFTER CONFINEMENT
Mr. GRAHAM WHITE moved the following new
clause :—
Any woman or young person employed in a factory
shall be entitled, on the production of a medical certificate
stating that her confinement will probably take place
within six weeks, to leave her work, and she shall not
be permitted to work during the six weeks following her
confinement.
Any woman or young person who shall have left her
work under the provisions of this section shall be entitled to
be re-employed at the end of the period of rest.
He would like, he said, this country to come into
line with the legislation and practice of foreign
countries.
Sir E. GRAHAM-LITTLE said that he hoped the
Committee would not accept the new clause. Any
hard and fast rules for the treatment of confinements
before and after delivery were entirely unscientific.
Every case should be judged onits merits, The whole
question was dealt with in a more sensible way in
the munition factories during the late war when
graded work was found for women during the
pregnancy period.
Viscountess ASTOR said the new clause, if adopted,
would do a great disservice to women. From the
point of view of the State it would be very wise on
the part of the Government to say that a woman
could apply for exemption a month, say, before the
child’s birth as well as a month afterwards, provided
she had full maternity benefit. Sooner or later
we must do something to protect women who went
into industry so that they should have full time for
child-bearing.
Mr. Ruys DAVIES agreed with Lady Astor.
Maternity benefit had not had the effect people
imagined it would. The women complained that
most of the money did not go to them to buy food and
clothing but to the people in the professions who
worked on them. He was satisfied that women in
industry who bore children ought to receive very
much more consideration from the community than
they did.
Mr. R. S. HupDsoN, Parliamentary Secretary to the
Ministry of Health, asked the Committee not to
accept the clause for several reasons. It was a clause
appropriate not to a Factories Bill but to a Public
Health Bill. Secondly, it attempted to put into force
part of a provision included in the draft Washington
Convention. Actually this was made dependent on
the provision that when a woman left work in these
circumstances she was to receive full and adequate
maintenance. He agreed with Lady Astor that
without the provisions of the Washington Convention
this clause would do much more harm than good.
At present any woman who could get a doctor’s
certificate to say that she was incapable of work
was entitled to sign off and receive benefit for four
weeks before the confinement, and no employer
was allowed knowingly to employ a woman within a
certain period after the date of confinement,
The clause was negatived without a division.
PROVISION FOR NURSING MOTHERS
Mr. GRAHAM WHITE moved another new clause :—
A woman or young person employed in a factory who
is nursing her child shall be allowed half an hour twice
a day for this purpose, and time so allowed shall be included
in the calculation of the total hours worked.
Mr. HupDson said he was afraid that he would again
have to ask the Committee not to accept this clause,
PARLIAMENTARY INTELLIGENCE
‘persons working at dangerous machines.
[JUNE §, 1937
because it was not in any way complete. In order
to be effective it would also have to include provisions
for insisting that factories should provide nurseries,
or rooms where the mother could nurse her children,
and some arrangement for bringing the children
from the home to the factory. They were informed
by their scientific advisers that in these times of a
much shorter working day provisions of this nature
were unnecessary, that it was sufficient in normal
conditions for a woman to nurse her baby before
she left for the factory and immediately after she got
home, and that provision for one artificial meal for
a child in the middle of the working period was a
much better arrangement than either expecting the
woman to go back home to nurse the child or arranging
for the child to be brought to the factory.
The clause was negatived without a division.
YOUNG PERSONS AND DANGEROUS MACHINES
Colonel SANDEMAN ALLEN moved a new clause
dealing with the training and supervision of young
He said
that he was not satisfied that in the case of young
persons there was at present sufficient supervision
or that the powers of the Home Secretary were
altogether adequate. The figures for accidents to
young persons had increased in the most alarming
way.—Mr. LLOYD said that the Government were
prepared to accept the clause.
The Committee stage being concluded, the Bill, as
amended, was ordered to be reported to the House.
NOTES ON CURRENT TOPICS
Eradication of Animal Diseases
In the House of Commons on May 27th Mr. W. S.
MorRIson, Minister of Agriculture, made a state-
ment on agricultural policy, in the course of which
he said that the Government proposed to initiate
a large-scale and more comprehensive campaign
for the eradication of anima] diseases in Great Britain.
Their object was to improve the health of livestock
and increase agricultural productivity by seeking
to eliminate what was perhaps the worst of all forms
of wastage and economic loss in agriculture. In
the first instance, efforts would mainly be directed
to the eradication of diseases among cattle. The
scheme would involve an additional charge on the
Exchequer of about £600,000 per annum for the
first four years. It would, however, involve centralisa-
tion of public veterinary services and as against the
increased cost to the Exchequer, the expenditure by
local authorities would be reduced by about £170,000.
Parliamentary authority would be required for these
proposals. The Government were anxious, however,
to lose no time in developing the existing schemes of
control of disease and accordingly he was arranging
at once to amend the Attested Herds Scheme under
the Milk Act, 1934, by providing additional assistance
in England and Wales, as had already been done in
Scotland, to owners of dairy stock who were desirous
of eradicating tuberculosis from their herds. This
revised scheme would become operative on June Ist
next. In the opinion of the Government the proposals
which he had outlined by increasing the productivity
of our agriculture, not only would enable it better
to meet the situation in the event of war, but would
be a substantial aid towards raising efficiency, lowering
costs and establishing the industry on a sounder
economic foundation in time of peace. The necessary
legislation to give effect to these proposals would
be introduced at the earliest possible moment.
Trade Marks and Proprietary Preparations
In the House of Commons on May 27th Dr. BURGIN
(then Parliamentary Secretary to the Board of Trade)
moved the second reading of the Trade Marks
(Amendment) Bill, which has already passed through
the House of Lords. He said that the Bill, generally
speaking, implemented the report of the Depart-
mental Committee which had reviewed the law
‘THE LANCET]
PARLIAMENTARY INTELLIGENCE
[JUNE 5, 1987 1377
relating to trade marks. Clause 4, which was the
main clause of the Bill, dealt with words used as
the name or description of an article, and would —
be of assistance to owners of well-known trade marks.
Mr. A. V. ALEXANDER, in moving the rejection of
the Bill, said that under the measure, if it was not
amended, trade mark infringement would occur
if any one made any reference to other goods which
they were selling under a mark. For example, it
would be impossible to sell a medicine as “ similar
to,” although in effect the two productions might
be identically made of common substance in which
there was no special virtue. The only virtue was
in the use of the adopted trade mark which might
perhaps lead to an exploitation of the public in price
which was absolutely indefensible. |
Mr. BARNES said that in many cases owners of
proprietary preparations were taking advantage
of the present legal protection to practise frauds
on the public in the claims they made regarding
the curative powers of their preparations, and the
prices they charged for them. Safeguards, which
were very essential for the protection of the public
at large, ought to be inserted in the Bill, and obligations
imposed on the owners of proprietary preparations
which would prevent them from exploiting the
public. There ought not to be, as a result of the Bill,
further restrictions in the realm of proprietary goods.
Mr. BROAD expressed the fear that some of the
provisions of the Bill would have the effect of enabling
people to build up a little preserve or monopoly.
He had a case in mind. Some chemical firms were
selling a new and very valuable kind of disinfectant,
for use asa gargle, and so on. It was called “ Thymol”’
and to make it ready for use, it was compounded in
some way with glycerine. Prescriptions were given
by doctors, to be taken to the chemist, for this
“ glycerine of thymol.’’ It became more generally
used, and then a very big American firm put up the
stuff as a standard article, and called it ‘‘ glyco-
thymoline.’”” Other firms began to do the same
thing, calling it ‘‘ glycerinated thymol,”’ or “ glycerine
of thymol.” Since ‘glycerine of thymol’”’ or
“* glycerinated thymol’’ sounded very like “ glyco-
thymoline,”’ it might be said that one could never
sell glycerine in combination with thymol because
of the trade mark ‘“ glyco-thymoline.’”’ He was
afraid of the creation of monopolies in that way.
Dr. BURGIN, replying to the debate, said defensive
trade marks were limited to invented words. There
would, therefore, never be any prohibition on members
of the public using simple language and descriptions
of articles by their proper names. If Clause 15
could really be thought to extend to the verbal boost
by a salesman that a certain thing was in his opinion
as good as, or equivalent to, aspirin then that was
nonsense. If-it was necessary to delete or insert
words to prevent that impression gaining ground, .
it could be done in committee. ‘There was a whole
series of things in regard to which a manufacturer
ought to be able to attach conditions, such as the
packing, stoppering, &c., of his goods. The idea
was that the manufacturer, when an article left his
factory in a particular state, should, if the customer
required it in a particular state, be entitled to say
that it should reach the customer in that state.
The motion for the rejection was withdrawn, and
‘the Bill was read a second time.
In the House of Lords on May 25th the Widows’,
Orphans’, and Old Age Contributory Pensions (Volun-
tary Contributors) Bill was read a second time.
The Children and Young Persons (Scotland) Bill
was read the third time and passed.
In the House of Commons on May 27th, the Public
Health (Drainage of Trade Premises) Bill, which has
already passed through the House of Lords, was read
a second time. .
In the House of Commons on May 28th the Marriage
Bill was read the third time by 190 votes to 37.
QUESTION TIME
WEDNESDAY, MAY 26TH
Approved Societies
Mr. PARKER asked the Minister of Health whether,
in view of the differing practices of various approved
societies in the administration of the National Health
Insurance Act, he was prepared to secure the introduction
of a uniform system under which the rights of insured
persons to benefit were more clearly defined.—Mr. HUDSON,
Parliamentary Secretary to the Ministry of Health,
replied : My right hon. friend has no reason to think that
under the system of administration? of national health
insurance through approved societies insured persons are
not aware of their rights to the benefits provided by the
Act, and, as every insured person has a right of appeal if
he is dissatisfied with the decision of his society on a claim
for benefit, my right hon. friend does not consider that
any such fundamental change as is suggested by the
hon. Member is either necessary or desirable.
Mr. Rays Davies asked the Minister of Health in
connexion with the freedom of choice of approved society
the approximate total membership of the few approved
societies which had agreed not to accept applications
for transfer from members of certain other societies, the
group of societies to which they mainly belonged and the
approximate percentage such membership bore to the
total membership of approved societies.—Sir KINGSLEY
Woop replied: Approved societies entering into arrange-
ments of the kind referred to by the hon. Member are not
required to notify such arrangements to my department,
and do not in fact do so. Iam not therefore in possession
of the information asked for in the question.
THURSDAY, MAY 27TH
Survey of Working-class Budgets
Mr. Tom Smirx asked the Minister of Labour whether
the inquiry into the question of the revision of the cost-
of-living index figure was yet completed; and, if so,
what action he proposed to take.—Mr. ERNEST BROWN
replied: The methods to be adopted in obtaining the
data required for a revision of the basis of the cost-of-
living index figures have for some time been under
consideration by my department, in consultation with an
advisory committee appointed for this purpose. The
committee have recommended that budgets should be
collected giving details of the expenditure of a repre-
sentative sample of some thousands of working-class
families in each of four weeks at quarterly intervals,
beginning in the autumn of this year, and the necessary
preparations for the collection of these budgets are now
being made.
Tuberculosis in Wales
Mr. JAMES GRIFFITHS asked the Minister of Health,
having regard to the high mortality-rate from tuberculosis
in Wales, what steps he proposed to take to deal with the
problem; in particular, what progress was being made
with proposals for rural rehousing; and whether these
plans could be expedited in view of the gravity of the
problem.—Sir KinesLtEy Woop replied: Although the
rate of mortality from tuberculosis in Wales is higher
than in England and Wales as a whole, I may remind the
-hon. Member that there has been a substantial decline
in the rate in Wales as well as in the rest of the country,
this decline amounting to 38 per cent. on the figures for
1935 as compared with 1910. In Wales, the arrangements
for the treatment of tuberculosis are made by the Welsh
National Memorial Association on behalf cf the Welsh
County and County Borough Councils, and a survey of the
services provided by the Association is at present being
undertaken by one of the Medical Officers of the Welsh
Board of Health. I am awaiting the results of this survey
before considering what further measures are required.
As regards the second part of the question, the position
is that 4300 houses are included in the slum clearance
programmes of the Welsh rural authorities and that
1339 replacement houses have been approved, of which
over 700 have been completed. A further 386 houses
have been approved for the abatement of overcrowding
and for general needs. My department is continually
1378 THE LANCET]
watching the progress of the clearance programme with
a View to expediting it where possible.
Committee on Corporal Punishment
Mr. Murr asked the Home Secretary whether he was
now in a position to announce the constitution of the
committee on corporal punishment.—Sir J. Simon replied :
At the suggestion of my right hon. friend, the Secretary
of State for Scotland, it has been decided. that the com-
mittee shall inquire not only into the English but also
into the Scottish law and practice. The committee’s
terms of reference will be : “ To consider the question of
corporal punishmenj in the penal systems of England
and Wales and of Scotland ; to review the law and practice
relating to the use of this method of punishment by
Juvenile Courts, by other courts, and as a penalty for
certain offences committed by prisoners; and to report
what changes are necessary or desirable.” As already
announced, the Hon. Edward Cadogan has consented
to act as chairman of the committee. The following
ladies and gentlemen have now accepted invitations to
serve on it: The Lady Ampthill, C.I., G.B.E.; Mrs. A. E.
Astley ; Prof. J. E. Brierly, O.B.E., J.P.; Mr. E. Ford
Duncannon, D.S.C., M.A., J.P.; Dr. Robert Hutchison ;
Sir William McKechnie, K.B.E., C.B.; Mr. H. R. Tutt;
and Mr. Cecil Whiteley, K.C. My right hon. friend and
I contemplate adding one other woman member, whose
name will be announced as soon as possible.
Duke-Fingard Treatment of Respiratory Disease
Mr. Rowson asked the Minister of Health if he would
set up a committee of inquiry, consisting of an equal
number of medical men and laymen, to inquire into the
efficacy and genuineness of the Duke-Fingard inhalation
treatment for diseases of the respiratory organs, such as
chronic catarrh, bronchitis, bronchiectasis, asthma, and
tuberculosis; and if he would take steps to have this
treatment made available for panel patients under the
Health Insurance Acts who were suffering from chest
complaints.—Sir KinesLtEy Woop replied: No, Sir.
I am not aware of any sufficient reason for instituting a
special inquiry into this treatment. As regards the
second part of the question, an insurance practitioner
is free to give such treatment as in his judgment is
appropriate for his patients.
Watered Milk
Mr. Davin Apams asked the Minister of Health whether
he had now decided to take further steps to protect the
public against watered milk, in view of the failures in
recent prosecutions in cases of proved watering to obtain
convictions before the magistrates.—Sir KINGSLEY Woop
replied : I have considered this matter again in the light
of the recent prosecutions to which the hon. Member
drew my attention. I understand that there was conflicting
evidence in these cases, and that the magistrates in their
discretion decided not to convict. In these circum-
stances, I do not as at present advised propose to introduce
any fresh legislation on this subject.
Admission of Foreign Doctors and Dentists
Mr. Rostron Dtckworts asked the Home Secretary
what was the present policy of his department with
regard to the admission into this country of foreign doctors,
dentists, research workers, and students; whether he
could give the aggregate number permitted to settle
here in the last two years; and what representations
he had received from professional bodies in this country
on the subject of this form of competition.—Mr, GEOFFREY
Lioyp, Under-Secretary, Home Office, replied: The
policy is to restrict closely the admission of foreign doctors
and dentists who wish to set up in practice in this country
after being admitted to the British Medical and Dentists
Registers. Since March, 1935, the rule has been not to
permit foreigners to engage in medical practice in the
United Kingdom save in the most exceptional circum-
stances; the same rule has béen applied in the case of
foreign dentists since February, 1936. No general figures
of the numbers to whom permission to practise has been
granted are available. The question of the admission of
refugee doctors and dentists from Germany has been the
PARLIAMENTARY INTELLIGENCE
[JUNE 5; 1937
subject of representations from and discussion with the
various professional bodies concerned and separate figures
have been kept of the numbers of refugee doctors and
dentists to whom permission to set up in practice has been
granted. They are 183 doctors and 78 dentists, of whom
the large majority, in the case of the doctors, had either
been granted permission to practise or had commenced
their studies for a British degree before March, 1935, and
in the case of the dentists had been admitted to the
Dentists Register before February, 1936. As regards
research workers and students whose work does not
involve employment in the service of a person or firm in
this country, no obstacles are placed in the way of their
admission provided their maintenance here is assured,
but they are expected to leave on the completion of their
research or study. If employment is involved they are
not admitted unless in possession of a permit issued by the
Minister of Labour to their prospective employer in
accordance with Article 1 (3) (6) of the Aliens Order, 1920.
MONDAY, MAY 31ST
Spanish Refugee Children and Public Assistance
Mr. MEssER asked the Minister of Health if he was
prepared to sanction public assistance committees provid-
ing accommodation for Spanish refugee children in homes
or institutions at public expense.—Mr. BERNaAyYs, Parlia-
mentary Secretary to the Ministry of Health, replied:
As financial responsibility for the Spanish refugee children
has been undertaken by a number of voluntary bodies,
my right hon. friend is not prepared to sanction expenditure
on their maintenance by local authorities from public
funds.
Ventilation of Telephone Kiosks
Sir Murray SUETER asked the Postmaster-General
whether any recent experiments had been conducted in
connexion with ventilating public telephone kiosks in
constant use; and whether some simple ventilation
contrivance could be devised and, if satisfactory, adopted,
in the interests of public comfort and health, in positions
where a 100 per cent. noise-proof telephone kiosk was not
necessary.—Major TRYON replied: If the question refers
to kiosks in the open, of which practically all are necessarily
on or near the highway, my information is that the noise
problem is far more important than that of ventilation.
If, however, the question refers to cabinets indoors, I
can assure my hon. and gallant friend that the question
of improvement in ventilation is being actively pursued.
Compensation for Silicosis
Mr. JAMES GRIFFITHS asked the Home Secretary if
he was aware that the South Wales Coalowners Indemnity
Society were refusing to pay compensation to men
certified by the medical board to be disabled by silicosis ;
that the reason given for this refusal was that the society
proposed to institute proceedings for the purpose of
seeking a declaration that the silicosis orders issued by him
were ultra vires; and that meantime these men were
compelled to seek public assistance; and what action
he proposed to take in the matter.—Sir SAMUEL HOARE
replied : I have no information to the effect suggested in
the question. Ishould be prepared to consider any fuller
particulars which the hon. Member may send me, but I
have, of course, no power to interfere with any legal
proceedings.
Mr. GRIFFITHS asked if Sir Samuel Hoare did not consider
it deplorable that employers should try to take advantage
of some possible technical flaw to deprive men suffering
` from this disease of compensation; and if he would give
an assurance, if the courts held that this order was ultra
vires, that these men would not be penalised but that the
Government would bring in a new order to give them
the compensation to which they were entitled ?
Sir SAMUEL HOARE said he agreed that this was a matter
of great importance, but he would rather not express an
opinion until he had further facts.
— ħama
ROYAL SOCIETY OF ARTS.—The Albert medal of this
society for 1937 has been awarded to Lord Nuffield for
“ services to industry, transport, and medical science.”
‘THE LANCET]
[JUNE 5, 1937 1379
PUBLIC HEALTH .
‘The Bournemouth Outbreak of. Enteric Fever
_ Tae official report on the outbreak of enteric fever
in Bournemouth, Poole, and Christchurch last summer
has now appeared,! and proves to be well worth
waiting for. In his explicit prefatory note Sir
Arthur MacNalty refers to the certainty that raw
milk was the vehicle of infection and to the strong
probability that the retailers bulk supply was
infected by a relatively small contribution, itself
produced without apparent fault. How the milk
became infected is not actually proved, but the late
Dr. Vernon Shaw, who compiled the report now
published, gives sound reasons for assuming a
connexion between this outbreak and a particular
‘“ carrier.” The sequence of events was as follows:
On August 21st the Ministry of Health received
a telegram from the medical officer of health for
Poole who reported a notification of a case of enteric
fever, stated that he had reason to believe others
might occur and asked for assistance. An hour later
a telegram was received from the deputy medical
officer of health for Bournemouth reporting some
cases of “suspected food poisoning enteric type,”
and also asking for assistance.
Dr. Shaw was sent to investigate and on August 22nd
‘was informed that 30 cases of enteric fever had been
notified during the preceding 24 hours, and that
a very large number of other potential victims were
under observation. The patients were scattered
throughout the three towns, without distinction
of age, sex, occupation, or social status. Dr. Shaw
ascertained that the only factor common to all the
patients was the consumption of raw milk retailed
by one distributor. This distributor, acting on
Dr. Shaw’s advice, adopted a method of commercial
pasteurisation (heating the milk to 160° F.) for the
whole of his supply, and distributed no unpasteurised _
milk after the morning round on August 22nd.
It was correctly anticipated that this would prevent
any further infection direct from the milk-supply ;
and that therefore no notification of a primary case
of enteric fever would be received after the expiration
of the incubation period 2 calculated from August 22nd
plus a week or ten days during which a doctor might
not be called in. Some of the alleged late cases were
in fact relapses in patients who had failed to call in
a doctor in the critical illness. So fər as is known
only four secondary cases occurred. Dr. Shaw con-
cluded that the milk had been infective for a period
of about 31 days preceding August 22nd. The total
number of known cases finally amounted to 718 (518
residents and 200 visitors). The deaths of residents
numbered 5l.
No source of infection could be discovered amongst
the distributors or retailers. At the 37 scattered
farms from which the milk was collected, 192 persons
were examined, and at one farm 2, the wife and son,
aged 12, of the farmer, were found to have enteric
fever. Dr. Shaw came to the conclusion that neither
was the cause of the outbreak, but that the milk
produced at the farm was the source of infection of the
retailer's supply and of the farmer’s wife.
In the adjoining house a fatal case of enteric fever
1 Report on an Outbreak of Enteric Fever in the County
Borough of Bournemouth and in the Borougbs of Poole and
Christchurch. By W. Vernon Shaw, O.B.E.,M.D. Rep. publ.
Hlth Subj. Lond. No. 81. 1937. London: H.M.
Stationery Office. Pp. 25. 9d.
2 For purposes of this inquiry an incubation period of
14 days was assumed. Dr. Shaw observes that most authorities
utit at 12-14 days; that it probably varies with the dose of the
fnfecting organisms, put the limits rarely lie outside 7-17 days.
had occurred in May, 1934, when the water-supply
of both houses—common to eight other houses in
the vicinity—was suspect. It was derived from a
well 162 feet deep, situated 100 yards from a small
stream which ran within a few yards of the two
houses. Repeated examination of the well water
proved that it was liable to pollution, although at
times it yielded a good potable water. At a point
about half a mile up stream from the farm the sewage
effluent from a house was found to be discharging
into the stream. Bacteriological examination of the
effluent proved negative for B. typhosus in September
and early October (4 tests), but the organism was
present in large numbers late in October (2 tests). <
An occupant of the house during the material periods
was found to be excreting typhoid bacilli in his
feeces ; he complied at once with the suggestions made
to eliminate any further contamination of the stream.
Dr. Shaw was satisfied that the outbreak was due
to the consumption of raw milk, contributions to the
supply having been infected by the contaminated
water of the stream. How the infection was conveyed
from the stream to the milk, whether by the use of
the water of a certain well or by the cows subsequent
to their drinking at the stream, was not determined.
The suggestion that a cow may excrete typhoid
organisms in her dung or even in her milk is apparently
a novel one which Dr. Shaw found himself unable to
reject.
Sir Arthur MacNalty, from the results of the inquiry,
draws the inevitable conclusion that “in the
present state of our knowledge, where large milk
supplies and commensurate risk are involved, the
only practicable way to reduce the risk of such
outbreaks to a minimum is by pasteurisation.”’
IRELAND |
(FROM OUR OWN CORRESPONDENT)
THE NATIONAL HOSPITALS ASSOCIATION :
A SET-BACK
A LITTLE over twelve months ago a movement was
begun to form an Association of Hospitals in Ireland
on lines similar to the associations which exist in
Great Britain, the United States of America, and
other countries. Its functions were to be consulta-
tive, advisory, and educative. Some fifty hospital
authorities expressed interest in the proposal. They
included the governing bodies of nearly all the
voluntary hospitals and a large proportion of the
local authorities which have the control of hospitals.
A preliminary meeting of representatives was held
just a year ago and a provisional committee was
appointed to draft a constitution. This task had been
carried out and a meeting was about to be called to
consider the draft scheme, when it was discovered
that the local authorities controlling the rate-
- supported hospitals had no power to contribute
toward the expenses of such an association. A deputa-
tion waited on the Minister for Local Government
and Public Health, who explained that he had no.
power to sanction any such payment by the local
authorities. An appeal has been made to him that
he should, at the earliest opportunity, introduce
legislation to legalise such payment. As a dissolution
of the Dáil is to take place within the next few
weeks immediate legislation cannot be expected, and
the provisional committee of the Association has had
no option but to advise that consideration of the
1380
draft constitution be postponed until legislation has
been carried. The voluntary hospitals could not,
by themselves, bear the financial burden of a hospitals
association, and the project cannot be pursued unless
the local authorities are given power to join. It is
pointed out that the first public suggestion for the
formation of a hospitals association came from the
Hospitals Commission, the body appointed by the
Minister to advise him how best to apply sweepstake
funds to the development of the hospital system of
the Irish Free State. In the report of the Com-
mission published early last year, comment having
been made on the lack of, and need for, coöperation
between the hospitals, the formation of a hospitals
association was advised. It is further pointed out
.that there are many precedents for permitting local
authorities to pay the expenses of delegates sent to
various congresses and conferences—health and
engineering, for example, and that one important
organisation in JIreland—the General Council of
County Councils—is supported by the subscriptions
of the several county councils as members. Have
the payments in these cases been irregular? If so,
THE LANCET]
MEDICAL NEWS
[JUNE 5, 1937
it is high time they were regularised, and such
developments as a hospitals association made possible.
THE TWENTY-FIRST HOSPITAL SWEEPSTAKE
The draw of the twenty-first of the Irish Hospital
Sweepstakes was held last week. As a rule the
receipts for the sweepstakes on the Derby are smaller
than those for the two other sweepstakes of the
year, because the period of preparation is briefer.
On this occasion, to the surprise of everyone, the
receipts showed a slight advance on those for the
Grand National, the draw for which was only two
months before. In opening the draw Lord Powers-
court, chairman of the Associated Hospitals Com-
mittee, was able to announce that the total proceeds
to the hospital funds up to the present amounted to
£11,118,859. Three county hospitals, eight district
hospitals, and three fever héspitals had already been
completed out of these funds, and nineteen other
hospitals were in course of construction. He had
recently received from the Minister a most encouraging
and satisfactory assurance as to the prospects of his
scheme of hospitalisation.
MEDICAL NEWS
University of Cambridge
On May 28th the following degrees were conferred :
M.D.—J. B. Harman.
M.B., B.Chir.—J. W. Crofton., J. W. Hannay, T. E. S. Lloyd,
W.J. E. Phillips, and G. F. Wright.
M.B.—*F. at Berridge, K. O. Black, F. G. Booker, F.
Braithwaite, T. C. Gipson, A. C. L. Houlton, A. R. Kelsall,
C. R. McLaughlin, L. J. Panting, T. L. H. Shore, R. H. A.
Swain, W. F. Walton, and J. Woodrow.
B.Chir.—*T. M. Daniel.
* By proxy.
University of Oxford
In future any student who has successfully completed
the first three years of a medical course at any university
approved by the hebdomadal council may be admitted
to the status and privileges of a senior student of the
University of Oxford.
It is hoped to make an election at the end of this term
to a William Hulme lectureship in physiology at Brasenose ©
College, which will have an initial stipend of £350 a year.
It will be tenable for three years and may be renewed for
a further two years. Applications should be sent to the
principal of Brasenose College before June 26th.
University of Glasgow
On Wednesday, June 9th, at 4.15 P.M., Prof. Ferdinand
Sauerbruch, director of the University Surgical Clinic
at Berlin, will deliver the fourth Macewen memorial
lecture at the university. He will speak on advances
in modern surgery and there wilf be a demonstration
by cinematograph on the artificial hand which can be
moved at will.
Society of Apothecaries of London
At recent examinations the following candidates were
successful :
Surgery.—J. R. Audy, Guy’s Hosp.; A. W. Box, Univ. of
Camb. and Guy’s Hos J. W. P. Morgan, St. Mary’s Hosp. ;
and W. G. Zorab, Guy’s Hosp.
Medicine.—A. *Bagon, Univ. of Manch.; P. A. Gardiner,
Guy’s Hosp. ; E. de C. Kite, Univ. of Glaag. ; ; B. A. R. Pitt
Guy’s Hosp.; and R. H. S. Thompson, Univ. of Oxford and
Guy’s Hosp.
Forensic Medicine. SA Bagon, Univ. of Manch. P. K
Gardiner, Guy’ s Hosp. ; E. de C. Kite, Univ. of Glasg. ; B.A.R
Pitt, Guy’s Hosp. ; and R. H. S. Thompson, Univ. of Oxford
and ‘Guy’ 8 Hosp.
Midwifery.—F. Bastawros, Royal Colleges, Pan A. W.
Box, Univ. of Camb. and Guy’ s Hosp.; . D. B. Perkins,
Guy’s Hosp. ; ; G. L. Young, Univ. of Camb. aa St. Bart.’s
Hosp.; and W. E. Young, Univ. of Oxford and Guy’s Hosp.
The following candidates, having completed the final
examination, are granted the dploma of the Society
entitling them to practise medicine, surgery, and mid-
wifery : A. Bagon, P. A. Gardiner, B. A, R., Pitt, R. H. S.
Thompson, and W. G. Zorab,
University of London
On May 19th the degree of Ph.D. in medical vital
statistics (non-clinical) was awarded to Ernest Lewis-
Faning.
University of Durham
At a special convocation to be held in connexion with
the centenary celebrations of this University on July lst
and 2nd the hon. degree of D.C.L. will be conferred on Sir
Cuthbert Wallace, president of the Royal College of
Surgeons of England.
British Homæœæopathic Congress
This meeting will take place at the Langham Hotel,
London, W., on June 17th and 18th. Further particulars
may be had from the secretary, 69, Elizabeth-street,
London, S.W.1.
Bedminster Health Centre
The Lord Mayor of Bristol has opened a new health
centre at Bedminster which provides all facilities for the
supervision‘ of the health of the pre-school and school
child, and for the expectant and nursing mother. The
routine medical inspections of school-children attending
24 neighbouring schools and the maternity and child
welfare services for South Bristol and Knowle will be
concentrated here.
Silicosis Symposium
The third Silicosis Symposium will be held at the
Saranac Laboratory, Saranac Lake, N.Y., in connexion
with the Trudeau School of Tuberculosis, from June 21st
- to 25th. The meetifig will be opened by Dr. Leroy Gardner,
director of the laboratory, and at the first session Dr.
A. J. Lanza will read a paper on the significance of the
silicotic problem and Dr. R. R. Sayers one on the etiology
of silicosis. Prof. Philip Drinker will also open a discussion
on dust concentrations and their measurement. On the
second day Dr. Gardner will give the opening address
in a discussion on the pathology of the pneumoconioses,
while Prof. W. S. McCann will speak on the physiology
of the fibrotic lung. On June 23rd Dr. E. P. Pendergrass
will discuss roentgenologic aspects of the normal and
silicotic lung and Dr. H. L. Sampson the roentgenologic
diagnosis of silicosis. On June 24th Dr. A. R. Riddell will
read a paper on the clinical picture and diagnosis of
silicosis with consideration of disability, and Mr. D. E.
Cummings on the occupational history. Dr. Riddell
and Prof. Drinker will afterwards discuss the control
of the disease from the medical and engineering aspects.
At the last session Mr. Cummings will consider the
administrative aspects of silicosis and Mr. T. E. Water
legislative control and compensation.
THE LANCET]
National Hospital for Diseases of the Heart
On Thursday, June 10th, at 5 P.M., at 1, Wimpole-street,
London, W., Dr. C. Laubry, professor of cardiology in the
University of Paris, will deliver the St. Cyres lecture of
this hospital. His title will be Considérations Patho-
géniques et Cliniques sur les Rhythmes de Galop.
British Social Hygiene Council
Prof. James Young, director of the department of
obstetrics and gynæcology at the British Postgraduate
Medical School, has been elected chairman of the medical
advisory board of the Council in succession to Sir Farquhar
Buzzard.
Research Defence Society
At a meeting of this society to be held at the London
School of Hygiene, Keppel-street, London, W.C., at 3 P.M.,
on Tuesday, June 15th, Prof. Grey Turner will deliver the
eleventh Stephen Paget memorial lecture. He will speak on
what research owes to the Paget tradition.
Medical Diary
Information to be included in this column should reach us
én 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, June 8th.
Therapeutics and Pharmacology. 5 P.M. Annual general
meeting. Dr. A. Loeser (Freiburg): Hyperthyroidism
and the Thyrotropic Hormone of the Pituitary.
FRIDAY.
Ophthalmology. 5 P.M. Annual general meeting. Mr.
E. F. King: The Epithelial Growths of the Con-
junctiva and Cornea.
MEDICAL SOCIETY OF INDIVIDUAL PSYCHOLOGY.
THURSDAY, June 10th—8.30 P.M. (11, Chandos-street, W.),
Dr. T. A. Ross: The Psychological Approach.
KENSINGTON MEDICAL SOCIETY.
- TUESDAY, June 8th.—8.30 p.m. (St. Mary Abbots Hos-
ital, W.), Mr. V. B. Green-Armytage: Tbe Value of
ystero-salpingography in General Practice.
SOUTH-WEST LONDON MEDICAL SOCIETY.
WEDNESDAY, June 9th.—9 P.M. (Bolingbroke Hospital
Wandsworth Common), Dr. C. E. Lakin: Physica
Signs: Are They Worth While ? (Bolingbroke lecture.)
LECTURES, ADDRESSES, DEMONSTRATIONS, &c.
TUBERCULOSIS ASSOCIATION.
THURSDAY, June 10th, FRIDAY and SATURDAY.—Annual
Provincial Meeting at the Central Library, Manchester.
NATIONAL HOSPITAL FOR DISEASES OF THE HEART.
THURSDAY, June 10th.—5 P.M. (1, Wimpole-street, W.),
Prof. Ch. Laubry: Considérations Pathogéniques et
ae sur les Rhythmes de Galop. (St. Cyres
ecture.
Saat gee POSTGRADUATE MEDICAL SCHOOL, Ducane-
road,
‘TUESDAY, June 8th.—4.30 P.M., Dr. D. Hunter:
tional Diseases.
WEDNESDAY.—Noon, clinical and pathological conference
(medical). 2 P.M., Dr. Janet Vaughan: The Reticulo-
cytes. 3 P.M., clinical and pathological conference
(surgical). 4.30 P.M., Prof. M. Greenwood, F.R.S.:
Experimental Epidemiology.
- THURSDAY.—2.15 P.M., Dr. Duncan White: Radiological
Demonstration. 3 P.M., operative obstetrics. 3.30 P.M.,
Mr K. Henry: Demonstrations of the Cadaver on
Surgical Exposures.
FRIDAY.—2.30 P.M., Mr. Russell Howard :. Diseases of the
Breast. 3 P.M., clinical and pathological conference
(obstetrics and gyneecology).
Daily, 10 a.M. to 4 P.M., medical clinics, surgical clinics, and
operations, obstetrical and gynecological clinics and
operations, refresher course for general practitioners.
WEST LONDON HOSPITAL POST-GRADUATE COLLEGE,
Hammersmith, W.
MONDAY, June 7th.—10 A.M., Dr. Post : X Ray Film Demon-
stration. Skin clinic. 11 A.M., surgical wards. 2 P.M.,
operations, surgical, and gynecological wards, medical,
surgical, and gynecological clinics. 4.15 P.M., Mr.
Green-Armytage: Abortion.
TUESDAY.—10 A.M., Medical wards. 11 A.M., surgical wards.
2 P.M., operations, medical, surgical, and throat clinics.
4.15 P.M., Dr. Hugh Gordon: Treatment of Acne.
WEDNESDAY.—10 a.M., children’s ward and clinic. 11 A.M.,
medical ,wards. 2 P.M., gynecological operations,
medical, surgical, and eye clinics. 4.15 P.M., Mr.
Harvey Jackson: Diseases of the Rectum.
Occupa-
MEDICAL DIARY .—-APPOINTMENTS
[JUNE 5, 1937 1381
THURSDAY.—10 A.M., neurological and gynecological
clinics. Noon, fracture clinic. 2 P.M., operations,
medical, surgical, genito-urinary, and eye clinics.
4.15 P.M., Mr. Simmonds: . Pyloric Stenosis.
FRIDAY.—10 A.M., Medical Wards, skin clinic. Noon,
lecture on treatment. 2 P.M., operations, medical,
surgical, and throat clinics. 4.15 P.M., Mr. Vlasto :
Hoarseness.
SATURDAY.—10 A.M., children’s and surgical clinics. 11 A.M.,
medical wards.
The lectures at 4.15 P.M. are open to all medical prac-
titioners without fee.
HOSPITAL FOR SICK CHILDREN, Great Ormond-street,
London, W.C. “
THURSDAY, June 10th.—2 P.M., Mr. T. Twistington Higgins :
Examination of the Urinary Tract. 3 P.M., Dr. Alan
Moncrieff: The Purpuras.
Sat petient clinics daily at 10 a.M. and ward visits at
P.M.
ST. MARY’S HOSPITAL, W.
TUESDAY, June 8th.—5 P.M. (Institute of Pathology and
Research), Dr. Wilson Smith : The Influenza Problem.
SOUTH-WEST LONDON POST-GRADUATE ASSOCIATION.
WEDNESDAY, June 9th.—Visit to Ford Motor Works,
Dagenham.
ASSOCIATION OF CLINICAL PATHOLOGISTS.
SATURDAY, June 12th.—9.30 a.M. (Royal East Sussex
Hospital, Hastings), Discussion on Blood Transfusion
and Saline Injections to be opened by Prof. A. E.
Boycott, F.R.S. Subsequent speakers: Dr. H. F.
Brewer: (Organisation : Medical Administration
of a Voluntary Blood Transfusion Service); Dr.
S. C. Dyke (Organisation of a Blood Transfusion
Service); Dr. J. A. Boycott (Grouping of Donors and
Recipients); Dr. H. L. Marriott and Dr. A. Kekwick
(Continuous Drip Blood Transfusion); Dr. R. J. V.
Pulvertaft (Abnormal Reaction following Blood
Transfusion) ; Dr. Lazarus-Barlow (Direct
Blood Transfusion); Dr. F. A. Knott (Transfusion in
Aplastic Anæmia and Agranulocytosis); Dr. Norah
Schuster (Storage of Blood); Dr. N. Hamilton Fairley
(Intravenous Hzmolysis with Special Reference to
Pseudo-Methremoglobin Production); Dr. Robert
Otticer (Post-operative Saline Treatment). Dr. Janet
Vaughan: Demonstration of Specimens from a Case of
Osteosclerosis with Leucoerythroblastic Anemia. Dr.
Lazarus-Barlow : New Method of Filtering Agar
Culture Media.
MANCHESTER ROYAL INFIRMARY.
TUESDAY, June 8th.—4.15 P.M., Dr. E. W. Twining:
The Radiology of Intrathoracic Suppuration.
FrRipay—4.15 P.M., Dr. Norman Kletz: Demonstration
of Medical Cases. i .
Appointments
Carson, James, M.D. Belf., D.P.H., Deputy Medical Super-
intendent at Booth Hall Hospital, Manchester.
Donaca, I., M.D. Lond., Clinical Pathologist to the Mount
Vernon Hospital, Northwood.
GLASS, MARGARET A., M.B. Glasg., D.P.H., Assistant School
Medical Officer for Barking. :
Hoce, WILLIAM, M.B. Lond., D.P.H., Assistant Medical Officer
of Health for Barking.
Hui, E. R., M.B. Belf., D.P.M., Deputy Medical Superin-
tendent at Calderstones Certified Institution, Whalley.
LAURE, J., M.B., M.R.C.P., F.R.C.S. Edin., Medical Super-
intendent at the Sharoe Green Hospital, Preston.
*O'KEEFFE, E. J., M.R.C.S. Eng., D.P.H., Assistant Medical
Officer of Health for Stepney. |
Toven, J. S., M.B. Edin., Surgical Registrar at Aberdeen Royal
Infirmary.
British Postgraduate Medical School.—The following appoint-
ments are announced :—
CASTLEDEN, L. I. M., M.D. Lond., Demonstrator in Clinical
Medicine ;
HorrMan, H. L., M.B., M.R.C.P. Lond., Demonstrator in
Clinical Medicine; and i l
KREMER, M., M.D., M.R.C.P. Lond., Demonstrator in Clinical
Medicine.
Bristol Royal Infirmary.—The following appointments are
announced :—
Buss, G. B., M.B. Brist., D.M.R.E., Hon. Radiologist ;
ADAMS, S. B., M.B. Brist., D.M.R., Hon. Radiologist ; and
DUNLEVY, A. A., M.B. Dubl., D.M.R.E., Radiodiagnostician.
Certifying Surgeons under the Factory and Workshop Acts:
. Dr. H. Morr (Currie District, Midlo ); Dr. G. O. TAYLOR
(Dorchester District, Dorset); Dr. ANDREW Law, jun.
Kilbride District, Bute); Dr. A. E. STRUTHERS (Paisley
District, Renfrew); Dr. W. E. Ivers (Youlgreave District,
Derby); Dr. E. E. STEPHENS (Edgware District, Middlesex);
Dr. J. B. DONALD (Stranraer District, Wigtown). :
Medical Referee under the Workmen’s Compensation Act,
1925: ATHOLL ROBERTSON, M.D., of Oban Argyll, for the
Oban Sheriff Court District (Sheriffdom of Argyll). |
* Subject to confirmation.
`
1382 THE LANCET]
VACANCIES
[JUNE 5, 1937
V acancies 5
For further information refer to the advertisement columns
averen Royal Infirmary.—Sen. Cas. O. for Out-patient Dept.,
tne “McCall Maternity Hosp., 165, Clapham-road, S.W.—
Sen. and Jun. H.S.’s
Ashton-under-Lyne District Infirmary.—Cas. H.S., £180.
Aylesbury, Royal Buckinghamshire Hosp.—Sen. Res. M. O., at
rate of £200..
Barnsley, Beckett ‘Hosp. and Dispensary.—H.S., £200.
Bath and Wessex Children’s Orthopedic Hosp., Conte Park.—
H.S., at rate of £120.
Bath, Royal United Hosp.—Hon. Asst. to Fracture Service.
Also H. P., at rate of £150.
Battersea General Hosp., Battersea Park, S.W.—Res. H.P.
and Cas. O., at rate of £120
Bedford County "Hosp. —Second H. S., at rate of £15
Birmingham, Dudley-road_Hosp. —Jun. M.O , at sis of £200.
sar RA, Selly Oak Hosp.—Jun. M.O.’s, each at rate of
Bolton Royal Infirmary.—H.P. and Two H.S.’s, at rate of £200
and £150 respectively.
Bradford Children’s Hosp.—H.S., £150.
Bradford Royal Eye and Ear Hosp. —Two H.S.’s, each £180.
Brighton Municipal Hosp.—Third Res. Asst. M.O. ., £300.
Brighton, Royal Alexandra Hosp. for Sick Children.—H.P., £120.
Brighton, Royal Sussex County Hosp.—Hon. Surg. Reg. H.P.,
£150. Also Cas. H.S., £120.
Bristol General Hosp. —Two H.P.’ s, Three H.S.’s, Res. Obstet.
, H.S. to Spec. Depts, each at rate of £80. Also Cas. H.S.,
at rate of £100.
British Postgraduate Medical School, W.—Three H.S.’s to
Surgical Unit, at rate of £105
Burnley Municipal General Hosp. —Jun. Res. M.O., at rate of
15
Canterbury, Kent and Canterbury Hosp.—Hon. Surgeon.
Cardiff, King Edward VII Welsh National Memorial Assoc.—
Res. Asst. Tuber. M.O., £500
Central Middlesex County Hosp., Willesden. —Visiting Ear, Nose,
and Throat Surgeon, 3 guineas per session. Two Res. Asst.
M.O.’s, each £400. "Also Res. Cas. M.O., £350.
Cheltenham General and Eye Hosps.— H.P., £150.
ee North ‘Derbyshire Royal Hosp. —H.S., at rate
City of London Mey, Hosp., City-road, E.C.—Asst. Res.
.O., at rate of £
Colchester, Essex nar Hosp. —H.S., £175.
Colonial Ae Service.—Associate Prof. of Medicine, Singa-
ore, £11
Coveniny and Warwickshire Hosp.—Res. H.S., Cas. O., and Res.
H.S. to Aural and Ophth. Depts., each "£150.
Croydon Mental Hosp., Upper Warlingham. —Asst. M.O., £400.
Derbyshire Hosp. for Sick Children.—Res. H.S., at rate of £130.
Derbyshire Royal Infirmary.—Cas. O. and Orthopsedic H.S., £150.
see a Mental Hosp., Downpatrick.—Jun. Asst. M.O.,
Dreadnought Hosp., Greenwich, S.E.—Receiving Room Officer,
at rate of £200. Also H.P. and H. S., each at rate of £110
Durham County Council. eer aes County M.O.H., £960. Also
Asst. Welfare M.O.,
East Ham Memorial os us ee eee g E.—Hon. Surgeon
to Orthopsedic Dept. ’Also two Anesthetists, each 1 guinea
per session.
Gloucestershire Royal Infirmary and Eye Institution.—H.P.
and H.S., each at rate of £150.
Golden-square Throat, Nose, and Ear Hosp., W.—House Anws-
thetist and H.S., £150 "and £100 respectively.
Hampstead General and North-West London Hosp., Haverstock-
hill, N.W.—Cas. Surg. O. for Out-patient Dept. and H.S.,
each at rate of £100.
Herefordshire General Hosp.—Res. Surg. O. and H.P., £150 and
£100 respectively.
Hertford County Hosp.—Res. Surg. O., at rate of £250.
Henn Ana Isleworth Borough.—Asst. "M.O.H. and School M. O.,
s50
Holland (Lincolnshire) County Council. —Asst. M.O.H., £600.
AR e Tropical Diseases, Gordon-street, W.C.—H. P., at rate
£120
Huddersfiad, St. Luke's Hosp.—Res. M.O., £200.
Hull Royal "Infirmary. —Second H.P. and H.S. to Ophth. and
Ear, Nose and Throat Depts., each at rate of £150. Also
H.S. for Branch Hospital, at rate of £160.
Ilford, King George Hosp.—Two H.S.’s, each at rate of £100.
Institute for the Scientific Treatment of Delinquency, Portman-
street, IV. —Med. Reg., £300.
Ipswich, "Kast Suffolk and Ipswich Hosp.—Cas. O., H.S. to
rthopeedic and Fracture Dept., and H.S. to General
Surgeon and Genito-Urinary Surgeon, each £144.
Jamaica, Lunatic Asylum.—Med. Supt., £750.
Kettering and District General Hosp. —Res. M.O. and Second
"Res. M.O., at rate of £160 and £140 respectively.
Lancaster County Mental Hosp.—Asst. M.O., £500.
Leicester Royal Infirmary.—Res. Radiologist, at rate of £200.
Liverpool County Mental Hosp., Rainhill—Second Asst. M.O.,
£650. Also Asst. M.O., 7- guineas per week.
fener Ped gee cera Hosp., Hope-street.—Res. M.O., at rate
of £120.
London County Council.—Asst. M.O.’s (Grade I), each £350.
Asst. M.O.’s (Grade II), each £250. Also Part-time M.O.
£100.
for Ashford Residential School, £285.
London Jewish Hosp., Stepney Green, E.—Rces. Cas, O.,
London University.—Laura de Saliceto Studentship, £150.
Also Examinerships.
Maidenhead Hosp.—Res. M.O., at rate of £150.
Manchester, Ancoats Hosp. —H. S. to Ear, Nose, and Throat
Dept., "at rate of £100.
Manchester « and Salford Hosp. for Skin Diseases.—H.S., at rate
o
Manchester, Booth Hall Hosp. for Children.—Res. Surg. O.,
Manchester Ear Hosp., Grosvenor-square.—Res. H.S., £120.
Manchester Park Hosp., Davyhulme.—Second Res. M.O., at
rate of £225.
Manchester Royal Children’s Hosp.—Sen. M.O., £300.
Manchester Royal Infirmary.—Jun. Asst. M.O. (Locum) to
Radiological Dept., 8 guineas per week.
Manchester, St. Mary’s Hosps. —H.S.’s, each at rate of £50.
Manchester, Withington Hosp.—Res. Obstet. O., £350.
Res. Asst. M. 2> at rate of £200. .
Marie Curie Hosp. , Fitzjohn’ s-avenue, N.W.—Asst. Director.
Middlesbrough, oti Riding Infirmary.—Sen. H.S. and
Third H.S., at rate of £175 and £140 respectively.
National Temperance Hosp., Hampstead-road, N.W —Cas. O.
at rate of £120.
Neue atie General Hosp.—Two H.S.’s and H.P., cach at rate of
5
e UO: -Tyne, Barrasford Sanatorium.—Res. Med. Asst.,
neu Or Mon., Royal Gwent Hosp.—Two H.S.’s, each at rate of
Norwich, Jenny Lind Hosp. for Children.—Res. M.O., £120.
Norwich, Norfolk and Norwich Hosp.—Two General H.S.’s,
each £120.
NOOR ao County Council.—H.S. for City Hosp., at rate of
Also
Nottingham General Hosp.—Res. Cas. O. and H.S. to Ear, Nose,
and Throat Dept., each at rate of £150.
Paddington Green Children’s Hosp., W.—H.S., at rate of £150.
Penshurst, Cassel Hosp. for Functional N ervous Disorders,
Swaylands. —Medical Director, £1200-£1500.
Plymouth City Hosp.—Deputy Med. Supt., £450.
Plymouth, Prince of Wales’s Hosp., Devonport. —Jun. H.S., at
rate of £120.
Pontefract General Infirmary.—Jun. Res. M.O., at rate of £150.
Preston County Borough. dal PTS School M.O., 500
Princess Louise Kensington Hosp. for Children, St. Quintin-
avenue, W.—H.S., at rate of £120.
Tuma, Hosp., Lower "Common, S.W.—Jun. M.O., at rate of
Reading, Royal Berkshire Hosp.—Res. Cas. O., at rate of £150.
Richmond, Surrey, Royal Hosp.—Jun. H.S., at rate of £100.
Rotherham een .—H.S. for Ophth. and Ear, Nose, and Throat
epts.
Royal Northern Hosp., Holloway, N.—H.S., at rate of £70.
St. Helens County Borough. —Asst. M.O.H., £500.
St. Pancras Metropolitan Borough —Asst. M O. for Antenata
Clinic, 14 guincas per session.
St. Peter’s Hosp. for Stone, &c., Henrietta-street, W.C.—Clin.
Assts. to the Hon. Staff.
St. Thomas’s Hosp., S.E.—Physician.
Salford, Hope Hosp.—Asst. Res. M.O., at rate of £200.
Salford, poles Diseases Hop —Jun. Asst. Res. M.O., £200.
Salford Ro Hosp.—Two H.S.’s, each at rate of £125.
Salisbury General Infirmary.—Res. M.O., £250. Also H.P.,
at rate of £125.
Sheer Children’s Hosp.—H.S., £100.
heffield, Jessop Hosp. for Women. —Asst.in Hosp. Labs., £300.
Res. M. O. and Sen. Res. O., each at rate of £150. Also Three
H.S.’s, each at rate of £106.
anean Royal Infirmary.—Ophth. H.S., at rate of £120. Also
H.S. and Aural H.S., each at rate of £80.
Southampton, Royal South Hants and Southampton Hosp.—
Cas O., and Res. Ancesthetist and H.S. to Ear, Nose, and
Throat Dept., each at rate of £150.
Southend-on-Sea General Hosp.—Res. Obstet. O., at rate of £100.
non: Rhodesia Medical Service—Government M. O., £600-
South London Hosp. for Women, Clapham Common, S.W —
Surg. Reg., £75
Seno Prestwood Sanatorium.—dJun. Asst. M. O., at rate of
Sic) ene poiian Borough.—Asst. Tuber. O., £600
Stoke-on-Trent, Bursiem, Haywood, and Tunstall War M emorial
Hosp. — Res. H. S., at rate of £175.
Stoke-on-Trent, Longton Hosp.—H.S., £160.
Stoke-on-Trent, North Staffordshire Royal Infirmary.—H.S. for
Aural and Ophth. Dept., at rate of £150.
Surrey County Council.—Jun. "Asst. M. O. for County Sanatorium,
at rate of £350.
Surrey County Hosp., Redhill.—Res. Asst. M.O., at rate of £375.
Swansea County Borough Mental Hosp. —Asst. M.O. ., £400.
Swansea General and Eye Hosp.—H.S., at rate of £150.
Tout n and Bath Mental Hosp. —Res. Second Asst.
Tilbury Hosp., Essex.—H.S8., at rate of £140.
Wakefield, Clayton Hosp. —Sen. H.S., £250.
Walard and District Peace Memorial Hosp.—H.S., at rate of
5
Wembley Urban District Council.—Asst. M.O.H., £500.
West London Hosp., Hammersmith-road, W. —Jun. Asst. M.O.
or y A Dept., £350. Also H.P. and Two H.S.’s, each at rate
o
Willesden General Hosp., Harlesden-road, N.W.—Cas. O., at
rate of £100
Winchester, Royal Hampshire County Hosp.—H.S., £125.
ae Mental Hosp., Barnsley Hall. —Deputy Med.
Sup
Worksop Victoria Hosp.—Jun. Res., £130.
York, Bootham Park Mental Hosp. Med. Supt., £800.
The Chief Inspector of Factories announces vacancies for
Certifying Factory Surgeons at Plympton (Devon) and
Folkestone (Kent).
THE LANCET]
[JUNE 5, 1937 1383
COMMENTS, AND ABSTRACTS
NOTES,
REFUGEES AT AN ENGLISH PORT
AS medical officer of health for Southampton,
Dr. H. C. Maurice Williams sends us a lively account
of the arrival there on May 22nd of the Spanish liner
Habana with 4056 refugees from Bilbao. At 5 P.M.
on the Saturday the ship was signalled off the Needles,
and the port sanitary staff, accompanied by customs
and immigration officials, left the docks in the port.
sanitary launch to board her as arranged. Another
launch followed with supplies of milk, glucose, meat
extracts, and medical requisites.
“It was an extraordinary spectacle,” Dr. Williams
writes, “to see a vessel, normally capable of carrying
between 400 and 500 passengers, steaming up Southampton
Water with every inch of her decks covered with human
beings. Even more extraordinary were the conditions
found on board. Children all herded together in the
public rooms, in the alleyways, and on all the decks.
Some were lying rolled in blankets, others running about
the ship screaming, and a few, cool and complacent,
. appeared to accept the circumstances of their arrival in
a strange land, having been parted from their parents,
without any emotion. It was with some difficulty that we
were able to reach the ship’s hospital to see a boy of 12
who, later the same evening, was removed by launch and
ambulance to the borough hospital for an operation on a
strangulated testicle.”
The ship was permitted to proceed to an inner
mooring station next morning for a detailed medical
inspection of all persons on board. On the Sunday
morning hundreds of the public, with préss repre-
sentatives and photographers, had collected along
the quay, but no one without an official pass issued
by the port sanitary department was permitted to
approach the ship’s berth or go on board. The names
and addresses of all who were given these official
passes were recorded, in order that the health
authorities throughout the country might keep them
under a surveillance in the event of any major
infection being discovered amongst the persons on
board. The adults accompanying the children were
first examined. The saloons were then cleared of all
except those taking part in the medical and immigra-
tion inspection, and within half an hour the children
were lined up in queues and the inspection began.
“ Nine medical officers of the department, each in a
separate screened cubicle, took up their positions in
the line of the queue. A health visitor assisted each
doctor by stripping the children to the waist. The child was
then examined, special attention being paid to an examina-
tion of the eyes for trachoma, the head for ringworm,
lice, or nits, and the skin for rashes and lice. The heart and
lungs were also examined in detail to decide on those
fit to live under canvas.
“ On completion of the examination, each child was
dressed by a health visitor and passed on in the queue to a
sanitary inspector, who stamped the identification card
attached to each child, indicating that the child had been
medically examined. In addition, he also tied a coloured
tape on the child’s left wrist, which served as a code
as to the destination of the child. White tape indicated
‘clean’ and allowed the child to proceed direct to
camp. Red tape indicated ‘verminous’ and to proceed
to the corporation baths for de-lousing. Blue for ‘infectious
or contagious’ conditions to proceed to the isolation
hospital or other institution. Blue and white tapes for
any other condition requiring general hospital treatment.
“ After the medical inspection was completed, each child
was passed on to the immigration officer, who stamped the
disc with his official stamp, and the child then proceeded
down the main gangway, at the foot of which sanitary
inspectors and health visitors collected them into groups
according to the colour of the tapes, and arranged for their
immediate disposal in the following ways: Clean children
went direct by motor omnibuses to the camp. Verminous
children were taken in lorries to the corporation baths for
de-lousing, and the hospital cases were transported by the
corporation ambulances to the appropriate institutions.”
_ Many of the children were thin, but the general
impression gained, especially before they stripped,
was that they were, for the most part, an alert,
intelligent group of children, who ‘‘ compared favour-
ably in physique with our own children.” The
clothing generally was very good, and when the cloth-
ing of the verminous ones was taken away from them
for disinfection many of them wept.
“ At the corporation baths we were allowed to use 40
of the slipper baths, and with the assistance of many’
voluntary and willing helpers, together with twelve
barbers, 712 of the children were de-loused and fitted with
complete sets of clothing, the latter being supplied by the
Spanish Relief Committee.”
At 7 P.M. on the Sunday medical inspection ceased
for the day. The medical staff had worked con-
tinuously for ten hours and had disposed of 3278
children. On the following morning the remainder
were examined and completed by 11 A.M.
DR. RIADORE AND THE EFFECTS OF
SPINAL IRRITATION
Mr. D. C. Thomson, writing from the registered
office of Osteopathic Trusts Ltd., complains that
in the opening sentence of an annotation entitled
“ What is Osteopathy ? ” in our issue of April 10th
we pled its American origin to discredit this theory
of healing. He goes on to say: ‘“.. . although Still
began to elaborate on his initial heresy at the end
of the nineteenth century, a British doctor preceded
him in a tentative announcement of similar con-
clusions. Many years earlier, namely in 1842, was
published in England an interesting suggestive
treatise on Irritation of the Spinal Nerves as the
source of Nervousness, Indigestion, Functional and
Organical Derangements of the Principal Organs
of the Body by J. Evans Riadore, M.D., ‘ and of the
Royal College of Surgeons, London.’ In this book
the author discusses ‘a lengthened catalogue of
maladies which are either engendered by, continued
by, or the consequence of either spinal irritation or
inflammation, with or without curvatures of the
spinal column—a class of disease of no small
importance, whether we regard their frequency or
the suffering and danger which attend them, the
nature of which, in consequence of our erroneous
views of the animal economy, has been overlooked,
and the sufferer thus deprived of all chance of
effectual assistance from our art.’ ”’
Dr. Riadore’s name appears in the London Medical
Directory for 1846 with the qualifications M.D. Giessen
and M.R.C.S. (April 4th, 1817), and an address at
713, Harley-street.
NEW PREPARATIONS
EXAMEN.—What is described as “the purest and
most highly concentrated liver extract ever achieved
on a manufacturing scale’’ has been put on the market
by Glaxo Laboratories Ltd., Greenford, Middlesex.
On Jan. 16th last, in our correspondence columns,
Laland and Klem, of Oslo, described this product
and mentioned that it would be made available
shortly. : Each 2 c.cm. ampoule is said to contain,
in an average of 10-15 mg. of solids, the hemopoietic
factor extracted from 100 g..of fresh liver. The
initial dose in relapse is given as 4 c.cm., by injection,
and the maintenance dose, at fortnightly intervals,
as2c.cm. It is claimed that Examen does not cause
pain after injection, and does not give rise to allergic
reactions. It can be administered intravenously in
emergency.
NAVIGAN.—Last year we published reports on the
use of Syntropan with Sedormid as a preventive
and remedy for sea-sickness (Lancet, 1936, 1, 226,
1263). Syntropan (a diethylaminodimethylpropanol
ester of tropic acid) is a synthetic antispasmodic
substance, related to atropine, which depresses the
action of the vagus, and especially its action on the
1384 THE LANCET]
NOTES, COMMENTS, AND ABSTRACTS
[JUNE 5, 1937
digestive tract. Sedormjd, the sedative experimentally
associated with it, has now been replaced by a
pyridine derivative. chemically known as dihydroxy-
diethylpiperidine, which is described as a mild sedative-
hypnotic having pharmacological properties resembling
those of carbromalum B.P. The manufacturers,
Roche Products Ltd. (51, Bowes-road, London,
N.13), call their new syntropan preparation Navigan
and recommend it both for the prevention of travel-
sickness (air, sea, train, car) and, more tentatively,
as an antispasmodic in abdominal colic. Navigan is
given by mouth in small tablets, or, if need be, in
suppository form. Accounts of its use at sea have
been encouraging.
‘ WELLCOME ”’ BRAND WHOOPING-COUGH VACCINE.
In issuing their vaccine made from recent strains
of Haemophilus pertussis (Bordet-Gengou bacillus)
Burroughs Wellcome and Co. point out that there
is no satisfactory laboratory test for potency and that
batches of vaccine made in different parts of the
world may not all be effective in preventing whooping-
cough. In the attempt to secure immunity against
this serious disease inoculation in infancy is advised,
preferably between the 7th and 10th months. Kendrick
and Elderling’s technique comprises five subcutaneous
injections (at weekly intervals) with a total of 70,000
million organisms: Madsen gives less and Sauer
more. The reactions seem to be somewhat more
troublesome than those of anti-diphtheria immunisa-
tion, especially in older children. If the vaccine
is used for treatment—on which opinions differ—
it should be used early. It is prepared at the Wellcome
i lie Research Laboratories, Beckenham,
ent.
FOLINERIN is a crystalline glucoside obtained from
the leaves of the oleander shrub (Nerium oleander)
and marketed by Schering Ltd., 185, High Holborn,
W.C.1. It is intended for administration, by mouth,
in cases where digitalis would normally be given
but a more rapid and constant action is desirable.
It is said to be a more powerful diuretic than digitalis
and to have a more persistent action on the heart.
Stability towards acids prevents its decomposition in
the stomach, and as a rule it causes no nausea.
KInoo PURE SILK BABY POWDER.—The manu-
facturers, Kinu Ltd. (6, Finsbury-square, E.C.3),
state that every tin of their Kinoo Baby Powder
contains at least 90 per cent. of pure cocoon silk,
with about 5 per cent. of boric acid and 5 per cent.
of zinc oxide. The powder is soft and silky to the
touch, as might be expected from its origin, and it
is said to be free from the disadvantages sometimes
attached to talc, chalk, starch, kaolin, and other
substances often applied to the skin. Among its virtues
are ‘‘ great absorbency without the possibility of
fermentation, dissolution, or the formation of a
smeary paste.” |
ZEPHIRAN CONCENTRATE is a new antiseptic made
by Bayer Products Ltd. (Africa House, Kingsway,
W.C.2). It is described as a watery solution of a
mixture of alkyldimethylbenzylammonium chlorides,
forming a faintly perfumed colourless fluid which
does not stain clothes or dressings. Subcutaneous
and intracutaneous injections of a 1 in 100 dilution
into the ear and abdominal] skin of a rabbit are stated
to cause no irritation of the tissues, and rabbits
tolerate 3-5 c.cm. per kg. of body-weight, taken
by mouth. Tests at a London teaching hospital
have shown a Rideal-Walker coefficient (Bacillus
typhosus) of 7°5, but the action of the disinfectant
for certain other organisms is relatively greater, and
comparable figures for hemolytic streptococci,
Staphylococcus aureus, and pneumococci are given
as 27, 31, and 137 respectively. In concentrations
up to 1 in 500 Zephiran Concentrate makes a strong
lather and no soap need be employed when it is
used for disinfection of the hands. When it is
employed for sterilising instruments anti-rust tablets
should be added, and these are supplied free on
demand. The manufacturers claim that even when
it is diluted with equal parts of serum their anti-
septic retains very considerable bactericidal power.
Wishing to show that BisopoL is more than a
crude mixture of its component parts, the makers
(Bisodol Ltd., 12, Chenies-street, W.C.1) invited
us to see its manufacture. The ingredients are sodium
bicarbonate, light magnesium carbonate, and bismuth
subnitrate, with the ferments diastase and papain,
and special attention is paid to their subdivision
in the powder, for on this depends the uniformi
of the suspension formed when water is added.
After a preliminary mixing the powder materials
are passed through a fine-mesh silk screen into a
mixing chamber, where they are stirred with revolving
blades for two hours. Peppermint oil is here added
in a fine spray from an atomiser.
BISMUTH THERAPY: CORRIGENDUM.—In a note
published on May 22nd reviewing a booklet issued
by Pharmaceutical Specialities (May and Baker)
Ltd., reference is made to a technique for intra-
venous injection of bismuth. Actually the technique
described was for intramuscular injection, its object
being to ensure that the needle is not in a vein, and
the manufacturers did not suggest that bismuth
can be given by the intravenous route.
MENTAL HYGIENE CONGRESSES IN PARIS.— The
second International Congress on Mental Hygiene will
be held in Paris from July 19th to 24th under the
presidency of Dr. Edouard Toulouse. The congress will
meet at the Centre Marcelin-Berthelot, Maison de la
Chimie, 28 bis, rue Saint-Dominique, Paris, VII. Copies of
the final programme of the meeting may be had from the
secretary of the National Council for Mental Hygiene,
76, Chandos-House, Palmer-street, London, S.W.1.
From July 24th to August lst the first International
Congress of Child Psychiatry will meet at the same place.
The inaugural address will be given by Prof. H. Wallon,
who will speak on the neurophysiological principles of
child psychiatry. Other subjects which will be discussed
are: conditioned reflexes in child psychiatry, methods of
education according to disturbances of intelligence and
character in children, and mental debility as a cause of
delinquency in children and adolescents. Further informa-
tion may be had from Dr. Grimbert, 11 rue Duroc,
Paris, VII.
p Births, Marriages, and Deaths
BIRTHS
HYATT.—On May 21st, at Evercreech, Somerset, the wife of
Major J. W. Hyatt, R.A.M.C., of a son.
JACKSON.—On May 23rd, at Devonshire-place, W., the wife of
Mr. Harvey Jackson, F.R.C.S., of a son.
PANTIN.—On May 25th, at Bentinck-street, W., the wife of
Dr. Guy Pantin, of a daughter.
MARRIAGES
GOADBY—Boacon.—On May 22nd, at Winchester Cathedral,
Hector Kenneth Goadby, M.D., F.R.C.P., only son of Sir
Kenneth Goadby, K.B.E., and Lady Goadby, to Margaret
Evelyn, daughter of Mr. R. O. Boggon, O.B.E., of Worthing,
formerly of H.M. Dockyard, Portsmouth.
DEATHS
COLLINS.—On May 24th, at Manor Park, E., Richard Hawtrey
Collins, M.D. Brux., M.R.C.S. Eng., aged 74.
Hucni.—On May 26th, at Streatham Park, S.W., George
Frederick Hugill, M.D. Durh.
KEMBER.—On May 20th, at Edinburgh, Arthur Thomas
Kember, F.R.C.S. Edin., for many years medical missionary
at the C.M.S. Hospital, Hang-chow, China.
LANGTON.—On May 27th, following an operation, in Kampala,
Edward Athol Clarence Langton, M.R.C.S. Eng., Uganda
Medical Service, aged 48.
LEE.—On May 26th, in London, William Emerson Lee, M.D.
camb of The East Sussex Club, St. Leonards-on-Sea,
age :
PAULson.—On May 29th, at Heybrook Bay, near Plymouth,
William Paulson, L.R.C.P. Lond., late of Mountsorrel,
Leicestershire, and Dartmouth, in his 95th year.
SHORNEY-WEBB.—On June Ist, at the Middlesex Hospital,
C. H. Shorney-Webb, M.S., F.R.CS.
WALLER.—On May 29th, at Stroud, Glos, Alfred Whalley
Waller, M.D. Durh., M.R.C.S. Eng.
N.B.—A fee of 7s. 6d. is charged for the insertion of Notices of
_ Births, Marriages, and Deaths,
THE LANCET]
ADDRESSES AND eee AL ARTICLES
SIMPLE NON-SPHINCTERIC SPASM OF
THE GSOPHAGUS
By Joux E. G. McGrson, M.B., B.S. Lond., D.L.O.
HON. LARYNGOLOGIST TO THE ROYAL SOUTHERN HOSPITAL,
LIVERPOOL; AND
J. H. MATHER, M.B.. B.Sc. Liverp., D.M.R.E.
HON. RADIOLOGIST TO THE HOSPITAL
Spasm is the most common individual manifesta-
tion of w@sophageal disease, and in the gullet its
Significance as an entity is probably greater than
in any other tubular organ of the human body;
in fact as Barclay (1931) has stated when discussing
the radiology of the æœsophagus, spasm may be
responsible for the whole of the symptomatic disturb-
ance presented by any intrinsic or extrinsic lesion.
It may be the sole radiological abnormality observed
in such varying pathological states as intra-œso-
phageal injury, impaction of small non-opaque
foreign bodies, esophagitis, central and peripheral
nervous lesions, and it may mask completely an
early esophageal malignancy. Teschendorf (1928)
- has described such a case in which a carcinoma
of the mwsophagus became obvious by radiological
examination only after the accompanying spasm
had been dissipated by an injection of atropine. `
CLASSIFICATION
Anatomically, spasm that develops at either
the upper or lower (sphincteric) extremity of the
«esophagus can be regarded as distinct from that
arising in the intervening (non-sphincteric) part,
although their pathology probably is similar. Non-
sphincteric spasm may be present in an apparently
healthy csophagus, or it may accompany a true
intrinsic lesion. In the earlier articles the former
was designated a ‘primary,’ ‘functional,’ or
“ idiopathic ” spasm, and the latter a “‘ secondary ”
spasm. Consideration of the etiology of non-
‘sphincteric spasm of the healthy csophagus shows
that a so-called primary spasm is usually due to an
altered state or disease of some other organ of the
body, and the term simple non-sphincteric spasm
-will be used to describe this lesion in the following
notes.
Abel (1929) has classified spasm of the non-
-sphincteric portion of the esophagus on an etiological
basis as follows :—
(1) Psychological cesophagismus,
(2) Reflex cesophagismus—i.e., spasm secondary to
-disease of other organs.
(3) Symptomatic cesophagismus—i.e.,
(a) disease of the csophagus itself ;
lesions.
All of the above except spasm due to csophageal
disease (3a) and some toxic cases (3c) can be
included under the title of simple non-sphincteric
spasm.
EXTENT AND TYPES
Simple non-sphincteric spasm may affect one or
more segments of the csophagus, its entire extent or
.a varying portion of its length, and according to the
radiological appearances observed the following
types may be described and are shown diagramatically
ain Fig. 1 :—
1. Localised spasm (Fig. 1B).
5987
_ gtaltic contractions.
spasm due to
(b) organic disease
-of the central or peripheral nervous system ; ; or (c) toxic
[JUNE 12, 1937
. Diffuse spasm :
(a) tetanic : ee 1 C), (2) partial (Fig. 1 D).
(b) irregular (Fig. 1 E).
(c) functional diverticula (Fig. 1 F).
Each type may vary considerably in the same and
different patients, and occasionally the various types .
may occur in the same individual.
Localised spasm is probably the most common
type. It affects only a small annular segment or
segments of the csophagus (Fig. 7) and when more
than two segments are contracted simultaneously
A A B C D E F
FIG. 1.—A. Normal œsophagus. B. Localised spasm. C. Total
tetanic spasm. D. Partial tetanic spasm. E. Diffuse irregular
spasm. F. Functional diverticula.
it is advisable to regard the lesion as a type of diffuse
spasm. It may be present in any portion of the
| œsophagus and Reyner (1924) has stated that its site
may vary in the same patient.
Diffuse spasm was recorded under this title by
Moersch and Camp (1934) and should include the
so-called functional diverticula described by Barsony
and Polgar (1927) and by Gregoire (1926). The
tetanic form of diffuse spasm may involve the entire
extent of the gullet so that opaque food cannot
enter its lumen and on radiological appearances
obstruction at the inlet only may be diagnosed,
or it may be confined to the lower half or third of the
viscus. Irregular spasm arises in that portion of the
csophagus controlled by unstriated muscle and it
appears to be an exaggeration of its normal peri- ,
Kohler (1928) holds that it is
very difficult, indeed almost impossible, to observe
peristalsis in a normal cesophagus or even above an
organic stricture, so that the radiological appearances
of this type of spasm are very striking and are well
shown in Fig. 4. Functional diverticula (Fig. 8)
become manifest only at the height of muscular
contraction and they are due to the development
of spasticity of two or more segments separated by
atonic areas. The radiological appearances vary from
that of a simple arching of a small portion of the
csophageal outline to a mushroom- or hat-shaped
diverticulum. Gregoire (1926) has described the
diverticula as pear-shaped dilatations which over-
hang the succeeding contracted segments. Often
they are multiple—Barsony and Polgar (1927)
report 5 cases out of 9 which were multiple—they arise
at any level of the esophagus, and they are associated
sometimes with atony of the entire organ or with
localised spasm. A functional diverticulum may be the
starting point of a true organic pulsion diverticulum,
and the writers mentioned above observed such a
development in one patient.
AA
1386 THE LANCET] MR, MCGIBBON &DR. MATHER: NON-SPHINCTERIC SPASM OF THE ŒSOPHAGUS [JUNE 12, 1937
DURATION
As a rule all types of spasm are transtent—there
is only a tendency to spastic contraction of the
csophageal muscles, and when this does occur it
is of short duration. Occasionally transient spasm
is observed accidentally ; this happened in Case 5
below, and it is probable that it is more common
than is generally believed, but that it escapes recog-
nition owing to its short duration and the absence
of symptoms. Less often spasm is intermittent as
in Cases 4 and 8 below—for example, spasm may
occur after some special dietary, thermic or psychical
stimulus. Very rarely spasm is perststent owing to the
continuance of the exciting cause, or possibly to
the development of a nerve-cell habit as described by
Chevalier Jackson, (1934). Thus in Case 2 spasm
lasted for 3} years, and in Case 1 for 7 weeks. Moersch
and Camp (1934) have recorded notes of a patient in
whom spasm was present for 9 years, and Barclay
(1931) quotes Grier’s account of a man with complete
obstruction of the middle third of the csophagus
due to spasm which persisted for 2 months.
NERVE-SUPPLY OF THE GSOPHAGUS
The type of spasm under discussion is a neurogenic
manifestation, and it is necessary to consider briefly
the nerve-supply of the wsophagus. This is derived
from the vagi and from the sympathetic chains
and is shown diagrammatically in Fig.2. The. vagal
supply has been recognised for a long time and it is
now definitely established that there is also a con-
tribution from the sympathetic system. There
are known branches from the inferior cervical ganglia
and from the celiac plexus, which accompany the
left gastric artery, but the question of the existence
of direct branches from the thoracic sympathetic
ganglia is still controversial.
Kuntz (1929) is of the opinion that the sympathetic |
supply for the csophagus comes chiefly from the
Vagus N. Recurrent N.
; i _-Sympathetic
[A “chai
Stellate —>-
ganglion ) i Br From
4 inf-cervical
ganglia
Thoracic —\—\, reat
ganglia SE Splanchnic N.
Lesser
i Splanchnic N.
~
Br From
Coeliac plexus
Coeliac
plexus, i
FIG. 2.—Diagram of the uerve-supply of the wsophagus.
inferior cervical ganglia but that further branches
do pass directly from the thoracic ganglia, or from
these ganglia via the aortic plexus or a plexus in the
posterior mediastinum to the gullet. Other writers
| _ Crico-
pharyngeus
__. Cardiac
Sphincter
B C
FIG. 3.—A. Normal cesophagus. B. Stimulation of or
removal of stellate ganglia. C. Stimulation of sympathetio
or division of vagi.
Effect of Nervous Impulses
Region | Stimulation | Bilateral | stimulation | Bilateral
of cso- of vagus of stellate | of stellate division
phagus. alone. ganglia. ganglia. of vagi.
Upper Tetanic con- Hyper- Nil.
third. | traction which tonicity. |
i only persisted |
with constant
stimulation.
No secondary
waves.
Dilatation
Middle | Tetanic contrac- r Diminution | with recur-
third. tion foliowed of tonus or | \, TOR eri-
by secondary increased 8 in
waves. contraction. | the lower
third.
Lower | Increased tonus Increased _ Slight
third. and mobility peri- diminution
which persisted stalsis. | of tonus and
or continue mobility.
as a series of
secondary
waves.
Sphincter Contraction
normal. of sphincter.
doubt the existence of a thoracic sympathetic supply.
The following short description is quoted from an
article by Woollard (1935).:—
“ Slender sympathetic filaments from the inferior
` cervical and thoracic sympathetic ganglia travel alongside
the intercostal vessels, but they are too small and delicate
to trace beyond the front of the vertebral column and
the aorta. It seems unlikely that the esophagus receives
other than a very scanty sympathetic supply from the
adjacent ganglia. Sympathetic fibres, however, do reach
the cesophagus from above, having entered the vagi from
the cervical sympathetic chain. The other route by
which sympathetic fibres may reach the cardia is by way of
the celiac plexus, from which they may travel in company
with the left gastric artery.”
As a result of the findings of Cannon (1907),
Meltzer (1898), and other investigators it is now
generally agreed that vagal stimulation causes
increased tonus and mobility of- the plain muscle
portion of the esophagus (Fig. 3 B) and that sympa-
thetic stimulation inhibits this (Fig. 3C). The
experimental work of Knight (1935) has done much
to explain the varying and often apparently contra-
dictory results obtained by previous workers, for
he has shown that the type of reaction obtained
by stimulation of the extrinsic nerves of the œso-
phagus depends upon the nature—whether striated
THE LANCET] MR. MCGIBBON & DR. MATHER: NON-SPHINCTERIC SPASM OF THE GSSOPHAGUS [JUNE 12, 1937
or unstriated—of the muscle content of the region
under consideration. In Knight’s experiments cats
were used, as their csophagi approach most nearly
to man in regard to distribution of striped and
unstriped muscle, and his conclusions are given
in the Table and shown diagrammatically in Fig. 3.
From a consideration of this it appears that spasm
of the wsophagus might be caused by an abnormal
increase of stimuli travelling via the vagi, by a
decrease or cessation of impulses via the’ sympa-
thetic, or by an imbalance of
the two sets of impulses. The
origin of such excitatory or
inhibitory impulses jis still
undetermined, but the find-
ings of Carlson, Boyd, and
Pearcy (1922), who showed
that stimulation of the gall-
bladder, intestines, and urin-
ary bladder gave rise to
cesophageal activity, is sug-
gestive; and Alvarez (1928)
has stated that inhibitions
that are produced by fear,
worry, or illness, probably
travel by way of the sym-
pathetic.
INCIDENCE
Simple non-sphincteric
spasm is not commonly diag-
nosed as probably in many
cases the condition is of very
short duration and its symp-
toms evanescent. Negus (1936)
has stated that he has never
observed a true example of
simple spasm and that
although he has examined
patients who had been diag-
nosed as suffering from such
by radiologists and physicians
they ultimately proved to have
an organic osophageal lesion.
Guisez (1923). is of the opinion
that simple spasm of the non-
sphincteric portion of the
cesophagus, except in its upper
third, is never seen ; Chevalier
Jackson (1934) also questions
its occurrence, and Balden-
weck (1925) regards these
cases as rare and ephemeral
presenting only in neurotic females and alcoholics.
These authoritative statements cannot be disregarded.
On the other hand Moersch and Camp (1934) have
reported a series of 8 patients with simple diffuse
spasm, Teschendorf (1928) and Barsony and Polgar
(1929) all have recorded notes of large series of
cases, and Sudhues (1932) has called attention to
the presence of simple spasm in children. Brown
Kelly (1936) considers that this type of obstruction
in the wsophagus is quite common, and the present
series consists of 8 cases seen in the past five
years, 4 of which were described briefly during a
recent discussion at the Royal Society of Medicine.
e compared with
of a cat’s
ZTIOLOGY
This type of spasm may occur at any age. In
our series the youngest patient was aged 8 months
and the oldest was 79, and it affects both sexes
equally. Many theories on the cause of simple non-
sphincteric spasm have been advanced.
FIG. 4 (Case 1).—Simple diffuse irregular
spasm of the lower half of the csophagus
probably due to a phobia, This should
ig. 124 in Knight’s
(1935) article which depicts a radiogram
cesophagus after bilate
removal] of the stellate ganglia.
1387
Congenital inferiority of the sympathetic ‘nervous
system in children has been suggested by Sudhues
(1932), and Brown Kelly (1936) is of the opinion
that in such young patients there may be a con-
genital predisposition to spasm, which occurs only
when the child is ailing or thwarted.
Nervous instability as a cause is mentioned by a
large number of observers. Patients who suffer from
simple spasm are usually highly strung and nervous,
and the attacks may be precipitated by nervous
FIG. 5 (Case 2).—Localised spasm of lower
cesop of 32 years’ duration, prob-
ably due to a phobia. Radiogram shows
a anoom stricture with “ awl-shaped ”
end,
excitement, worry, anger, or grief. Lust (1923
has recorded the occurrence of simple csophageal
spasm in children when presented with food which
was distasteful to them. Moersch and Camp (1934)
consider that nervous instability is more evident
in these cases than it is in patients who suffer from
achalasia. Spasm due to emotional disturbances
corresponds to Abel’s (1929) “ psychological œso-
phagismus,” and he has mentioned the theory of
Lemaitre that a small superficial abrasion of the
esophageal mucous membrane that would pass
unnoticed in a normal person may give rise to spasm in
an unduly receptive individual. Bruzzi and Alagna
(1930) also consider such slight trauma to be a common
causal factor.
Two cases of simple non-sphincteric spasm appar-
ently due entirely to a phobia were present in our
series :—
CasE 1.—A female aged 35 stated that 7 weeks pre-
viously she thought a crust stuck in her throat, and
1388 THE LANCET] MR. MCGIBBON & DR. MATHER: NON-SPHINCTERIC SPASM OF THE CESOPHAGUS. [JUNE 12, 1937
since that date she had experienced difficulty and pain on
swallowing. General clinical examination was negative.
Radiography showed a diffuse irregular outline of the
lower half of the cesophagus (Fig. 4). Endoscopy revealed
no lesion of the csophagus, and the symptoms and
abnormal radiological appearances disappeared after
passage of the cesophagoscope.
It is interesting to note the similarity of the radio-
logical appearances of this patient’s wsophagus and
that of Fig. 124 in Knight’s (1935) article which
FIG. 6 (Case 5).—Simple localised spasm of
N PET accidentally in a
patient with chronic gastric disease.
depicts a cats œsophagus after bilateral removal
of the stellate ganglia.
CasE 2.—A female aged 53 stated that she had experi-
enced pain and difficulty in swallowing for 3 months
so that she could take only soft food, and that she thought
she was “ suffering from cancer.” General clinical examina-
tion was negative. Radiography showed ‘*‘ definite spasm
present at lower part of gullet.” The blood Wassermann
reaction was negative. Gsophagoscopy revealed a stricture
with some associated oesophagitis of the lower- third
of the œsophagus (Fig. 5). This was dilated without
improvement in swallowing, and two years later, as the
lesion was considered to be neoplastic, a Souttar's tube
was inserted into the stricture and left in situ for a year.
Six months after removal of the tube the dysphagia
disappeared and radiography showed that the paste
made a normal passage to the stomach.” The patient
has remained well for nine months.
Disorders of deglutiiion are suggested as a cause of
spasm by Guisez (1923). He has stated that spasm
“ primitif” is nearly always due to trouble in the
act of swallowing, since csophageal peristalsis is
FIG. 7 (Case 7).—Simple localised spasm of
ztiology. The radiogram shows a smooth
rounded outline of the stricture with atony
of the upper portion of the cesophagus.
only produced by deglutition and not by stimulation
of the pharynx alone. In his opinion this type of
spasm usually occurs in nervous females aged 18-30,
and never below the upper third of the esophagus.
This subdivision should not include those cases
in which a large, ill-masticated and hurriedly
swallowed bolus gives rise to a brief cesophageal
spasm, as this is not a disorder of deglutition,
but rather that the mass has acted as a tem-
porarily. impacted foreign body.
Organic disease of the central
or peripheral nervous system is
a probable cause of cso-
phageal spasm. It may occur
in nervous disorders such as
tabes, bulbar palsy, exoph-
thalmic goitre, and in organic
or toxic lesions of the æœso-
‘phageal nerves. Mosher (1933,
1934) has shown that in acute
and chronic general or abdo-
minal infections and also in
general degenerative condi-
tions lymphatic permeation
and fibrosis may occur in the
lower part of the wsophagus,
and Rake (1930) and other
observers have demonstrated
atrophy of the csophageal
nerve ganglia in cases of
achalasia. Simple non-sphine-
teric spasm associated with
achalasia has been reported
by Forbes (1926) and Teschen-
dorf (1928); and Barsony and
Polgar (1927) have watched
the incidence of mega-ceso-
phagus in patients who pre-
viously exhibited functional
diverticula. It is not dificult
from the findings of the above
observers to formulate a
theory that the vagal nerve-
endings may be irritated by
toxic or degenerative products
giving rise to spasm; they
then recover or atrophic
changes supervene leading
cssophagus of 2 days’ duration and unknown to achalasia and mega-
cesophagus. One case of
simple non-sphincteric spasm
due to an organic central
nervous lesion occurred in the present series :—.
CasE 3.—A male aged 8 months, suffering from primary
amentia, was admitted to hospital with a history of
attacks of screaming on and off for four months and
regurgitation of feeds during the preceding two days.
General clinical examination was negative. Radiography
showed a complete hold-up of the test-paste in the ceso-
` phagus at the level of the 6th dorsal vertebra. Œsophagos-
copy revealed no abnormality of the csophagus save
that the mucous membrane was redder than normal.
The child died in spite of feeding by means of a stomach-
tube. Permission for an autopsy was not obtained.
Reflex stimulation from lesions of the thoracic and
abdominal viscera has been regarded as a cause of
simple non-sphincteric spasm by numerous observers.
The experimental results of Carlson and his co-workers
(1922) have been mentioned above. Moersch and Camp
(1934) record notes of a man who suffered from simple
spasm for nine years ; he was found to be suffering from
a duodenal ulcer and the spasm was cured by per-
formance of gastro-enterostomy. Teschendorf (1928)
THE LANCET] MR. MCGIBBON & DR. MATHER: NON-SPHINCTERIC SPASM OF THE CESOPHAGUS [JUNE 12, 1937 1389
recounts the findings of several writers who have seen
simple spasm of the cesophagus apparently caused
by reflex stimulation from carcinoma of the stomach,
simple ulcer of the stomach and duodenum, disease
of the gall-bladder, movable kidney, hernia, and
lesions of the uterus, lung, mediastinum, and aorta.’
Three cases of simple non-sphincteric cmsophageal
spasm associated with gastro-intestinal disease
occurred in the present series :—
CasE 4.—A female aged 45 gave in 1933 a history of
four years’ intermittent difficulty and pain on swallowing.
Radiography, cesophagoscopy, and biopsy showed a
peptic ulcer of the cesophagus 13 in. from the. incisor
teeth. A few weeks later cesophagoscopy was repeated
and the ulcer was then found to be healed by scar tissue.
Since that date the patient has had attacks of complete
cesophageal obstruction lasting two or three ‘days and
recurring three or four times a year, although repeated
cesophagoscopy has been negative in regard to any intrinsic
lesion. It has been very difficult to persuade her to come
to hospital during an attack of dysphagia. It was possible,
however, to radiograph her during the most recent attack
and the film, which will not reproduce, showed diffuse
tetanic spasm of the lower third of the cesophagus. This
patient is known to be suffering from a duodenal ulcer,
and the frequency of the spasmodic attacks has been
lessened by the administration of large doses of alkalis.
CasE 5.—A male aged 52 gave a history of four years’
chronic gastritis and was found to have in addition com-
plete achlorhydria and a microcytic anemia. Routine
radiography showed a simple cesophageal spasm (Fig. 6).
Unfortunately the patient was not examined with the
cesophagoscope, but the subsequent disappearance of his
symptoms following treatment and lack of recurrence
over a long period is proof of the correctness of the
diagnosis.
Case 6.—A male aged 40, suffering from a duodenal
ulcer, was admitted to hospital under the care of Mr.
J. T. Morrison, by whose kindness we examined the case.
He complained of dysphagia and occasional pain in his
left shoulder on and off for 12 months. Radiography
showed a “narrowing of distal third of wsophagus with
dilatation above. ? Growth involving lower third of
cesophagus.”” By csophagoscopy no intrinsic lesion was
found, but spasm of the lower part of the csophagus
was observed. He has been free from dysphagia since,
but nearly 5 years later he was readmitted for another |
complaint and radiograms showed “some dilatation
of the lower half of the esophagus without any evidence
of obstruction.”
Other cases.—There is`a residue of cases in which
none of the above factors is evident, but possibly this
may be due to an incomplete clinical examination.
The two following patients both exhibited simple
spasm of the wsophagus without any other dis-
cernible lesion, but in view of their ages there are many
possibilities :—
CasE 7.—A male aged 79 stated that he had been
unable to swallow even fluids for two days. He gave a
history of two similar attacks of dysphagia—1l15 years
and 10 years previously. A radiogram by Dr. P. H.
Whitaker showed a complete smooth rounded hold-up
of test-paste in the lower third of the esophagus (Fig. 7).
Csophagoscopy revealed no intrinsic lesion. He swallowed
comfortably two days later, and a further radiogram
demonstrated a normal passage of opaque meal to the
stomach.
Case 8.—A female aged 77 was examined by ie
courtesy of Mr. C. A. Wells. She complained of attacks of
substernal pain which were relieved by vomiting mucus on
and off for 7 years. She had not lost weight and her
general health was good. Five weeks before examination
she had vomited blood on four occasions. General clinical
examination was negative. Radiography of the ceso-
phagus by Dr. Whitaker showed a pouch-like appearance
in its lower third. This was shown in a series of radio-
grams (Fig. 8). A few days later she was admitted to
hospital, when X ray examination showed no abnormality
of the cesophagus and cesophagoscopy was negative.
The patient has continued to suffer from attacks of pain
and regurgitation at fortnightly intervals without any
symptoms in the intervening periods.
SYMPTOMS AND SIGNS
Simple non-sphincteric spasm may give rise to no
symptoms whatever and it may be discovered acci-
dentally as in Case 5 above. More commonly inter-
mittent dysphagia and pain on swallowing are out-
standing features, and the pain varies in character
from a dull substernal ache to severe shooting
paroxysms, which occasionally occur spontaneously
and waken the patient at night—in two cases reported
by Moersch and Camp (1934) the pain was so severe
that a diagnosis of angina had previously been made.
In the present series the pain complained of was of the
FIG. 8 (Case 8). —Solitary functional diverticulum of the
lower csophagus.
dull aching variety. These symptoms may be accom-
panied by a feeling of anxiety and sometimes by
palpitation and dyspnea. Barsony and Polgar (1927)
state that functional diverticula may occur without
symptoms and that patients who do experience
pain and dysphagia have in addition some dilatation
of the csophagus. During the acute phase swallowed
_material is regurgitated, and regurgitation is the
predominant symptom of spasm in children.
RADIOLOGY
The routine examination of the esophagus is made
with the patient standing in the left posterior oblique
position—that is in a semi-lateral position with the
left shoulder resting against the fluorescent screen
—so that a clear space can be seen between the
cardiac and aortic shadows anteriorly and that of the
vertebral column posteriorly. The head is turned
slightly towards the left shoulder and the chin raised
to obtain a clear view of the pharynx. The patient
is given a spoonful of opaque food of the consistency
of very thick cream which is retained in the mouth.
until directions are given to swallow and the passage
of the opaque bolus is then watched through the
pharynx and osophagus into the stomach. If no
abnormality is detected the patient is questioned
as to the exact character of the food which gives rise
to dysphagia, and the consistency of the opaque food
should be altered or crumbs of toasted bread added
and the examination repeated: for as Barclay (1931)
has pointed out “at one examination the opaque
AA 2
1390 THE LANCET] PROF. S. L. BAKER: URINARY SUPPRESSION FOLLOWING BLOOD TRANSFUSION [JUNE 12, 1937
food allays the irritation and no obstruction is
observed, at the next a hard particle may set up the
irritation and produce spasm.” Radiograms are taken
immediately after the screen examination and also
with the patient standing in the right posterior
oblique and anterior positions, as an abnormality
may be demonstrated more clearly in ‘either of the
latter positions. When spasm is demonstrated it is
advisable to repeat the examination later in the day,
on the following day, or even at a still later date.
Many of the radiological features of simple non-
sphincteric spasm have been mentioned in the text
of this article but the following additional points may
be noted :—
(1) Spasm is best observed radioscopically because of its
changing appearance.
(2) In diffuse and localised spasm the area above the
hold-up is everywhere smooth.
(3) The shadow of the paste above a localised spasm
has usually a rounded end as in Fig. 7, or occasionally
an ‘“‘ awl-shaped ” end as in Fig. 5.
(4) With the patient supine and the hips raised it is
possible.in some cases to fill the portion of the cesophagus
below the spasm with opaque material.
(5) Atony of the cesophagus may be associated with
spasm. In Fig. 7 an enlarged cesophageal shadow is shown
which is due to atony and not to pressure dilatation, as
the spasm had been present only for two days and the
cesophagus showed normal radiological dimensions when
the spasm had resolved, whereas Fig. 5 shows no enlarge-
ment of the cesophageal shadow although the spasm had
persisted for 33 years.
(6) At other times there is a definite increase of tonus
of the muscles, particularly in cases of diffuse spasm when
the entire csophageal shadow may appear as a narrow
ribbon between the actual attacks.
TREATMENT
In many patients simple non-sphincteric spasm
resolves spontaneously, whilst in others it persists
in spite of active treatment, and a consideration
of the many presumptive causes demonstrates the
impossibility of generalisation in regard to treatment
and affords an explanation of its failure in numerous
cases.
-= All of the possible causative factors must be sought
for in each patient, and if found the appropriate
psychological, therapeutic, or surgical corrective
measures can be adopted. The success of this approach
` to treatment is illustrated by the patient of Moersch
and Camp (1934), who was cured after nine years
suffering by gastro-enterostomy, Case 1 above in ~
whom reassurance brought about resolution of the
spasm, and Case 4, who is improving with massive
doses of alkalis.
On the other hand a study of the case-notes recorded
above shows that symptomatic treatment alone is
unsatisfactory—for instance the mere passage of an
cwsophagoscope or even actual dilatation will not
bring about relief of spasm as it will do in the sphinc-
teric regions, This fact also has been mentioned by
Moersch and Camp (1934) and is illustrated by Case 2
above. As regards drugs, sedatives and antispas-
modics do not appear to be of great assistance.
Teschendorf (1928) advises large doses of atropine
pushed almost to the limit of safety. Apomorphine
has been given by Boehm (1921), and Lepametier
and Dermas (1926) report resolution of symptoms
after the administration of Sedobrol.
SUMMARY
Spasm arising in that portion of the csophagus
between the cricopharyngeus and the cardiac sphincter
without any intrinsic wsophageal lesion is described
as simple non-sphincteric spasm of the csophagus.
The diagnosis of this is a dangerous one without
the most careful investigation, as spasm of the
esophagus is common and may mask a grave lesion.
Simple non-sphincteric spasm may be localised
or diffuse and includes the so-called functional
diverticula; and it may be transient, intermittent,
or persistent in character. .
The radiological appearances are typical, and as a
rule csophagoscopy is negative.
It is a neurogenic manifestation and is often
associated with other nervous manifestations such as
general atony or increased tonus of the wsophageal
muscles. Occasionally it may be followed by achalasia
or mega-osophagus.
This type of spasm appears to be secondary to
disease or an altered state of other organs, and if it
does not resolve spontaneously satisfactory relief can
only be obtained by treating the primary lesion.
In addition to the acknowledgments made in the text
our thanks are due to Dr. R. Steel and Dr. Swanson
Hawks for the radiological reports in Cases 2 and 6
respectively, and to Dr. T. J. O’Donnell for the after-
history of Case 8.
REFERENCES
Abel, L. (1929) rophagoal Obstruction, London, p. 89.
Alvarez, UA C. 1929) The Mechanics of the Digestive Tract,
o
paigenweck, P? 1625) J. Laryng. (Abstr.) 40, 141.
Barclay, A E. (1931) The Digestive Tract, Cambridge, 3b; ag aaa
Barsony, T., and Polgar, F. (1927) Fortschr. Rontgenst
Boehm, G. ‘al 331) Dtsch. Arch. klin. Med. 1
Bruzzi, P and Alagna, G. (1930) J. parma: (abstr.) 45, 900.
Cannon, W. B. (1907) Amer. J. Physiol. 1
aa A.J-.B , Boyd, T. E., and Pearcy, J. F. (1922) Arch. intern.
kornen H H. (192 6) J. Laryng. 36, 190.
Gregoire, R. (1926) Arch. Mal. Appar. dig. 16, 251.
Guisez, J: a 923) Rétrécissements de lcesophage et de la trachée,.
a
Jackson, C., and Jackson, C. L. (1934) aS Sa Œsophago-
y, and aastroseopy, P Philadel lphia, 3ED. p. 345.
Kelly, A P, (1936) J. L
Knight C. (1935) Brit. S its » 3. 155.
Ko ler, 4 Ne (1928) Rontgenology, ondon, p. 379.
Kuntz, A. (1929) Autonomic Neon System, London, p. 188.
Lepametier, A., and Dermas, S. (1926) Bull. Soc. radiol. l. med.,
Paris, 14
Lust, F. ( (1923) Mschr. Kinderheilk. 27, a
Meltzer, S J. (1898) Amer. I Physiol. 2, 266.
Moeroa H. J. , and Camp, J. D. 1954) Ann Otol., £c.,
Mosher, iis 5, Hass 43, 116 o olaryn., , Chicago, 18, 562.
R. Soc. Med. 29, 917.
St. Louis,
Sudhues, M
Teschendorf, W. (1928) A ee. ph nee 3, 175.
Woollard, H. H. (1935) Brit. J. Surg. 23, 428.
URINARY SUPPRESSION FOLLOWING
BLOOD TRANSFUSION
WITH REPORT ON A CASE PROBABLY DUE TO OVER-
HEATING THE BLOOD
By 8. L. BAKER, M.Sc. Manch., Ph.D. Lond.,
M.R.C.S. Eng.
PROCTER PROFESSOR OF PATHOLOGY IN THE UNIVERSITY
OF MANCHESTER
DEATH following and attributable to blood trans-
fusion may occur immediately—i.e., within a few
minutes or hours—or after an interval of several or
many days. The causes of the rapid deaths usually
remain doubtful and are difficult to investigate and
to separate from the primary condition for which the
transfusion was performed.
The delayed deaths are the result of complete or
partial suppression of urine and examination of the
kidneys shows that the tubules are plugged by
blood pigment in the form of brownish granules and.
THE LANCET] PROF. 8. L. BAKER: URINARY SUPPRESSION FOLLOWING BLOOD TRANSFUSION [JUNE 12, 1937
masses; it is generally agreed that this condition
is associated with an intravascular hemolysis of the
donor’s corpuscles due in nearly all cases to incom-
patibility between bloods of the donor and recipient.
Blood-grouping has greatly reduced, though not
entirely eliminated, the chances of such incompatible
transfusions.
In most cases in which the donor’s and recipient’s
bloods have been re-examined after the occurrence
of a hemolytic reaction they have been found to be
incompatible. DeGowin and Baldridge (1934),
however, report two cases of death with suppression
of urine in which a re-test of the donor’s and recipient’s
bloods showed no evidence of incompatibility ;
in one of these hemoglobinuria and the development
of a definite jaundice left no doubt that intravascular
heemolysis had occurred. Two cases out of seven
reported by Goldring and Graef (1936) showed no
evidence of incompatibility of the bloods on re-check-
ing but presented undoubted evidence of hemolysis
of the transfused corpuscles. In the first two of these
cases citrated blood was used, in the last two the
transfusion was direct.
In cases where the transfusion is not direct one has
to consider the possibility of some form of mishandling
which would damage the red cells and either hemolyse
them or render them lable to hemolysis in the
recipient’s circulation. Facey (1937) discussing
reactions after blood transfusion stresses the possi-
bility of faulty technique, particularly in the case of
inexperienced operators, and mentions overheating
as one of the errors. I have recently had sent to me
sections of the kidney and an account of a case in
which it appears probable that overheating was
responsible for the hemolysis of the transfused
blood.
A middle-aged woman was transfused for uterine
hemorrhage. The donor was Group IV and his blood was
matched against the recipient’s and showed no incompati-
bility ; 800 c.cm. of citrated blood was used and this had
been kept standing for nearly two hours in a receptacle
with a watewjacket the temperature of which was about
130° F. Within half an hour after transfusion catheterisa-
tion produced 25 c.cm. of dark brown urine containing
spherules of pigment and giving a strong Kastle-Meyer
reaction for iron-containing hæmoglobin derivatives.
Spectroscopically it showed the bands of methsemoglobin.
The pigment gradually disappeared from the urine during
the next two or three days, but a nearly complete suppres-
sion of urine (2—3 oz. daily) had developed and the blood-
urea steadily rose reaching 540 mg. per 100 c.cm. on the
twelfth day after transfusion. The patient meanwhile
became more drowsy with occasional vomiting but no
jaundice and died on the fourteenth day after transfusion.
Post mortem the kidneys (weighing 200 g. each) showed
a ‘“‘ deep purple red colour” of the outer part of the
‘cortex and a ‘‘ very dark purple ” medulla with ‘‘ streaks
of deeper colour along the lines of the collecting tubules.”
The frozen section received proved not sufficiently good
for fine details, but the most obvious lesion was a large
amount of dark brown pigment in the lower convoluted
and collecting tubules. The only other abnormality
was cedema of the lower lobes of both lungs.
There seems no rational reason for heating blood
for transfusion purposes above room temperature.
As far as concerns the preservation of the blood, this
undergoes least change at low temperatures (5° C.).
Blood kept outside the body at body heat (37° C.)
deteriorates more rapidly than cool blood both as
regards the condition of the red cells and as regards
the various demonstrable antibodies in the plasma.
As far as the cooling effect on the patient is concerned
in rapid transfusion the blood is still warm from the
donor, and in slow transfusion, unless special apparatus
is used to heat the blood at a point close to the needle,
1391
it cools down to room temperature by the time it
reaches the patient’s vein. On making inquiries at
Manchester Royal Infirmary I find that large numbers
of slow transfusions have been given, with complete
success, without any attempt to keep the blood warm.
If, for any reason, it is necessary to keep the blood
for any length of time before transfusing, it is
certainly undesirable to keep it warm during this
period.
Cause of Suppression of Urine
Collections of brown granular pigment in the renal
tubules are characteristic of suppression of urine
following blood transfusion but they are also found
in cases of intravascular hemolysis due to other
causes, particularly in blackwater fever where death
from suppression of urine is not uncommon.
Yorke and Nauss (1911) while investigating the
pathogenesis of blackwater fever produced deposits
of brown granular pigment in the renal tubules
of rabbits by intravenous injections of solutions of
hemoglobin. By this means they succeeded in
producing suppression of urine in several animals,
but found that this result could only be achieved if
the animals were kept on a dry diet free from green
food. Rabbits kept on an ordinary diet with green |
vegetables excreted thé hemoglobin in an unchanged
condition in the urine ; no pigment was deposited in
the tubules and no urinary suppression resulted. It
appeared that the formation of the granular pigment
in the renal tubules was related in some way to the
condition of the urine, but the precise factors necessary
for its deposition were first worked out by Baker and
Dodds (1925).
We repeated and confirmed the findings of Yorke
and Nauss and further concluded that if hæmoglobin
is injected intravenously into rabbits it is excreted
by the-kidneys and reaches the renal tubules where
one of two events may occur. (a) If the reaction
of the urine be on the alkaline side of pH6 the hemo-
globin will be excreted unchanged and appear in the
urine as oxyhemoglobin; the urine will be red and
the kidney will take no harm. (b) If the reaction of
the urine is as acid as pH6 and if there is sufficient
concentration of sodium chloride (over 1 per cent.)
the hæmoglobin will be precipitated in the tubules
as a brown granular pigment. The urine will then
be brownish, will show a brown precipitate, and will
contain casts of the urinary tubules composed of
similar brown granules massed together.
The kidneys of the rabbits secreting brown urine
showed brown granular debris filling many of the
renal tubules, chiefly the collecting tubules. A
certain proportion of these rabbits developed sup- |
pression of urine and became ill, and showed an
increase of blood-urea (up to 300 mg. per 100 c.cm.).
Rabbits secreting the hæmoglobin in an unchanged
state as oxyhzemoglobin never showed any evidence
of renal damage.
On the strength of these animal and chemical studies
and by the study of two human cases of suppression
of urine following transfusion we concluded that the
urinary suppression resulted from hemoglobinuria
only when the urine was acid, and we pointed out
that the timely administration of alkalis, preferable .
intravenously, should prevent this complication.
Both the cases we reported occurred, unfortunately,
before we had worked out the problem and we have
never had the opportunity of observing the effect of
alkalinisation on a human subject. Since our paper
was published in 1925 many cases of post-transfusion
suppression have been reported, but in only very few
of these can I find that alkalinisation has been
1392 THE LANCET] PROF. S.L. BAKER: URINARY SUPPRESSION FOLLOWING BLOOD TRANSFUSION [JUNE 12, 1937
attempted and even in'these it has obviously been
tried much too late. |
Several writers on the subject have evidently
failed to grasp the significance of our findings which
have, unfortunately, not been generally applied
to the prevention and treatment of this condition.
Their significance has, however, been realised by
two recent groups of workers, Goldring and Graef
(1936) and DeGowin, Osterhagen, and Andersch
(1937). The latter have repeated our experiments
using dogs instead of rabbits and have confirmed the
fact that animals secreting an alkaline urine suffer
no renal damage while those secreting acid urine
are liable to die from renal insufficiency produced
by obstruction of the kidney tubules by pigment
derived from hæmoglobin. They conclude their
paper with the remark: ‘“‘ These studies substantially
confirm the experiments performed on rabbits by
Baker and Dodds.” It is satisfactory to find that
our conclusions, based largely on studies of the
rabbit, which normally secretes an alkaline urine,
are equally applicable to the dog, which, like man,
normally secrets acid urine.
ALTERNATIVE EXPLANATIONS
Before considering in more detail the mechanism
of intrarenal obstruction it will be as well to discuss
briefly some alternative explanations of the renal
failure.
Bordley (1931) from a consideration of 17 cases,
14 of which were collected from the literature,
concludes that there are four possible explanations
of the renal damage :—
(1) Mechanical blockage of the tubules by the granular
debris.
(2) The kidneys are sensitive to certain bodies contained
in the injected blood and the functional decline results
from a local reaction which is of the nature of an
anaphylactic shock.
(3) The immediate transfusion reaction brings about a
metabolic disturbance that affects renal function.
(4) Damage to the renal tissue by toxic substances
set free in the blood at the time of the transfusion.
The last three of these possibilities cover a wide
and indefinite field and the problem cannot profitably
be discussed under these headings. It will be more
to the point to consider first what part of the trans-
fused blood is responsible for the renal damage,
(1) Is it the plasma or the corpuscles ?—The answer
to this is given by a case reported by DeGowin and
Baldridge (1934) where hæmoglobinuria, jaundice,
and a fatal suppression of urine followed transfusion
with washed red corpuscles. This case and the
experiments of Yorke and Nauss (1911) and Baker
and Dodds (1925), in which suppression of urine in
rabbits was produced by lysed washed red cells,
prove definitely that the corpuscles are responsible
for the damage.
(2) What part of the corpuscles ts responsible ?—
The corpuscles can be separated into the hæmoglobin
and the stroma and in our experiments on rabbits it
was found necessary to remove the stroma by filtra-
tion in order to avoid capillary emboli and thrombosis
in the lungs, which caused immediate death in these
animals when whole lysed corpuscles were injected
intravenously. In our experiments therefore urinary
suppression and nitrogen retention was produced
by the hæmoglobin fraction alone. We can say
therefore that hemoglobin liberated by intravascular
hemolysis of the transfused corpuscles is responsible
for the renal damage.
(3) Is hæmoglobin per se toxic to the kidneys or is the
effect dependent from the formation of the granular
precipitate in the tubules {—DeGowin and Baldridge
(1934) quoting the experiments of Mason and Mann
(1931) and Hesse and Filatov (1933) who showed that
Somoza nin had a vasoconstrictor effect on the kidney,
say: ⁄‘ It is as yet not possible to say whether the
vasoconstrictor effect or the blocking and destruction
of tubular epithelium is the more important.” It
is clear that the idea that the suppression of urine
is due to a vasoconstriction produced by hæmoglobin
would not explain the fact that, in rabbits and dogs
secreting an alkaline urine, hæmoglobin produces
ùo signs of serious renal damage as judged by micro-
scopic examination of the kidney and by the absence
of nitrogen retention. Moreover of the 7 cases of
post-transfusion suppression reported by Goldring
and Graef (1936) 4 (Cases 2, 3, 5, and 7) developed a
complete or partial suppression which lasted from
seven to sixteen days, but was then followed by a
diuresis and gradual recovery. Case 2 showed only
a short period of hæmoglobinuria which had dis-
appeared entirely by the fourth day following the
transfusion, yet the non-protein nitrogen of the
blood continued to rise during a further seven days,
after which diuresis set in and recovery took place.
This would be a peculiarly persistent vasoconstrictor
effect ; especially in view of the fact that Mason and
Mann describe the effect of hæmoglobin as “ a definite,
sharp, transient decrease in volume of the kidney.”
DeGowin, Osterhagen, and Andersch, in their
(1937) paper quoted above, bring further evidence
against the vasoconstriction hypothesis of Hesse
and his co-workers.
The outstanding fact which cannot be explained
by any of the suggested alternatives but can be
‚explained on our hypothesis is that under certain
conditions a gross hemoglobinuria may occur without
any evidence of renal damage, whereas under other
conditions the secretion of urine is suppressed.
Hemoglobinuria without appreciable failure in
renal function occurs in man in (1) paroxysmal
heemoglobinuria ; (2) in blackwater fevers particularly
in those cases treated with alkalis; and (3) after the
experimental injections of hemoglobin carried out
by Sellards:and Minot (1916). In animals Bayliss
(1920) found that injection hemolysed blood was
innocuous to the cat and dog, and as already stated,
rabbits with normally alkaline urine are not adversely
affected by transfusion with filtered hæmoglobin
solutions. On the other hand, we have the cases of
post-transfusion and blackwater-fever suppression
in man and the experimentally produced suppression
in rabbits and in dogs secreting an acid urine.
THE AUTHOR’S VIEW
The following summarises what I believe to be the
correct explanation of these apparently contradictory
findings. ,
The urine is excreted from the glomeruli as a dilute
transudate the reaction of which is in the region of
that of the blood plasma. During its passage through
the renal tubules it becomes more concentrated either
by absorption of water or by the addition of salts.
In hemoglobinuria the hemoglobin must either pass
out in the glomerular transudate or it must be excreted
by the tubules; in either case it will arrive in the
lower convoluted tubules where the urine is becoming
more concentrated. If the concentrated urine is
sufficiently acid and has a sufficient salt content
the hemoglobin undergoes a change, first to methsmo-
globin and then to hematin, the latter forming a
brown granular precipitate in the renal tubules. If
the urine does not become sufficiently acid and
THE LANCET] PROS. S. L. BAKER: URINARY SUPPRESSION FOLLOWING BLOOD TRANSFUSION [JUNE 12, 1937
1393
concentrated the hæmoglobin undergoes no change
but is excreted in solution as oxyhemoglobin; in
this event the kidney suffers no ill effects.
With a concentrated murine which precipitates the
hemoglobin there are three possibilities depending
on the amount of hemoglobin excreted and on the
degree of concentration of the urine.
(1) With a considerable hemoglobin excretion and a
very concentrated urine there is a massive precipitate of
hematin in the renal tubules ; this packs down into masses
which cause permanent blockage and death from complete
or nearly complete suppression of urine.
(2) With either a small amount of hemoglobin or a
rather less concentrated urine the precipitate is less
copious and produces a similar but less massive obstruction.
With the gradual extrusion of the hematin casts, possibly
encouraged by a diuresis produced by the raised blood-
urea, the obstruction is relieved and the patient recovers.
(3) With still less hemoglobin or only a moderately
concentrated urine a light precipitate of hematin forms
in the renal tubules; this is easily passed out and appears
in the urine as lightly packed granular casts which are
associated with a fair amount of brown granular precipitate
formed in the bladder. No urinary suppression or gross
functional damage to the kidney results in these circum-
stances. This condition was evidently present in the
case of paroxysmal hemoglobinuria whose urine we had
the opportunity of examining (Baker and Dodds, 1925).
Récovery from Intrarenal Obstruction
In a series of 17 cases of post-transfusion suppression
reported by Bordley (1931) there were 5 recoveries
and in a recent series of 7 reported by Goldring and
Graeff (1936) 4 recovered. The mechanism of this
recovery presents an interesting problem.
The sequence of events is usually as follows. After
a period of partial suppression and steadily rising
azotemia with uremic symptoms, lasting from seven
to sixteen days, the excretion of urine begins to
improve and in the course of four to six days mounts
steadily from an almost complete suppression to an
output of 3-4 litres a day. With the establishment
of this diuresis there starts a steady fall in the non-
protein nitrogen of the blood and the patient makes
a rapid recovery. Recovery may take place after a
high grade of azotzemia has been reached ; in Case 5
of the series reported by Goldring and Graef recovery
occurred after sixteen days’ partial suppression with
an azotzmia reaching 520 mg. non-protein nitrogen
per 100 ccm. The prolonged obstruction produced
no permanent impairment of renal function in this
case. s
We noted a very similar recovery of renal function-
in our experiments on rabbits and made the following
remark (Baker and Dodds 1925, p. 254).
“ Even when the urine is made acid it is not an easy
matter permanently to obstruct the kidney of a rabbit
by injections of hæmoglobin. Such an animal may
recover after several 20 c.c. injections of strong hæmo-
globin solution. There is no doubt that such injections
lead to a temporary blockage of the renal tubules. It
can be shown, however, that the kidney is capable of 7
recovering its function after such an obstruction.”
At the time of these experiments we were not aware
that a similar process of recovery could take place
in man and were surprised at the powers of recovery
of our rabbits.
` The evidence that recovery is dependent on the
extrusion of the hematin casts from the renal tubules
is based on the examination of the urine of rabbits
recovering from obstruction; our remarks on this
were as follows :—
“ When obstruction has occurred in a rabbit with an
acid urine an examination of samples of urine passed during
the period of recovery shows numerous darkly coloured
compact casts which form a slight sediment in an otherwise
perfectly clear urine. These casts undoubtedly correspond.
to the more compact masses of debris which are seen in
sections blocking the straight tubules; their extrusion
no doubt frees the kidney to a considerable extent.”
I have never had the opportunity of examining
the urine of a patient who recovered from post-
transfusion suppression, nor does there appear to be
any record of studies of the urinary deposit in such
a case,
Nature of Granular Precipitate in Renal Tubules
A detailed chemical study of the precipitate in the
renal tubules and in the urine has, as far as I am
aware, never been made. It would obviously be
very difficult to investigate in any detail the pigment
in the tubules; it has, however, been shown that
it gives a positive benzidine reaction (Goldring and
Graef 1936) and that it does not give the Prussian-
blue reaction for inorganic iron. This proves that
it is either hemoglobin or one of its degradation
products containing organically combined iron. Its
brown colour and granular form tells us that it is not
unchanged hæmoglobin. As regards the pigment
in the urine, part of which is derived from casts
extruded from the kidney, this consists of at least
two substances for, if the urine is allowed to settle,
the supernatant fluid gives the spectrum of methzemo-
globin while the granular precipitate gives the reactions
for hematin (Baker and Dodds 1925, p. 258).
Hematin, like the pigment in the renal tubules,
gives the benzidine but not the Prussian-blue reaction.
These two pigments (methzemoglobin and hematin)
were produced in vitro by adding hemoglobin to acid
urine.
The exact chemica] composition of the precipitate
is, however, of purely academic interest; what is
of practical importance is the mechanism of its
formation, and this is set forth in detail in our paper.
An important point, which explains the different
grades of renal obstruction (ranging from complete
to nil), is the variation in the amount of precipitation
with changes in the pH and salt content of the urine.
With a very concentrated urine the precipitation is
complete and relatively rapid and little if any
methemoglobin remains in solution; with less
concentration its precipitation is slower and partial.
With a fairly rapid and complete precipitation,
which would only occur with a very concentrated
urine, it is quite possible that no soluble pigment
would escape from the kidney even though some
urine was excreted. This probably explains the
exceptional cases where hemoglobinuria was definitely
stated to be absent, although pigment was found in
the renal tubules post mortem. Pigment casts
would almost certainly have been found in the urine
in these cases had they been looked for.
Although hemolytic jaundice usually occurs, it
is not always present ; its absence, even in carefully
recorded cases, cannot be taken to negative an
intravascular hemolysis. This point is illustrated
by the very well-recorded series of 7 cases collected
by Goldring and Graef (1936). All these showed
hemoglobinuria and all developed jaundice except
Case 5; but there must have been hemoglobinemia
in this case to produce the hemoglobinuria. Hæmo-
globinuria without jaundice was also present in the
case I report in this paper.
Changes in the Kidneys
The naked-eye appearance of the kidneys is variable
and not very distinctive. They are usually enlarged,
1394 THE LANCET] PROF.S. L. BAKER: URINARY SUPPRESSION FOLLOWING BLOOD TRANSFUSION [JUNE 12, 1937
sometimes weighing up to about 8 oz. each; the
cortex is usually swollen and may show the pale
opaque appearance of marked albuminous degenera-
tion or, on the other hand, it may be congested. The
medulla shows a dark red-brown striated appearance
produced in part by congestion of the vasa recta
and in part by deposits of brown pigment in the
medullary tubules. Microscopically the character-
istic change is a deposit of granular brown pigment
in the tubules ; this is most obvious in the collecting
tubules, but may in some cases extend as high as the
second ‘convoluted tubules (as in our Case 1
and Dodds 1925). This pigment is in the form of
granules of size varying from that of a micrococcus
up to globules and masses considerably larger than
red blood-cells. In unstained sections it is brown
in colour, but it appears red or brownish-red with
eosin staining and, as noted above, it gives a benzidine
but not a Prussian-blue reaction. The pigment is
mixed with a variable amount of cell debris mainly
derived from the tubular epithelium and tends to
form compact casts in the lower parts of the tubular
systems.
The other changes in the kidneys consist of (a)
albuminous degeneration of the tubular epithelium,
and (b) dilatation of the tubules and of Bowman’s
capsules. @Œdema and infiltration of the interstitial
tissues with chronic inflammatory cells have been
described in several cases. The enlargement of the
kidneys appears to be produced by albuminous
degeneration and dilatation of the tubules and
possibly to some extent by oedema and cellular
infiltration of the interstitial tissues. The albuminous
degeneration may be marked but there is no tubular
necrosis nor are appreciable fatty changes present.
The amount of dilatation of the tubules and of
Bowman’s capsules is very variable and possibly
depends on the extent of the precipitate within them
(and the point at which obstruction occurs). In
our first case where the pigment precipitate extended
as high as the second convoluted tubules there was
a general dilatation of all the tubules and of Bowman’s
capsules, and I have sections of a kidney from a case
of blackwater fever with urinary suppression which
shows an almost identical condition. In Witts’s
case (1929), in which a detailed description of the
microscopic appearances of the kidneys was given
by Turnbull, all the tubules were dilated, but the
capsule of Bowman was “usually only slightly
dilated.” The deposit of pigment did not extend
as high as the convoluted tubules in this case, In
our second case there was no obvious dilatation of
the tubules or of Bowman’s capsules and the pigment
was confined to the lower part of the tubular
system.
Interstitial oedema and perivascular and inter-
tubular infiltration with chronic inflammatory cells,
which were noted in Witts’s case and in several
others, if directly related to the renal obstruction,
appear to be late results; neither of these features
were present in our first case which died early on the
fourth day following transfusion.
We may therefore summarise the more important
microscopic findings as follows :—
(1) A precipitate of hematin in the lower parts of the
tubular systems extending, in some cases, into the second
convoluted tubules.
(2) Albuminous degeneration of the tubular epithelium |
without necrotic or fatty changes but with desquamation
of some of the cells into the tubular lumina.
(3) A variable degree of general dilatation of the tubular
systems which may be marked and may also involve
Bowman’s capsules.
, Baker |
(4) No signs of inflammatory or other significant lesions
in the glomeruli.
(5) As a late result a varying amount of edema and,
possibly, chronic inflammatory infiltration of the peri-
vascular and intertubular connective tissues.
Prevention and Treatment of Post-transfusion
Suppression
Since hæmoglobin is precipitated only “when the
urine is acid intrarenal obstruction will not occur
in a patient whose urine is neutral or alkaline during
the period of hemoglobinuria following an incom-
patible blood transfusion. If, however, a precipitate
has formed in the renal tubules in a patient with an
acid urine it is doubtful whether alkalinisation will
effect a cure.. Precipitates of hematin are not very
soluble in alkaline urine (pH 7-5) but they are more
soluble in this than in acid urine. When the
precipitate is sufficiently. massive to produce complete
suppression one can, presumably, expect little from
alkalinisation ; but in’ most cases the suppression
is not complete and an alkaline urine should help
by dissolving some of.the precipitate in the tubules.
Since, as we have seen, a fair proportion of cases
have recovered from the obstruction spontaneously,
probably ,by the extrusion of the obstructing casts,
a relatively slight solution of some of the pigment
may well turn the scale in favour of recovery. Early
recognition and prompt treatment of the condition
by alkalinisation appears to offer the best prospect
of recovery. The treatment of blackwater fever by
alkalis has been practised for many years.
Cases must occur in which an incompatible trans-
fusion results in hemoglobinuria, but, because the
patient’s urine is not very acid, there is no suppression
of urine. I have heard of one such case, but the
majority have evidently not been considered worth
recording.
SUMMARY
1. A case is described in which urinary suppression
followed transfusion with overheated blood.
2. The mechanism of post-transfusion suppression
is discussed in the light of older and more recent work
and it is concluded that the view put forward by Baker
and Dodds (1925) furnishes the only adequate
explanation of the observed facts.
3. According to this view the urinary suppression
results from an intrarenal obstruction due to excretion
of hemoglobin with a urine of high acidity and salt
concentration. Under these conditions the excreted
hæmoglobin is converted into a granular deposit of
hematin which obstructs the renal tubules. Hæmo-
globin per se is innocuous to the kidney.
4. The prevention and treatment of the condition
is briefly considered.
REFERENCES
Baker, S. L., and Dodds, E. S (1925) Brit. J. exp. Path. 6, 247.
Bayliss, W Ww. M. (1920) Ibid, 1,
Bordley, J. (1931) Arch. eed "Med. 4
DeGowin, E. L., , and Baldridge, C. W. i Amer. J. med. Sci.
, 55
— Osterhagen, H. F.» and Andersch, M., Arch. intern. Med.,
March, 1937, 432
p-
Facey, R. V. (1937) Brit. med. J. 1, 40
Goldring, W., and rael I. (1936) reh. intern. Med. 58, 825.
Hesse, E., and PENOY A R ) Z. ges. exp. Med. 86, 211.
Mason, J. B., F. C. (1931) Amer. J. Physiol. 98, 181.
Witts, T: LEET EA EY 129
Yorke, n ‘and Nauss, R. W. (1911) Ann. trop. Med. Parasit.
HosPITAL’S CHANGE OF NamMeE,—The City of
London Hospital for Diseases of the Heart and Lungs,
Victoria Park, has been renamed the London Chest
Hospital.
= sz. —
. \
THE LANCET]
TRANSPLANTATION OF THE CORNEA
FROM PRESERVED CADAVERS’ EYES
By V. P. Frmatov, M.D.
OF ODESSA, U.S.S.R.
Tur recently the chief source of material for the
. transplantation of the cornea in man consisted of
eyes enucleated from living people owing to some
disease of the eye or of the orbit. The possibility
of obtaining a permanent, transparent union of the
corneal graft from the living eye has been proved
beyond any doubt; many cases have been recorded
where the transparency of the cornea has been
observed for nine months or more—notably 31 cases
from Elschnig’s clinic (Ascher 1919, 1922, Liebsch
1930, Stanka 1927), 16 from my own observation
(Filatov 1935b), and the cases of Zirm (1907), Plange
(1912), Löhlein (1912), Tudor Thomas (1933, 1934),
Castroviejo (1933, 1934, 1935), Vasiutinsky (1935),
Belajev (1924), and other authors. About 70 cases
are on record of successful transplantation of the
cornea from living eyes. Almost all of these successes
have been obtained with the method of partial
penetrating transplantation; in a few of the cases
the lamellar partial transplantation was made;
while one only fairly successful case has been recorded
{Schimanovsky 1913) of complete transplantation.
All my cases were under observation for not less
than a year, the only exception being a patient who
died seven and a half months after the operation.
As regards more remote results of transplantation
from the living eye a number of cases have been
recorded by Elschnig, as :well as by myself, which
have been under observation for several years.
Fig. 1 shows eyes whose transplants were found
to be transparent after varying periods.
GRAFTS FROM THE LIVING
CasE A.—Complete leukoma, developed after recur-
ring scrofulous keratitis. In the leukoma were some
remnants of the semi-transparent corneal tissue. Vision
before operation (Oct. 18th, 1923) was equivalent to
perception of light; vision after operation was 3/60
on aphakic correction. This vision remained unchanged
till the patient died 6 years later (Filatov 1925).
Case B.—Dense opacity after parenchymatous keratitis.
Vision before operation (Dec. 23rd, 1930) 0-025. The
transplant retained a fine transparency during the time
of observation (54 years). Vision after the operation
was 0-7 till May, 1934, when it became and remained
0-4. Fundus oculi clearly visible (Filatov and Velter
1932) (Fig. 1).
Case C.—Dense opacity of the central part of the cornea
of the right eye and less dense opacity on its periphery ;
both developed after parenchymatous keratitis. Vision
before the operation (Feb. 2nd, 1932) was 3/60. The
transplant is now, 4 years and 7 months after
the operation, still fully transparent. Vision was 0:5
{Filatov and Velter 1934) (Fig. 1).
Case D.—Opacity developed in the left eye after
parenchymatous keratitis. Vision before the operation
{March 10th, 1932) was 5/60. The transplant is now,
44 years after the operation, fully transparent. Vision=0:3
(Filatov and Velter 1934).
‘Case E.—Leukoma developed after a traumatic ulcer.
In the upper third of the cornea a strip of the tissue is
transparent. Vision before the operation 1/60; after
the operation, performed in December, 1931, by Prof.
Zykulenko, vision rose to 0:4. Binocular vision was
restored. Length of observation time 4 years 9 months
(Zykulenko and Velter 1933) (Fig. 1).
DR. V. P. FILATOV : TRANSPLANTATION OF CORNEA FROM CADAVERS’ EYES [JUNE 12,1937 1395
These results illustrate the bright prospects of
corneal grafting, and there is now reason to think
that the operation may prove to be a practical means
of overcoming the blindness and disablement due
to leukoma,
NEED FOR NEW SOURCES
The question now arose whether the number of
suitable eyes removed from living people would be
enough for all the cases in which the transplantation
was indicated. For it must be kept in mind that there
are six million blind in the world and fifteen millions
suffering from diseases of the eye (Samoilov and
Braunstein 1935). According to the official census
in 1926 there were 234,800 blind people in the Soviet
Union (Savvaitov 1932). In at least 43 per cent.
of this number blindness is due to leukoma, for to
this cause may be put down all cases of blindness
from trachoma (20-64 per cent.), from small-pox
(10-63 per cent.), from diseases of the cornea (8-43
per cent.), and from blennorrhea of the newly born
(3-45 per cent.); it is also necessary to add some
cases of blindness due to trauma. Of this number
—-about a hundred thousand—a great many cases
are not fit for the operation of corneal transplantation
owing to various complications, such as glaucoma,
atrophy of the eye, staphyloma, symblepharon, and
persisting trachoma. Yet the number of cases in
which the operation is indicated still amounts to
many thousands. The number of candidates for
corneal transplantation would be increased even
more by those who, though afflicted with leukoma
in both eyes, have not been registered as being
blind because their vision is above 1/200. Such
cases lend themselves particularly well to the opera-
tion of corneal transplantation, for these leukomata
contain remnants of corneal tissue. Furthermore,
since the transplantation, of the cornea successfully
competes with iridectomy, the number of candidates
for the operation may indeed be enormous.
In view of the great success already achieved in the
work with corneal transplantation it seemed high
time to attempt to find a new source of transparent
corneas if the serious difficulty of supply was to be
overcome, It was only natural for me first of all to
turn my attention to the dead body. For some time
cadavers’ eyes, from adults as well as from fetuses,
had been employed in a few single cases by several
surgeons. Some used corneas immediately or during
the first hours after death (Fuchs 1901, Schimanovsky
1913, Magitot 1912, Saveliev 1927). Other surgeons
removed the eyes from the stillborn 10-36 hours after
death. Only in the case reported by Magitot (1912),
however, was a permanently transparent union of
the transplant established by fairly long observation.
These data were of course far too meagre, and the
use of cadavers’ material on a large scale, as a
substitute for living material, to meet the demands
for transplantation had not previously been considered
by anybody. l
This then was the state of affairs when I studied
the problem in 1931. Its solution I based on the
remarkable case reported by Morax and Magitot
(1912) who obtained a permanently transparent
union of the cornea removed from a living person
and preserved in the donor’s blood at a temperature
of minus 6° C. for eight days.
METHOD
From the very beginning of my investigation on
the feasibility of transplanting cadavers’ cornea I
employed corneas taken from cadaver-eyes preserved
for many hours before the operation at a relatively
!
1396 THE LANCET] DR. V. P. FILATOV: TRANSPLANTATION OF CORNEA FROM CADAVERS’ EYES [JUNE 12, 1937
low temperature, The eyes were obtained: (1) from
bodies of those who had not died from infectious
diseases nor, malignant tumours—syphilis was
excluded by serological tests before or after death
and sometimes also by autopsy ; (2) after death from
accidents or suicide, brought into the medico-judicial
morgue—syphilis was excluded by serological tests,
and the absence of acute infections by the anamnesis
and sometimes by autopsy.
The enucleated eyes were in some cases placed in
a sterile jar with a tight-fitting stopper, cornea
upwards; sometimes the jar was filled with the
donor’s fresh clotted blood while
in still other cases the blood was
citrated. The jars were kept in an
ice-chest at 4°-6° C. On the day of
operation the jar containing the
eye, surrounded by ice, was
brought into the operation room,
where it remained for about an
hour before the cornea was excised
and transplanted. The corneas of
eyes preserved in this manner
usually appeared to be somewhat
dimmed, the epithelium being slightly stippled. The
eyes were kept for periods varying from 10—56 hours,
while in one case it was six days. Before excising
the transplant the cornea was washed with a fresh
aqueous solution, brilliant green (1 : 1000).
, RESULTS
From 1932 till January, 1936, I have performed
95 operations of the partial penetrating transplanta-
tion of corneas prepared in this way (Filatov 1934,
1935a). In nearly all of these cases I used my own
operative technique.
I employed either an FM 1 or an FM 3 trephine
and covered the transplant with a flap of conjunctiva
(Filatov 1934a and b, 1935b and ©).
tissue film had formed on the posterior surface of the
transplant, must not be referred to the total number of
eyes operated on, but only to 49 of them, since in
46 eyes the leukomata were greatly complicated by
glaucoma, buphthalmos, applanation, subatrophy
_ of the eye, &c. ; in such eyes there is no hope at all
of obtaining a transparent union, While the opera-
tion is performed in the last resort as a concession
to the supplications of the patients, it is necessary
to keep separate records for such eyes.
Out of the 18 operations in which transparent
union was recorded, 14 cases have been under observa-
Case C.
FIG. 1.—Corneal grafts from the living.
tion-for over nine months, the remaining 4 cases having
been followed up for a shorter time, - Some of these
18 cases of transparent union are summarised below
and illustrated by untouched photographs :—
Case 1.*—Leukoma due to scrofulous keratitis. Vision
before operation : perception of hand movements. Trans-
plantation of cadaver’s cornea on March 17th, 1935.
The eye had been taken from the cadaver 12 hours after
death and subsequently preserved for a further 25 hours
at 4°-6° C.
Result.—Vision = 3/60, on eccentric fixation (amblyopia),
Fundus oculi clearly visible. Length of observation
(Oct. lst, 1936) 14 years (Fig. 2).
_ Case 2.*—Leukoma developed after an ulcer. Vision :
perception of hand movements. Transplantation of
Case 1.
Case 2.
Case 3. Case 4,
FIG. 2.—Corneal grafts from cadavers. The eyelids are retracted to display the cornea.
There was not a single case of necrosis of the
transplant. The post-operative course was pretty
much the same as in transplantation from living
eyes.
The following were the results of the 95 operations.
There were 46 cases of non-transparent union and
17 cases of half transparent union. In one of these cases
a greyish film has formed on the posterior surface of the
transplant.
In 4 cases, in one of which the transplantation was
performed after six days’ preservation of the eye, the
union was transparent, but a connective tissue film
had formed in each case on the posterior surface of the
transplant.
Lastly, there were 18 cases of transparent union. By
this I mean that the details of the anterior chamber
could be clearly made out at least through a part of the
transplant or that there was a good light reflex through it.
The 18 cases of transparent union, and alse those
cases of transparent union in which a connective
cadaver’s cornea on Dec. 12th, 1935. The eye taken
from the cadaver had been preserved for 27 hours.
Result.—Vision = 0:4. Fundus oculi clearly visible.
Anterior pole cataract distinctly visible. Length of
observation (Nov. Ist, 1936) 10} months (Fig. 2).
Case 3.—Leukoma formed after a thermic burn. Vision
before the operation: perception of hand movements.
Transplantation of cadaver’s cornea on Oct. 28th, 1934.
The eye had been removed from the cadaver 3 hours
after death and subsequently preserved for 27 hours.
Result.—Vision = 0-4.: Anterior pole cataract. Fundus
oculi clearly visible. Length of observation (Nov. Ist,
1936) 2 years (Fig. 2).
Case 4.—Aged 12. Leukoma after parenchymatous
keratitis. Vision before the operation: able to count
fingers held before her face. The eye had been taken
from a cadaver 12 hours after death and subsequently
preserved for 26 hours.
*Cases 1, 2, and 5 were demonstrated at the All-Union
Mecting of Ophthalmologists of the U.S.S.R. in June, 1936.
THE LANCET] DR. G. W. THEOBALD : CALCIUM AND VITAMINS A AND D IN TOX2MIA [JUNE 12, 1937 1397
Result.— Vision = 0-1 with a
oculi distinctly visible.
1936) 24 years (Fig. 2).
Case 5.*—Leukoma after parenchymatous keratitis.
Vision before the operation = 0-02. Transplantation of
cadaver’s cornea on Oct. 28th, 1935. Eye removed from
—9 D lens. Fundus
Period of observation (Oct. lst,
the cadaver 2 hours after death, preserved a further |
28 hours.
Result.—Vision = 0-9. _ Length of observation (Nov. Ist,
1936) 12 months.
The cases cited above bear witness to the fact that
& cornea from a cadaver’s eye, preserved at a
temperature of 4°—6° C., is perfectly suitable for trans-
plantation. Analysing my material and taking into
account the quality of the leukomatous substratum,
in which the transplant from the cadaver is placed,
I have gained the impression that the results of
transplantation from cadavers’ eyes are not inferior
to those obtained with grafts from living eyes. For
a final opinion it is of course still necessary to follow
up the more remote results of the operations. On
the other hand it may be said that the present results
in my series of cases that have been under observation
from 1} to 24 years, would already seem to justify
the expectation that the more remote results will be
favourable.
Investigations are being made in my laboratory
on the retention of vitality by the cornea under various
conditions of preservation. Experiments carried
on by Dr. Bazhenova have shown that the cornea
of rabbits’ eyes may show a good tissue growth
when planted in vitro even after ten days’ preserva-
tion at a temperature of 2° C. In collaboration with
Bazhenova I have obtained a tissue culture from
dried cornea. Working in my laboratory Velter
has shown in rabbits the possibility of transparent
union of the cornea taken from eyes, preserved
at a temperature of + 2° C. for as long as fifteen
days.. My pupil, Dr. Pupenko, has brought forth
evidence for migration of cells and their forma-
_ tion into clusters in the cornea (and in other tissues)
after preservation of the material for eight days at a
temperature of 2° C.
| CONCLUSIONS
The cornea from eyes of human cadavers, removed
some hours after death and preserved at a temperature
of 4°-6° C., is suitable for homoplastic transplanta-
tion in man, the transplant retaining permanent
transparency after union with the substratum.
The new source of material for transplantation
opens up great possibilities for further investigations
on corneal grafting.
In connexion with the transfusion of preserved
cadavers’ blood, first applied to dogs by Prof. W. N.
Shamov and to man by Prof. Yudin, the successful
transplantation of preserved cadavers’ corneas is of
great interest not only from a clinical but also from
a general biological point of view.
REFERENCES
reese (ror) v. H Arch. Canha 99, 339.
— ) Ibid, 107, 241 and 439.
Belajex EA Med. JEN. Povolgia, 3, 52.
ene ts old, 17, aur J. Ophthal. 15, 825.
1933 J. med. Soc. N.J. 3
Filatov, he 2B (1925) ie Mol. Eqns 74, 746.
(1927) Ibid, 78, 247.
TEN Sovetsk. tinik oflal. 4, 2.
(1934b) Arch. Oftal. Hiep: Amer. 34, 289.
(1934c) Ann. Oculist, 171, 721.
and Velter, T. (1932) Arch. Augenheilk. 106, 167.
— (1934) ’Sovetsk. vestnik. oftal. 4, 5.
(1935a) J. med. Acad. S. ee, 4, 1421.
888e) Arch. Ophthal. N.Y. 321.
1935c) Klin. Mbl. Augenheilk: 3è 756.
A. (1901) Z. Augenheilk. 5
(Continued at foot of next column)
BI TTI TTT
EFFECT OF
CALCIUM AND VITAMINS A AND D ON
INCIDENCE OF PREGNANCY TOXAMIA
By G. W. THEOBALD, M.D. Camb., M.R.C.P. Lond.,
F.R.C.S. Edin., F.C.0.G.
THE following experiment, carried out at St. Mary
Abbots Hospital,* London, during 1936, was devised
to determine whether the mere addition of calcium
and vitamins A and D to the dietaries of patients
attending the antenatal clinic would have any effect
on the incidence of toxamic symptoms.
Apparently healthy women, not more than twenty-
four weeks’ pregnant, were divided by the sister
into two groups when they first attended at the
clinic, no attention being paid to their previous
obstetric histories: They were divided at random
in the following manner :—
An equal number of blue and white beads were placed
in a box. Each woman accepted for the experiment was
asked to draw a bead from the box. Those who drew blue
beads were placed in Group A while those who drew white
beads were placed in Group B. The beads drawn out
were placed in a separate container.
The patients in Group A were requested to take daily,
for the remainder of their pregnancies, calcipm lactate
20 grains, vitamin A (11,000 international units)
and naturally occurring vitamin D (450 units) ;
while those in Group B served as controls. The oil
containing the vitamins was supplied in capsules,
of which four were to be taken every day, while the
calcium lactate was distributed in the form of tablets.
No advice concerning diet was given to either group
of patients.
Each group contained 50 women. In Group A
25, and in Group B 26, were primigravide. The
symptoms were recorded by independent antenatal
officers who had no knowledge as to which patients
were receiving the additional substances. All patients
developing albuminuria, showing hypertension, or
suffering from excessive vomiting, or cdema were
admitted into the antenatal ward. Those suffering
from insomnia or severe headaches were also advised
‘to go into hospital.
RESULTS
The results obtained are shown in Tables I and II.
The symptoms of the patients admitted for
albuminuria and hypertension are not included,
so that the nee “symptoms ” refers to patients
* This obstetric unit is affiliated to the British Postgraduate
Medical School, Hammersmith, London.
(References continued from previous column)
Komaroviten (1930) Russ. oflal. J. 12, 327.
Liebsch, W. (1930) Arch. SLOME 103, 603.
Löhlein (1912) Arch. Ophthal. N.Y. 41, 3.
Maven (1912a) Arch. d’Ophth. 32, 173.
— (1912b) Ann. Ocul. 147, 44.
— (1912c) J. Amer. med. Ass. 59, 18.
Plange (1912) Klin. Mbl. Augenheilk. 50, 490.
Samoilov and Braunstein (1935) Kharkov Biomedgis. 1, 424.
Savvaitov (1932) Sovetsk. sad at oftal. 1, 1.
Saveliev (1924) Russk. oftal. J 228.
Sipe oa Nara (1913) Oftal. Pesthi. 29, 711.
Stanka, R. (1927) v. Graefes Arch. Ophthal. 118, 335.
Thomas, J. W. T. (1933) Proc. R. Soc. Med. 26, 597.
— (1934) ater J. Ophthal. 18, 124.
esta ear y G. (1935) Sovetsk. vestnik oftal. 6, 29.
Zirm, E. (1907) Wien. klin. Wschr. 3,
Augenheilk.
Zykulenko
9,44.
2
and Velter, T. (1933) Klin. Mol.
AA 3
1398 THE LANCET] DR. G. W. THEOBALD: CALCIUM AND VITAMINS A AND D IN TOXZMIA [JUNE 12, 1937
not included in the above two categories. A systolic
blood pressure of, or exceeding, 140 mm. Hg was
considered evidence of hypertension. The numbers
TABLE I
Inċidence of Toxic Symptoms in Treated (A) and Untreated
(B) Women 7
- Group A (50). GROUP B (50).
Primi- Primi-
Cases. gravide. Cases. gravidæ.
Albuminuria and
hypertension 2 2
Hypertension 3 4
Albuminuria bi 2 3
Other symptoms 6 4
~ Totals .. ..| 13 13
TABLE II
Analysis of “Other Symptoms ”
— Group A. Group B
Hyperemesis car “aes 2 4
Œdema .. ; 3 3
Headaches .... 2 5
Cramps .. 1 3
Insomnia 2 6
Totals... .. 10 21
suffering from ‘other symptoms” are shown in
Table II, most patients complaining of more than
one symptom.
COMMENT ON THE FINDINGS
Prof. E. S. Pearson, of the department of
statistics at University College, London, has been
kind enough to study these figures and has expressed
the opinion that the difference in incidence of
“ complications ” between the two groups is very
unlikely to have arisen by chance. It is therefore
desirable to consider factors, other than the diet,
which may have contributed to this difference.
Of the 100 patients, 76 were between twenty and
thirty years of age. Of the primigravide 4 (2 in
each group) were under the age of twenty, each being
nineteen years of age. The number of women over
thirty was 20, including 2 primigravide in each group :
9 of these were in Group A and 11 in Group B. It
is thus evident that the ages of the women in the two
groups were strictly comparable.
It has already been stated that no regard was paid
to the previous obstetric histories of the multigravide.
There are arguments in favour of confining future
experiments to primigravidx, but it would have been
impossible to take previous obstetric histories into
consideration unless all the confinements had taken
place in comparable institutions. One woman in
Group A, admitted for albuminuria and hypertension,
had been twice previously confined—on both occasions
in St. Mary Abbots Hospital. In her first pregnancy
she had suffered from eclampsia, and during her
second pregnancy she was admitted for albuminuria
-= and hypertension. As the result of treatment in the
ward her urine became protein-free and her blood
pressure returned to normal limits before she was
delivered of her third child. The previous obstetric
histories of many -of the patients were unobtainable,
but it is significant that the same difference in
incidence of ‘complications’ between the two
groups is observed among the primigravid as among
the multigravida.
All the patients in the experiment were observed
equally often over approximately the same period of
time. No woman was included who was not in the
position to take the “ protective substances >° for
sixteen weeks before delivery, and no one took them
for more than twenty weeks. The social status
of all the patients was, so far as could be judged,
strictly similar. There. was no room for variation
in the “ standards” adopted by the antenatal officers,
for the criteria were well defined. If albumin was
found in the urine a catheter specimen was
subsequently obtained and tested. No patient was
recorded as suffering from albuminuria unless albumin
was detected in a catheter specimen. Similarly, no
patient was admitted for hypertension unless, after
rest, the systolic pressure equalled or exceeded
140 mm. Hg. A symptom, such as headache, was
accepted only if it persisted and was severe. More-
over, I myself saw every patient who was admitted
to the antenatal ward and confirmed the findings
of the antenatal officers.
It therefore seems logical to assume that the
difference in the incidence of ‘‘ complications ”
between the two groups must, if not due to chance,
be attributed to the substances given. This assump-
tion is strengthened by the results of the dietetic
treatment of these patients in the antenatal ward.
The symptoms cleared up in every case. A slight
degree of albuminuria, not exceeding 0:05 per cent.,
persisted in 3 of the 13 patients admitted for this
condition, while the blood pressure returned to the
normal in 13 of the 16 patients admitted for hyper-
tension. These results strongly suggest that the
other main factor in the prevention of the toxsmias
of pregnancy is the vitamin-B complex.
It is somewhat disappointing that, after, waiting
so long for the opportunity of conducting this experi-
ment, the number of women included should be so
small. This is due to the fact that only a small
proportion of the patients booked sufficiently early
and attended the hospital antenatal clinic throughout
their pregnancies. These results, however, point
in the same direction as those obtained by Mendenhall
and Drake,! and are published in the hope that
further experiments on a larger scale will be conducted
elsewhere. There is no proof that all the patients
in Group A took their capsules and tablets regularly,
and it might be expedient to incorporate a trace of
methylene-blue in each tablet.
Experiments conducted on these lines would show
to what degree, if any, the different protective
substances are associated with toxemic symptoms.
It is my belief, for instance, that vitamin A is of more
importance in preventing senile changes in the
placenta, and consequent death of the fetus, than
in preventing toxemic symptoms. Then, too, experi-
ments conducted in different parts of the country
might show that the degree of deficiency of any
given protective substance varied from area to area.
On the other hand, all the protective substances could
be incorporated in a pill and a capsule and be
distributed at a cost not greatly exceeding that of a
daily pint of milk.
There is one further and still more important
reason why such investigations should be under-
1 Mendenhall, A. M., and Drake, J. C. (1934) Amer. J. Obstet.
Gynec. 27, 800.
THE LANCET]
taken. Some authorities maintain that the great
majority of the adult population suffers from some
degree of malnutrition, while others deny that there
is any evidence, other than an incidence of secondary
anzmia, in favour of such a conclusion. Dietetic
surveys indicate that the average intake of the
protective substances is inadequate, when calculated
on a rat basis, but the transference of results from
the rat to man is not justified, and it must be admitted
that: the optimum and minimum human require-
ments of these substances are not known. It is,
however, universally accepted that pregnancy makes
an increased demand on the maternal stores of the
vitamins and minerals, and this is true of every
experimental animal. If, therefore,
toxzemias of pregnancy nor intra-uterine death of the
foetus are to be attributed to dietetic deficiencies,
then it may. be asserted that there is no evidence
whatsoever that any significant section of the adult
population suffers from malnutrition. Conversely,
CLINICAL AND LABORATORY NOTES
neither the.
[JUNE 12, 1937 1399
if the toxemias of pregnancy are due to this cause
then there is every justification for the assumption
that similar symptoms and “diseases,” such as
insomnia, headaches, cramps, pyelitis, albuminuria,
hypertension, skin rashes, and jaundice, occurring
in the non-pregnant state, may likewise be due to
dietetic deficiencies. It may, with reason, be con-
cluded that the proof, or disproof, of the dietetic
deficiency hypothesis of the toxsemias of pregnancy
affords the only available experimental means of deter-
mining whether malnutrition, other thaniron deficiency,
is a significant cause of ill health and diminished
vitality in the adult population of this country.
I have pleasure in thanking Sir Frederick Menzies,
medical officer of the County of London, for permission
to carry out this experiment, and to publish the results.
I should also like to take this opportunity of thanking
Miss F. R. Sindon, the maternity sister, for so willingly
undertaking the extra work necessitated by this
investigation. |
CLINICAL AND LABORATORY NOTES
INTUBATION OF THE MAXILLARY
ANTRUM FOR ACUTE EMPYEMA
By N. Asuerson, M.B. Lond., F.R.C.S. Eng.
ASSISTANT SURGEON TO THE CENTRAL LONDON THROAT, NOSE,
AND EAR HOSPITAL
PUNCTURE, with subsequent lavage, of the maxillary
antrum through the inferior meatus is a common way
of dealing with an acute empyema of the antrum for
both diagnosis and therapeusis. Antral puncture is
especially indicated when, after a cold or influenza
the antral infection gives rise (as it frequently does) to
severe face-ache,
facial neuralgia,
or supra - orbital
with the upper lip. It is retained in situ by strapping the
threads to the cheeks.*
Using this special retainable antrum cannula, the
antrum is punctured with the trocar and cannula
through the inferior meatus. The trocar is with-
drawn and the cannula left in situ. The antrum is
perfused with saline. A loose pad of gauze is also
strapped over the nose.
The patient is confined indoors or to bed, and every
3 hours the first day, every 4 hours the next day,
and subsequently three times daily the antrum is
irrigated, about a pint of sterile tepid saline being
used. The cannula is left in for up to a week, when
it is withdrawn, cleaned, sterilised, and re-inserted
Should the
ostium of the
maxillary antrum
neuralgia. This
underlying acute
Sinusitis is a
condition which
is more frequently
overlooked (ex-
cept by rhino-
logists) than any
other disease.
When the presence of an empyema of the antrum is
confirmed by the lavage, it may be necessary to
repeat the puncture and lavage on subsequent
occasions. Patients shrink from this repeated
puncture under local anzsthesia and consequently
I always (where possible) perform antral puncture
under a short nitrous oxide and oxygen anesthesia,
The patient is permitted to regain complete conscious-
ness before the lavage is commenced.
Antral drainage (antrostomy) is called for the
case that fails to respond to repeated antral puncture
and lavage. This operation is not devoid of complica-
tions, of which the most frequent are otitis media
and acute streptococcal tonsillitis. |
i METHOD
Repeated antral punctures and even an antrostomy
can be avoided by the following procedure, which
I term intubation of the antrum.
The intubation cannula (see Figure) is short, straight,
and of wide bore. The flange is perforated by a slot on
each side, to which a strong thread is applied. The
cannula is of such a length that when it is inserted into
the antrum, the flange lies just outside the nose, flush
Above: The intubation trocar and cannula.
‚Below: The cannula alone (natural size).
be blocked—as
shown by an ina-
bility to perfuse
the antrum—the
cannula should be
left in situ for
24 hours and the
lavage again at-
tempted. Sooner
or later this becomes possible as in Case 2.
ILLUSTRATIVE CASES
I originally devised intubation for use in the first of
the following cases, where a plastic operation on the
cheek, on the same side as the empyema of the antrum,
was contemplated. A pedicle graft from the abdomen
had already been grafted on to the forearm, pre-
liminary to transplanting it on to the cheek to cover
a scarred area left after the treatment of an extensive
facial nævus. |
Case 1.—Acute empyema of antrum cured by intuba-
tion of the antrum.
A girl of 20 complained of a right nasal discharge with
severe pain over the antrum, due to an acute empyema
of the antrum. An enormous amount of stinking pus was
removed by antral lavage following the antral puncture.
The cannula was left in situ and antral lavage was then
performed every four hours during the day for two weeks,
the cannula being changed every five days. For the
first 10 days pus was irrigated from the antrum, but within
3 weeks the infection cleared up completely.
*The cannula is made to my design by Messrs, Mayer and
Phelps, London.
1400
It was necessary in this case (a) to get rid of the
antral infection rapidly, in view of the imminent
grafting of the pedicle flap from the arm to the face ;
(6) a Caldwell-Luc operation was not possible as
encroaching on the plastic surgeon’s field; (c) intra-
nasal antrostomy would not have obviated the
necessity for repeated antral lavage apart from carry-
ing the risk of an acute otitis media or streptococcal
tonsillitis.
Case 2.—Acute exacerbation of a chronic antral
infection treated by intubation of the antrum.
A man of 42 developed an acute infection of the left
antrum followed by an acute otitis media. Transillumina-
tion and radiography revealed an opaque antrum. On
puncture of the antrum no fluid or air could be perfused
owing to the ostium being blocked. The cannula was
left in situ for 24 hours, after which antral lavage was
THE LANCET]
easily accomplished, the ostium having become patent.
with the relief of the tension in the antrum through the
intubation tube.
SUMMARY
Intubation has the advantage of giving that
continued antrum drainage which is otherwise only
obtainable by an operation ; avoids any complications
of the latter; does not incapacitate the patient to
any extent; and its application in suitable cases
will prevent the condition from becoming chronic.
HAMOGLOBINURIA FOLLOWING
EXERTION
By W. H. W. ATTLEE, M.D. Camb., M.R.C.P. Lond.
PHYSICIAN TO KING EDWARD VII HOSPITAL, WINDSOR
THE association of hemoglobinuria with exertion
is well recognised. In Germany it has been described
under the name Marschhemoglobinurie and in
America very full notes of a case have been given by
Watson and Fischer (1935). MacManus in this country
in 1916 reported three cases in army recruits, and
Witts in 1936 published notes of two cases. In all
of them, with the possible exception of the army
recruits of MacManus, the symptoms followed
muscular exertion and had no relation to exposure
to cold.
It has been noticed on several occasions that only
certain kinds of muscular exertion will produce
symptoms in some individuals. For example the
patient described by Watson and Fischer was under
observation for many weeks and hemoglobinuria
occurred only after walking.: Meyer points out that
other kinds of exercise such as cycling do not lead
to hemoglobinuria.
The following notes are of two cases of hæmo-
globinuria in public school boys. Both were in the
habit of playing strenuous school games and running
long distances on grass, without symptoms, but
attacks followed immediately after running on a hard
road.
CasE 1.—A schoolboy, aged 174, complained on Feb. 16th,
1916, of passing blood in the urine after running in the
final heat of a mile race on the road. He had noticed it
on two previous occasions after running on the road. The
race was at 12.30 p.m. and the urine passed at 2.30 was
dark brownish red and gave a strong reaction with the
guaiacum test for blood. It contained a great deal of
albumin and many urate crystals, but no red blood
corpuscles. At 6 P.M. it was slightly smoky and contained
a quantity of albumin. At 10 P.M. it was clear and of
normal appearance and free from albumin, and remained
so. On March Ist after running in a half-mile race on
grass, the urine was normal and contained a faint trace
of albumin only. Several tests were made later after
exercise, but hemoglobinuria was never found again.
CLINICAL AND LABORATORY NOTES
[JUNE 12, 1937
This boy was in hard training for athletic sports and
was in the habit of taking much exercise. Hemoglobinuria
was never noticed except on these occasions after running
on the road. In December, 1936 (twenty years later),
he reported that he was perfectly well and that the
‘symptom had never recurred, though he had played
football, cricket, and squash racquets in the interval.
Case 2.—A schoolboy, aged 17, after having played
in several preliminary football ties ran about two miles
on the road as part of his training for the final. Immediately
afterwards he passed urine that was slightly turbid and
almost black and gave a strong guaiacum reaction. After
centrifuging, the supernatant fluid was dark brown, and
the deposit consisted entirely of granular detritus. No
red blood corpuscles were found and no pus or crystals,
Two hours later the urine was sherry-coloured, and con-
tained a trace of albumin but no red corpuscles. After
another two hours it was pale, perfectly clear, and
apparently normal.
This patient too was in hard physical condition and had
been playing strenuous football for many weeks and
running long distances without symptoms. The only
occasion on which hemoglobinuria was noticed was after
this run on the road. The blood Wassermann reaction
was negative.
It seems unlikely that this sequence of events
can be nothing more than a coincidence, but it is
difficult to see the connexion. Lordosis has been
suggested as the cause which precipitates an attack.
Neither of these patients had marked lordosis, and
there seems no reason to think that running on a
road should induce a more lordotic posture than
running on grass. No tests were carried out to prove
whether the pigment was blood hæmoglobin or
muscle hemoglobin. Neither patient had any
symptoms other than the hsemoglobinuria, and
neither was anzemic nor jaundiced. The rareness of
hemoglobinuria is general and this association in
particular seems perhaps to justify these notes.
I am indebted to Mr. Herbert Perkins, pathologist to
the Paddington Green Children’ 8 Hospital, for his help
in urine analyses.
REFERENCES
' Lang, K., ans Braun, A. (1931) Z. re ae 118, 374.
MacManus, (1916) Bril. med. ;
Meyer, E. (rads) Handbuch der Ge und pathologischen
Physiologie, Berlin, vol. 596.
Watson, E. M., and Fischer, L. G (1935) Amer. J. clin. Path.
, 151.
Witts, L. J. (1936) Lancet, 2, 115.
RUBBER AND SPERM-SURVIVAL
By R. M. RANSON
(From the Sir William Dunn School of Pathology, Oxford)
IN the annotation on Dr. Huhner’s work on sperm-
survival in THE LANCET of May 22nd it is stated that
sperms may die from the action of some chemical
used in the manufacture of rubber condoms. Dr.
Huhner does not mention this in the paper referred
to, but he states that the dusting-powder used to
ensure easy adjustment of the condom kills the
sperms. These are subjects which have been studied
for some time in the course of the general research
on chemical contraception carried out under the
direction of Mr. John R. Baker, D.Phil., in the Sir
Wiliam Dunn School of Pathology.
It has been found that ordinary dusting-powder
(french chalk) is without effect on sperms, but
certain sorts of rubber are spermicidal. There is
a great difference in various sorts of rubber in this
respect. The most spermicidal appears to be latex
rubber, for example Durex, made by the London
Rubber Co., and the teat-ended sheaths for use in the
tropics made by the Hygienic Stores Ltd. The least
spermicidal are the grade A.l and grade 2 teat-ended
THE LANCET]
sheaths made of moulded rubber by the Hygienic
Stores. The following are intermediate: Lambutt
No. 7 made by: Lambert’s Ltd., and the following
products of the Hygienic Stores: Lion X.L., Inflated
Para rubber, No. 2 washable moulded rubber, trans-
parent Ceylon rubber, Paragon, Paragon dyed red.
In my experiments sperms are caught in sheaths of
the least spermicidal sort, transferred at once to
glass tubes, and brought to the laboratory. Here
they are put into various sheaths in a damp chamber
maintained at 37° C. For.economy I put only 0:5 c.cm.
of semen in each sheath. In the highly spermicidal
sheaths nearly all the sperms are dead in three-quarters
of an hour, and all life is extinct in one hour. In the
scarcely spermicidal sheaths there is still full activity
at 14 hours, and the sperms are not all dead until
5 hours. The control sperms, in a glass tube at 37° C.,
are still at full activity at 5 hours. |
ROYAL SOCIETY OF MEDICINE: EPIDEMIOLOGY AND MEDICINE
[June 12, 1937 1401
Research is in progress with a view to finding out
whether the spermicidal powers of certain sorts of
rubber can be utilised as a means of contraception.
When a physician wishes to examine a specimen of
semen for motility, he should get his patient to use
a sheath of the least spermicidal sort and to transfer
the sperms soon after coitus to a clean glass specimen-
- tube provided with a ground-glass stopper or waxed
cork, This should be left at room temperature until
examination, which should be done after the sperms
have been warmed up to 37°C. for ten minutes.
With this technique the sperms of some donors will
still show full activity at 39 hours after ejaculation,
and a few will still be alive at 34 days.
I wish to thank Mr. J. Tynen for much practical assist-
-ance, and the Hygienic Stores Ltd. for providing material.
The work was done under the auspices of the Birth Control
_ Investigation Committee.
MEDICAL SOCIETIES
ROYAL SOCIETY OF MEDICINE
SECTIONS OF EPIDEMIOLOGY AND OF
MEDICINE
AT a combined meeting of these sections held on
May 28th, with Surgeon-Captain S. F. DUDLEY in
the chair, a discussion on
Air Conditioning
was opened by Mr. R. FREDERICK, an Admiralty
research worker, who dealt with the subject of
ventilation. His experience, he said, had been
gained with ships and naval establishments. In
ships special attention had to be paid to ventilation
because the living space was so limited. Samples of
air were sent for examination to the Royal Naval
Medical School, Greenwich, or when for any reason
the conditions had to be examined in situ a trans-
portable laboratory was used. This, with its equip-
ment, he described and demonstrated. A reliable
and quick means of determining respiratory impurity
was, he said, by carbon dioxide determination.
A proportion of 12 parts of carbon dioxide per 10,000
was quite harmless. If the respiratory CO, in that
room were increased to 200 parts per 10,000 nobody
would be aware of it. It might be noticeable at
250 parts, but it was only when CO, exceeded 300
parts per 10,000 that the effect became really appre-
ciable. Anyone who had lived in an atmosphere
where the respiratory impurity was 500 parts per
10,000 would probably remember it for the rest of
his life. The apparatus used was devised by J. S.
Haldane; the ordinary form of this apparatus read
only to 100 parts, which was ample for civil purposes,
but a more refined apparatus was necessary for
Service purposes. The amount of air which must be
supplied to keep the CO, down to a proper level was
from 2000 to 3000 cubic feet per man per hour. This,
however, was more and more coming to be regarded
as only one factor; no less important was the
question of floor space.
- For the maintenance of comfort and a feeling of
well-being, the first requisite was a moderate tem-
perature with a moderate humidity. In temperate
climates the dry bulb was of chief interest, and in hot
climates the wet bulb. It had been suggested that
the ideal was a temperature of 60° F. and 50 per cent.
relative humidity, but most people would find that
too cold. The greatest measure of agreement would,
he thought, be accorded to the following :
For hard work 60-62° F.
For sedentary work 62-64° F,
For leisure.. s 64-66° F.
with a relative humidity of 70 to 75 per cent. The
wet-bulb figures given by Haldane had been widely
accepted ; they were:
\
In still air 88° F, for sedentary work.
78° F. for hard work,
93° F. for sedentary work,
85° F. for hard work.
He thought these temperatures could be placed
considerably higher.
Temperature and humidity afforded a certain
amount of information whether conditions were such
as to interfere with the loss of body heat, but there
was another factor to be considered. The beneficial
effect of air movement was due to its continual
dispersal of the envelope of hot air between the clothes
and the skin of the individual and to the increased
effect of convection currents—in other words, the
cooling power of the air had been increased. Apart
from the relation of respiratory impurity, ventilation
could be assessed by the dry and the wet bulh tem-
peratures, the felative humidity and the air move-
ment. In America this combined effect had been
termed the effective temperature, and a comfort
zone had been worked out, which for various reasons
was not applicable in this country.
Mr. ©. W. Price (Home Office) dealt with air
conditioning in factories. The outstanding feature of
the industrial field was, of course, the variety of
conditions in various industries. One ship’s cabin
was much like another, theatres compared with
theatres, and schools with schools, but factories could
not be compared as the conditions under which they
had to be run, imposed upon them by the nature of
the processes, covered a wide range, In the term
factory he included flour mills, cement works, dye
works, gas works, and electrical stations, and many
diverse industries. A proportion of these could be
air conditioned, but it was obvious that in any large
number of factories or parts of factories air condi-
tioning would not be adopted nor recognised as
within. the realm of practical politics. The problem
in its physical aspects was difficult, and the advent
of the large single-storey partitionless factory had
not made it easier. On the other hand, there was
a large range of factory premises to which air
In moving air..
1402 THE LANCET]
conditioning could be applied just as well as to
non-industrial premises, and many plants had
been installed for partially conditioning the air-
supply, including plenum installations for supplying
warm air in cold weather, particularly in industries
in which light work was carried on. A number of
plenum installations were also in use for supplying
cool air to furnace workers.
were used for extracting deleterious products from
manufacturing processes, and might be responsible
for the whole of the ventilation since the air extracted
must be replaced. The regulation of humidity in
this country had so far not been adopted in the
ordinary factory. There was nothing comparable
with the practice in the United States and Canada.
If ordinary factories were adequately ventilated as
the law required, the problem of humidity was (and
would continue to be) regarded as of little significance.
The new Factories Bill would assist in bringing about
more efficient air conditioning in many workrooms,
Dust of any kind must now be extracted where
practicable if produced in quantity—the provisions
in force were limited to harmful dust. In not a few
factories advance had already been far reaching.
Even in workrooms where peculiar difficulties had
to be overcome, and dangerous processes were Carried
on, good conditioning might be found. This had
come about because employers had agreed to the
provision for higher standards of ventilation while
not neglecting temperature requirements. Radiation
was not an air-conditioning factor, but one to be
taken into account in any relative temperature
evaluations. He concluded by asking to what extent
in factories complete air conditioning should be
adopted or recommended; even where it might be
adopted with advantage, he was doubtful if the
regulation of humidity was in general necessary.
Prof. E. M. FRAENKEL discussed allergic conditions
and air purification. Pollution of the air was of
importance in different types of allergic complaints
such as hay-fever, asthma, and some cases of urticaria
and eczema. The types of allergens which were
effective were either outdoor or indoor impurities.
The latter might be brought in by air or clothing or
might consist of allergen-forming material already
present (horsehair, feathers, woollen carpets, moulds,
rugs, and the like) or of breakdown products formed
from innocuous indoor material by the action of
moulds. Air purification in the case of allergic
patients was not identical with air conditioning.
The walls and the contents of the rooms must be
constructed of suitable material, as indoor allergens
were a frequent source of trouble. Impurities from
outside might be solid particles, fine droplets of
moisture, or even gases and vapours—mostly a com-
bination of two or more of these. Various methods
such as filtration, freezing, washing, or the influence
of an electrostatic field had been devised for air
purification. He had himself worked out a special
method of chemical and physical filtration for use in
connexion with masks, sleeping bags, and cubicles
for the diagnosis, prophylaxis, and treatment of
allergic cases. This method was demonstrated by a
- film of an asthma subject sensitive to dog hairs.
Sir WELDON DALRYMPLE-CHAMPNEYS called atten-
tion to the psychological factor in ventilation. In
the tropics he had found that white people stood up
to moist heat badly, not only because they did not
sweat satisfactorily, but because they were depressed
by the idea that the atmosphere they were living in
was too hot and too moist. He had been struck by
the reactions of his companions to increasing heat
and humidity, not to be accounted for on a purely
GERMAN HEMATOLOGICAL SOCIETY
Air-exhausting plants -
,
[JUNE 12, 1937
physical basis. People of phlegmatic temperament
stood up better to increasing heat. The same sort of
thing was found in dug-outs in the war. Some men
could not stand them, not on account of claustro-
phobia, but because they thought the place was
getting unhealthy. He had also noticed in cabins in
ships in hot weather when the portholes had to be
kept closed how people felt as if they were being
suffocated. The importance of odours in the air
could not be disregarded. Odours gave some people
the impression that they were being suffocated and
made them very uncomfortable, although the actual
physical conditions were not unsatisfactory.
GERMAN HAMATOLOGICAL SOCIETY
INTERNATIONAL CONGRESS AT MUNSTER
THE first meeting of the newly formed German
Hematological Society took the form, of an inter-
national congress held at Minster, Westphalia,
from May 10th—13th.
Prof. Victor SCHILLING (Minster), who presided,
gave an introductory address on the historical
development and modern applications of scientific
hematology. Outlining the gradual advance of
hematological knowledge until the end of the
nineteenth century, he dealt in detail with the work
of the great hematologists of the early twentieth
century and the foundation of the old German
hematological society in 1908. He then reviewed
the advances made in the last thirty years which
would provide the themes for discussion at the
congress.
The scientific communications were opened by a
paper by Prof. Lupwic AscHorr (Freiburg), who
discussed the
Monocyte Question
from the anatomical and histopathological stand-
point. Reviewing his own work and that of others
he came to the conclusion that his original view
that monocytes were derived from tissue histiocytes
or sinus lining cells could not be maintained and
that it was most probable that they arose from
undifferentiated mesenchymal elements in lymphoid
tissue and were directly transferred to the blood
stream, as monocytes were never found in the lymph.
He emphasised the distinction between monocytes
and lymphocytes and went on to discuss the relation-
ship of the plasma cell with the lymphocyte, question-
ing whether the marrow plasma cell was identical
with that of the connective tissue, and suggested
that there was still much work to be done both
from the histological and cytological aspects in
glandular fever and experimental B. monocytogenes
infections.
The PRESIDENT surveyed the clinical aspects of the
subject and held that few cases of true monocytic
leukemia had been described; his criteria being,
in addition to the blood picture, a leukzmic infiltra-
tion of the organs. Rather surprisingly he main-
tained that the bone-marrow should show no altera-
tion. Dealing with other forms of monocytosis, he
mentioned the false monocytosis sometimes found
when the specimen of blood has been collected from
the ear; it only occurs if the first drop of blood
is used for examination and is most common in
cyanotic patients. He suggested that this was a
static phenomenon and produced convincing evidence
that the cells were not shed vascular endothelium
as has been suggested.
THE LANCET]
Dr. E. Laupa (Vienna) reviewed the relation
of the spleen to blood disorders, laying especial
stress on the evidence for an endocrine function
which controlled bone-marrow activity and the
part played by the spleen in iron metabolism. He
believes that splenic siderosis is indicative of cellular
dysfunction rather than increased activity and that
there may be both active and passive hemolysis in
the spleen, of which the latter is the more common.
The afternoon was occupied by a series of admirable
papers on the
Pathology of the Bone-marrow
Prof. H. ScHuLtteEN (Hamburg) described the
normal cytology and technique of sternal puncture.
He upheld the trialistic view of hsemopoiesis but
questioned the existence of the hzemocytoblast.
He was in doubt as to the difference between a
pro-erythroblast and pro-megaloblast, although em-
phasising that the megaloblastic family of erythro-
cytes must be clearly distinguished from the normal
erythroblastic series. He suggested that mature cells
did not remain long in the marrow.
This communication was followed by an account
of the pathology of the bone-marrow by Prof. HENNING
(Firth) which was one of the best contributions to
the congress. He described the changes in sternal
puncture preparations found in many blood diseases.
In pernicious anemia, for example, in addition to the
megaloblastic proliferation, there are abnormalities
in the granulocytes and megakaryocytes, in both of
which hypersegmented giant forms are seen; these
revert to normal after liver therapy. This change
together with an enormous erythroblastic activity
can be seen twenty-four hours after the first injection
of liver. Prof. Henning doubts whether one should
accept the idea of two distinct erythrocytic series—
the megaloblastic and erythroblastic. He said he had
observed a reduction of megalocytes in the circulating
blood before the increase of the reticulocytes and
although there were equally striking alterations in the
granulocytes after liver therapy yet it had never been
suggested that there were two families of these cells.
Arsenic was found to produce an increase in ripening
of the megaloblasts in pernicious anemia, but only
of pathological ripening with the result that there was
a considerable increase of megalocytes. Marrow
puncture in the leukemias was of little value except
in the aleukzmic cases when it was of great diag-
nostic help. In agranulocytosis the cytology varied :
in some cases there was an absence of free elements
with a proliferation of reticulum cells—this was the
so-called “empty marrow ’’; in other cases there was
an apparently normal marrow but the most mature
cells were lacking; and in the third type there was a
great increase in myeloblasts or pro-myelocytes. In
every case the cells were abnormal, showing vacuola-
tion and nuclear changes. In glandular fever there was
no cellular proliferation in the marrow and the
abnormal cells found there were derived from
the circulating blood. Prof. Henning described the
various changes found in infectious diseases and the
value of sternal puncture in the diagnosis of parasitic
diseases—malaria, kala-azar, &c. Finally he discussed
the value of bacteriological culture of bone-marrow.
In a series of 350 cases of typhoid fever a positive
culture was obtained from the sternal puncture
material before a growth could be obtained from the
circulating blood.
Prof. Rowr (Zurich) discussed the mechanism
controlling the entry of cells into the circulation and
suggested that the bone-marrow could be regarded as
a closed or controllable system whereas the spleen
GERMAN HAMATOLOGICAL SOCIETY
[gunz 12, 1937 1403
was an open system; in conditions such as the
leukoses, in which there was myeloid proliferation
in the spleen and liver, the abnormal cells in the
circulating blood were derived from these organs
rather than from the bone-marrow.
Dr. R. Krma (Vienna) described the changes in
the bone-marrow in multiple myelomatosis’ and
Hodgkin’s disease. In cases in which there was
clinically a localised myeloma in one of the long
bones, he had invariably found myeloma cells in the
sternal puncture. He regarded myelomatosis as a
systematised proliferation analogous to the leukoses,
and suggested that the myeloma cell was closely
related to the marrow plasma cell which he derived
from the myeloblast but distinguished from the
plasma cell found in the connective tissue in chronic
inflammatory conditions. In Hodgkin’s disease,
although at autopsy the bone-marrow was involved
in 70 per cent. of cases, no characteristic changes
could be found by means of sternal puncture during
life. Dr. Klima believed, however, that diagnosis
could be made by means of lymph node puncture ;
but neither his criteria nor his conception of the ;
typical cytology-appear to correspond with the present
pathological views.
The second day opened with an account of
Blood-platelets
by Prof. Hirrmarr (Wels, Austria). He discussed
difficulties of enumeration and suggested that for
ordinary purposes a visual estimation of their numbers
in a supravital preparation was sufficient. When
a numerical count was made the method must be
stated owing to the enormous variation in normals
with the different techniques (250,000 Fonio might
read 900,000 Hoffmann). Prof. Hittmair upheld
Wright’s theory of a megakaryocytic origin for blood-
platelets although as he admitted he was putting
his head into the lion’s mouth by doing so at Minster.
(Prof. Schilling maintains that the platelets represent
the shed nuclei of the erythrocytes and that mega-
karyocytes are merely histiocytic in nature.)
In bone-marrow studies, however, the number
of platelets was the same as that of the circulating
blood and the formation of platelets from mega-
karyocytes could only be observed under abnormal
conditions ; Prof. Hittmair upheld Rohr’s view of an
explosive rupture of the megakaryocyte in their
formation. He discussed the changes in platelets
in various diseases and their relation to blood
coagulation which, he felt, was only secondary.—
An animated discussion followed this paper in which
the President put forward his views and demonstrated
the method of rapid fixation of the blood by which
he believed he could substantiate his theory.—Prof.
Voit (Solingen) showed that platelets contained no
thymonucleic acid, although all cell nuclei including
those of isolated erythrocyte nuclei contained large
quantities of it.
Prof. WERNER SCHULTZ (Berlin) read a paper on
The Aplasias
with special reference to the hemorrhagic diathesis.
He described the changes in aplastic anemia and
agranulocytosis, mentioning that in the latter although
the platelets, bleeding time, and coagulation time were
normal, yet there was a severe fibrinopenia. In
discussing the hzmorrhagic diseases he emphasised
the distinction between blood coagulation and the
stopping of hemorrhage. The latter he associated
with capillary function, showing that in a normal
person the bleeding time was almost the same whether
the investigation was carried out in the air, under
1404 THE LANCET]
water, or even under heparin; however, hirudin
which acted on the capillaries as well as on the
coagulation mechanism prolonged the bleeding time ;
further, the bleeding time is not markedly prolonged
at 0° C. although blood does not coagulate at that
temperature.
Leucocytes.—Parasitology
In the afternoon Prof. Horr (Wiirzburg) discussed
the dynamics of leucocyte regulation and Dr.
THADDEA (Berlin) described changes in the leucocyte
adrenaline response in disorders of the suprarenals.
In Addison’s disease the normal leucocytosis obtained
after the subcutaneous injection of 1 mg. of adrenaline
is absent but treated cases give a normal reaction ;
on the other hand in cases of cortical adrenal tumour
the leucocyte adrenaline reaction is exaggerated.—
Dr. UNDRITZ (Orselina-Locarno) described a series of
cases showing the inherited Pelger-Huét anomaly of
the granulocytes and Prof. ADLER (Switzerland)
described a new form of inherited granulocytic
abnormality in which the nuclei were normal but the
cells showed large darkly staining granules.
Prof. Kixuts (Elberfeld) showed that in malarial
treatment no drug has been found which attacked the
free merozoites. Plasmoquine destroyed the sexual
forms, and Atebrin and quinine the asexual forms.—
Following this Prof. P. MUHLEns, director of the
tropical institute at Hamburg, demonstrated some
excellent cinematographs of the life-cycles of malaria,
leishmaniasis, and various types of spirochetes and
filariæ.
The last day was devoted to
Anæmia
The PRESIDENT read a paper on the structure of the
erythrocytes. He dealt particularly with the relation
of reticulation to polychromasia and described the
peculiar inclusions found in methxemoglobinemia
and the significance of bartonella-like bodies found
in the erythrocytes in anæmia.
Prof. E. MEULENGRACHT (Copenhagen) dealt with
pernicious anemia Recapitulating his experimental
work on the pig stomach (see Lancet, 1935, 1,
493) in which he showed that intrinsic factor was
only to be found in the pylorus, duodenum, and
cardiac region and was absent from the fundus, he
went on to describe his observations in a number
of stomachs obtained post mortem from pernicious
ansemia cases. These showed a severe atrophy of the
fundic region with intestinal heterotopia but prac-
tically no change in the pylorus or duodenum—a
finding completely the reverse of that which he had
anticipated from his animal observations.
it had been shown that the proportionate. amount
of intrinsic factor per c.cm. was unchanged in per-
nicious anæmia but the total quantity of gastric
juice was reduced and he was at present investigating
the amount of pyloric and Brunnerian glandular
substance in the pernicious anzmia stomach. He
believed that regular oral administration was preferable
to occasional injections both from the point of view
of cost and in minimising the possibility of nervous
changes. He found that a subtherapeutic dose of
stomach powder (5 g. daily) when taken with liver
residues (after extraction of the active factor) which
were inactive alone produced a therapeutic result
far greater than could be explained by a mere
additative effect.
In the discussion which followed it was agreed
that oral administration was mostly preferable to
parenteral; but it was imperative that the anti-
anzmic substance should be taken in the form of
GERMAN HZ; MATOLOGICAL SOCIETY
However,
= [sone 12, 1937
medicine and not as a foodstuff which might be
shared with the rest of the family, and in many
cases it was only by means of parenteral administration
that one could be sure that the patient was receiving
adequate and regular treatment.
Dr. H. J. Wor (Göttingen) read a preliminary
communication on the experimental anemia produced
in rabbits by means of typhoid toxin, which was only
controllable by the administration of active liver
material and might be made to serve as a biological
method of assay. However, there were considerable
difficulties, the chief being the severe illness produced
in the animals which often resulted in a fatal outcome
before the effect of the anti-ansmic substance could
be judged.
Dr. Krıma discussed the classification of the
anæmias and suggested that it was impossible to group
them solely according to cytological, xtiological, or
therapeutic criteria and that it was more valuable
to consider them from the point of constitutional and
familial aspects.
The concluding communication was by Dr. L.
HEILMEYER (Jena) on the iron-deficiency anzsmias.
He dealt in particular with the iron, content of the
serum in various conditions; this was estimated
photometrically and in males found to be 100—150 Y
per cent. and in females 50-100 y per cent., but this
difference between the sexes disappeared after the
menopause. In anormal person, said Dr. Heilmeyer,
the serum iron is fairly constant in value, the iron
depots being full and any excess iron being excreted
by the gut and skin, never by the urine. However, in
iron-deficiency anzemias the serum iron is low and the
deficiency of storage may be demonstrated by the
intravenous administration of 10 mg. of iron and
repeated estimations of the serum iron. In a normal
person the serum content rises to 400 y and then falls
very slowly ; in deficient iron storage it rises to 180 y
and then quickly falls. In acute infections the
serum iron drops to a very low figure even when no
anzmia is present and large quantities of iron must
be given to maintain it at a normal figure during the
infection. The explanation of this is obscure but
may be related to the increased activity of the reticulo-
endothelial system and it is known that a siderosis of
the spleen is not uncommon in infections. In untreated
pernicious anzmia, the serum iron is almost invariably
high and this drops to a normal figure after treatment,
but in those cases in which there is deficient iron
storage it will drop below normality and it is these
cases whose recovery is delayed until iron is given in
addition to anti-anemic principle. Dr. Heilmeyer
pointed out that the hematological criteria for iron
deficiency were hypochromia and planocytosis. Micro-
cytosis was not invariably associated with iron
deficiency. As tothe form of iron therapy,in most
cases it made little difference provided it was given
in sufficient amounts and although the ferrous salt
was biologically active, ferric salts were readily
reduced, probably with the aid of vitamin C. In
some cases it was expedient to give a ferrous salt
and in severe dyspepsia intravenous iron was to be
recommended.
At the conclusion of the meeting Prof. MEULEN-
GRACIIT expressed the appreciation of the foreign
delegates from the fifteen countries represented
at the conference of the arrangements made.
Dr. Stortr (Rome) announced that the Italian
Hematological Society, of whom he was the repre-
sentative, would hold an International Congress in
Rome in 1941 and invited the delegates present to
attend it.
eee a ee eee eee
1
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GENERAL MEDICAL COUNCIL
[JUNE 12, 1937 1405
serious trouble.”
” On cross-examination he said
GENERAL MEDICAL COUNCIL
SUMMER SESSION, MAY 25TH-29TH, 1937
‘New Penal Cases
(Concluded from p. 1349)
ERASURE FOR CANVASSING .
The Case of Bakhtawar Singh Jain, registered as of
Hindustan House, Weoley Castle-road, Selly Oak,
Birmingham, L.R.C.P. Edin., 1921; L.R.C.S. Edin.,
1921; L.R.F.P.S. Glasg., 1921, who had been
summoned to appear before the Council on me
following charge :—
That being a registered medical practitioner, you
have canvassed the patients of other registered medical
practitioners for the purpose of inducing them to become
patients of .yours, and in particular: (1) on Oct. 3lst,
1936, canvassed Albert Bird, obtained from him the
medical card issued to him as a person insured under the
National Health Insurance Acts, and procured his transfer
to you as an insurance practitioner; (2) in or about
October, 1936, canvassed Arthur Eccleston and his wife
Doris Eileen Eccleston, and endeavoured to obtain them
and their child as patients; (3) in or about September,
1936, on two occasions canvassed Winston Haig Evans with
a view to inducing him to transfer to you as an insurance
practitioner; (4) in or about October, 1936, on two
occasions canvassed Mrs. Florence Jones with a view to
inducing her and her husband and three children to become
patients of yours. And that in relation to the facts so
alleged you have been guilty of infamous conduct in a
professional respect.
Dr. Jain appeared, accompanied by Mr. Arthian
Davies, counsel, instructed by Messrs. Cole and
Matthews, agents for Mr. Frank Rowland, solicitor,
Birmingham, The complainant, Dr. Francis Ronald
Gedye, a local practitioner, was represented by
Mr. W. A. Macfarlane, counsel, instructed by Messrs.
Le Brasseur and Oakley, solicitors.
Mr. Macfarlane did not call evidence to support
the charge of canvassing Albert Bird. He called
Mrs. D. E. Eccleston, who said that in October,
1936, her doctor and her husband’s had been
Dr. Gedye. She had just returned from hospital,
and one afternoon Dr. Jain had knocked on the door
and she had opened it and spoken to him on the door-
step. He had asked her whether she had a doctor. She
had replied, ‘‘ Yes.” He had then asked her whether
her husband had a doctor, and she had again answered
‘* Yes,” and that they were attended by Dr. Gedye.
Dr. Jain had asked if she would like her daughter
to go on his panel, and had given her a professional
visiting card. This she had later burnt. Her
husband, who had been sitting in the front room,
asked who was there, and when she had told him
that it was Dr. Jain he had shouted, ‘‘ Tell him to
clear off.”
Cross-examined by Mr. Davies, she said that
respondent had never attended her daughter, nor
had she ever taken the child to his surgery. He
had told her that he had been attending her next-
door neighbour, a Mrs. Kesterton, who had told
him that Mrs. Eccleston was ill and asked him to call
on her. Mrs. Kesterton had never said anything
to her about asking Dr. Jain to call.
‘Arthur Eccleston, her husband, said in evidence
that he had known the doctor by sight. In this
conversation, all of which he had overheard, the
doctor had asked her if she and her husband would
go on his panel, and whether they would like the child
. to go on it as well. As Dr. Jain was leaving he had
said “I shall have to call round again.” Witness
had replied, ‘‘ You’d better not, or you'll get into
that he had made a statutory declaration at the
request of a gentleman from London. Mr. Davies
_put to him a document which he admitted writing
and signing on a later date; it said that his wife
told him that the doctor had been sent by Mrs.
Kesterton ; that he had not warned the doctor he
would get into trouble; that the doctor had not
asked him and his wife to come on his panel, and that
the allegations of canvassing had been put into his
mouth by a solicitor’s clerk. Asked the circumstances
in which he had written and signed this document, he
said that some weeks ago a woman who kept a small
draper’s shop some distance away had unexpectedly
sent for his wife and offered her work on two mornings
a week. Three days before the hearing she had asked
him and his wife to supper ; they had gone there, and
afterwards Dr. Jain had walked in and talked about.
the case, showing them some papers and saying that
he was a good doctor and there was no reason why
witness should go to London to give evidence against
him. He had also said that he was taking proceedings
for slander against another doctor, and that if he
did not win his case before the G.M.C. the witness
would be brought into the slander case and get into
serious trouble. Witness had therefore considered
that the best thing to do was to wash his hands of
the G.M.C. case. He had written the contradictory
statement at the respondent’s dictation.
Mr. W. H. Evans said that from June, 1936,
onwards he was on the panel of a Dr. Thomas. He
had first met Dr. Jain in July in his lodgings, but had
not spoken to him. They had conversed in September
at the same place; Dr. Jain had asked him on whose
panel he was, and then whether he would like to
change over to his panel. Witness had refused, but
several times after that his landlady had tried to
persuade him to. change. On the first occasion
Dr. Jain had asked the witness for his medical card.
In cross-examination he said he had a brother called
David, but that the respondent was not asking him
about David’s card. After he had made a statutory
declaration a gentleman whom he did not know had
induced him to sign a contradictory statement, of
which part was true and part was not, as he had
“got timid.” This gentleman had told him that
he would be the only one going to London. Respon-
dent had not said he had been asked to return
“witness’s medical card.
Mrs.. Florence Jones said that in the latter half
of 1936 she had had no doctor but her husband had
a panel doctor. They had recently moved to their
present house. A fortnight after they had moved
in Dr. Jain had spoken to her on the doorstep and
asked her if she would like to sign on with him.
She had said, No, she would sign on with another
doctor before she would sign on with him. He had
given her a card, which she had burnt. A week later
Dr. Jain had again asked her to come on his panel
but her husband had said that they had already signed
on with another doctor. In cross-examination she
said she did not know whether respondent was
attending her next-door neighbour or another
neighbour, Mrs. Facey.
Mrs. Ellen Atterbury said she had known Dr. Jain
by sight and had moved to her present address
at the end of August, 1936. She and her husband
then already had panel doctors. Dr. Jain had
called at her house some time in October and her
small daughter had admitted him. Witness had told
him that her husband was in town on business.
He had remarked how nice the front lawn was looking.
He had gone on to say that he was attending a child
1406 THE LANCET]
GENERAL MEDICAL COUNCIL
[JUNE 12, 1937
oS re Se eS Le eS Se ae
in another street, but that her child looked healthy
enough. He had left his card for her husband and
had called back again the same evening. In cross-
examination, she said that Dr. Jain had not called
for the purpose of seeing her husband about his
garden.
Dr. Jain, giving evidence in his own defence, said
that he had first seen Mrs. Eccleston when he was
attending Mrs. Kesterton’s child. Mrs. Kesterton
“had told him that Mrs. Eccleston wanted a doctor.
He had seen Mrs. Eccleston standing at her door ;
she had greeted him, and he had entered into
conversation with her. He had once treated her
child in his surgery, on June 27th, 1936, and the
visit had been entered in his day-book, which he
produced. He had asked Mrs. Eccleston how she
was and she had replied, and said she had a doctor
of her own. He had asked after the child, and she
had recalled to him the day she had brought the
child to the surgery; she had said that she hoped,
if it got ill again, he would not mind her bringing
it back. He had not seen her husband nor given
her a card, nor indicated that he wanted to attend
on her child. The lady who kept the drapery shop
had been one of his patients and had planned the
meeting of her own accord. Mr. Eccleston had told
him that he had been pestered for the last few weeks
by solicitors and their clerks to go to London and
wanted to wash his hands of the whole affair, because
he had made a statement which was not correct
but had simply been put into his mouth, Dr. Jain
replied that if he signed statements at all he had better
write the truth then and there. He had written it
in his own words and handwriting, and no part of
it had been dictated to him.
Dr. Jain said he had spoken to Mr. Evans thinking
that he was David Evans, a brother who had been his
patient since August. The Birmingham Insurance
Committee had twice written to him asking him to
return David Evans’s medical record card, and he
had therefore said to Mr. W. H. Evans that he had
been asked to return his medical card. He put in
evidence the letters from the committee. Mr. Evans
had replied that he must have mistaken him for
David. He had not asked Evans to become his
patient. Dealing with Mrs. Jones’s evidence, he
said that one day on his way to his surgery he had
been asked by Mr. Jones, whom he had not then
known, whether he was treating Mrs. Facey’s child,
and he had replied that he was. Mr. Jones had then
said that Facey had spoken to him about the respon-
dent and that one of these days Jones would come to
see the respondent, for he had just moved away from
his present doctor and would like to sign on with
respondent. Mrs. Jones, who was standing by,
had then said she had a nasty cold and would come
to see respondent. He had not asked her to sign on.
He had not seen either of the Jones’s after that. The
Atterburys lived next door to the Faceys, whose
child he was attending. Mr. Atterbury had on one
occasion been working in his front garden and had
greeted respondent, who had complimented him on
the look of the garden. Desiring to put the garden
of his surgery in order he had called a few days later
to see if Atterbury would work on it. He had found
Mrs. Atterbury in and had left his card, and in the
evening he had called again and spoken to Mr. Atter-
bury about the garden. He had never invited any
of the witnesses to come on to his panel.
Crogss-examined, he said that he had been surprised
to find the Ecclestons at the house of his patient,
though he had known they were to be witnesses
before the G.M.C. Mr. Eccleston had said that he
wanted to hear the true story from respondent, as
he had been pestered by solicitors.’ Respondent
had shown him some documents to prove the allega-
tions were untrue. ‘The brother of one of his patients,
a Mr. Waterfield, had brought him Evans's state-
ment. This patient had asked Evans about his
evidence and Evans had replied that his statutory
declaration had been made under influence and that
he was prepared to give the true facts. The patient
had then put down his statements and handed them
to respondent.
His day-book showed receipts of money on each
day. These were entered at the time of receipt,
therefore they were presumably in chronological order,
The Legal Assessor pointed out two dates in 1936
and asked him whether the 6 had not been altered
from a 7. Mr. H. L. Eason put to him that the last
entry on one of the left-hand pages was the name of
Joyce Eccleston; the next entry at the top of the
right-hand page bore a date which had been altered
from a 7 to a 6, and lower down another entry had
been similarly altered. Lower still there were two
more entries, corresponding in sequence of date
but purporting to be 1937 and not 1936. On the
next page two other dates had apparently been
altered. All these entries were subsequent to the
entry of Joyce Eccleston, which would then corre-
spond to the date on which respondent had said he
had seen her. In reply, respondent said he must have
copied this material from another book which he
had not with him.
The Legal Assessor: ‘“‘ Why then did you get the
entries out of order ? ”—“ It must have been through
a slip of the pen.”
“ They are all slips of the pen, are they ? Is that
your explanation ? ’’—“ Yes.”
Re-examined by Mr. Davies, he said he kept two
books for income-tax purposes. He had not altered
this book to show that he had attended Joyce
Eccleston in June, 1936. The entry had been made
on June 27th, 1936.
After deliberation in camera the President
announced that the second, third, and fourth charges’
had been proved to the satisfaction of the Council
and the Registrar had been ordered to erase the name
of Bakhtawar Singh Jain from the Register.
CHARGES OF CANVASSING DISMISSED
The Council dismissed the charges brought against
Hugh MeNicholl, registered as of c/o 105, London-
road, King’s Lynn, Norfolk, M.B., B.Ch. 1933,
N.U. Irel, who had been summoned to appear
before the Council on the following charge :—
That being &a registered practitioner you have
systematically canvassed personally and/or by means of an
agent or agents for the purpose of obtaining patients, and
in particular : (1) in 1936 or 1937, or in both of those years,
canvassed patients of Guy Kinneir, a registered medical
practitioner, by furnishing or causing to be furnished to
them professional cards on which your name, qualifications,
address, and telephone number were printed; (2) in
1936 or 1937 canvassed Mrs. Stacey by causing one of the
professional cards to be furnished to her, and by endeavour-
ing yourself to obtain from her the medical card issued to
her husband as a person insured under the National
Health Insurance Acts; (3) in or about March, 1936,
canvassed by means of an agent Mrs. Bertha Florrie
Gardiner and thereby obtained a child of hers as a patient ;
(4) in or about March, 1936, canvassed the said Mrs.
Bertha Florrie Gardiner and thereby obtained the transfer
to yourself as an insurance practitioner of her husband,
‘Thomas Reece Gardiner, a person insured under the
National Health Insurance Acts; (5) in or about March,
1936, employed the said Mrs. Bertha Florrie Gardiner as an
agent for the purpose of obtaining patients by means of the
THE LANCET}
distribution of professional cards, which you handed to her,
and on which your name, qualifications, address, and
telephone number were printed; (6) in or about May,
1936, attempted to employ the said Mrs. Bertha Florrie
Gardiner further as an agent for the purpose of obtaining
patients; (7) in the summer of 1936 employed Mrs.
Collins as an agent for the purpose of obtaining patients by
means of the distribution of professional cards which you
handed to her, and on which your name, qualifications,
address, and telephone number were printed; (8) in or
about February, 1937, canvassed Mrs. Kimber by means of
an agent by whom a professional card on which your
name, qualifications, address, and telephone number
were printed was furnished to her; and (10) in or about
December, 1936, on two occasions canvassed Charles
Hartridge by means of an agent by whom a professional
card on which your name, qualifications, address, and
telephone number were printed and furnished by him.
And that in relation to the facts so alleged you have been
guilty of infamous conduct in a professional respect.
The complainants were the London and Counties
Medical Protection Society, and members of the
Council who were also members of that society
withdrew. The complainants were represented by
Mr. Macfarlane, instructed by Messrs. Le Brasseur
and Oakley; and Dr. McNicholl appeared, accom-
panied by Mr. Charles Davis, solicitor, of Messrs.
Bulcraig and Davis.
The first witness called in support of the charges
was Dr. Guy Kinneir, a practitioner of Mottingham,
London, S.E., who said that he had started practice
in that neighbourhood in 1935. The respondent had
come afterwards, and lived about a mile away.
. The patients who would give evidence lived on a
housing estate nearby. One other doctor lived in
the estate, but neither witness nor respondent lived
there. About a year ago a Mr. Bailey, who with his
wife and daughter had been witness’s patient for
some time but was now dead, had brought witness
a professional card of the respondent (put in evidence),
A Mr. Kimber, who would give evidence, was also
a patient of the witness’s.
Mrs. Gardiner said she had moved to her present
address in March, 1936. A few days afterwards her
little girl had had an accident in the street and her
face had been cut. A woman had suggested that
witness should take her to the “shilling doctor”
and had shown her a house where respondent was
visiting at the time. The respondent had put a
stitch in the child’s face, and witness had taken the -
child to his surgery to see him several times afterwards.
On one of these occasions he had asked witness if
she had a panel doctor. She had replied that her
husband was on the panel of a Dr. Power but that his
medical card had not come through. Respondent
had asked the witness if her husband would go on
to his panel and, if so, whether she would bring
respondent the card. She had taken it to the respon-
dent and he had kept it. Her husband had not
transferred to respondent’s panel until April, 1936.
Respondent had told her that he had come from
Greenwich, where he had been assistant to a doctor
at £8 a week, and was trying to work up a practice,
He was earning only £4 a week, so he was anxious
to get patients. He had given her about twelve
small cards with his name, address, and telephone
number. She had been in the habit of going to help
women who were being confined, and she had two
of respondent’s cards bearing the addresses of
maternity patients whom she had been going to
attend for him. Respondent had asked her to get
patients for him. She had left two cards next
door, at the house of a couple called Bargraves, who
had both become his patients; and at the houses
of certain other persons, who, as far as she knew,
GENERAL MEDICAL COUNCIL
[JUNE 12, 1937 1407
were all on respondent’s panel. They had been
strangers to the district. She had given three of the
respondent’s cards to a solicitor’s clerk. These were
in evidence.
On a day in May, 1936, respondent had visited her
in her house and asked if she had any more patients
for him. Her husband had said that this was not
right and that doctors should not canvass. Respon-
dent had answered that he must get patients, as there
was so much competition about, and her husband
had said he would not permit her to canvass. She
had got no more patients for respondent. She
had seen one of the cards in the possession of Mrs.
Collins, and had also seen Mrs. Collins visiting from
house to house and leaving the cards. Mrs. Kimber ©
was a friend of the witness’s, and she had seen a
similar card in her house.
In cross-examination, Mrs. Gardiner said that
at the time of her first visit with her daughter to
the respondent she had told him about her affairs
and her husband’s complaints. Her husband was
a shell-shock patient who suffered from neurasthenia.
Respondent had not at the time asked her to bring
her husband’s card to the surgery ; he had done this
at about the third interview. She had told him that
she understood the work of a handy-woman and would
like some work. Asked if she and the doctor had
not fallen out, she replied that if this was the respon-
dent’s version of the facts it must stand; as far as
she was concerned, it was a secret. She agreed that
she had fallen out with him, but denied that she dis-
liked him a good deal. She had walked with Mrs.
Collins part of the way round the streets when
Mrs. Collins was leaving cards at every house.
Mrs. Collins had asked the inhabitants whether they
had a panel doctor, and had told them that the card
was that of a thoroughly good doctor whom she
could recommend, Witness admitted that she had
been very concerned about finding the respondent’s
card with Mrs. Kimber; there were four doctors
in the neighbourhood, all of whom had to make a
living; ‘“ We make it our concern.”’ She had kept
the cards because there had been rumours going round
that she did not know her work and was responsible
for Mrs. Collins’s illness after her confinement ;
also that she was going to be persecuted in one way
and another, and that respondent was going to bring
an action against her for slander.
Respondent’s solicitor admitted that two other
patients had received cards from Mrs. Collins, but
denied that she was respondent’s agent.
Dr. Charles Wortham Brook, another practitioner
of Mottingham, said that after receiving certain
information from a patient he had written a letter
to respondent saying that a woman had been trying
to persuade the wife of one of his patients to go on
respondent’s panel, and asking for respondent’s
explanation. He had had no reply until respondent
had telephoned to him eleven days afterwards saying
that he had sent a reply. He had since received
respondent’s cards from several of his patients.
Respondent had, over the, telephone, suggested a
meeting, but after careful consideration witness had
decided that he ought not to meet him alone. He
had got into touch with other practitioners, who had
advised against the meeting. He had sent the papers
to the Medical Defence Union, but this body had
taken no action, as respondent was also a member.
He was not codperating with other practitioners to
get respondent out, although respondent was putting
them in a difficult position.
Dr. MeNicholl, examined on his own behalf, said
that he had never authorised anybody to canvass
¢
—_
1408 THE LANCET]
GENERAL MEDICAL COUNCIL
[JUNE 12, 1937
or give his cards away. He had had a number of
cards printed so that he might give them to patients
to remind them of his consulting hours-and address.
He had not given them to anyone other than his
patients. (The first he had heard of the allegations
had been in a telephone conversation with the
- secretary of the Medical Defence Union, whom he had
afterwards visited. The secretary had told him that
Dr. Brook had complained that one of his patients
had received a card, and advised him to find out the
person responsible. The description of the woman
who had given the card corresponded with that of
Mrs. Collins, his housekeeper. On returning home
he had asked Mrs. Collins if she had distributed cards,
and she had denied it, but eventually she confessed
that she had taken some of his cards out of his surgery
to give to her friends. Mrs. Collins had been a
patient of his early in 1936 and he had attended her
in her confinement. Mrs. Gardiner had been looking
after the house. He had had high words with
Mrs. Gardiner, after which she had never done any
more work with him, He would not employ her any
more, because she interfered with him. Mrs. Collins
had afterwards asked him for work and he had
employed her, first as his charwoman in his surgery
and afterwards, when he bought the house, as his
housekeeper.
On the occasion when he had first treated Mrs.
Gardiner’s child, she had asked him if he took panel
patients, and said she would like to get her. husband
on to his panel, because he always had fits whenever
he saw his present doctor. Later she had brought
the panel card to him for signature. The only cards
he had ever given Mrs. Gardiner had borne the
addresses of maternity patients to whom he was
introducing her as a handy-woman. He denied
ever asking her if she had got him any more patients
or telling her anything about what he was earning.
In addition to a part-time assistantship he had two
appointments ; he was never short of money and in
fact had soon been able to buy his house. Mrs.
Stacey had consulted him for a skin rash and he had
prescribed injections. At one interview her husband
had asked him if he was on the gas company’s panel,
and on hearing that he was had offered himself as a
patient, and respondent had signed his card then and
there. He had never at any time canvassed for
patients. He had been warned against Mrs, Gardiner
by another doctor and would never have asked her
to do anything for him. He had never employed
Mrs. Collins as his agent, and when he had found out
that she had canvassed he had told her to go. He
was retaining her for the time because she had no
other means of livelihood.
Cross-examined, he said that he had not received
Dr. Brook’s letter until six days after its date. He
had sent a reply saying that he knew nothing about
the canvassing and could only suppose that it had
been done maliciously ; a copy of the letter was
in evidence. Mrs. Collins said in evidence that she
had consulted respondent in March, 1936, and he had
attended her in her confinement in September.
Mrs. Gardiner had been recommended to her by
respondent, but Mrs. Gardiner and respondent had
quarrelled. Respondent had given her work and had
lent her money. He had never given her any cards
to distribute, but in her gratitude to him she had taken
some cards without his knowledge and distributed
them. He had discovered this and said he could not
understand how people were getting his visiting
cards. She had not at the time enlightened him,
because she did not want to lose her sole means of
support. Ie had, however, challenged her on a
later occasion and she had confessed. He had*wanted
to put her out of the house there and then, but she
had persuaded him to keep her on, which he had done
out of compassion.
Mrs. Ivy Doyle said that she had called every
day to set the respondent’s house in order. Respon-
dent had asked Mrs. Collins in her presence if she had
taken any cards out of the surgery, and Mrs. Collins
had denied it. Witness had afterwards asked her
the same question and Mrs. Collins had again denied
it, but afterwards admitted it to the respondent.
She had asked the witness to beg her off from dismissal.
Mrs. Elizabeth Perrott testified that respondent
had been attending her at her house when Mrs.
Gardiner had come and asked him to see her child.
Mrs. Gardiner had been very talkative and had given
respondent her whole life-history. Respondent
had told her to bring the child to his surgery ; she
had not been able to understand the address, so
witness had given her one of respondent’s cards which
she had by her. Mrs. Gardiner had asked respondent
if he would take her husband on to his panel.
A Mrs. South also said in evidence that Mrs. Gardiner
had requested respondent to take her husband on
to his panel. :
Mr. T. C. Smith, formerly the owner of respondent’s
house, said that he had given one of the respondent’s
cards to Mrs. Kimber without respondent’s knowledge,
as Mrs. Kimber had asked him for the address of a
doctor to treat a stye in her eye. Mr. Stacey said
in evidence that he had gone on to respondent’s
panel of his own accord. He had previously had a,
card left at his house, but did not know by whom.
Respondent had been attending his wife when he had
transferred to respondent’s panel.
After deliberation in camera, the President
announced that the charges had not been found
proved to the Council’s satisfaction.
The Case of Albert Rudolf Rellum, registered
as of 39, Dockhead, Bermondsey, London, S.E.1,
L.R.C.P. Edin., 1921; L.R.C.S. Edin., 1921;
L.R.F.P.S: Glasg., 1921, who had been summoned
to appear before the Council on the following charge :—
That being a registered medical practitioner, you
have canvassed the patients of Joseph Frelich, a registered
medical practitioner, with a view to inducing such patients
to become patients of yours, and in particular: (1) in
or about the month of November, 1936, you canvassed
William Selley, a patient of the said Joseph Frelich ;
(2) in or about the month of November, 1936, you can-
vassed Elizabeth Selley, the wife of the said William Selley,
a patient of the said Joseph Frelich; (3) in or about
the month of November, 1936, you canvassed George
Fred Selley, a son of the said William Selley and Elizabeth
Selley, and induced him to become a patient of yours ;
(4) in or about the month of November, 1936, you can-
vassed William John Selley, a son of the said William
Selley and Elizabeth Selley, a patient of the said Joseph
Frelich. And that in relation to the facts so alleged you
have been guilty of infamous conduct in a professional
respect.
Dr. Joseph Frelich, a practitioner in Bermondsey,
presented his own complaint, and Dr. Rellum
was accompanied by Mr. John Ritchie, counsel,
instructed by Messrs. Simon, Haynes, Barlas and
Ireland.
Dr. Frelich said that Dr. Rellum had been his
assistant but he had dismissed him early in March
of the present year. Mrs. Selley had called at his
surgery and told him that the respondent had been
canvassing members of her family, patients of
Dr. Frelich, to become respondent’s patients.
Mr. and Mrs. Selley and two of their sons gave
evidence to show that Mr. Selley had had an accident
`
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some years ago and had claimed compensation.
Dr. Rellum, who had then been Dr. Frelich’s assistant,
had examined him and given him a certificate on
which he had made good his claim. The family
had been friendly with the respondent, who had
been chronically short of money and had frequently
borrowed various sums from Mr. Selley. On one
occasion he had said that he must get as many
patients as he could and had asked them to go on
REVIEWS AND NOTICES OF BOOKS
his panel.
[sue 12, 1937 1409
‘They had refused, except the youngest
son. Mr. and Mrs. Selley admitted that they knew
that Dr. Rellum was under a bond not to practise
in the neighbourhood, and that he had received a
letter from the insurance committee saying that he
could not visit patients in Bermondsey.
Without calling on the respondent, the Council
decided that the charges had not been proved to its
satisfaction.
REVIEWS AND NOTICES OF BOOKS
Diagnosis and Treatment of Arthritis
By Russet, L. Cecu, M.D., Sc.D., Professor of
Clinical Medicine, Cornell University. London:
Humphrey Milford, Oxford University Press.
1937. Pp. 263. 21s. |
THis is one of a series of monographs, edited by
Dr. H. A. Christian and written by leading authorities,
whose object is ‘‘ to bring to the practising physician
a knowledge of the most approved methods for the
diagnosis and treatment of disease.” Dr. Cecil, whose
investigations into the infective nature of acute rheu-
matism and rheumatoid arthritis are of recognised
importance, has written the volume on arthritis.
At the outset he states—and few will differ from him
—that ‘‘there is no disease in the whole field of -
medicine in which purely symptomatic treatment
leads to more barren results.” The title is used
to cover a wide field including rheumatic fever, and
certain of the less common forms of arthritis are
-~ unusually well described. Septic arthritis, including
gonococcal and staphylococcal and rarer forms,
traumatic, syphilitic, and tuberculous arthritis and
intermittent hydrarthrosis among others are clearly
differentiated. In view of the important researches
carried out by the author himself into the bacteriology
of rheumatic fever and rheumatoid arthritis it is
natural that much space should be devoted to this
aspect. The work of other investigators receives due
consideration, and the conclusion is reached that
though the streptococcus is an important ztiological
factor, the particular type of streptococcus involved
is not yet settled; the findings appear to strengthen
the view that mutation takes place between the
different types. The author favours the use of strepto-
coccal vaccine by the intravenous route in the treat-
ment of rheumatoid arthritis but warns against
overdosage which may cause a severe exacerbation
of the discase. There is certainly a reaction against
this form of treatment and any benefit that may
accrue is now generally attributed to desensitisation
rather than immunisation. Other methods of treat-
ment are fully described together with useful systems
of diet,
The section on gout adds nothing to common
knowledge: It is curious that the British spas where
gout has been successfully treated for centuries are
not mentioned whereas certain continental spas of
less importance in this. respect are approved. The
section on spondylitis is scanty; the so-called von
. Bechterew type is regarded as the osteo-arthritic
form, which is not the view held by most of those
who have referred to von Bechterew’s original
description.
The book is well got up and the illustrations are
good. It will be found a useful and practical guide
to the management of a common but difficult group
of diseases and though it is sketchy in parts a very full
list of references is supplied.
Early Science in Cambridge
By R. T. GUNTHER, M.A., Hon. LL.D., Curator
of the Oxford Museum of the History of Science.
Oxford: Published by the author at the Old
Ashmolean, Oxford. 1937. Pp. 513. 42s.
Dr. Gunther has earned everyone’s gratitude by
what he has done for the Old Ashmolean Museum
and for the series of books on early science in Oxford
. which he has published. He now turns his attention
to Cambridge. His work is not a formal history
but, as he says, more a series of notes centring
round a list of surviving instruments which have
been associated with teaching and research in
Cambridge, many of which were shown at an exhibi-
tion in the Old Schools in 1936. It is full of interest,
and if we fail to find something which we might
expect we come across a great deal which is surprising.
How those who discuss the curriculum must envy
the education which Wiliam Stukeley got about
1705: “ We hunted after butterflys, dissected
frogs, used to have sett meetiùgs at our chambers
to confer about our studys, try chymical experiments,
cut up dogs cats and the like” ; small wonder that
when he reached the dignity of Goulstonian lecturer
he had risen to dissecting an elephant. Or read of
the wise royalist Dr. Bowles who, having to treat
for a dysentery a roundhead captain who had been
tearing up prayer books, cured his patient by a
decoction of the prayers for the visitation of the sick
from the defiled volumes boiled in milk. No very
clear distinction seems to be made between work
done in Cambridge and work done elsewhere by
Cambridge men, and there are we suspect a fair
number of small inaccuracies, but we can heartily
commend the book for casual reading. It wil
probably incite many journeys to Cambridge to see
such things as Charles Darwin’s red handkerchief
draped over the microscope he used to use, and to
residents will no doubt be quite a revelation.
Milk Products
By W. CLuNie Harvey, M.D., D.P.H., Medical
Officer of Health, Southgate; and H. HILL,
Sanitary Inspector, Southgate. London: H. K.
Lewis and Co. 1937. Pp. 387. 16s.
THE milk products described are ice-cream, cream,
butter and margarine, cheese, condensed milk,
evaporated milk, dried milk and some subsidiary
milk products such as fermented milks and malted
milk. The subjects are dealt with on a regular
orderly plan which is convenient and easy to follow :
definition, food value, bacterial content and their
sources, manufacture, any diseases transmitted by the ©
particular food, chemical composition, bacteriological
and chemical examination, legal position, and where
appropriate any legal or recognised standards. The
balance between these different sections is, for the
most part, well maintained. Ice-cream is fully
I
1410 THE LANCET]
discussed—this chapter occupies 84 pages—while
evaporated milk might have been given a little more
space. Very little of importance is omitted but
no mention is made of staphylococcus food-poisoning
in connexion with cream-filled pastry, a matter of
increasing importance. No colour tests are given
for the presence of vitamins added to margarine;
indeed, the chemical examination of margarine seems
to be omitted. The difficulty of making a satisfactory
injection emulsion for examining cheese for tubercle
bacilli is not dealt with. Under the heading sweetened
condensed milk the hydrometer is given as the only
instrument whereby the progress of concentration
can be determined; the use of a viscometer is not
mentioned. Emphasis might have been given to
the importance of the retainer in connexion with the
moisture and bacterial content of dried milk.
Much of the information given is not readily
accessible elsewhere and the authors have done a
considerable service in making it available in this
well-written and convenient form.
Hospital Law Notes ,
By W. E. C. Baynes, M.A., LL.M., Barrister-at-
Law. London: Joint Council of the Order of
St. John and the British Red Cross Society. 1937.
Pp. 93. 5s.
Mr. Baynes, who is honorary legal adviser to the
British Hospitals Association, has found that the
same questions are repeatedly put to him by secretaries
of voluntary hospitals. He has therefore collected
for publication the notes on points of law which form
the substance of his replies. They cover almost every
conceivable legal or semi-legal difficulty which a
hospital secretary is likely to encounter. There is
an adequate index and footnote references are given
to the principal leading cases. The allusions to the
National Health Insurance Act of 1924 need to
be adjusted to the consolidating statute of 1936.
Similarly in the note on infectious diseases the
references on pp. 21 and 22 to the public health
enactments of 1875 and 1925 and the Infectious
Disease (Notification) Act of 1889 will need to be
replaced next October by references to the equivalent
provisions of the big new Public Health Act, 1936,
which Mr. Baynes cites at p. 55 as if already in
force. These, of course, are minor points; the law
is accurately stated but the statutes where it is
now to be found have been rewritten in the past twelve
months. The notes on road accident patients, on
the recovery of income-tax under subscribers’ seven-
year covenants, and on liability for negligence are good
instances of the clear and concise help which Mr.
Baynes offers to his readers. The secretaries of
hospitals and similar institutions who buy his little
book will get good value.
War Dance
A Study of the Psychology of War.
Hower, M.B., B.S. Lond., D.P.M. London:
and Faber. 1937. Pp. 315. 7s. 6d.
IT is no indictment of Dr. Graham Howe’s work to
state that his thesis is a search for a mystical solution
of the problems of human behaviour. War represents
one of the types of disharmony which can, he holds,
be overcome by the same methods which he has
attempted to expound in earlier books (“ I and Me,”
and “‘ Morality and Reality ”)—i.e., by a resolution
of the antinomies in the self—the duality of inner and
outer, private and public, cognitive and conative,
thinking and spontaneous living. Dr. Howe enjoys
By E. GRAHAM
Faber
REVIEWS AND NOTICES OF BOOKS
[JUNE 12, 1937
similes and aphorisms (some penetrating, others
singularly impenetrable) carrying the reader along
in a pleasant flow of bright ideas and dark sayings.
But as one reads on, it seems that one has not
progressed in a stream, but raced in a whirlpool
Dr. Howe has been unwise, perhaps, to invoke the
Fourth Dimension. Of course, if we could be in all
dimensions at once, woefully as we are tied to three
(and quite incapable of living in one or two) reality
would certainly be revealed to us. But here we must
use mathematical notation and not surrealistic
(polite variety) drawings which do not, for most
people, clarify the issues. Dr. Howe would have
succeeded better, indeed perhaps brilliantly, if he
had chosen another title. For he has said little
about war and the reader is left with the impression
that ‘‘ cest magnifique, mais ce mest pas la guerre.”
British Journal of Children’s Diseases
(VoL. XXXIV., AprilJune).—In an article on
Epidemic Myalgia in Children, Dr. W. N. Pickles
` reviews the literature and records his experience of
an outbreak of 31 cases which occurred in Wensleydale,
Yorkshire, in the summer of 1933 ; 15 were in children
under 11 years of age, 15 in young adults, and one
in a man of 52. His conclusions are as follows: The
disease appears to spread by direct contact, and
the incubation period is short, ranging from two to
four days. The period of infectivity continues during
the course of the disease which is also short. There
is no evidence that the disease is conveyed by food,
water, or animal vectors. It occurs mainly in the
late summer and autumn. One attack does not
confer immunity. The chief importance of the disease
which has good prognosis is its tendency to simulate
' serious conditions such as acute pneumonia and acute
abdominal emergencies, especially appendicitis and
intussusception.—In his paper on Morbilli Bullosi Dr.
G. W. Ronaldson, who records two personal cases,
one in a girl aged 4 years who recovered, and another
in a female infant of 10 months who died, illustrates
the rarity of this condition by the fact that they were
the only examples of morbilli bullosi in a series of
4362 cases of measles admitted to the South Eastern
Fever Hospital in the period 1930-36. Ronaldson
maintains that morbilli bullosi should be defined as
a variety of the measles exanthem and not as a distinct
variety of the disease. He classifies the reported cases
into one or other of the following three groups:
(1) cases in which a bullous eruption was associated
with a morbilliform erythema; (2) well-authenticated
measles with an eruption which had pemphigoid
elements, of which his two cases were examples; and
(3) cases of measles in which a bullous eruption
followed the true rash either immediately or after
varying intervals.—Dr. E. F. Dawson-Walker and
Dr. E. G. Brewis contribute a paper on Two Unusual
Cases of Diphtheria. The first was a case of a severe
naso-pharyngeal form of the disease in a female
infant aged 9 days. Recovery followed two intra-
muscular injections of antitoxin. Nasal and faucial
swabs showed C. diphtheria of the intermedious type. °
The second case was that of a boy 12 years old who
developed chorea in the course of characteristic
diphtheritic paralysis, and recovered. Similar
examples of this very rare complication of diphtheria
have been recorded by Globus (1923), Critchley (1924),
and Miihlenkamp (1934).—Dr. D. MacIntyre and Dr.
H. L. W. Beach report a case of Acute Encephalo-
myelitis Complicating Chicken-Pox., The patient was
a girl aged 7 years, in whom the complication
developed on the twelfth day of an attack of chicken-
pox. Complete recovery took place without any
special treatment in the course of three months, and
when seen about eight months after discharge from
hospital the child showed no sign of mental or
physical weakness.—The abstracts from current
_literature are devoted to acute infectious diseases.
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———
THE LANCET
LONDON: SATURDAY, JUNE 12, 1937
WAGES AND HEALTH
THE prospect of a declining population was
recently reviewed in our columns.? It may be,
as some of the writers'on the subject contend,
that the low and falling net reproduction-rate
arises rather from psychological than economic
causes. Nevertheless, those who live below the
margin of subsistence have a specially good reason
to make increasing use of the contraceptive
measures now at their disposal and.so accelerate
the fall. Science has given the poverty stricken
a practical answer to the assumption that their
continuance in that state is an inevitable, if regrett-
able, feature of the social system. They can now
die out of their own volition. Whether the
prospect of a falling and ageing population is a
matter for alarm or not, there are students of
economics who maintain that there is no reason
why the extreme forms of its economic origins
should continue. Mr. SEEBOHM ROWNTREE has
recently rewritten his book, first published in
1918, on the ‘‘ Human Needs of Labour.” ? His
basic facts are derived from a survey of 2875
completed families in the town of York; families
completed in the sense that the mother was aged
40 to 45 years at the date of the 1931 census. He
has been able to trace the number of dependants
in different sizes of family from year to year since
the eldest child was born. He gives reason for
believing that York is a fair sample of the country,
but admits that his investigation is too small to
yield absolutely conclusive results. Of these
families, 17-7 per cent. had no children, 25-1 had had
a maximum of one child, 24:5 two children, and
14-7 three children simultaneously dependent at
some time, the percentages rapidly diminishing
for larger maximum dependencies. The per-
centages of children in these families, arranged
in the same order of classification, but excluding
the childless families, were 12-34 for one child,
24:02 for two children, 21-63 for three children,
and so'on, dependent at any one time.
Mr. Rowntree’s line of inquiry is designed to
explore the problem of a living wage and it shows
that, if such a bare minimum wage were to be based
on the needs of families with two children only,
63-6 per cent. of the children of all fathers receiving
it would be inadequately provided for at some time
and 58:8 per cent. would be in this condition for
five years or longer. Even if the minimum wage
were determined on the needs of families with
three children, 42 per cent. of families of all sizes
would be inadequately provided for over varying
1 Lancet, April 17th, 1937, pp. 933, 9
44,
2 London: Longmans, Green and Co. 1937. Pp. 162. 2s. 6d.
WAGES AND HEALTH
[JUNE 12, 1937 1411
periods, and 34-5 per cent. for five years or more.
In his view, a minimum wage is necessary and
practicable. It should be fixed on the needs of a
man, woman, and three children, the requirements
of larger families at low income levels being met
by the admittedly difficult provision of State
family allowances. In endeavouring to determine
such a wage he uses average retail and other prices
of his own ascertainment applied to the estimated
needs of a family of five persons. As regards food
he has been guided by the dietaries contained in
“ Family Meals and Catering ” published by the
British Medical Association, giving 3400 calories
per man for a family equivalent to 3-78 adult
males. In this way he builds up a minimum wage
of 53s. per week, including 20s. 6d. for food,
9s. 6d. for rent, 8s. for clothing, 4s. 4d. for fuel
and light, ls. 8d. for household sundries, and 9s.
for personal sundries. Mr. Rowntree has been
publicly criticised by the Children’s Minimum
Council 3 for the meagreness of his dietary, but he
has been careful to state that he has deliberately
erred on the side of stringency rather than
extravagance, that even this wage (or its equivalent
of 41s. in the case of agricultural workers) would
be a great advance on anything earned by a large
proportion of workers at the present time, and
that his experience on a trade board leads him to
believe that its gradual but reasonably rapid
application to all industries would have no crippling
results. He is aiming at the bare subsistence
necessary for health and well-being not at an
income above the level of which they could not
be improved.
If this minimum income of £137 16s. per annum
for industrial workers is accepted, it would be
important to: know how many families are main-
tained below this level. This, unfortunately,
it appears to be impossible to ascertain with any-
thing approaching accuracy. A general impression,
however, may be gained from official figures and
from ‘estimates made by various writers. In their
latest book 4 G. D. H. and M. I. Coxe paint
a picture of our society on a much wider canvas
than Mr. Rowntree’s, bringing together data |
gathered by experts about national and class
incomes, nutrition, housing, unemployment, educa-
tion, standards of life, social services, taxation,
production, and the past and prospective struggles
of working men for better conditions. The facts
are as near the truth as the available methods of
scientific investigation permit, whatever may be
our view of the remedies proposed by the writers.
In May, 1936, there were nearly one and a half
million males unemployed, of whom more than
one million were over 25 years of age. Some of
these were certainly unmarried and many at such
an age that their families had ceased to be necessarily `
dependent, but it is well known that a large number
have a wife and three or more young children to
maintain. Unemployment benefit for such a
family is at the rate of about £78 a year; for the
chronic unemployed who come under the Public
3 Times, May 8th and 17th, 1937.
4 The Condition of Britain. London: Victor Gollancz.
1937.
Pp. 470. 7s. 6d.
1412 THE LANCET]
BATHING AND THE EARS
[JUNE 12, 1937
Assistance Board it may be higher according to
circumstances but, in any case, usually it is less
than £100. When to those groups are added the
families who are entirely dependent upon local
poor-law assistance, usually at comparable rates,
it is evident that many of the non-earning families
in the community have far less to live on for pro-
longed periods than the estimated subsistence wage.
As to those who are earning, it appears from
estimates of CoLIN CLARK, quoted by the Cores,
that more than 60 per cent. of the national incomes
in 1929 (i.e., before the financial crisis) were below
£125 per annum and, indeed, that the average of
all incomes was below £200 per annum. It should
be remembered that more than one income may
be represented by one family; there are, in fact,
more than twice as many incomes as there are
families. Nevertheless, it is clear that many
young families dependent on a single wage earner
must fall into the lower earning categories.
Knowledge of local families and their wages
indicates that this is the case.
If, then, scientific work on nutrition and the
inquiries into the costs of commodities are anywhere
near the mark, the volume of those who are inade-
quately fed must be large. The Government has
recognised this position by urging local authorities
to make fuller use of their powers to provide free
or cheap meals and milk for children, and for
expectant and nursing mothers. In recent years
the urgent need for an outlet for the surplus
production of agriculture has provided a new
incentive to the governments of all countries
represented at Geneva to arrive at an international
policy which will increase the consumption of food.
In the meantime, there is scope for further intensive
inquiries into local family incomes, such as those
included in the London and Merseyside surveys and
in MoGoniIcLe’s investigations at Stockton.
Possibly the survey to be carried out by the Ministry
of Labour in connexion with the cost of living will
afford information covering a wider range of the
population than any data at present available.
The needs of people can only be estimated roughly
but actual incomes should be ascertainable with
a reasonable measure of precision.
BATHING AND THE EARS
As summer weather has now happily arrived,
we may expect the usual crop of ear troubles due
to bathing. Man is not an aquatic animal and,
unlike many mammals that have reverted to a
life in the water, he has no mechanism for closing
the auditory meatus or the nostrils; hence
water can reach his ear either through the meatus
or through the Eustachian tube, though harm is
rare in proportion to the number of bathers.
Water easily gets into the meatus during swimming
and produces a disagreeable sensation, but it soon
runs out again from an unobstructed canal. If,
however, there is any considerable quantity of
wax, this imbibes the water, swells, and obstructs
the passage; so that the sensation of water in
the ear, persisting long enough to cause the
sufferer to seek advice, is nearly always caused by
cerumen and cured by its removal. Those who.
secrete much wax should have it removed before
the bathing season. This retention of moisture
readily leads to a dermatitis and is the usual cause
of external otitis resulting from bathing. Apart
from the presence of wax, those with a tendency
to eczema are apt to suffer an exacerbation from
bathing ; such people should wear an efficient
plug and dry the ears carefully afterwards ; they
may with advantage insert a few drops of oil
or of nitrate of mercury ointment (1 drachm
to an ounce of equal parts of olive oil and liquid
paraffin). In some tropical regions, a very severe
form of external otitis is a common complication
of bathing apparently caused by minute larval
forms of marine organisms; “‘ Bombay ear” and
“ Singapore ear ” are well-known examples.
Much more important than external otitis is
the middle-ear suppuration that may result from
bathing. One important cause of this is the
entrance of water through an old quiescent perfora-
tion of the drum—an event liable to be followed
by very severe suppurative otitis and the danger
of serious complications. Patients with an open
perforation should never bathe without using
really efficient means of preventing the entry of
water into the ear. A plugging material, made of
a mixture of animal wool and plasticine or wax,
is obtainable at chemists and is satisfactory if
intelligently applied; but ordinary cotton-wool
is worse than useless since it only gives a false
sense of security ; a rubber bathing-cap to cover
the ears should be worn over any plug. Unfor-
tunately, people with perfectly healthy ears,
too, may get acute otitis media after bathing,
owing to the entrance of water into the tympanum
through the Eustachian tuba This occurrence is
assisted by swallowing and, more frequently and
particularly, by forcibly blowing the nose while
the nasal passages are still full of water. If the
public could but be taught to refrain from blowing
the nose until the water has drained out of it,
otitis media after bathing would become rare.
Patients with otitis from bathing very often give
a history of a sudden crack and pain in the ear
on blowing the nose, followed soon by earache.
The ear is peculiarly susceptible to infection by
micro-organisms thus introduced, and although
of late much care has been devoted to the purifica-
tion of swimming pools and baths, these may play
an important part in the spread of streptococcal
infections when, as in a school, such diseases as
rhinitis and tonsillitis are present. Epidemics of
nasal sinusitis have also had a similar origin.
But infection of the bathing water is not an
essential condition, for organisms from the patient’s
own throat or nose may be carried with the water
along the Eustachian tube. Otitis media from this
cause is naturally more likely during an attack of
coryza or sore-throat and bathing should be
avoided by people thus afflicted.
In conclusion, it may be said that when the
external meatus and drum is healthy, plugging
the canal is unnecessary except to prevent direct
damage in high diving. The subject of a perforated
drum runs a substantial risk from the entry of
THE LANCET]
water and must be very careful to exclude this
if he bathes at all. A healthy drum can only be
infected through the Eustachian tube, and this is
_ unlikely if the bather refrains from swallowing
while in the water and, especially, from blowing the
nose on coming out, and if he does not bathe while
he has a cold or a sore-throat.
‘ELEMENTS OF POPULATION
Ir the predictions of both amateur and pro-
fessional soothsayers are even reasonably near the
truth, the future of our population is a question
likely to remain in the public eye for quite a long
time. The basis of these predictions is, of course,
the present level of fertility and mortality, with
various adjustments made to each according to
the worker’s idea of what may happen to those
rates in years to come. One and all are agreed
that (apart from immigration) our population
must within a few years begin to decline, and unless
there is a considerable increase in the birth-rate,
‘to decline at an accelerating rate. And so the
question arises as to whether anything can be
done to check a further decline in fertility, whether
with the aid of a Royal Commission the urge to
contraception cannot be stayed. Most, but by
no means all, competent observers believe that the
fall in fertility is mainly, if not entirely, due to
deliberate control of the size of family. But
clearly contraception is only a means to an end,
and it is the basic causes that lead to the adoption
of the means that we want to know more about.
It seems a far cry from Royal Commissions and
planned families to fruit flies and flour beetles,
but as RayMoND PEARL, a pioneer of the experi-
mental approach in this field, has recently
emphasised, the fundamental problems of popula-
tion are biological problems. What, for instance,
is it that makes populations slow up in their
growth rate and approach ever nearer to a limiting
size which they never quite reach ? What is the
explanation of the phenomenon of periodic rapid
multiplication of populations of lower mammals,
of which lemmings are the classic example ?
Are there laws of population growth by which man,
- as well as the lower animals are bound, so that the
best laid schemes of committees can have little
effect upon his development? The sociologist,
the experimental biologist, and the ecologist
" must play their part in solving such problems ;
none of them can succeed in doing so alone.
The experimental method has already given
results of much interest. For instance several
studies suggest that groups of insects survive
the effects of various environmental poisons
more easily than do isolated individuals. These
have shown that morphological changes may
take place under certain conditions of crowding.
The factor which has had most attention paid to
it is density, and a very interesting discussion of
its influence has been published ? by Dr. THomas
PARK, of the department of biology of the school
of hygiene and public health, Johns Hopkins
1 Amer. Nat. 1937, 71, 50.
2 Ibid, p. 21.
ELEMENTS OF POPULATION
[JUNE 12, 1987 1413 -
Unjversity. Praru’s work on drosophila is well
known; it shows the inability of this fly to
oviposit and feed adequately when disturbed and
this provides evidence that population density
may alter the behaviour of its components. Less
familiar perhaps are the experiments which Park
quotes of various workers with Tribolium confusum,
a beetle which spends its entire life-cycle in flour.
Here also a limiting size to the population in
relation to its environment has been observed.
These beetles eat their own eggs and this.
cannibalism varies directly with the number of
eggs and imagos present, so that when the
concentration of the latter is high the rate of
cannibalism is high. Also, flour in which dense
populations of tribolium have lived has its nutritive
value reduced and is affected by the addition of
excretory and metabolic wastes. It has been
shown that beetles living in this “conditioned ”
flour have their fecundity drastically lowered and
their larval mortality increased. It thus seems
that an environmental modification takes place
which is a result of the activity of the population
itself, and this modification plays an important
part in guiding the course of the tribolium popula-
tion. PARK also quotes the work of MacLacan
and Dunn * on the grain weevil sitophilus which
shows decreased fecundity with increasing density,
which seems to be due, as with drosophila, to
reduction of the times available for feeding,
Ovipositing and resting, which caused adverse
effects upon the physiological ,processes of
reproduction.
_ Such studies as these are still adding to the little
we still know of insect populations and the under-
lying principles of their growth. Of mankind
we know perhaps even less. PEARL’s interpretation
of the scanty data seems the most reasonable—
that for thousands of years the human population
of the earth grew slowly till some 300 years ago the
development of scientific discovery (including
exploration as well as technology) ‘suddenly
expanded man’s effective universe and has kept
on expanding it. There has followed a spurt of
population growth of an explosiveness that is
seen, when plotted to a proper time scale, to be
comparable to that of an epidemic.” This history
PEARL compares with what we know of the lemming.
The essential biological elements he suggests are
these: first a-population relatively constant .or
very slowly growing as a consequence of the
operation of natural check; secondly, during a
relatively short period on the total time scale of
the species these checks are abated and a large
expansion results ; thirdly, the increasing density
leads to disturbance reactions; and lastly these
reactions lead to undirected mass migratory
movements and ultimate destruction of major
parts of the population. Up to a point there
seems to be a parallelism in the history of man-
kind. Unrest is a dominant characteristic of
human behaviour to-day, perhaps a’ symptom of
discomfort associated with density. Not being a
prophet PEARL does not envisage ‘‘ mankind
3 Proc. Roy. Soc. Edinb. 1935, 55, 126.
1414 THE LANCET] THE CAPITATION FEE AWARD [JUNE 12, 1937
marching to a watery grave just behind a horde
of frantic lemmings. But does anyone,’ he
asks, “ find it difficult to conceive of man marching
off in the not too distant future to a war? ‘Or
to doubt that, once well started, that war will
entangle in its meshes the major portion of man-
kind before it is finished ? Or, finally, to doubt
that the next world war will achieve a destructive-
ness hitherto undreamed of in the wildest flight
of imagination ? ” The thought is not a cheerful
one ; perhaps, as PEARL admits, -it is essentially
false. But the problems of population are difficult
and serious; nothing but good can come of each
form of attack upon them while general discussions
such as PEARL has published merit thought and
attention.
ANNOTATIONS
THE CAPITATION FEE AWARD
THE court of inquiry into the insurance capitation
fee met at the Ministry of Health on four successive
days from May 26th to 29th when Dr. H. Guy Dain
presented the case for the Insurance Acts Committee
of the British Medical Association and Mr. T. D.
Harrison presented the case of the Ministry of Health
and of the Scottish Department of Health. The
Medical Practitioners’ Union and the Joint Conference
of Friendly Societies also gave evidence. At the
conclusion of the inquiry Lord Amulree, the chairman,
expressed the court’s high appreciation of the cases
which had been presented so fairly by the parties
concerned and added the hope that the decision
the court would presently announce would give
satisfaction. After an interval of a week the finding
of the court was published on Monday last to the
effect that the appropriate capitation fee should
remain 9s., the figure applying both to insured persons
over the age of 16 and to employed adolescents under
16 when they become legally entitled to medical
benefit. The. Minister of Health in making the
announcement adds that the introduction of legisla-
tion to entitle boys and girls to medical benefit
immediately on becoming employed (on reaching the
school-leaving age) has awaited this decision. It will
now be possible to introduce the necessary Bill.
VARICELLISATION
ALTHOUGH a mild disease, chicken-pox is a trouble-
some one, especially in children’s wards and schools ;
for it is very infectious, has a long incubation period,
and may take a long time to heal completely. Satis-
factory means of prophylaxis are still to seek ; isolation
and quarantine, however prompt, are seldom wholly
successful if the susceptible contacts are young.
Specific prophylaxis by injection of the pooled serum
of convalescents has had very equivocal success ;
the age-groups of the children exposed, the degree
of exposure, and especially the variability of the
antibody content of the samples of serum which
composed the pool may account for the failure of
one experiment or the apparent success of another.
The suggestion of Amies! that by meansofagglutina-
tion reactions it may be possible to select sera of
high antibody content instead of pooling samples of
unknown titre may form a sound basis for future
work. Lastly there is varicellisation, the counter-
part of variolation and its contemporary since, as
J. D. Rolleston,? points out, it was first employed
by William Heberden the Elder in 1767. Rolleston
remarks that ‘‘in striking contrast with small-pox,
the results of the inoculation of chicken-pox have
been remarkably inconstant. Willan was unsuccessful
at the beginning of the nineteenth century. Steiner,
however, seventy years later was more fortunate
1 Amics, C. R. (1933) Lancet, 1, 1015.
i 2 Holleston: J. D. (1937) History of the Acute Exanthemata,
ondon.
and since then occasional successes have been reported
by other workers.” Some of these are mentioned
by Prof. J. W. Bigger, who gives details of the
apparently successful varicellisation of his daughter
by means of the intradermal injection of the contents
of vesicles derived from his son. During the 48 hours
before the appearance of the boy’s eruption (and
therefore during the most infective phase of chicken-
pox) the young adult sister had been in close contact
with the school-boy brother. One insertion was
made into the girl’s forearm, of the fluid—a minute
quantity—collected from five vesicles and suspended
in saline. On the eighth day after inoculation the
site was slightly red ; next day a definite papule was
present, and 24 hours later this had become a vesicle
indistinguishable from a lesion of chicken-pox.
There was no pyrexia or constitutional disturbance ;
the local lesion disappeared in a few days, and no
generalisation took place. As to the duration of
immunity Dr. Bigger expresses no opinion, but it
may be said that in some at least of the recorded
examples immunity was temporary, although the
clinical attack following a subsequent exposure was
mild. It is clear in any case that the method, like
the long-abandoned variolation, is unsafe for general
employment; familial protection is another matter.
Dr. Bigger’s only anxiety was, he says, the possibility
of producing herpes zoster. The intradermal inocula-
tion employed by him appears preferable to the
puncture- or scratch-insertions used by others.
NUTRITION AND INFECTION
IN reviewing the latest report of the Foot-and-
Mouth Disease Research Committee (p. 1290) we -
remarked that the by-products of the research done
have a value of their own. One of these by-products,
which requires further analysis, is the observation by
Mr. J. T. Edwards, D.Sc., that well-nourished rats .
can be infected with foot-and-mouth disease more
readily than those that are ill-fed.4 Early workers
at the Lister Institute and elsewhere had found that
young guinea-pigs, and those in a poor state of
nutrition, are more liable than others to resist this
infection, and since 1932 experiments have been done
at the Lister Institute and the Pirbright Experi-
mental Station to decide how far these differences of
reaction are due to nutrition and how far to size, age,
race, or to other conditions. Rats were used for
most of the experiments because they are not
easily upset by changes of food. They were divided
into groups and each group was inoculated intra-
dermally with virus after a period on a particular
diet. The two factors found to influence suscepti-
bility and severity of illness were age and nutritional
state: very young and very old animals and those
3 Bigger, J. W., Irish J. med. Sci. March, 1937, p. 126.
¢ This observation was mentioned by Dr. Edwards at a
sectional meeting of the Royal Soa of Medicine reported in
our issue of April 3rd, p. 811. Details are given în the Com-
mittee’s report (pp. 195-223).
ee OER ESAE I IAT E E EN SA E EREN A ey ee
THE LANCET]
which were ill-nourished were relatively insusceptible
—a finding which applied, though less definitely, to
guinea-pigs and hedge-hogs as well as to rats. A
third factor which lessened susceptibility was con-
current infection, possibly by lowering the general
state of nutrition. Whether any one component of
the diet is especially concerned was not determined ;
but it was noted that addition of raw liver appeared
to increase susceptibility within a few days. If the
rats then went back to a less nutritious diet it was
more than three months before they lost their
abnormal susceptibility to inoculation—a finding that
could be explained by suggesting that a pro-infective
factor in the liver was stored in the animal. The
decreased susceptibility of the rats on an inadequate
diet was found to be associated with the presence of
a definite anemia, and the addition of liver to the
diet may have acted by correcting this. Whether
these observations apply to farm animals has not been
investigated, but Dr. Edwards gives a chart showing
that in India foot-and-mouth disease in cattle is
commonest at the time of year when fodder is
plentiful and the animals are in prime condition,
and is comparatively rare in the “hot weather”
when they are often grossly undernourished.
OPIUM-SMOKING IN THE FAR EAST
On April 22nd what is known as “the Bangkok
Agreement on the Suppression of Opium-Smoking
in the Far East” became effective, and another
stage was reached in the effort to control or restrict
narcotic addiction by inhalation. By the Hague
Opium Convention of 1912 the contracting powers
engaged to “take measures for the gradual and
effective suppression of the manufacture of internal
trade in, and use of, prepared opium ”—i.e., opium
to be used for smoking. They also undertook to
‘< prohibit the import and export of prepared opium ” ;
_moreover, those powers which were not then ready
immediately to prohibit such export undertook to
do so as soon as possible. Little, however, was
done in this direction, and indeed the: Geneva
Conference of 1925, having registered the opinion
that smuggling in the Far East hampered “‘ effective
suppression’? as had been contemplated, agreed,
by protocol, to postpone the measures undertaken
in 1912 until a period of not more than 15 years
from a date by which the obstacle referred to had
been removed. A commission of three visited the
Far East and reported in 1931 to a conference at
Bangkok on the situation as then disclosed. The
agreement then arrived at provided for the retailing
and distribution of opium for smoking to take place
only from Government shops or under Government
supervision. Smoking under 21 years of age is
- prohibited and prepared opium may be sold by the
Government monopolies for cash only. Licensing,
rationing, or registration of smokers is provided for.
Penalties for offences are prescribed and provision
is made for research as to the effects of opium-smoking
and means to facilitate its cure. Reports are to be
made annually to the League of Nations and a
‘‘ special opium revenue account ” is to be kept.
The agreement which has now come into force has
been ratified by all the Governments parties to it—
` viz., the United Kingdom for the Malay States and
Hong-Kong, Burma, the Netherlands for the Nether-
lands Indies, France for Indo-China, Siam, Portugal
for Macao, and Japan for Formosa and Kwantung.
It will be remembered that the commission of inquiry
felt that opium-smoking could not be dealt with
apart from opium-eating and recorded their opinion
THE PHARMACEUTICAL SOCIETY’S NEW HOUSE
`
. [JUNE 12, 1937 1415
. that “the radical method of dealing with illicit .
trafic in opium is by controlling effectively the
cultivation of the poppy.” This fundamental question
of the limitation of the production of the raw materials
is now, at long last, under instruction of the Council
and Assembly, engaging the attention of the League
of Nations.
THE PHARMACEUTICAL SOCIETY’S NEW HOUSE
THE Council of the Pharmaceutical Society has
- approved the architect’s plans of a new building for
the society’s headquarters. The site which has been
acquired has a main frontage in Brunswick-square of
237 feet and a minor frontage in Hunter-street of
113 feet. The architect is Mr. Herbert J. Rouse of
Liverpool; he built Martin’s Bank Building in that
city and other edifices which have attracted admiration.
The structure provides six floors of accommodation
above the street level with general service rooms of
all kinds in a basement. By the use of separating
courts for light, three wings are provided, each
enjoying a maximum light exposure on three of their-
sides. The plans of the third, fourth, and fifth floors
show that continuous depths of laboratory accom-
modation are provided along the whole length of the
front served by corridors lighted from the courts.
The school of pharmacy occupies the whole of the
third and fourth floors, together with the portions
of the ground, first, and second floors which make up
the east wing of the building. The fifth floor is
utilised for pharmacology, including a nutrition
department. The assembly hall, library, and main
lecture theatre occupy the centre of the ground and
first floors, and the council suite is placed centrally on
the second level. On the ground floor a lofty
vestibule at the entrance is flanked on the right
and the left by the assembly hall and library respec-
tively, while directly facing the vestibule is a lecture
theatre to seat 250 persons. The assembly hall itself
extends over the height of two ordinary floors and
will seat 400 persons. The library is also a room of
two floors in height, and is planned with bays in
which are placed small tables for reading. The
west wing is devoted to the publications and editorial
department. The estimated cost of the building is
£200,000. .
CONDITIONED DEFICIENCY DISEASE IN
ANIMALS
Ir is now known that man may suffer from many
deficiency diseases even when his diet is in every way
adequate. The fault lies in defective gastro-intestinal
function, which prevents the use of the food by the
body—in other words, there is a conditioned deficiency.
In Addisonian pernicious anæmia lack of the hemo-
poietic principle is due to a failure on the part of the
stomach to excrete the intrinsic factor. In hook-
worm anemia, though the diet is often deficient,
the presence of parasites is held by some to play
some part in preventing the proper utilisation of
iron. Important studies of a wasting disease in
sheep known as “ Border pining” recently made! by
W. L. Stewart and his colleagues suggest that this
may also be a conditioned deficiency ‘disease due to
parasites. That pining was in some way due to
diet was suggested as long ago as 1831 by James
Hogg, the Ettrick shepherd, because he found that
it was improved by changing the pasture. Since its
most characteristic feature was a severe anzemia it
was formerly considered that it was due to a lack of
ns Say W. L., and Piercy, S. S. (1935) J. comp. Path.
1416 THE LANCET]
iron in certain pastures. It was found that iron
content of pastures was on the whole lower in pining
areas than elsewhere. On the other hand, in the
Border country at least, the provision of iron-contain-
ing licks for sheep has not been effective in preventing
the disease. Stewart and his colleagues therefore
undertook a further study ? of the condition and have
made interesting observations. The constant symp-
toms are emaciation and an ansmia that appears
to be normocytic in type, both red cells and hæmo-
globin being equally affected. This might in itself
suggest that lack of iron alone is not the cause of
the disease since simple iron-deficiency anzmia
is usually hypochromic. Examination of the fæces
showed a higher proportion of ova in pining sheep
than in normal controls, and the egg index varied
inversely with the severity of the disease and the
intensity of the anemia. Nematode parasites were
found post mortem in the stomach and intestines
of all sheep examined, the largest number being
present in animals seen during the summer, when
pining is at its worst. In 13 cases there was damage to
the gastric mucosa, the typical lesion being a thickening
and roughening of the membrane. Stewart believes
that the sheep surviving a summer attack of pining
remain in poor condition and often die of malnutrition
and broncho-pneumonia during the winter. At this
stage the parasites may be few and post-mortem
examination may fail to give conclusive evidence of
the important part they play. This disease at once
suggests a possible analogy with hookworm anæmia
in man. Damage caused to the stomach and intestines
by the parasite, of which Stewart has found histo-
_ logical evidence in the sheep, may result in deficient
absorption of iron especially if the amount in the
diet is low.
HAEMOPHILIA RECORDS
Tue clinical history and description of 98 patients
suffering from hemophilia, with a series of 75 pedigree
charts, forms the text of a monograph recently pub-
lished by Dr. Carroll Birch.? It would be difficult to
overestimate its value. It supplies such details of a
unique series of unselected cases, personally examined,
as enable the reader to get an idea of the case-to-case
variations in the course of the disease and of the
accidents to which individual sufferers may be
subject. Particulars of 113 cases of death in hemo-
philics are given, showing that no fewer than 57 per
cent. of the persons affected died during the first five
years of life. Dr. Birch finds no uniformity in the
variation in the severity of the disease at different
periods of life; some patients appear to have more
severe and more frequent hemorrhages as they
grow older; of others the converse was reported.
Many factors may contribute to fluctuation in the
severity of the disease at various periods during life.
The pedigree charts will be welcome to geneticists ;
only those who have attempted the investigation of
family histories can fully appreciate the labour
involved in this section of the monograph. Pedigrees
worked out as a routine measure, in every case of a
disease seen, have not only their own particular
interest but reveal much about the genetical character
of a condition which can only be discovered from
material collected in this way. Discussing the
occurrence of hemophilia and colour-blindness in
different members of the same family, Dr. Birch
2 Stewart, W. L., and Ponsford, A. P. (1936) Ibid, 49, 49.
3 Hemophilia. Clinical and Genetic Aspects. By Carroll La
Fleur Birch. Illinois Medical and Dental Monograph. Vol. I.
No. 4. Published by the University of Illinois Press. 1937.
Pp. 151. $2.00.
THE RISE OF THE TUBERCULOSIS DISPENSARY
[JUNE 12, 1937
writes that the combination of these two anomalies
in one male is theoretically impossible.
are likely to question this statement—indeed, several
pedigrees have been recently published which demon-
strate a very close linkage between the two conditions
in certain families.
Good pictures and diagrams illustrate this mono-
graph and Dr. Birch deserves thanks for a valuable
contribution to the subject of hemophilia.
PLANTAIN HAY-FEVER
IN a group of 180 sufferers from hay-fever Blum-
stein and Tuft 1 found 14 (7-7 per cent.) who were
sensitive to plantain pollen, and among 70 cases of
spring hay-fever there were 5 in which plantains
appeared to be the sole exciting cause. The observa-
tions recorded suggest that the “ English ” narrow-
leaved and the “common” broad-leaved plantain
—the lesser and the greater plantain respectively—
contain a common antigenic factor quite distinct
from that found in Timothy grass or ragweed. The
. dry pollen nasal test was found to be an invaluable
aid to the diagnosis of plantain hay-fever and
Blumstein and Tuft believe that intractable cases of
spring hay-fever will often yield to treatment if
plantain extract is included in the injections of
grass-pollen extracts.
THE RISE OF THE TUBERCULOSIS
DISPENSARY
FIFTY years ago a young graduate started in three
small rooms at 13, Bank-street, Edinburgh, the
Victoria Dispensary for Consumption. When he
founded it Dr. Robert Philip, as he then was, prob-
ably did not himself realise what a world-wide
development of the antituberculosis organisation he
had inaugurated. There are times in the history of
most movements when an entirely new idea is con-
ceived and progress is rapid, and there are times.
when the movement settles on its lees and becomes
stagnant. The years 1882 to 1887 were a turning
point in the history of the fight against tuberculosis,
and Sir Robert Philip, looking back upon it after
fifty years, may well be proud of his share in it.
The period which preceded it marks the growth of
the special voluntary hospitals. Beginning with the
foundation of the Royal Chest Hospital in 1814,
some sixteen hospitals for tuberculous diseases had
been founded in the British Isles by the time the
Victoria Dispensary saw the light. Some of them
came into being for the purpose of helping the patient.
with advanced disease whose lot, with nothing but
the old poor-law infirmary to look forward to, was
gloomy in the extreme; others, regrettably few in
number, definitely set out to treat incipient consump-
tion. But whether the early or the advanced case
was the object, the conception of the hospital was the
sick person and him alone. The outstanding advance
of the dispensary movement has been not merely the
picture of a patient with physical signs but the realisa-
tion of the sick and infective person in his environ-
ment of home and community. From this time
onwards there has been a new conception of tuber-
culosis, a chronic infective disease in its setting of
family and immediate surroundings. And with this
new conception came the idea of the contact and the’
search for the primary case in each family focus of
infection.
Philip’s ideas were only slowly followed up and
Great Britain, the country of its birth, had to
1 Blumstein, G. I., and Tuft, L., J. Amer. med. Ass. May Ist,
1937, p. 1500.
Geneticists '
THE LANCET]
PASTEURISATION AND THE NUTRITIVE VALUE OF MILK
[JUNE 12, 1937 1417
wait until the report of the Astor Departmental
Committee in 1912 before the dream of its founder
was realised. Flick has pointed out that the period
of voluntary hospital development in this country
saw a marked decline in tuberculosis mortality. In
-1848 the death-rate was 2:97 per 1000 living; in
1888 it had fallen to 1:54. Now it has been nearly
halved again, and although these declines in
‘mortality cannot be attributed to any one
agency, there can be no doubt whatever that
-the dispensary movement has justified the faith of
its founder.
IN DEFENCE OF RESEARCH
Prof. G. Grey Turner, professor of surgery in the
University of London at the British Postgraduate
Medical School, who has recently been elected a vice-
president of the Research Defence Society,
deliver the eleventh Stephen Paget memorial lecture
at the annual general meeting of the society which is
being held on Tuesday, June 15th, at 3 P.m., at the
London School of Hygiene and Tropical Medicine,
Keppel-street, W.C. Prof. Grey Turner will speak on
what research owes to the Paget tradition, and the
chair will be taken by Lord Lamington, president of
the society, who will be supported by Sir Arthur
Stanley and Prof. A. V. Hill, F.R.S. Members are
invited to bring their friends to the meeting. The
society may be addressed at 11, Chandos-street,
Cavendish-square, London, W.1.
“INDUCTION AS A ROUTINE
Mathieu and Holman? of Portland, Oregon,
compare the results in some 750 consecutive cases
in which premature labour was induced, with those
in another 750 contemporary cases in which the onset
of labour was left to Nature. A study of these two
series should (but may not) leave the reader convinced
that no woman ought to be allowed to go into labour
spontaneously. In the series in which induction was
performed, the maternal mortality (one death) was
half what it was in the other group, while the fetal
mortality (corrected) was in the same proportion.
The length of the first stage of labour was considerably
diminished in the induced series, and there was no
difference in the morbidity-rate. The method of
induction used is said to have been completely
successful, At 7 A.M. an enema is given, followed at
7.30 by a variable dose of pentobarbital. The patient is
asleep in half an hour, and pituitary extract in 3-minim
doses is injected at half-hour intervals afterwards.
If labour has not started after the third or fourth
injection and the membranes are still intact, they
are ruptured artificially. (It should be noted that
this is not advised if there is a malpresentation or if
the fotal head is not engaged.) The injections of
pituitary extract are then continued until the patient is
definitely in labour. In Mathieu and Holman’s series
there were no untowards results—no pituitary shock,
no premature separation of the placenta, no precipitate
labour—and it is somewhat ironical that the only
case of rupture of the uterus was in the series of
controls in whom labour was not induced. The
indications for induction are stated most briefly
as ‘‘ those cases which promised trouble, the toxzmias,
large babies, contracted pelvic outlets, apprehensive
and nervous patients, &c.” The results seem to
have been excellent, yet we are not altogether
1 A tribute is paid by the Edinburgh medical school to Sir
Bay, 1987. 7 s work in tho Edinburgh Medical Journal for
ay,
2 Mathieu, A., and Holman, A., Amer. J. Obstet. Gynec.
Feb., 1937, p. 268.
complications was negligible.
to that of raw milk.”
surprised that many of the speakers at a meeting
to which they were related commented adversely
upon the procedure, and suggested that it is better
to allow labour to start spontaneously unless there
is some definite reason for the termination of
pregnancy. Be this as it may, certain facts do
demand careful attention. The method was employed
over a large number of cases, and the incidence of
Pituitary extract was
used as a routine but in small repeated doses, and its
administration was stopped as soon as labour pains
were established. There was no report of. uterine
inertia, and this is of interest in view of the attention
lately drawn to the high incidence of inertia of the
uterus in women in whom labour had been started
by the insertion of bougies. The advisability of
administering pituitary extract during induction of
labour needs tartane examination.
PASTEURISATION AND THE NUTRITIVE VALUE
OF MILK
Tar dangers of raw milk as a vehicle for the
conveyance of disease are well known and repeatedly
emphasised in our columns, as well as the safety.
given by efficient pasteurisation. These are demon-
strable facts that cannot be gainsaid ; so the opponents
of pasteurisation, who fear its advent chiefly because
of the disturbance they believe it will cause in present
methods of distribution, have to fall back on the
argument that heat reduces the nutritive value of
milk, They are apt to talk vaguely of the possible
presence of some component that might be affected
by pasteurisation, but they cannot isolate or define it.
A valuable report issued by the Milk Nutrition
Committee? provides no reason for thinking that
milk contains any such factor and shows that there
is little difference between the nutritive value of
raw and pasteurised milk. Further evidence may
be found in a report on the nutritive value of raw and
pasteurised milk for calves by Prof. Wilson, Prof.
Minett, and Mr. Carling.? Their experiment, which
lasted over two years, was made with milk from a
healthy shorthorn herd. Calves as they were born
were allotted alternately, without any selection,
into two groups, one fed on the raw milk and the
other on the same milk after pasteurisation. Mixed
morning milk was used, and it was given in measured
quantities in strict relation to the weight of the calves.
This impartial allocation was not perfectly satis-
factory and in fact operated against the pasteurised
group because fewer bull calves happened to be
allocated to this group while it included two weaklings
who died from other causes. Apart from these two,
all the animals throve well and showed no signs of
rickets or anemia. The average increase in weight
over the eight-week period for the animals in the
raw-milk group (25 calves) was 53:72 lb.; in the
pasteurised-milk group (23 calves) it- was 53-86 lb.
Incidentally the highest individual gain among the
bull calves and also among the heifer calves was in
an animal fed on pasteurised milk. No physical
differences could be noted by any observers between
the animals in the two groups. Prof. Wilson and his
colleagues conclude that “there is nothing in these
results to suggest that the nutritive value of
pasteurised milk for calves is in any way inferior
Earlier studies have suggested
that one effect of pasteurisation is to diminish the
availability of the calcium and phosphorus in milk,
1 See Lancet, May Lori, 1937
2 Wilson, G. S., Minett, F. C., and
J. Hyg. 37, 243.
p. 1179.
arling, H. F. (1937)
“
~
1418 THE LANCET]
This could have no influence upon its nutritive
utility for children, since the need of children for these
minerals is less than that of calves, judging by the
lower content of calcium and phosphorus in human
milk, On the other hand, if the diminution were
really substantial it would presumably affect the
growing -calf, and the fact that it did not do so—
which surprised the investigators—makes it clear
that this objection to pasteurisation of milk for grow-
ing children has no force behind it. Nor, in fact,
have any of the other objections, and it is more than
time that the medical profession, realising the import-
ance of milk-borne infection, ranged itself solidly
behind the demand for a safer supply.
E. L. EHLERS
THE three diseases with which the name of Prof.
Ehlers is most closely associated are syphilis, leprosy,
and scabies. He was president of the Danish Associa-
tion for Combating Venereal Disease and also for
seven years president of the International Union
against Venereal Disease. His interest in leprosy
helped to make him a great traveller, and he did much
to lighten the lot of the leper in many parts of the
world, from Iceland to the West Indies. : In 1897
he was the organiser of the first International Leprosy
Conference, in Berlin; and from 1900 to 1914 he
was the chief editor of an international publication
on leprosy. His most important contribution to
scabies was its ambulant treatment. A welcome
visitor in many countries, it was particularly in France
that he was known and appreciated. He died on
May 6th at the age of 74.
THE PHYSICAL BASIS OF STUFFINESS
REcENT fluctuations from arctic to equatorial
climatic conditions should stimulate interest in
methods now available for the control of indoor
temperature and humidity. The subject was dis-
cussed at the Royal Society of Medicine on May 28th
(see p. 1401) when special consideration was given to
the requirements of ships in the Royal Navy and in
factories. In this country, where extreme condi-
tions are rare, regulation of humidity is not usually
employed in factories as it is in the United States,
attention being concentrated on ventilation, tempera-
ture, and the extraction of dust. In a recent article 1
C. P. Yaglou of Boston considers the physical and
physiological principles of air conditioning and
collects a number of interesting observations. Although
the percentage of CO, in the air may be used as a
convenient guide to atmospheric purity this gas does
not in itself produce discomfort in the concentrations
ordinarily met with in stuffy rooms; imponderable
amounts of organic matter appear to be far more
effective in this respect; this observation has the
support of experiments on the isolated frog’s heart
in which it was found that the weakening action of
expired air was greater with old and sick persons
than with the young and healthy. Dr. Yaglou
considers that the preference which still exists for
window ventilation may be due to the monotony
of the air movements produced by mechanical
systems of ventilation which are found to be less
stimulating than oscillating gusts of air coming
through an open window. Dr. Bedford’s new book ?
on ventilation contains a chapter on air conditioning
1 J. Amer. med. Ass. May 15th, 1937, p.1708
2 Modern Methods and Principles of V entilation und Heating.
By T. Bedford, D.Sc., Ph.D., Investigator to the Medical
Research Council’s Industrial Health Research Board. London:
H. K. Lewis and Co. 1937. Pp. 85. 4s. 6d
THE PHYSICAL BASIS OF STUFFINESS.—AGAINST RHEUMATISM
[JUNE 12, 1937
in which a clear account may be found of the apparatus
used for filtering, warming or cooling, humidifying
or drying atmospheric air. Dr. Bedford also notes the
importance of organic matter in producing a disagree-
ably stuffy atmosphere ; he quotes a table compiled
by Dr. Yaglou from which it appears that the number.
of cubic feet per minute required by a group of people
is inversely proportional to the frequency with which
they take baths. Thus school-children of the poorer
class require 38 cubic feet per min. each as compared
with only 18 for children in a higher social grade.
AGAINST RHEUMATISM
REMARKING that most services are promoted
by the force of public opinion, Capt. G. S. Elliston,
M.P., at the Margate Congress last month, said
that first among the conditions now needing attention
is chronic rheumatism. No steps, he said, commen-
surate with its importance have yet been taken;
and he was right. Since he spoke, the welcome news
has come of a gift of 10,000 guineas by Mr. Alexander
Maclean to the Empire Rheumatism Council to
finance a rheumatism research unit, together with a
promise of a further £2500 from the same source.
The Council was constituted last November, when
Lord Horder, as president, urged the need for a
comprehensive research campaign for which the help
of prominent citizens throughout the British Empire
would be sought. In congratulating the Council on
the success already achieved we take the oppor-
tunity of ‘mentioning a modest appeal made some
time ago for another and related enterprise. The
International League against Rheumatism has done
much to inspire the present interest in rheumatic
diseases: besides maintaining a quarterly journal,
an information bureau, and a library it has held
five large congresses in European capitals, in which
the medical profession and the governments con-
cerned have shown great interest. The sixth congress
is to be in England next year; and it is somewhat
unpleasant to reflect that the English national
rheumatism committees have hitherto not been in a
position to give any financial support to the League’s
work, which has been supported, throughout the
depression, chiefly by the smaller countries and,
in emergency, by the honorary secretary. The
League is likely to receive adequate support hence-
forward, but having missed the aid that might have
been expected from this country it has barely struggled
through the years of difficulty and must be restored
to security. If any of our readers have rheumatic
patients who happen to retain some faith in the
value of international coöperation the appeal might
fittingly be passed on to them. Of the £1000 asked for,
about a fifth has been secured and the situation is
one in which a small sum may do substantial good,
eSince it will make possible the continuance of work
that was formerly, and will again be, financed by
regular national contributions. Cheques should be
made payable, and sent, to Barclays Bank Ltd.,
54, Lombard-street, London, E.C.3.
EPIDEMIOLOGY OF THE BASQUE CAMP
TuE arrival of 4000 refugee children from Bilbao
confronts us with an old but ever-fascinating problem.
Should the “‘ herd at risk’? be kept concentrated or
scattered ? In this particular case, should the Basque
children be split up into units of not less than 50 or so
and moved into the various homes prepared for them
in different parts of the country ; or should they, on
health grounds, remain in their original camp at
Eastleigh ? If the children were experimental herds
THE LANCET]
of mice, it would seem better that they should be
kept together, provided no new additions were made
to the herd, rather than that they should have the
chance of infecting other “ herds ” all over the country.
But the children are not mice; and though their
health record so far is good their camp was designed
for a considerably smaller population and, as the
House of Commons was told last Monday, it is highly
desirable that the number of children there should
be reduced as speedily as possible. The objection
_ raised is that they would be going to homes and
institutions some of which already contain healthy
children and have no special medical arrangements
in operation, such as have been made at the camp.
Again, in theory, the argument seems to be chiefly
in favour of delaying dispersal. But what are the
actual dangers to be feared ? The children were all
medically examined before embarkation and those
who took responsibility for the examination, Dr.
Richard Ellis and Dr. Audrey Russell, give good reason
for thinking that the risk of importing trachoma
is by no means as serious as has been suggested.
Two cases of diphtheria and three of measles have
arisen among the 4000 children, but have been suit-
ably isolated. And finally, there have been six cases
of typhoid fever. All of these, however, have
appeared within the incubation period since leaving
Spain, and presumably there is little likelihood of
infection occurring after arrival in England. Hence
we are not considering the dispersal of an unhealthy
‘ herd” as in the poliomyelitis outbreaks of 1926
and 19321 but of a healthy one. The visitors to
the Bournemouth, Poole, and Christchurch district,
who scattered back to their homes during the 1936
milk epidemic, for example, presented a much greater
risk to the country. At Eastleigh each child is to
have three full medical examinations before leaving
the camp.
The Ministry of Health, though it has no direct
responsibility, has been asked for its advice and has
been in direct touch with the camp authorities through
its medical officers. Its advice is, apparently after
some hesitation, to allow evacuation of children going
direct to empty homes and institutions where they will
not be in contact with other children—provided that
the medical officer of health of the district is prepared
to accept them. The remainder are being inoculated
against typhoid and will be evacuated when immune.
This advice we regard as sound. Medical officers
of health are not likely to grudge any extra trouble
the present policy may entail, nor will they want
to put unnecessary obstacles in the way of colleagues
who have done and are doing a fine piece of humani-
tarian work.
THE Inter-Departmental Committee appointed in
April, 1936, to inquire into the restoration of working
capacity in persons injured by accidents has made an
interim report (H.M. Stat. Office, 4d.). The object
to be aimed at is the covering of the country with
a network of “ fracture services ’ attached to existing
hospitals, whether voluntary or controlled by the
local government authorities. A “ model ” scheme has
been prepared by the committee, capable of adapta-
tion to the varying circumstances and needs of
different localities and areas. The maximum size
of a fracture clinic compatible with an efficient
unified control is put at one capable of ‘dealing with
3000 to 3500 cases a year, of which about one-third
would, on a general average, need in-patient treat-
ment, involving the provision of, say, 40 beds. The
1See Lancet, 1926, 2, 1070 ; 1932, 2, 903, et seq.
EPIDEMIOLOGY OF THE BASQUE CAMP
1419
needs of rural areas would be met by linking them
up with a fracture clinic at some convenient centre to
which cases could be transferred. The committee
offers its assistance in. any difficulties presented by
the application of such a scheme to local circum-
stances. Sir Malcolm Delevingne has presided over
the committee, whose medical members are Miss
Muriel Bywaters, Mr. W. A. Cochrane, Dr. T. Ferguson,
Prof. E. W. Hey Groves, Dr. J. F. E. Prideaux,
Mr. H. S. Souttar, and Mr. A. C. T. Woodward.
[JONE 12, 1937
THE inquiry into the physical, psychological, and
genetic aspects of mental deficiency carried on
in the research department of the Royal Eastern
Counties’ Institution at -Colchester has received
valuable aid from ‘the trustees of the Rockefeller
Foundation. Hitherto the research department,
under Dr. Lionel Penrose, has been financed by the
Medical Research Council, the Darwin Trust, and
by the Institution itself. Recently also a generous
donation of £2200 was made by the Hon. Alexandrina
Peckover towards the cost of a new laboratory and
research offices provided by the Institution. Now
the trustees of the Rockefeller Foundation have
opened the way to further developments by making
a grant at the rate of £600 per annum for five years
to provide additional research workers and a non-
recurrent grant of £700 towards the cost of laboratory
equipment.
Sir THomas NEILL, who died last week at the age
of 81 years, was one of the three insurance com-
missioners appointed by Mr. Lloyd George when the
Act of 1911 came into force. He had had much to
do with framing the scheme itself from his long
experience with the Pearl Assurance Company, and
after serving as commissioner he became chairman
of the National Amalgamated Approved Society.
This post he held until his retirement last year, com-
bining it with many other important executive offices.
His judgment was sound, and in conference his
opinion was influential and decisive. He had a
slight stutter, but there was nothing hesitating
about his mind, which worked like a well-oiled
machine. His decisions, which were nearly always
right, were quickly made and tenaciously held ;
though keen and firm in business he ‘was one of the
kindest-hearted of men, as his staff well knew. He
found difficulty in passing street collectors on flag
days, and on Queen Alexandra’s day he would
arrive at his office richly decked with roses. He
will long be regretted by those who worked with
him,
AN account of the memorial tothe late Sir Walter
Morley Fletcher, printed for the trustees of the
memorial fund at the University Press, Oxford, has
been issued to all the subscribers to the fund. It is
embellished by two illustrations, one of which shows
Miss Dora Clarke’s posthumous portrait bust of
Walter Fletcher, photographed from the clay model,
the other a corner of the library of the National
Institute for Medical Research with the finished
bronze in position.
LEWES VICTORIA HOosPiITAL.— This institution,
whose accommodation has lately been doubled, needs
an increased income of about £400 yearly if the work
is to go on successfully. A nurses’ hostel has been built
and the hospital extensions proved more complicated
and expensive than had been expected. Private wards
had to be closed last year because of the work and the
income of the hospital suffered in consequence,
1420
THE LANCET]
[JUNE 12, 1937
SPECIAL ARTICLES
THE LISTER INSTITUTE
A YEAR’S INVESTIGATIONS
On June 2nd the governing body of the. Lister
Institute of Preventive Medicine, London, presented
its annual report, signed by Prof. William Bulloch,
F.R.S., as chairman. The year has seen several
changes in the staff working at the institute under
the general direction of Sir John Ledingham, F.R.S.
Dr. E. Weston Hurst left in September to become
director of the Institute for Medical Research at
Adelaide; Dr. C. Russell Amies ‘(formerly a research
fellow in bacteriology) and Dr. A. S. McFarlane
(research fellow in biophysics) have joined the staff ;
and on the departure of Mr. J. M. Gulland, D.Sc., in
the autumn Mr, A. R. Todd, Ph.D., joined the bio-
chemical department, of which Miss M. G. Macfarlane,
Ph.D., is now also a permanent member.
The following notes describe some of the many
inquiries pursued during the year.
VIRUSES
Attiology of rheumatic dtseases.—Dr. Q. H. Eagles,
with the assistance of Dr. P. R. Evans, Dr. J. D.
Keith, Mr. A. G. Timbrell Fisher, and Dr. W. H.
Bradley, has continued the study of a possible virus
agent in acute rheumatism, rheumatoid arthritis,
and chorea, Specific agglutination tests with the
sera of patients suggest that these diseases have in all
probability a common etiological factor, though other
factors such as concomitant infection by strepto-
cocci probably play a part. Infection experiments
have not so far given unquestioned confirmation of
serological findings, but in two monkeys grave
cardiac involvement has followed intrapericardial
injection of rheumatic virus-body suspension. In
one instance the suspension was inoculated alone ;
in the second it was inoculated with a small dose of
a streptococcal toxin. In both cases myocardial
damage was revealed by histological study, but the
typical Aschoff node was not demonstrated. Results
of control experiments indicate that toxin alone is
probably not responsible for the myocarditis. Experi-
ments are under way to discover the cause of the
prolongation, in monkeys, of the P-R interval,
which is considered to a large extent pathognomonic
of early rheumatic carditis in man.
Dr. C. R. Amies has continued his investigations
of the tumour-producing agents in filtrates of avian
sarcomata. His results confirm the fact that fowls
bearing Rous sarcoma No. 1 develop antibodies for
the tumour agents. This immunity reaction can be
demonstrated by neutralisation tests and also by
agglutination and complement-fixation reactions. It
has now been found that the sera of rabbits which
have been hyperimmunised with normal fowl protein
exhibit strong neutralising activity against these
purified suspensions of the Rous No. 1 agent. The
observations, so far as they go, are held to confirm
experiments carried out some years ago by W. E. Gye
and W. J. Purdy, on which their conception of the
dual nature of the infective complex is largely based.
For some time Sir John Ledingham has been
investigating the relationship of the viruses of rabbit
myxomatosis (Sanarelli) and rabbit fibroma (Shope).
It has been found that animals infected with the
fibroma virus develop agglutinins for myxoma but
often little or none for fibroma until a dose of
myxoma is given, when agglutinins for both appear
in the serum. Dr. E. W. Hurst passed the myxoma
virus through the brains of rabbits and obtained a
variant whose capacity to cause death after intras
cerebral inoculation was much reduced. The dis-
covery of this variant should greatly facilitate further
inquiries, for it is now possible to study animals that
have recovered from myxoma without having to give
them the fibroma virus first. .
Staining of elementary bodtes—Dr. M. Gutstein
(Berlin) has elaborated a method for rapid staining of
the larger virus bodies, based on the use. of basic
dyes in alkaline solution. No mordant is required
and excellent microscopical pictures are obtained.
Vaccinta.—Dr. M. H. Salaman has shown that
the virus-neutralising power of an antivaccinal
serum can be removed by absorption with a sufficient
dose of washed elementary bodies, but not by absorp-
tion even with large doses of the soluble antigen.
On the other hand, precipitins and agglutinins could
be absorbed from such serum in varying degrees by
the bodies and by the soluble antigen.
ANTIGENIC CONSTITUTION AND IMMUNISING
PROPERTIES OF BACTERIA
The Vi antigen of typhoid bacillus—Mr. A.
Felix, D.Sc., with Miss R. M. Pitt, has continued the
investigation of the properties of the Vi antigen of
Salmonella typhi. The conclusion that only strains
containing both the O and Vi antigens possess the
highest degree of virulence of which this organism ig
capable has been further strengthened. In spite of
numerous attempts, a method of preparing anti-
typhoid vaccine which would enable the Vi
antigen to be preserved in its most effective form
has not yet been devised. Dr. Felix, in cooperation
with Dr. W. D. Nicol, tested the antibody response
in 50 persons who had been given three doses of an
alcohol-killed typhoid vaccine by the subcutaneous
route. A marked increase in the O antibody was
observed in all those inoculated, and a significant
increase in the Vi antibody in about half. But
re-examination of the vaccine after storage for half
a year, with or without the addition of phenol or
tricresol, showed that the vaccines had almost
entirely lost their capacity of stimulating formation of
Vi antibody in the rabbit. Dr. Felix has also been
investigating the possible value of Vi agglutination
in the detection of typhoid carriers. Sera from 45
carriers have been examined and the results suggest
that Vi agglutination has a definite place in the
routine diagnosis of typhoid carriers. It is note-
worthy that all the 25 strains from chronic typhoid
carriers examined were found to contain Vi antigen.
Dr. H. L. Schiitze and Dr. P. A. Gorer are continuing
their investigations of genetic constitution and immunity.
Working with two pure lines and two selected lines
of mice, they have tested resistance to infection with
Salmonella typhi-murium and S. enteritidis; also
response to immunisation and the facility with which
H and O antibodies are produced. Significant genetic
and sex differences have been observed in resistance
to infection and in ability to produce antibodies, but
there seems to be no simple relationship between
such ability to produce antibodies and natural
resistance to infection. ;
Dr. Gorer has studied the genetic basis of antigenic
differences demonstrable in the erythrocytes of mice
with special reference to the antigenic basis of tumour
transplantation.
THE LANCET]
Two such antigens were found to depend upon single
dominant genes. A sarcoma arising in a pure line of
albino mice was found to be transferable to ‘all other
members of the line and certain hybrids derived from
it but not to unrelated mice. It was found that all hybrids
susceptible to grafts of the tumour possessed an antigen
in their erythrocytes derived from the albino ancestors.
If the antigen was absent the tumour invariably regressed.
‘The sera of mice in which the tumour has recently regressed
may often be shown to contain agglutinins for the
erythrocytes of albinos. It was concluded that the fate
of a transplanted tumour largely depends upon
iso-antigenic differences between the transplant and tissues
of the host.
MALE ”?” SEX HORMONES
Examination of the effects of the sex hormones
has been continued by Dr. V. Korenchevsky with
the assistance of Mrs. M. Dennison and Miss K. Hall.
The most remarkable property of the male sex
hormones studied is their bisexual function—i.e., the
property of stimulating the development of the
sexual organs of both sexes in normal rats and bring-
ing about a return of the atrophied organs of gonadec-
tomised animals to, or towards, the normal condition.
But whereas the restorative effect on all the sexual
organs of the male rat is complete, in females the
complete effect was obtained only when testosterone
propionate was administered simultaneously with
the female hormone (estrone). It is also important
to note that with cestrone alone it was found impos-
sible to obtain (with the doses examined) a complete
recovery of all the atrophied sexual organs. The
‘* male ” hormones investigated may be arranged in
descending order of activity as ‘‘female sexual
stimulators ” as follows: (1) testosterone propionate,
(2) testosterone, (3) androstanediol, (4) androstenediol,
(5) androstenedione, (6) transdehydroandrosterone,
(7) androsterone. In ovariectomised rats, with a few
exceptions, the male hormones produce changes—
chiefly in the vagina but in some cases (testosterone
propionate) in both vagina and uterus—similar to
those seen during pregnancy. These are most pro-
nounced when the male and female hormones are
injected simultaneously. -
Unlike the other male hormones, testosterone
propionate has a stimulating though slowly decreas-
ing action on the sexual organs for as long as 9 days
after injection. For this period it completely main-
tains its effect on the adrenals, while the katabolic
effect on the metabolism, as shown by the changes.
in the body-weight, even increases. This property
of testosterone propionate gives it an especial thera-
peutic value, since results can be obtained with
injections as infrequent as once in 10 or even perhaps
14 days.
RENAL FUNCTION.—BLOOD COAGULATION
Prof. P. Ellinger and Dr. A. Lambrechts (Liége)
have studied the localisation of the glycosuric action
of phloridzin. They find that phloridzin interferes
with the passage of certain substances from the
lumen into the epithelium of the proximal tubules.
The mechanism of this blockade has, however, not
yet been ascertained.
The cerebro-spinal fluid in acromegaly.—Prof.
Ellinger, in collaboration with Dr. Dorothy Hare and
Dr. S. Levy Simpson, has studied the influence of the
. cerebro-spinal fluid of an acromegalic woman on the
urinary chloride and water excretion of rabbits,
injected subcutaneously with the fluid, and given
water per os simultaneously.
A definite increased rate of chloride elimination resulted,
but normal water diuresis was unaffected. On the other
hand cerebro-spinal fluid from normal people and sera
THE LISTER INSTITUTE
[JUNE 12, 1937 1421
from the acromegalic patient and other control patients
had no action either on chloride excretion or on diuresis.
This effect was less after irradiation of the pituitary gland,
which also produced clinical improvement. In control
experiments a standard solution of pitressin gave an anti-
diuretic effect as well as an increased rate of chloride
excretion. It is concluded that the spinal fluid of the
acromegalic patient contained sufficient amounts of a
hormone of the posterior lobe of the pituitary gland, but
so far it has not been possible to decide whether the anti-
diuretic and chloride eliminating effects are due to different
hormones or whether the antidiuretic effect of the posterior
lobe hormone was masked by that of some other substance
in the spinal fluid of this patient. |
Dr. J. O. W. Barratt has completed his investiga-
tion of anticoagulant action. It has been found
that sodium chloride, chlorazol, and heparin resemble
hirudin in producing their anticoagulant effect upon
thrombin: no action upon fibrinogen could be
observed. With improved technique it was possible
to obtain an index fof anticoagulative power and
also to calculate coagulation-times corresponding to
varying concentrations of anticoagulant.
OBSERVATIONS WITH ULTRACENTRIFUGES
The two ultracentrifuges provided by a grant from
the Rockefeller Foundation were completed in time
for the visit of the designer, Prof. T. Svedberg
of Upsala in September (see Lancet, 1936, 2, 874).
The smaller equilibrium centrifuge which runs at
speeds up to 18,000 r.p.m. has been found to be
adaptable to the study of certain viruses and to the
recently discovered virus proteins. Excellent sedi-
mentation photographs have been obtained of tobacco-
mosaic virus protein and a study of the factors which
determine its homogeneity in respect of molecular
size is in progress. The behaviour of the blue respira-
tory protein (hæmocyanin) of the blood of Helix
pomatia has been exhaustively studied recently
by Svedberg and may be used as a model of homo-
geneity in a substance of molecular weight of the
order of millions. Preparations of elementary bodies
from rabbit and -sheep vaccinia virus have been
investigated by means of the photographic technique,
and unexpected facts have come to light; prepara-
tions of herpes virus have also been examined. A
form of micropipette has been designed which enables
fluid at different levels in the centrifuge cell to be
accurately removed after the run.
The high-speed ultracentrifuge, running at the
maximum speed for routine use (60,000 r.p.m.),
has been used to study the sedimentation of hemo-
globin, serum albumin, and serum globulin. It is
also being used at lower speeds to investigate the
behaviour of visual purple. On a visit by Prof.
Svedberg in February, the velocity centrifuge was
run up: to the maximum speed considered safe
(65,000 r.p.m.); no trouble was experienced, this
speed was maintained for four hours, and oppor-
tunity was taken to analyse a specimen of horse
serum.
NUTRITION
Vitamin A.—A collective investigation has been
organised by Miss E. M. Hume, as secretary of the
Vitamin-A Subcommittee, in which ten different
laboratories have participated to compare the results
of biological and spectrographic estimations of
vitamin A. The results showed a satisfactory degree
of concordance and gave no support to any alteration
of the value 1600 adopted for the conversion factor
at the 1934 International League of Nations Vitamin
Standardisation Conference ; but certain discrepancies
leave a possibility that the spectrographic method
1422 THE LANCET}
will have to be abandoned and vitamin-A standardisa-
tion made to depend only on the biological test.
Vitamin B,—Dr. F. Vivanco (Madrid) has investi-
gated a specimen of “oryzanin,” the crystalline
vitamin-B, hydrochloride prepared from rice polish-
ings provided by Prof. Suzuki. An average amount
of 3:3 y of the crystalline material had a potency
equal to that of 1 international unit of vitamin B,.
Ætiology of pellagra.—Miss Hariette Chick, D.Sc.,
has collaborated with Mr. T. A. Birch and Sir Charles
Martin, F.R.S., at the Department of Animal Patho-
logy, Cambridge, in experiments on the nutritive
defects of maize.
Young pigs were the experimental animals. The diet
given contained over 80 per cent. ground whole white
maize supplemented with peameal and a small amount of
purified casein to increase the protein content, extra salts
and cod-liver oil. Dogs maintained on this diet develop
a disorder known as nutritional black tongue, characterised
by anemia, diarrhea, and stomatitis with necrotic changes
in gums and tongue, which is held by many to be the
analogue of human pellagra. After about six weeks on
this diet the young pigs ceased to grow, showed a loss of
weight, anemia, and severe diarrhea, and died unless the
diet were changed. They showed no skin sensitisation
to sunlight. The disease was prevented if 4 per cent.
yeast was included in the diet or if the maize was replaced
by a mixture of wheat and barley; it was cured in a
dramatic manner when yeast or an autoclaved protein-
free yeast extract was added to the diet. These facts
pointed to a deficiency in maize of some heat-stable
constituent in the yeast extract—e.g., some constituent
of vitamin B,. Preliminary tests with flavin gave negative
results and trials will now be made of other heat-stable
fractions and preparations from yeast extract. The above
black-tongue diet has been found relatively satisfactory
for growth and maintenance of rats so that the missing
anti-black-tongue (? anti-pellagra) factor appears either to
be non-essential for the rat or to be adequate for this
species in small amount.
to be a more suitable experimental animal.
In continuation of his work in this field Prof.
Ellinger, together with Dr. W. Beckh and Prof. T. D.
Spies (Cincinatti) has studied porphyrin excretion
in non-endemic pellagra. In 10 out of 14 cases of
“ alcoholic ” pellagra observed at Lakeside Hospital,
Cleveland, U.S.A., an increased porphyrin excretion
(coproporphyrin) was observed, the intensity of
which showed a rough relation to the severity of the
clinical symptoms. Dr. Chick has been examining
the nutritive value and light-sensitising properties
of buckwheat in the hope of finding the causes of the
light sensitivity characteristic of pellagra. A small
daily ration (0-1 g.) of the dried flowers caused a high
degree of light sensitivity in albino rats, and Mr. T. F.
Macrae, Ph.D., is collaborating in attempts to isolate
the active substance.
Wheat and bread.—Miss A. M. Copping has continued
the investigation begun by M. H. Roscoe in 1935.
As was to be expected more vitamin B, and B, was
found in wholemeal flour and bread than in white
flour and bread. The last two, however, proved to
be unexpectedly rich in vitamin B, and control
experiments with ground polished rice, in which the
rats developed characteristic nervous symptoms
of vitamin-B, deficiency, emphasised the difference
between polished rice and white flour in this respect.
The content of flavin was low in both types of flour
and breads, the white flour and bread being definitely
inferior to the wholemeal. The second constituent of
the vitamin-B, complex (so called “‘ vitamin B,”’’)
was abundant in the wholemeal flour and bread and
less so in the white flour and bread. The nutritive
value of wheat flour and bread therefore appears to
be limited by their low content of flavin. °
(To be concluded)
MEDICINE AND THE LAW
The pig, therefore, appears
years of age.
[JUNE 12, 1937
MEDICINE AND THE LAW
Novel Point in Examination under the
Lunacy Act
A FRESH pitfall for the medical practitioner seems
to have been discovered in the Lunacy Act. The
simple inference to be drawn from Section 285 is
that a justice may direct a medical practitioner
to examine an alleged lunatic and may order the
examiner to be paid reasonable remuneration. A
recent case in the county court at Ross-on-Wye,
however, has disappointed the doctor who drew
this conclusion. The disappointment was mitigated,
rather than explained, by a passage at the conclusion
of the judgment of the court. The plaintiff doctor,
who was represented by counsel instructed by the
Medical Defence Union, was said by the judge
‘to’ have acted as any doctor of repute would be
expected to act, especially upon the serious infor-
mation he had received; the examination was
made at the request of the justice of the peace
and the proceedings were properly carried through.
This judicial tribute was the more gratifying because
there had, at committees of the defendant county
council, been violent criticisms of the doctor’s conduct
and he was naturally aggrieved when these criticisms
received publicity in newspaper reports. But, not-
withstanding the judge’s favourable comments,
judgment was given against the plaintiff on his claim
to be paid one guinea as reasonable remuneration
under the section already cited.
In lunacy litigation where medical practitioners
are concerned there is usually a complaint that
certification has been too lightly made. In the
case at Ross-on-Wye, the practitioner, after making
his examination, declined to certify. The question
of examination arose because certain information
had reached the doctor. Whether the information
was true or not the county court judge was not in a
position to say; he was satisfied nevertheless that
the doctor, having had that information, was bound to
act as he did. In view of this expression of the court’s
opinion, it would perhaps be unnecessary to summarise
the evidence, were it not that some statement of the
facts is needed in order to show the apparent gap in
the present law. The plaintiff doctor was medical
attendant to a father, mother, and daughter. The
daughter, whom we will call Miss X, was some thirty
The doctor from his own observation
had formed the opinion that she was unbalanced, but
his view was evidently influenced by what he learnt
from her parents who consulted him in great anxiety.
She was said to believe it necessary to disinfect every-
body and everything. She was said to have poured
disinfectants over her father and mother, to spend
much of her time washing her clothes and her money
in disinfectant, and to use a piece of paper or a cabbage
leaf even for opening a door. One Sunday morning
the doctor was summoned to the home of the family
where he found the father suffering from a heart
attack and lying on the floor as the result of an
alleged assault by the daughter. The mother soon
afterwards required medical attention for nervous
breakdown attributed to the daughter’s conduct.
It was stated that on another occasion Miss X knocked
her mother down and emptied a bowl of disinfectant
over her. Miss X was also stated to have run about the
garden without her clothes. The anxious parents
asked the doctor’s advice; they wanted to place their
daughter in a nursing-home. He suggested, as there
was no home in the neighbourhood, that the daughter
Cai
THE LANCET]
should enter a mental hospital as a voluntary patient.
The mother replied that the daughter would refuse to
do so and that the fees were beyond her means,
After further discussion the doctor was asked to
speak to the local relieving officer. He did so and
the officer brought him next day a form of certificate
which included the usual space for facts communi-
cated to him by others. He filled in this space at the
request of the relieving officer who said it would
save time. He seems also to have signed the certi-
ficate by mistake but the county court judge declared
that the mistake was not one of any magnitude
and could have no material effect upon the case.
The relieving officer arranged for the presence of a
justice of the peace and the parties (the justice, the
_ relieving officer, and the plaintiff doctor) went to the
place where Miss X had her work. She was a school-
mistress and they went to her school—at her mother’s
suggestion since Miss X was apparently not sleeping
‘at home. The justice said to the plaintiff ‘ Will
you go in and examine her ? ” This was the direction
on which the plaintiff relied under Section 285 and
the justice in his evidence agreed that it had been
given, Although they had fixed a time when school
‘would be over, there were two children still present.
The doctor waited till they had gone and then dis-
cussed with Miss X the matters of complaint already
mentioned. He ultimately came to the conclusion that
he could not properly certify her; he went outside
and said so to the magistrate. She asked who the
people outside were and asked them to come in. The
subsequent events, and in particular the complaints
and criticisms of the doctor’s conduct on the part of
the defendant county council, were not placed before
the court and were presumably irrelevant. The
justice who saw Miss X stated in his evidence at the
county court that there were no sufficient grounds for
ordering her removal to a nursing-home. Having
satisfied himself of the terms of Section 285, the
Justice made an order “for payment of reasonable
remuneration ” by the county council as the statute
provides.
The county council denied all liability. It con-
tended that Section 285 did not apply to the facts
of this particular case. Its legal representative drew
the court’s attention to Sections 14, 16, and 17 of the
Lunacy Act which relate to paupers deemed or alleged
to be lunatic (or, in the euphemistic language sub-
stituted by virtue of Section 20 of the Mental Treat-
ment Act of 1930, rate-aided patients deemed or
alleged to be of unsound mind). The council argued
that Miss X, who was paid as a school teacher, could
not be called a pauper. Section 13 relates to a person
‘‘ not a pauper and not wandering at large ” who is
deemed to be a lunatic and is not under proper care
- and control. Section 15 relates to a person, ‘“‘ whether
a pauper or not,’ who is wandering at large. The
council contended that none of these sections fitted
the case of Miss X, and that, unless the action of the
doctor could somehow be brought within the ambit
of the Lunacy Act, Section 285 (on which the plaintiff
relied) did not apply. The court took this view ;
the plaintiff had to show that he had been doing some-
thing within the Act; he had failed to prove his case.
The claim was stated in court to have been the
first of its kind. If it be indeed a casus omissus,
it would appear a proper matter for which Parliament
should make provision when at length the law of
lunacy is rewritten. The one consideration upon
which everyone is agreed is that early examination
and diagnosis is essential in mental treatment. This
step can be taken only by bringing in the medical
practitioner. In the facts under review it may be
MEDICINE AND THE LAW
[JUNE 12, 1937 1423
that the practitioner, the relieving officer, and the
justice acted under a misunderstanding of a series of
complicated enactments. The medical practitioner
was not negligent, nor did he act in bad faith. There
was obviously a proper case for investigation. If
the justice could direct examination and could make
the order for reasonable remuneration, and if the
county court judge could say that the plaintiff
acted as any doctor of repute would be expected to
act, the county council might well have found itself
able to honour the justice’s order. Local authorities
do not always behave prettily in litigation; there
are ugly examples, for instances, of their repudiation
of liability for work ordered and completed where the
contract was not under seal. But allowance must be
made for a proper desire to protect ratepayers’
pockets and for a natural susceptibility to influences
local and personal.
Maclean’s Stomach Powder
Members of the. medical profession would scarcely
encourage trade monopoly in the treatment of ill
health. They do not seek to protect their prescrip-
tions by patent for personal gain. It would be
unfortunate for a doctor if, after giving the public
the benefit of his scientific research, he were involun-
tarily to appear a party to its commercial exploitation.
The case of Prof. Hugh MacLean, which comes to
mind in this connexion, has just been recalled in
litigation before Mr. Justice Farwell between two
firms of manufacturers, one of which was named,
“ Macleans Ltd.? A report of the hearing (in the
Pharmaceutical Journal of May 29th and June 5th)
shows that the proceedings arose out of an application
by Macleans Ltd. for an injunction to prevent a
rival firm from passing off certain medicated sweet-
meats as the goods of the plaintiffs. The defendant
firm (Lightbown Ltd.) was marketing sweets adver-
tised as containing Prof. MacLean’s powder; it was
also using the expression ‘“‘ Maclean’s sweets ” in a
manner likely to deceive the public into thinking
that the defendant firm was selling preparations
made by Macleans Ltd.
If the main issue in the litigation was the con-
fusion in the sale of sweets, there was naturally an
occasional allusion to the possible confusion due to the
similarity of the name of Dr. Hugh MacLean and that
of the plaintiff firm. The judge paid his tribute to
the generosity of Dr. MacLean in giving the public
the benefit of his work. Counsel and witnesses
mentioned Dr. MacLean’s research at St. Thomas’s
Hospital into the alkaline treatment of gastric ulcer
and other ailments. His prescription was published,
it was said, in 1929 both in the Pharmaceutical Journal
and in the Chemtst and Druggist. In 1931 Macleans
Ltd., the plaintiff. firm, ‘“ introduced to the public ”
a preparation named “ Maclean’s Brand Stomach
Powder.” The firm had been founded by a Mr.
Alex. C. Maclean; hitherto it had been concerned
with tooth powders and other toilet requisites. It .
now sold the powder in bottles on which the name
“ Alex. C. Maclean”? was printed. Mr. Lazell, a
director and secretary of the firm, told Mr. Justice
Farwell of discussions with Dr. Hugh MacLean who
had raised no objection to the firm’s action. ‘‘ We
were anxious,” said Mr. Lazell in the witness-box,
“to do nothing which would harm the professor
in the medical profession; we coined the word
‘stomach’ and in 1931 the powder was put upon
the market ; on the cartons were the words ‘ specially
prepared according to the formule of Dr. Hugh
MacLean.’’’ Soon afterwards, continued Mr. Lazell,
the firm received a letter from Mrs. MacLean, taking
1424 THE LANCET]
exception to this use of the name of her husband
who was ill at the time. The words were consequently
altered to ‘specially prepared according to the
formule of an eminent physician,’ and later were
altered again to “prepared in accordance with the
formulz used in the leading hospitals.” Finally the
words were altered to a mere statement that the
formula was selected from a number of others.
Macleans Ltd. had also registered the trade-mark
“ Macs,” and it sold throat lozenges under this name,
The defendant firm, Lightbown Ltd., has been selling
medicated sweets under the name “ Merrimacs”’
which Macleans Ltd. said was calculated to deceive
and cause confusion. In addition, as already men-
tioned, the defendant firm had described its goods
as ‘‘famous Maclean sweets,’ ‘‘ Maclean sweets,’
and “ containing the genuine Dr. MacLean’s stomach
powder.” Lightbown Ltd. set up a defence which
unsuccessfully challenged the plaintiff's right to use
the trade-mark “ Macs” ; with regard to the words
“ Maclean ” and “ Macleans,” it was-contended that
they were not a trade-mark; the defendant firm’s
sweets did contain stomach powder made up accord-
ing to Dr. Hugh MacLean’s formula. During the
hearing Mr. Justice Farwell observed that he was
more concerned with the sweets than with the
powder; Dr. Hugh MacLean had never made any
sweets. The judge came to the conclusion that
Lightbown Ltd. had made a deliberate attempt to
filch from the plaintiff firm the reputation which
Macleans Ltd. had made for its sweets. He granted
an injunction to restrict the defendant firm’s use of
the name ‘ Merrimacs”’ or the description ‘‘ famous
Maclean sweets ”’ or ‘‘ Maclean’s sweets.” He did not,
however, grant one thing for which Macleans Ltd.
had asked. He refused to issue any injunction in
respect of the description “containing the genuine
Dr. MacLean’s stomach powder.” Macleans Ltd., he
said, had no monopoly in the powder prescribed by
Dr. Hugh MacLean. The right to use Dr. MacLean’s
prescriptions was not confined to any one person.
Prior to 1931 ‘‘ MacLean’s powder,” ‘‘ MacLean’s
alkaline powder,” or ‘“‘ MacLean’s stomach powder ”
were terms ‘“ quite well known among doctors, to a
large extent known among chemists, and to a lesser
extent known among the public.” Macleans Ltd.
had made up this powder, put it on the market, and
sold it under the signature of “ Alex. C. Maclean ”’ ;
that fact did not prevent Prof. MacLean’s powder
being sold as MacLean’s powder; Macleans Ltd.
claimed no monopoly in the powder and could
have none.
UNITED STATES OF AMERICA
(FROM OCCASIONAL CORRESPONDENTS)
BIRTHS, DISEASES, AND DEATHS
THE provisional mortality figures published in
Public Health Reports for May 7th are based on data
for twenty-five States and the District of Columbia
for 1936. Mortality from all causes, which had been
unusually low throughout the depression, increased
in 1936 about 5 per cent. over 1935, and the rate
was the highest recorded since 1929. Only three
States (Montana, South Dakota, and Iowa) reported
lower mortality than in 1935. Six diseases, however,
registered new minimum death-rates during 1936:
these were typhoid fever, measles, whooping-cough,
diphtheria, poliomyelitis, and diseases of the puerperal
state. Scarlet fever was the only major disease of
childhood which failed to register a new minimum
UNITED STATES OF AMERICA
[JUNE 12, 1937
death-rate. Perhaps the most disquieting feature
of the mortality conditions in 1936 was that the
decline in tuberculosis mortality almost ceased :
in fact twelve of the twenty-six reporting districts
noted increases. The so-called degenerative diseases
—cancer, diabetes, cerebral hemorrhage, and heart
conditions—continued their. upward trend. The
combined mortality from influenza and pneumonia
was the highest since 1929 and represented an increase
of nearly 10 per cent. over 1935. The birth-rate
continued to decline during 1936: it was 16-2 per
thousand population, being 1-2 per cent. below that
for 1935 and 5-6 per cent. below that for 1932.
Ten States reported higher rates than in 1935, thirteen
States lower rates, while three reported no change,
Although the infant mortality-rate increased about
2 per cent.: over the previous low record in 1935,
it was still less than any other rate recorded. ‘The
report closes with the statement that “The time
will soon come in this country, if present trends
continue, when 95 per cent. of the new-born infants
will survive the first twelve months after birth.”
AMERICAN PSYCHIATRIC ASSOCIATION
Some 2000 neurologists and psychiatrists attended
the 93rd annual meeting of this association held
in May in Philadelphia. Among the 100 papers pre-
sented for discussion those describing the American
experience of insulin shock in the treatment of
dementia przecox were of major interest. The electrical
activity of the brain cortex during epileptic seizures
was described by Dr. W. G. Lennox of the Harvard
medical school, and the audience was fascinated by his
suggestion that the solution of the problem of epilepsy
must be sought in the chemistry of the gene. An
increase is noted in puerperal insanity.
Data of great sociological import were disclosed in
a case study by Dr. Leo Kanner of Johns Hopkins
University of 102 women released from the Baltimore
training school for the feeble-minded. These girls were
released on writs of habeas corpus granted by careless
courts on the application of unscrupulous lawyers.
The lawyers could not have obtained their fees without
the interested collaboration of women in search of
cheap domestic labour. None of the girls so released
were paid normal servants’ wages ; some received no
wages whatsoever. Of 102 girls released 17 acquired
and transmitted serious communicable disease, ll
died before the age of thirty-two, 8 of them within
five years of release. No less than 48 of the girls
married. “‘ Making every possible allowance,” Dr.
Kanner was able to describe 10 of the husbands as
“ relatively stable and responsible individuals ;’’ 7
had prison records, 14 were habitual drunkards, 17
ultimately abandoned wife and family. To these
hapless unions 165 children were born of whom 108 |
were “obviously and incontestably feeble-minded.”
Of the 102 girls 29 became prostitutes,
RABIES
The daily press and the magazines have lately
carried many scare stories about rabies. The situa-
tion has been well known to public health officials,
and has been potentially dangerous for a consider-
able time in many different sections of the country.
For several years rabies has been almost endemic
among dogs and in districts where control has been
relaxed human rabies has already appeared
occasionally. In many districts stray dogs are allowed
to become practically wild, and some of them have
become rabid and bitten children without warning ;
and in many districts there is divided responsibility
with regard to the handling of dogs and the reporting
THE LANCET]
of bites. The attention of the public is being called
to these facts and already there has been some
improvement in coöperation between various agencies. _
As has been pointed out in the medical journals, the
fact that the disease is primarily one of dogs has
done much to enlist the support of humane societies.
THE ATLANTIC CITY MEETINGS
The annual meeting of the American Medical
Association is to take place from June 7th to 11th,
in Atlantic City, New Jersey. This occasion is
usually accepted as an opportunity for the meeting
of a number of other societies at or near the same time
and in the same place. These include the American
Bronchoscopic Society, the American Laryngological,
Rhinological, and Otological Society, the American
Neurological Association, the Association for the
Study of Allergy, and the American Association. for
the Study and Control of Rheumatic Diseases.
By this arrangement, it is possible for a great many
specialists to concentrate their major medical meet-
ings into a relatively short period and to save a great
deal of time and money in travelling—which, consider-
ing the distances involved, is of great importance.
THE 1937 CHRISTMAS SEAL
The National Tuberculosis Association has already
published its design for the 1937 Christmas seals.
This is no accident but part of a well-planned
publicity campaign which will make the American
public more than ever seal-conscious when the period
between Thanksgiving Day and Christmas releases
these most valuable revenue raisers for sale. The
picture shows a bell-ringer, lantern clasped in his
left hand, his bell swung vociferously above his right
shoulder. The association is encouraging schools
to study bell music and has arranged for the publica-
tion of a “ unit” on bell music (a unit is a sort of
brick in the structure of a school curriculum), They
quote from Mrs. Coleman of Columbia University, who
will prepare this unit, as follows :—
‘The sound of stone, of hollow, resonant wood, and of
- all the metals that come out of the earth, have made a
strange appeal to the mind and emotions of man. He
has fashioned these materials into various forms; bells,
of some kind, have been known all over the world—
civilized and uncivilized—and practically. all primitive
peoples have used them. Rude tribes living in the
remotest islands in the midst of the sea have been found
to possess bells ; and no matter how civilized and cultured
people become, they are still moved in some way by their
sound.”
When the art and science of salesmanship has pro-
gressed a little farther into the field of preventive
medicine what wonders we may yet behold !
BUDAPEST
(FROM OUR OWN CORRESPONDENT)
THE CAMPAIGN AGAINST SYPHILIS
AT a recent meeting of the Royal Medical Society
Dr. Joseph Kiss, secretary to the Ministry of Health,
detailed the development of the Hungarian campaign
against syphilis. The decreased number of new
patients at clinics and the diminished intensity of
the disease among them, of which there is statistical
evidence, provides but little information of the
position in the country generally, and the aim of the
antisyphilitic campaign is to reach patients infected
with syphilis wherever they live. The spread of
infection from patients with definite symptoms of
BUDAPEST
[JUNE 12, 1937 1425
infection or those who present symptoms of other
disorders in whom the disease is discovered by means
of laboratory tests can be prevented, but the problem
remains of discovering and treating effectively those
who harbour the infection and pass it on without
knowing it, The most direct way of tracking hidden
infections would be the systematic performance of
serological tests, “but the present financial and
economical conditions in Hungary do not allow the
introduction of this costly solution, which more-
over has disadvantages. A practical method for the
discovery of a considerable proportion of infected
persons suggested by Dr. Kiss was the serological
examination of all pregnant women. On the assump-
tion that 80 per cent. of all macerated foetuses are
syphilitic, an attempt since 1932 has been made to
estimate the number of macerated foetuses amongst
stillborn babies. The records from the obstetrical
clinics and hospitals show that in 1933, 1934, and
1935 nearly 40 per cent. of the stillborns were
macerated, making 1-2 per cent. of the total births.
After the birth of a macerated fetus at the Budapest
obstetrical clinics the parents are advised to have a
serological test made; among deliveries taking place
at the patients’ homes no such advice has hitherto
been given. During the period 1933-35 out of 6146
macerated footuses 4573, that is 74:4 per cent., were
born at home. It is probable that in the future
these parents will be made to subject themselves to
serological test and when reports are positive to
undergo regular treatment. The National Sickness
Insurance Institute already enacted that every single
pregnant woman calling on the panel doctor must
submit to such a test,
EFFECT OF PROSPERITY ON FERTILITY
In several European countries where the problem
of legalised abortion has been discussed the opponents
of strict prohibition always base their arguments on
the importance of social position, stating that in
most cases it is poverty and the inability to bring up
her child in comfort that drives the wife to the
abortion-monger. That this is a false assumption is
proved by the everyday experience that it is not the
poor that seek relief for getting rid of their burden
but the well-to-do, who are impelled by motives of
personal comfort and vanity. In Hungary it is pro-
verbial that in the Dunantul, beyond the Danube,
it is the custom to have only one child, though this
part of the country enjoys the greatest possible
prosperity. The statistical returns relating to the
fertility of married women, as shown by the census
of 1930, point to the fact that the number of children
of farmers and tenants holding over 100 acres of land
averages 3:38 per family, while in those with less
than 100 acres the number is 3-75, and in agricultural
servants and farm hands 4:20. These figures show
the checking effect of property on the birth-rate.
A COMMITTEE FOR THE PREVENTION OF
BLINDNESS
After the formation of the International Com-
mittee for the prevention of blindness branches have
been established in every country. The Hungarian
committee was formed as a separate section of the
National Public Health Association, and its opening
ceremonies were held recently. The president is the
Countess Juliette Károlyi and the vice-president
Prof. Emile Grosz. The latter, speaking at the
inaugural meeting, detailed the history of international
organisations against blindness. He said that in
Hungary there are about 6000 persons incurably
blind, and of these the vision of about 2500 could
1426 THE LANCET]
BUDAPEST.— PARIS
[JUNE 12, 1937
have been saved if precautionary measures had
been applied in time. The most important
tasks are to diminish the devastation of infectious
eye diseases and to check the occurrence of industrial
accidents in connexion with the eyes. The committee
has set itself as one of its tasks the education of
those with impaired vision.
STILLER’S CENTENARY
Hungarian physicians have just celebrated the
centenary of the birth of the late Prof. Berthold
Stiller, physician and director of the Jewish hospital
in Budapest. His treatises on the asthenic consti-
tution—his morbus asthenicus—began to appear in
the ‘nineties, and these, were collected into one
volume in 1907. He enumerated certain diseases,
particularly pulmonary tuberculosis, to which the
asthenic type is specially predisposed, and he pointed
out that there are other diseases that do not occur at all
in this type of subject. In his description he paid
most attention to certain anatomical peculiarities,
especially to a mobile tenth rib, as well as to a laxity
of the connective tissue, giving rise to the visceral
ptoses. He was also the founder of the science that
investigates the connexions between bodily consti-
tution and character, and which is generally attributed
to Kretschmer. Accordingly Calvin, Schiller,
Rousseau, Frederick the Great, and Robespierre
were asthenics and their individualities were deter-
mined by their stature. A leading article in THE
LANCET reviewed the book at the time and paid
tribute to Stillers “admirable critical faculties.”
Though the seed sown by Stiller proved very fertile,
it did not meet with such a general recognition in
Germany as elsewhere, but some years later they too
acknowledged his merits and the importance of his
work. But Stiller was not only an observant natural
philosopher; he was also wholly a physician.
Toward the end of his life he entered into a fierce
dispute with the prominent Danish surgeon Rovsing,
who advocated treating gastroptosis and nephroptosis
by operation, while Stiller himself believed in improv-
ing the general condition and tuning up the whole
body.
PARIS
(FROM OUR OWN CORRESPONDENT)
TUBERCULOSIS CAMPAIGN IN AN INDUSTRY
THE Michelin works at Clermont-Ferrand, not far
from Paris, present a useful object-lesson in com-
munity welfare with special reference to tuberculosis.
At the beginning of this century, this industry, with
some 22,000 souls dependent on it in the town,
began to set its house in order, pulling down slums
and replacing them by model houses at a moderate
rental. Between 1909 and 1930, 3087 such model
dwellings were built, and by 1932 the slum area had
ceased to exist. In 1915 Michelin made those family
allowances which in 1932 became compulsory by law
for the whole of France. In 1921 a dispensary was
organised for the benefit of the tuberculous and the
pre-tuberculous, and while in 1922 as high a proportion
as 13 per cent. of the attendants at this dispensary
represented advanced cases, in 1935 the proportion
was only 1:5 per cent. The Grancher system of
boarding-out children exposed to infection in their
homes has also been adopted by this community ;
and of the 229 children found to be exposed to infec-
tion between 1922 and 1927, 147 were promptly
isolated, 23 were isolated after some delay, and 59
were left in contact with infectious cases, and the
tuberculosis mortality in these three groups was
0-6, 13, and 25-4 per cent. respectively. Finding that
applications for sanatorium treatment meant intoler-
able delays, the directors of Michelin opened a sana-
torium of their own in 1926 with 90 beds. Here there
is no limit to the duration of treatment, and 70 per
cent. of the patients admitted to this institution have
been discharged under the heading ‘“ amélioration
présumée durable.” Children exposed to infection
are given BCG and are examined at the dispensary
three or four times a year. Thanks to these and many
other benefits, the incidence of tuberculosis among
the 22,000 members of the Michelin community has
been greatly reduced. In 1931 there were 181 new
cases of tuberculosis discovered in the community.
The corresponding number in 1936 was only 84—a
fall from 8-2 to 3-8 per 1000 inhabitants.
AMATEUR THORACIC SURGERY UNDER A CLOUD
In a circular letter dated April 7th, addressed to
French prefects by the Minister of Public Health,
attention is drawn to the fact that during the last
few years surgical methods of treatment of pulmonary
tuberculosis have not ceased to improve and now
have become common practice in sanatoriums.
But such operations should be in the hands only of
skilled surgeons with adequate clinical and operative
experience. The Minister of Public Health, on the
advice of the Tuberculosis Commission, has therefore
ruled that the names of all the doctors undertaking
the division of pleural adhesions, phrenicectomies,
thoracoplasties, &c., in public sanatoriums must be
submitted to him for his approbation with a complete
dossier concerning their ages, addresses, and qualifica-
tions with special reference to their fitness for such
work.
GUIDANCE FOR FOREIGN MEDICAL STUDENTS AND
DOCTORS IN FRANCE
Although I have already referred from time to
time to the Association pour le Développement des
Relations Médicales entre la France et les Pays
Etrangers, it may not be amiss to refer to it again
now that during this summer and autumn Paris will
be more than ever a centre of medical studies, not
least post-graduate studies. The offices of this
association are in the Salle Béclard, Faculté de
Médecine, 12, rue de l Ecole-de-Médecine, and they are
open every day from 9.30 to 11 and from 2 to 5 except
on Saturdays. At these hours Mademoiselle Huré,
who is Prof. Hartmann’s right hand, gives advice to
students and doctors as to where they should go
and what they should see. Her telephone numbers
are: Danton 09.59 or Danton 55.36.
In the quarterly bulletin of the association dated
April, 1937, Prof. Hartmann, who is the president,
gives some instructive figures with regard to the
attendance of foreign medical students and doctors
at the Paris medical school since 1929. He deplores
the change which has come over the scene in the
interval owing to the world crisis, currency difficulties,
xenophobia, and the competition of brand-new
buildings and schools of medicine in the South
American countries. While in 1929 there were 293
foreign medical students registering in the Paris
faculty of medicine, the corresponding figure in
1936 was only 31. It might have been thought that
Mademoiselle Huré’s work would have diminished
in proportion to the decline in the number of foreign
medical students, but of late French medical students
have found their way in increasing numbers to her
office, and her services have been much in demand
THE LANCET]
in connexion with post-graduate classes in Paris.
On this subject Prof. Hartmann is hopeful. As he
points out, there has of late been an encouraging
rise in the number of such courses—a rise which
assuredly reflects the growing appreciation they
enjoy. In 1933, the low-water mark for several years,
there were only 1013 persons attending these post-
graduate classes, whereas in 1936 the corresponding
number was 1200. ‘It is certain,” Prof. Hartmann
writes, “‘ that if these courses were announced early
enough, if they were well co-ordinated and well
organised, we would see a considerable rise in the
number of their attendants.” Might it not be possible
for arrangeinents to be made between the French
University. authorities and the Anglo-Saxon press
to give effect to this suggestion ?
SCOTLAND
(FROM OUR OWN CORRESPONDENT)
THE FACIAL EXPRESSION OF THE SICK CHILD
AT a meeting of the Medico-Chirurgical Society of
Edinburgh last week Dr. William Brown, senior
physician to the Royal Hospital for Sick Children,
Aberdeen, spoke of the face and ‘facial expression in
the sick child, and showed illustrative lantern slides.
He pointed out that the maldevelopment of the lower jaw
is often due to faulty methods of feeding, and that the
adenoid facies may be caused by various disturbances
of the upper respiratory tract. An excess of hair is
common in cases of mental deficiency but is often
seen in children suffering from diseases of the lung:
long eyelashes are often observed in tuberculosis.
The colour of the child’s face should be studied
during sleep owing to the frequent vasomotor changes
which occur when the child is awake. Cyanosis in
infants generally means heart disease. A unilateral
malar flush may indicate the side of the lesion in
lobar pneumonia.
other respiratory infections, but also in meningitis.
Thick and everted lips occur in severe mouth infec-
tions and also in cases of severe cough, when it is
accompanied by cyanosis and swelling of the eyelids.
Thirst is indicated by an open mouth and a dry tongue,
and when these signs are present fluids should be
introduced by every available route. An open
mouth, or its opening and shutting also suggests
hunger, and the sight of a bottle produces the sucking
reflex in such cases. Wasting may be due to loss of
fat or loss of fluid: the last fat to disappear from a
baby’s body is the sucking pad in each cheek.
Dehydration has a distinct facies which calls for the
urgent administration of fluids: the orbits are
hollow, the fontanelle is depressed, the eyes sunken
and staring, and the skin of the lower jaw loose and
redundant. In cases of pyloric stenosis the forehead
is lined with parallel horizontal furrows, an appearance
according to Dr. Brown almost diagnostic of this
condition. The sudden development of codema
suggests frontal sinusitis or cavernous sinus throm-
bosis. C£dema of the eyelids is often observed in
children who have been starved; persistent odema
involving only one eye may occur in middle-ear
disease. It is important to observe the eyes of
infants; a sign of pain is wide dilatation followed by
contraction. In a congenital heart disease the eyes
are often dark brown and very bright. The sudden
onset of squint or ptosis suggests meningitis, but
temporary ptosis may occur in middle-ear disease.
The appearance of open fixed eyes when the child takes
SCOTLAND .— IRELAND j
Herpes is seen in pneumonia and `
[JUNE 12, 1937 1427
no interest in his surroundings is a bad sign. When
the child is conscious, has wide open eyes, and finds
difficulty in breathing pyelitis is often present. The
facial expressions of children are simple and in
infants there are only three—complete repose,
pleasure, or annoyance. Dr. Brown referred to the
mask-like face of chorea and pointed out that the
reappearance of expression is a sign that the acute
stage is passing off. The child suffering from Pink
disease is really miserable. He cannot sleep, eating
is painful, and the extremities are tender. Infants
and very young’children never smile when seriously
ill, so that the first smile is a welcome sign of
improvement,
' OCCUPATIONAL THERAPY
The annual report of the medical superintendent
of the Astley Ainslie Institution, Edinburgh, shows
that the number of patients who entered the insti-
tution was 1077 during the past year, and that the
average stay for each patient was 9-6 weeks. Fifty-
one of the patients had been in the institution for
over six months. The maintenance cost per bed for
a year is now £151. An interesting development has
been the building of an occupation therapy depart-
ment which was opened in May of last year. The
building has one storey and consists of a central
section with two large wings projecting from either
end to conform with the “ butterfly’. pattern of the
existing pavilions. The wings contain the main work-
shops; one for the quiet crafts such as weaving,
painting, basket-making, and the other subdivided
into two arms, the larger for the noisy crafts such as
carpentry, the smaller for pottery work. Large
windows form the greater part of the wall space of
the main workshops so that when the weather is
suitable the patients work under open-air conditions.
The daily average number of patients ‘“ treated ” in
the workshop has been 97,
IRELAND
(FROM OUR OWN CORRESPONDENT)
FEES FOR INOCULATION AGAINST DIPHTHERIA
THE annual meeting of the Irish Free State Medical
Union was held in Dublin on June 3rd, when Dr.
Conor Maguire was re-elected president for a second
year. The report of the council stated that there
were 871 members on the register of the Union at
the end of 1936. The number has increased consider-
ably. since that date. It was announced that arrange-
ments were being made for the publication of a
monthly journal, and that the first number would be
issued on July Ist.
A long discussion took place on the question of the ~
remuneration for the work of immunisation against
diphtheria. The demand of the Union hitherto '
has -been for a fee of two guineas for a session, each
session to cover not more than twelve completed
cases. The Minister for’ Local Government and
Public Health had refused to sanction fees greater
than ls. 6d. per case where the one-injection method
was followed, and 2s. 6d. per case where the three-
injection method was followed. For several months
past country practitioners have been engaged in the
work, receiving no fees, but leaving the settlement
as regards fees in suspense. Dr. J. P. Shanley,
honorary secretary of the Union, related the steps
that had been taken to secure a satisfactory settlement.
Recently the parliamentary secretary had suggested
1428 THE LANCET]
a sessional basis for remuneration, a fee of one guinea
to be paid for each session of twelve patients. As
this was worse than what the: department had
previously been willing to sanction, the offer had been
refused. The medical secretary, as the result of
inquiries made in Belfast and London, had found that
in Northern Ireland the two-injection method was
most in use, and a fee of 2s. 6d. was given for each
injection. In England the fee varied from 5s. to
10s. per injection, the medical practitioner
supplying the material in the areas where the higher
fees were paid. After protracted discussion a resolu-
tion to the effect that the fees should not be less than
2s. 6d. per injection was passed, and if this offer
were not accepted within four weeks it would be
withdrawn.
ANNUAL DINNER OF THE UNION
The first annual dinner of the Irish Free State
-= Medical Union was held on the evening of the annual
meeting in the Dolphin Hotel, with the president
in the chair. Over a hundred members and guests
were present, including Mr. Sean T. O’Kelly (Minister
for Local Government and Public Health, vice-
president of the Executive Council), Mr. Alfred
Byrne (lord mayor of Dublin), Dr. Denis Coffey
(president of University College), and Mr. P. Doran
(chairman of the Hospitals Commission).
THE DUBLIN HOSPITAL PROBLEM
The daily press of Dublin has given wide publicity
recently to a plea made in the annual report of the
board of governors of Sir Patrick Dun’s Hospital
that the Minister for Local Government and Public
GRAINS AND SCRUPLES
GRAINS AND SCRUPLES
\
[June 12, 1937
Health should come to a decision about the future
of the Dublin hospitals. Attention is drawn by the
governors to the recommendation made to the
Minister by the Hospitals Commission some eighteen
months ago in favour of the development of four large
voluntary hospitals in Dublin, each to contain
accommodation for some five to six hundred beds.
The governors believe that the Commission under-
estimated the needs of Dublin. They point out that
the demands for hospital accommodation are steadily
increasing. In order, as far as possible, to meet
these growing demands, the governors have, as a
temporary expedient, found it necessary to use
stretchers and temporary beds, yet many patient
have had to be turned away for sheer lack of space.
This condition clearly cannot be allowed to continue.
Even if the Minister decides on the erection of five
large hospitals, much time must elapse before the
buildings can be. occupied. During that time
temporary accommodation must be provided. Sir
Patrick Dun’s is one of four small hospitals which
accepted cordially the suggestion of the Hospitals
Commission that they should amalgamate to form
one hospital of 500 or 600 beds. They believed
that the era of small hospitals had passed, and that
larger hospitals must be built if efficient service was
to be rendered. Their proposals have been before
the Minister for some eighteen months, backed by
the support of the Hospitals Commission, but they
have been unable to obtain a decision. They must
make some provision to meet the demands on their
service and accommodation. They are waiting to
be told whether the provision is to be temporary or
permanent. l `
Under this heading appear week by week the unfettered thoughts of doctors in
various occupations.
Each contributor is responsible for the section for a month ;
his name can be seen later in the half-yearly index.
BY TWELFTH MAN
II
Ir has been said repeatedly in recent years that
surgery is the greatest of the arts. . When I first read
this I believed the writer to be jesting, but as the
assertion was frequently repeated I concluded that
it was intended to be a statement of fact. The
psychologist would regard this as a ‘‘ wish-fulfilment ”
definition. For if surgery is the greatest of the arts
and X the greatest living surgeon, then it follows
that X is a finer artist than Brangwyn or Sickert,
Epstein or Gill, Tom Webster or David Low. In
fact, as Arnold Bennett used to say, a terrific swell.
An artist creates beauty but a surgeon creates
nothing. Moreover, the surgeon works in perishable
material and the artist who uses his hands 1s careful
to select a medium that has durability.
‘‘But beauty vanishes; beauty passes ;
However rare, rare it be ;
And when I crumble—who will remember
This lady of the West Country ? ”
Or indeed the surgeon who defiled her beauty with
his so-lovely gastro-jejunostomy? Surgery must
be placed amongst the crafts; but here again it
takes a lowly place unless the crafts are being adjudged
solely for their dramatic quality or utilitarian value,
when it goes top. Surgery may confer imperishable
value on the human race by prolonging the life of a
true artist or a real craftsman. But it may render
dictators the saine service. Who can hope to cast the
balance-sheet of such indiscriminate life-saving ?
x x x
This desire to make the best of a world other
than one’s own has something to do with the com-
plaint that clinicians are so infrequently awarded
the Fellowship of the Royal Society. Lewis,
Trotter, Parsons, Gordon Holmes, and a few
others and the list is complete. I think there is
little reason to complain. The first-class clinician,
be he physician or surgeon, rarely adds much
to the sum of human knowledge; his chief claim
to distinction is his highly developed clinical skill
which dies with him. Moreover, he gets a larger
share of material success than falls to the lot
of the pure scientist—honours, wealth, and fame.
Not that an F.R.S. is always a badge of poverty and
social insignificance.
* x *
Hospital staffs were just emerging, when I was a
student, from the sometimes mild but often bitter
antagonism which existed between physician and
surgeon. Physician and surgeon are now united, as
brothers engaged in empirical living, before the cold
disdain of the scientist and research worker. No
doubt we shall soon have passed through this phase
also, but the clinician is sometimes stimulated to
counter-reaction. A London Surgeon wrote in Grains
and Scruples that ‘“ most men who undertake research
THE LANCET]
of set purpose do so less from a passion for discovery
than from a knowledge of their own inadequacy
for the battle of life, from a desire for ‘some sad
mechanic exercise, like dull narcotics, numbing
pain?” A Doctor without Patients replied that
‘our faculty suffers too much from mutual scorn.
Sir A. B. in Harley-street sneers at the high-browed
Prof. C.: A ‘cleverish man, my dear fellow, but no
breadth at all, no vision,’ and secretly fears and envies
C’s exact knowledge.
with anecdotes of ‘ that priceless fool B’s’ ignorance
and is secretly annoyed that B can afford a better
car and more exciting holidays than he. ... They really
know very little one of another.”
The opinion of A London Surgeon is elaborated
by Aldous Huxley in his recent novel “ Eyeless in
Gaza °—“ Scholars, philosophers, men of science—
what other class of men has succeeded in getting the
world to accept it and more astonishing, go on accept-
ing it at its own valuation. ... But, in fact the Higher
Life is merely the better death substitute. A more
complete escape from the responsibilities of living than
alcohol or morphia or addiction to sex property....
The Higher Lifer can fairly wallow in his good
conscience. For how easy to find in the life of scholar-
ship and research all the equivalents for the usual
virtues—Chastity of artistic and mathematical form.
Purity of scientific research. Courageousness of
thought. Bold hypotheses. Logical integrity.
Temperance of views. Intellectual Humility before
the facts. All the cardinal virtues in fancy dress.
The Higher Lifers come to think of themselves as
saints—saints of art and science and scholarship.”
This I take-to be Aldous Huxley’s way of saying that
he is every bit as good a man as was his grandfather,
the great T. H. But, seriously, which of us avoids
this “sad mechanic exercise’’ ? Isn’t life for all of
us, as A Doctor without Patients said, ‘‘ one damned
thing after another, in the eighteenth or the twentieth
centuries, country practitioners or university pro-
fessors’?? Is there no ‘battle of life” in the
laboratory (‘‘ I have thee by the throat, thou million-
murdering death’’)? Are we not all, in some sense,
escapists from responsible living? Who shall cast
the first stone ?
xk xk xæ
The desire of some clinicians to see their art trans-
formed to an exact science is understandable but it is
less excusable in our day when science itself is regarded
as a form of art “‘ an imaginative picture constructed
by the human mind of the workings of the universe ”
—and when, as C. E. M. Joad has said, the kind
of information which ‘science has to offer in
respect of many things is not generally regarded
as the kind of information which matters.” 1 I once
heard Sir Almroth Wright address an audience of
medical students and, in inimitable fashion, abjure
them to flee like the devil from the salius emptricus
and cling, as they would to their hope of salvation,
to the passus sctentificus tutus.
Listen to two doughty and distinguished opponents
of this conception of clinical medicine as a science.
A Rusticating Pathologist wrote: “I was rather
shocked to read in THE LANCET the other day that
the conservator of the Hunterian Museum thought
that the ‘student should be well trained to the experi-
mental method because he would find when he came
to clinical work that diagnosis was conducted in the
same way.’... This is either bad experiment or bad
medicine. ... It has always seemed to me that the
great trouble of the doctor is that he has to do sums
1 Guide to Modern Thought. London: Faber and Faber,
GRAINS AND SCRUPLES
Prof. C entertains his friends `
[JUNE 12, 1937 1429
with numbers which are often very uncertain and
his great pride that he usually gets the answer some-
where near right. If he failed to come to a conclusion
adequate for action he would be a bad doctor, if he
drew a conclusion from such froward data he would be
a worthless experimenter, ... And, again as a patient,
I judge that his first business is to be a doctor. ... To
cure a patient without knowing what is wrong with
him is no mean performance.” And Sir Auckland
Geddes, most unexpected of allies: “ The real business
of clinical medicine was not science ; it was a personal
relationship into which much sincerity and medical
knowledge were suffused by the physician, and trust
and some dependence on the patient. . . .- Too
many come to the sick-room thinking of themselves
as men of science fighting disease and not as healers
with a little knowledge helping nature to get a sick
man well. Beyond their scientific knowledge of man
lay an incompletely explained area in which important
things happened without discernible physical
cause. . . . Once they had ceased to fear what
seemed to them non-rational and recognised that
human reason could not grasp all reality they could
get to know a good deal about man.” This view
-of the function of clinical medicine does not, on the
one hand, require the abrogation of human reason
nor, on the other, neglect the new knowledge which
streams from laboratories.
* * *
Before I leave this matter of clinical medicine, let
me refer to this new, ‘‘this happy breed of men,”
the Clinical Scientists. It will be interesting to see
just how much clinical medicine benefits from the
attempt to apply laboratory methods in the investiga-
tion of disease in the human subject. It is one thing
for men of genius like Thomas Lewis and James
Mackenzie after many years of varied activity
deliberately to limit themselves to work in a restricted
field. They will certainly produce results of value.
But the neophytes who follow them, patiently
imitative, having known no other good than this and
desiring none, will they too bring in the sheaves with
them ? How can the self-sterilised be fecund? I
met a precious young man just down from Oxford
who, when I asked him what he was going to do, told
me he was going to be a dramatist. He ignored the
fact that dramatists begin life as actors, journalists,
authors, shop assistants, stockbrokers, barristers,
dramatic critics, schoolmasters, and doctors, for the
sufficient reason that life is the dramatist’s workshop.
So it is with clinical research. A man will only pursue
his own ideas with passion and profit. Fruitful ideas
for clinical research will arise in the course of clinical
practice, so that the clinical scientist must evolve
from the practising clinician. It is, therefore, no
coincidence that James Mackenzie and Thomas
Lewis each began a scientific research into clinical
problems late in life. To encourage young men to
become clinical scientists by giving them whole-time
salaries which do away with the need for clinical
practice is.as absurd as it would be to attempt to
create a new School of British Drama by putting
all the potential dramatists in a closed community,
compelling them to do nothing but read Shakespeare,
Sophocles, and Shaw.
xk * x
This week I have stolen too much of other men’s,
thunder. With shame I recall that A Public Health
Clinician wrote, ‘“‘ To-day, with the passage of the years,
I rarely use quotations but I endeavour to express
myself clearly and give no one else credit for my ideas.”
How he must deprecate my derivative performance.
1430 THE LANCET]
x
(JUNE 12, 1937
PANEL AND CONTRACT PRACTICE
Court Finding on Capitation Fee
THE Ministry of Health issued on June 7th the
finding of the court of inquiry set up by the Minister
of Health and the Secretary of State for Scotland under
the chairmanship of Lord Amulree, to consider the
question of the’ capitation fee payable to medical
practitioners under the scheme of National Health
Insurance. The court was asked to investigate the
question whether any, and if so what, alteration
ought to be made in the amount of the doctors’
capitation fee, having regard to any changes since
1924 in the cost of living, the working expenses of.
practice, the number and nature of the services
rendered to insurance patients, and other relevant
factors, and on the assumption that as from Jan. Ist,
1938, employed persons under the age of 16 will
have become entitled to medical benefit by virtue
of amending legislation. The finding of the court
is that the appropriate capitation fee should be 9s.,
the figure at present obtaining in regard to insured |
persons over the age of 16.
The introduction of legislation to entitle boys and
girls to medical benefit immediately on becoming
employed after reaching the school leaving age has
awaited this decision, and the Ministry hopes it
will now be possible to introduce the necessary bill
in Parliament.
Delayed Acceptance Forms
The London medical benefit subcommittee asked
the service subcommittee to investigate a case in
which a practitioner had been remiss. In July,
1936, his attention had been drawn to the fact that
during 1935 he had submitted only five acceptances
and then on March 3lst, 1936, he had submitted
no less than 165. A temporary improvement followed
but from Sept. 30th, 1936, to April Ist, 1937, no
acceptances were submitted. On the latter date
101 medical cards were submitted, some of which had
evidently been in the possession of the practitioner
since October, November, and December, 1936.
The doctor told the subcommittee that he under-
stood other practitioners were in the habit of sub-
mitting acceptances once a quarter and he had not
appreciated that by retaining the medical cards he
had in fact committed a breach of the terms of
service. The subcommittee pointed out to him that
the seven days’ limit, laid down in Clause 3 of the
Allocation Scheme, was not a troublesome piece of
red tape but was an essential part of the machinery
for the provision of medical benefit: Apart altogether
from the interference with efficient administration
the insured persons had been deprived of their medical
cards, which was likely to cause inconvenience if they
should require treatment away from home. The report
of the subcommittee points out that this is the first
time they have been called upon to deal with a breach
of the terms of service of this nature but they under-
stand that the practitioner concerned is by no means
the only offender. Beyend deciding that there had been
a breach of the terms of service the committee took
no action but they indicated that should there be a
repetition of the offence they would feel compelled to
take a more serious view of the matter, The prac-
titioner has in effect fined himself because in many
cases he neglected to submit acceptances during the
quarter in which they were made.
Interference with Choice of Doctor
Two doctors were in partnership and, as sometimes
happens, were not on speaking terms. The partner-
ship was to be dissolved, and the junior who was going
out found that insured persons whom he had accepted
were receiving medical cards bearing the name of the
senior partner. The insurance committee had an
examination of the acceptances made when it was clear
that in a number of cases the junior’s signature had
been erased or obliterated and that of the senior
substituted. Certain insured persons were interviewed
by the medical service subcOmmittee and made it
clear that they wanted the junior partner, and
in some cases did not even know his colleague. ‘The
senior partner admitted the deliberate alteration of the
medical cards because he thought that as the junior
was leaving the practice shortly it was absurd for
him to continue to accept patients. He accordingly
instructed the secretary to the partnership to inter-
cept acceptances by the junior and to submit them to
him for signature. He had no ulterior motive and at
the time quite failed to appreciate that he was treating
the wishes of the patients as of no effect. He offered
to consent to the transfer of any of the patients to other
doctors but the subcommittee decided against this ;
instead they caused the acceptances to be cancelled
and open medical cards to be sent to the insured
persons. The secretary admitted having held up the
acceptances (although she had been told to send them
in weekly) and having erased the junior’s signature,
saying that she regarded herself as employed by the
senior and that she did not feel it her duty to tell the
junior what she had done. The subcommittee had no
doubt that the strained relatidns between the partners
explained in some degree the action taken by the
senior. There was no attempt at forgery—the
alterations were obvious—nor was there any financial
advantage to the senior because the profits had
to be divided in accordance with the partnership
deed. On the other hand they regarded as serious
the interference with the right of insured persons
to choose their doctors. There being no provision
in the terms of service which the senior partner could
be held to have infringed the committee simply
put on record that the actions of the senior partner
were deserving of censure,
Approved Societies and Hospital Treatment
The Central Bureau of Hospital Information has
just published a useful addition to the numerous
memoranda prepared for the assistance of hospital
administrators. Memo. No. 108, replacing Memo.
No. 49, contains (1) a list of the approved societies
which have included hospital benefit in their fourth
valuation schemes of additional benefits, and (2) a
list of approved societies which, although not pro-
viding hospital benefit, yet allocate an annual sum
for the purpose of making donations to charitable
institutions, including hospitals. There are 273
societies in the former list and 85 in the latter;
and among the 273 societies providing hospital
benefit are 70, which, in addition, make dona-
tions to hospitals and other charitable institu-
tions. It is not so widely known as it should be
that approved societies are not only empowered to
set aside an annual sum from which to make donations
to charitable institutions, but may also, with the
consent of the Minister of Health, include hospital
benefit in their scheme of additional benefits adopted
THE LANCET].
after the completion of the fourth valuation. Pay-
ments made to hospitals by a society providing the
benefit are based on the number of the society’s
members treated as in-patients and the duration of
the period of treatment in each case; and it is
necessary for a hospital in applying to the societies
for payment in respect of their members treated to
furnish to the society a quarterly statement con-
taining certain particulars of each patient, which are
set out in the memorandum. Payments are made
only in respect of those members who were in the
society during the period in which the surplus accrued
out of which hospital benefit is payable. Copies of
the memorandum, which seems indispensable to all
hospital administrators, can be obtained from the
Director of the Bureau, 12, Grosvenor-crescent,
London, S.W.1. The price for single copies is 4d.
post free, and for 12 copies, 3s. 6d.
o
THE LANCET 100 YEARS AGO
Jume 10th, 1837, p. 410.
From A CALEDONIAN SURGICAL REPORT,
““ EXTRAORDINARY SURGICAL OPERATION.—In passing
along the South Bridge yesterday forenoon, our attention
was arrested by a great crowd of gentlemen, at the gate of
the Royal Infirmary, pressing inward. Joining in the crowd,
we were carried along with it to the surgical hospital, where
we found the operating theatre crammed to excess, chiefly
by medical gentlemen and students; amongst these we
recognised Sir George Ballingall, Dr. Maclagen, Mr.
Newbigging, Dr. Campbell, the surgeons of the 14th
Light Dragoons and 42nd Regiment, besides many country
surgeons, The excitement we have described was occasioned
by the knowledge that an operation never performed in
Great Britain was to be done upon a young man by
Professor Lizars. The case was what is technically called
aneurism of the subclavian artery, so near the heart that
the first large trunk required to be tied, namely, the
arteria innominata. The young maA, a carter from Dalkeith,
was placed upon the table, and the Professor commenced.
by making an incision in the neck, and progressively cut
down to the artery, when the ligature was applied. The
operation was completely successful. The patient, who
bore it with uncommon fortitude, was only on the table
for fifteen minutes altogether. This, as we have already
said, is the first operation of the kind which has been
attempted in Great Britain. We understand that it was
once successfully performed at Berlin by Dr. Graefe, and
once in New York by Dr. Mott.” —Caledonian Mercury,
June 1. |
*,* The details of this case were set out with a
full description of the technique of this operation, at
which the patient was not 15 minutes on the table,
in the issues of THE LANCET in the same volume
dated June 17th, p. 445, and July 15th, p. 602.
The patient survived for 21 days after the operation
—EDp. L. |
From lectures on Materia Medica and Therapeutics
delwered by GEORGE G. SIGMOND, M.D., at the Windmill-
street School of Medicine, p. 396.
... It is in the paroxysm of spasmodic asthma that
stramonium has been most generally used,—formerly very
often without first seeking that advice and assistance which
should only be sought from the medical man of long
- experience and careful observation. Indeed, the paroxysm
of embarrassment of breathing is so very distressing, that
an individual flies to every object which holds forth
to him a promise of relief; and hence it is that the bold
and impudent adventurer has so often chosen, as the
province in which he will carry on his nefarious practice,
diseases of the respiratory organs. A sufferer will have
recourse to any remedy that he believes can control the
disease, and for instantaneous relief he will encounter any
difficulty. During the paroxysm, life is insupportable . ..
THE LANCET 100 YEARS AGO
[JUNE 12, 1937 1431
MOTHERS AND CHILDREN
(FROM A CORRESPONDENT)
Tue seventh English-speaking Conference on
Maternity and Child Welfare was held in the great
hall of B.M.A. House on the first three days of June.
The decision to hold it a month earlier than usual
enabled many distinguished visitors who had come
over for the Coronation to take part.
HISTORY OF THE CHILD WELFARE MOVEMENT
Reprints 1! of a brief history of the child welfare
movement, written by Dr. G. F. McCleary, chairman
of the Association of Maternity and Child Welfare
Centres, were distributed beforehand to the delegates
to enable those unfamiliar with the history of the
movement to grasp how it came about. The urge to
do something sprang from the Congrès international
des gouttes de lait in Paris in 1905 at which were
present, besides himself, Bailie W. F. Anderson and
Dr. A. K. Chalmers of Glasgow, Dr. S. G. Moore
and the late Alderman Benjamin Broadbent of
Huddersfield. Largely owing to the influence of these
British delegates the movement quickly took root in
Britain and in June, 1906, the first Conference on
Infantile Mortality was held in London under the
presidency of Mr. John Burns, then chairman of the.
Local Government Board. But perhaps we must go -
further back than Dr McCleary to find the roots of the
movement, amongst which may well be (1) the rapid
fall of the birth-rate in France, (2) the terrible toll
of death from infantile diarrhoea in hot summers,
especially in 1899, (3) the fact that though preventive
medicine had done much to reduce the incidence of
disease and the general death-rate, it had so far
done nothing to reduce infantile mortality, which
stood constant between 100 and 200 per 1000 born,
according to locality.
MATERNAL MORTALITY
The conference, organised by the National Asso-
ciation for the Prevention of Infantile Mortality of
which Miss J. Halford has been hon. secretary since
the first conference in 1906, was opened by Sir
Kingsley Wood, Minister of Health, who spoke on
the progress of midwifery practice in Britain during
the past five years. He reported the maternal mor-
tality for 1936 as the lowest for five years at 3-81
per 1000 live births; antenatal attention, he said, is
now given to about 50 per cent. of pregnant women,
and the number of women delivered in institutions
has risen by 50 per cent. since 1932. He referred to
the committee he has appointed to inquire into the
practice of induced abortion and to the reports
recently issued by his department on the so-called
black areas. A delegate from the United States
stated that her country compared favourably with
ours in the reduction of child mortality but that the
maternal mortality was much higher—about 6 per
1000. It should be borne in mind, however, that in
the States the rate is not computed in exactly the
same way as it is here, nor is it similar in all the
States furnishing returns. Making allowances for
differences of casting, maternal mortality of England
is the lowest of any community speaking our common
tongue, suggesting that English practice is the best
expression of the traditional British approach to
midwifery. Our rate is also lower than that of any
country with midwifery traditions different from ours,
with the possible exception of Scandinavia.
1 Published in Mother and Child, Lond., for J une, 1937.
1432
THE LANCET]
BACKWARD AREAS
At the first session two papers on welfare work
amongst people living in primitive conditions overseas
were presented, but not read: one by Dr. Mary
Blacklock, formerly of Sierra Leone, the other by Dr.
Mabel Brodie, now of Kedah, Malaya, and formerly
of Durham county council. The writers spoke upon
their papers and dominated the discussion, the most
important points of which were the solution of the
difficulties of welfare work amongst primitive races
where approach must be different from what it is in
England, and in places, such as parts of Australia,
where populations are sparse and distances enormous.
Of.special interest were Dr. Blacklock’s reference to
the “‘ hungry season” in Tropical Africa where the
natives live mainly by rude agriculture and have
recurrent seasons of short rations, often augmented
by failure of crops; the obstruction to sound mid-
wifery by tribal customs and religious prejudices and
the difficulty of implanting what was best in the
European system on what is good, or if not good
must be tolerated, of local tradition and practice.
It is surprising what progress has been made,
especially as in many parts of the Empire the official
health service has not the staff to attend to more
than the rudiments of sanitary administration.
PROGRESSIVE LEGISLATION
At the second session, which considered progressive
legislation in connexion with maternity and child
welfare, the chief speakers were Mr. R. J. Howard
Roberts of the London County Council and Miss
Eleanor Harwarden of South Africa. Two interesting
items of the discussion were a plea by Alderman Miss
Kellett of Shoreditch for convalescent homes for
mothers delivered in their own homes, and another
by Councillor Schwann of West Ham for control of
factory inspectors by local authorities. The latter is
an old contention, somewhat outside child welfare
proper, and it was not discussed. Dr. Ethel Cassie
of Birmingham called attention to the fact that
foster children can be dealt with under the maternity
and child welfare authority only until they are five
years old, after which age they must pass to the public
assistance committee which under the Children Acts
then take responsibility until the children are nine
years old. This matter, now it has been raised,
should be capable of adjustment without special
legislation. At the same session, Mrs, Braddock of
Liverpool restated her well-known objections to
children’s courts. Her views, if stated somewhat
more softly, would meet with much sympathy.
OTHER TOPICS
Two sessions on the second day were devoted to
the education of parents in the care of their children
and to nutritional problems in relation to parent and
child, Dame Enid Lyons of Australia presiding in the
morning and Dr. R. E. Wodehouse, Deputy Minister
of Public Health of Canada, in the afternoon. Papers
by Dr. Eric Pritchard, Dr. Ursula Cox, and Mrs.
Charlesworth (of Northampton Voluntary Infant
Welfare Association), Dr. Robert McCance, and Dr.
R. Jewesbury, describing situations not unfamiliar to
the British section of the audience, were very welcome
to the foreign visitors, for they brought out clearly
our ordinary everyday English child welfare practice.
Here was a case in which much was gained and
nothing lost by presenting old matter with no new
trimmings.
The last day touched more contentious subjects,
psychology in the morning and orthopedics in the
‘ MOTHERS AND CHILDREN .—THE SERVICES
[JUNE 12, 1937
afternoon. The chairman at the former was Dr. J. F.
Gaha, Minister of Health for Tasmania, and at the
latter, Dr. Josephine Baker, representing the U.S.A.
Government. The chief speakers on psychology were
Dr. Margaret Lowenfeld, hon. director of the Institute
of Child Psychology, and Dr. J. A. Hadfield, director
of studies at the Tavistock Clinic. Both dealt
with maladjustment and its prevention. Prof. Helen
Koch of Chicago described an experiment in treating
asocial children which is being tried with fair success
in America, Prevention was the keynote of this
session and the net result of the discussion was the
impression that lack of parental love was the primary
cause of asocial tendencies and neurotic perversions,
There was more than a suspicion that over-anxiety
to avoid the cedipus and electra complexes may
lead to the rupture of what might be called the
family love bond which ties the generations together
and is the base of our social conventions.
At the last session Dr. B. E. Schlesinger (Royal
Northern Hospital) spoke of the management of
child rheumatism, and Mr. E. S. Evans (Heatherwood
Hospital) on general orthopedics.
THE SERVICES `
ROYAL NAVAL MEDICAL SERVICE
Surg. Comdr. A. W. Gunn, M.V.O., to Hawkins.
Surg. Lt.-Comdr. C. Cussen promoted to rank of Surg.
Comdr.
Surg. Lt.-Comdrs. D. A. Newbery to Pembroke for
R.N.B. and to Sussex (on recommg.); and E. E. Malone
to Shropshire.
Surg. Lt.-Comdr. (D) J. C. Benson to Victory for R.N.B.
Surg. Lts. H. O’Connor to Inglefield; F. P. Ellis to
Victory for R.N. Hospital, Haslar; G. H. C. R. Critien
to Resolution ; G. R. Rhodes to Rochester; D. B. Jack
to Wildfire; and .F. W. Baskerville to Pembroke for
R.N.B. and to Sussex (qn recommg.).
Surg. Lt. (D) K. E. J. Fletcher to Suffolk.
The Gilbert Blane Medal for 1937 has been awarded
to Surg. Lt. W. J. Forbes Guild, M.B.St. And., of the
R.N. Hospital, Portland.
Surg. Lt. G. S. Thoms (not G. S. Thomas, as stated
last week) transferred to Permanent List.
ROYAL ARMY MEDICAL CORPS
TERRITORIAL ARMY
Capt. J. N. Russell to be Maj. i
Lts. J. R. Hamerton and J. R. Dawson to be Capts.
The annual competition for the Territorial Army
Ambulance Challenge Shield will be held at the Royal
Army Medical College, Millbank, London, S.W.1, on
Saturday, June 19th.
ROYAL AIR FORCE
Flying Offrs. promoted to the rank of Flight Lts. : R. F.
Courtin, R. M. Outfin, J. H. Neal, D. G. Smith, R. H.
Pratt, S. G. Gordon, J. C. Bowe, G. P. Jones, and J. G.
Rountree.
Flight Lt. C. F. R. Briggs to R.A.F. Station, Honington.
Flying Ofirs. W. T. Buckle to R.A.F. Station, Church
Fenton, and D. W. I. Thomas to R.A.F. Station,
Donibristle.
Dental Branch.—H. B. Shay is granted a non-permanent
commission as a Flying Offr. for three years on the active
list and is seconded for duty at Guy’s Hospital.
Flying Ofirs. A. P. Britton and A. J. S. Wilson promoted
to the rank of Flight Lts.
INDIAN MEDICAL SERVICE
Col. I. M. Macrae, C.I.E., O.B.E., K.H.P., to be Maj.-Gen.
. Lt.-Col. W. L. Watson, O.B.E., to be Col.
Indian Medical Department.—Sub,-Maj. and Hon, Lt.
Rai Sahib Madho Parshad to be Hon, Capt.
THE LANCET]
uae 12, 1937 1433
CORRESPONDENCE
ADLER AND THE GENERAL PRACTITIONER
To the Editor of THE LANCET
Sir,—May I add one thing to the excellent account
of the late Prof. Adler in your issue of June th.
It has been well said that a number. of medical
men after meeting Adler seemed to have found some-
thing entirely new and satisfying in their medical
practice; not just new knowledge but a new outlook
and a feeling that what they were doing was really
worth while. I should like to corroborate that remark
and I think the rapid success of the Medical Society of
' Individual Psychology, which now numbers 127
members, chiefly general practitioners, is evidence
of its truth. No one attending those meetings can
fail to observe the fresh interest which the Adlerian
concept has stimulated in the members and the way
in which the very type of case which was most
tiresome to them has now become one of the most
interesting. In view of the wide prevalence of the
minor as well as the major forms of psychoneuroges
I think it is clear that Adler’s influence will play an
important ` part in increasing: the efficiency and
helpfulness of general practice.
I am, Sir, yours faithfully,
W. LANGDON-BROWN.
Cavendish-square, W., June 25th.
DIAGNOSIS AND TREATMENT OF GASTRIC
AND DUODENAL ULCER .
To the Editor of THE LANCET
Sir,—Sir Arthur Hurst’s comments on my paper
require brief replies :—
1. Carcinoma.—I used the term “relatively ”
uncommon deliberately. One need hardly quote
figures to show that one sees 1 case of carcinoma for
every 10 or 12 of “‘simple”’ ulcer.
2. Incidence of gastric and duodenal ulcer.—Since
the general population is composed as to 90 per cent.
of the ‘hospital class,’ it is obvious that there
need be no quarrel between Sir Arthur Hurst and
myself on this score. Possibly the eminent writers of
text-books have taken their figures exclusively from
their rich patients. But I am still inclined to think
that surgical experience determined the usually
quoted figures of 4 duodenal to each gastric ulcer.
3. Blood m stools.—I specified the benzidine
reaction. The spectroscope was not used, nor do I see
the value of it in this connexion. One requires
a test with a certain ‘‘ threshold,” very much as the
Fehling reaction is designed to ignore the normal
100 mg. per 100 c.cm. of glucose in urine, The
tests were performed by the biochemical laboratory
of the hospital, under the direction of Mr. F. Morton,
B.Sc., A.I.C. I cannot see that other statements
made by Sir Arthur under this heading contradict
anything written in my paper.
4, Diagnosis.—Sir Arthur has quoted from my
paper in a way that has misrepresented what I said,
which was that while iron deficiency was the most
likely cause of anæmia with achlorhydria, it was
safest to assume that ulcer was present until proof
to the contrary was forthcoming, by negative stool
tests, absence of blood from test-meal, and negative
radiogram. I also, as stated in my paper, have not
seen achlorhydria with duodenal ulcer. My incidence
of achlorhydria with gastric ulcer was 2 in 39, Sir
Arthur’s is 1 in 114. No doubt if one accumulated
several hundred cases the true incidence would be
found, but I would not be particularly concerned if
it were proved that I were wrong, and that achlor-
hydria does not occur in gastric ulcer. Faber and others °
have shown that “ gastritis ” with diminished acidity
is the usual forerunner of ulcer; whether acid is
absent or only just present probably depends merely
on the number of functioning cells remaining.
5. Sir Arthur gives no reasons for his advocacy of
surgery. I remain convinced, as stated in the paper,
that beyond perforation, surgery is only justifiable
for gross anatomical deformities which make life
intolerable and which are unaffected by some months
of “ medical ” treatment.
I am, Sir, yours faithfully,
Birmingham, June 6th. DUNCAN Leys.
INFECTION THROUGH THE OLFACTORY
MUCOSA
To the Editor of THE LANCET
Sır —Not being a chemist by training I am
diffident of entering too deeply into what may be a
purely chemical controversy ; nevertheless I believe
that Dr. Pickworth’s letter in your issue of May Ist
merits some reply. .
When our work was begun I was of Dr. Pickworth’s
opinion that we were using a chemical solution.
However we soon discovered that, no matter what the
origin of the many samples of potassium ferro-
cyanide and iron ammonium citrate we used, when
equal volumes of 10 per cent. solution of these two
chemicals are mixed, granules and aggregates of
granules are formed, On first mixing the fluid remains -
clear, but after a few seconds turns cloudy. If this
change be followed under the microscope it will
be seen that the clouding is due to a formation
of particles (singly or in aggregates) throughout the
fluid. The particles vary in size but many are about
0-2 micron in diameter, which is of the same order
of magnitude as the prussian-blue particles demon-
strable in the tissues after fixation and only slightly
smaller than pneumococci. They can be thrown out
of suspension in an angle centrifuge, quite an appre-
ciable amount being deposited in 15 minutes at
3500 r.p.m. We have also noted that the formation
of these particles is brought about, in part, by visible
wave-lengths at the blue end of the spectrum, actually
by those waves shorter than 5000 A°. Any mixing
of the two solutions by daylight will certainly cause
the particles to form; moreover we have been
unable to prevent the formation of particles, albeit
in smaller numbers, even by carrying out the manipula-
tions in the dark room.
As to the chemical nature of the particles or granules
used, I believe that they are prussian blue. My
belief is based largely on the personal assurance
given me by many expert chemists. Perhaps also
I may be allowed to quote from Mellor (Modern
Inorganic Chemistry, 8th edition, London, 1936) ;
he says that prussian blue “‘ is formed when a solution
of potassium ferrocyanide is added to a solution of a
ferric salt. It is insoluble in hydrochloric acid, but
soluble in oxalic acid forming a deep blue solution.
Besides the ‘insoluble’ Prussian blue, a soluble or
colloidal Prussian blue is formed when a ferric salt
is added to a solution of potassium ferrocyanide or a
ferrous salt to a solution of potassium ferricyanide.
By the addition of salt to the solution, the ‘ soluble’
Prussian blue is coagulated ‘or salted out’ and the
1434 THE LANCET]
precipitate is then ‘insoluble’ Prussian blue.” (The
italics and inverted commas are Mellor’s.)
It will be clear to Dr. Pickworth, I hope, that
if I have misinterpreted Le Gros Clark I have done
so not because of mere assumption on my part, but
. because our investigations had led to the belief that
Clark was using a suspension of particles. Indeed
it is difficult for me to believe that he did not, despite
Dr. Pickworth’s statements to the contrary. I must,
however, take this opportunity of thanking Dr.
Pickworth for again drawing my attention to this
point and leading me to study the matter further.
Since reading his letter I have reinvestigated most of
the former work and have taken the further step
of testing the behaviour of our mixture of potassium
ferrocyanide and iron ammonium citrate when sub-
jected to ultra-filtration through a Cellophane mem-
brane. This has shown that soluble prussian blue in
our mixture will pass through membranes which hold
back serum proteins. It would seem, therefore, from
this most recent work that, in actual fact, we are
dealing with a suspension of prussian-blue particles
in a solution of prussian blue. Any further informa-
tion which Dr. Pickworth has on the point would be
most welcome.
Finally, even leaving the ‘‘ supposed passage of
particles ” out of the question, I cannot agree with
Dr. Pickworth that I used bacteriological methods
only. Surely he does not consider the direct micro-
scopical demonstration of pneumococci in the peri-
neural spaces, in the subarachnoid space, and in the
cells of the pia mater within two minutes of their
being instilled into the nose a bacteriological method
only. I am, Sir, yours faithfully,
4
G. W. RAKE.
Poona ugur Laboratories, University of Toronto,
Canada, May 25th.
MIDDLE-EAR DISEASE
To the Editor of THE LANCET
SıR,—Otitis media is of perennial interest to general
practitioners, and your weighty remarks thereon
prompt me to record the following experience. At
the end of 1930 I treated for a long time a man with
the most profuse and persistent otorrhea I can
remember, and by the irony of fate it followed on
the only paracentesis I had ever performed—I believe
quite correctly. In despair he asked me to try any-
thing short of operation so after some months I one
day washed out his ear with staphylococcus anti-
virus liquid and left some of the fluid in situ. The result
was dramatic, for he failed to come again as instructed,
and when, after six days, I searched him out he
said he was cured. Actually he had had no discharge
for three days and only a slight dampness since.
After a few more treatments his ear was quite dry
and has remained so.
This was, I believe, the first such case ever treated
in this way, and it was certainly the start of the fairly
widely adopted treatment of otitis media by anti-
virus preparations (not that all cases respond so
rapidly as he did). It is, unfortunately, often con-
sidered unscientific because it is said to lack a sound
theoretical basis ; but surely the scientific attitude is
to observe and try to appreciate results and then
seek to find the underlying theory. Whatever the
rationale of the method may be, I know of no more
convincing demonstration of the potency of a bio-
logical preparation than to watch the extraordinary
way it will determine improvement in a few hours
in an inflamed, and even bulging, ear drum, which
may return to normal within two or three days.
MIDDLE-EAR DISEASE
{JUNE 12, 1937
One of my earliest cases was that of my own little
son, aged three, who for a whole day had been crying
with earache while I tried the effect of one after
another of the ordinary and proprietary preparations
without avail. ‘To watch him settle down to a quiet
sleep within half an hour of instilling the antivirus
was one of the most gratifying experiences of twenty-
odd years’ practice, and it has been no less satis-
factory to hear of similar results in nearly every case
of earache I have treated in this way since. Later
on, at my suggestion, antivirus was put up in a jelly
form which is much easier to use in these cases and
gives results almost equally good.
Where the issues are so serious I would not like
to seem to say a word against the operation of
paracentesis, but I would like to urge that prac-
titioners and otologists alike should carry a tube of
antivirus jelly in their bags, and that they shoald
instil some as soon as they have had a good look
at the tympanum. They can then make preparations
for paracentesis if they wish; but unless my almost
consistent experience is exceptional they will usually
find that in a short time the pain will have gone and
tHe need for operation will have passed. What the
effect would be in the so-called silent cases or tuber-
culous ones I do not know, nor do I prophesy, but I
am sure that it is a line of treatment abundantly
worth trying. I am, Sir, yours faithfully,
Winsford, Cheshire, May 29th. W. N. LEAK.
LEFT INFRAMAMMARY PAIN
To the Editor of THE LANCET
SIR, —I read with much interest the article on this
subject in your issue of May 29th by Drs. Shirley
Smith, Stephen Hall, and Jocelyn Patterson, especially
on ‘‘ the disturbance of the heart muscle either from
lack of sugar supply or inability to metabolise sugar.”
Having had a large experience of such cases in
hospital and private practice I would like to refer to
the more common causes of this pain and effective
methods for its relief. Exposure of the chest to cold,
physical fatigue, and a rheumatic temperament are
among the many causes of this trouble. Treatment:
after consideration of the history, occupation, and
temperament and a thorough examination of the
heart and circulation have been made with a negative
result, the probability is that the intercostal muscles
are affected and that rest is the more hopeful method
of giving relief. I have several strips of plaster
about 14 in. wide of sufficient length to extend from
the spine to the middle of the chest in front. If
possible the patient stands erect steadifixing his
body by holding his hand to a mantelpiece; the
plaster is first fixed on the spine and firmly brought
round the side of the chest. Three or four strips
are generally sufficient. The effect is sometimes
quite dramatic. For the next few days treatment of
the possible cause is carried on. If after removal of
the strips the pain remains the treatment is repeated.
At times a dull ache remains, when a liniment
containing menthol and methyl salicylate will complete
the cure. I am, Sir, yours faithfully,
CHARLES W. CHAPMAN.
Wimpole-street, W., June 8th. .
METHODS OF DESTROYING BED-BUGS
To the Editor of THE LANCET
Sir,—In your issue of May Ist Mr. J. M. Holborn
makes certain criticisms of the use of heavy coal-tar
naphtha for the destruction of bed-bugs, according to
the method we described (Lancet, Feb. 27th, 1937,
l
THE LANCET]
p. 530).
reply :—
(1) Toxicity to insects.—To ensure a 100 per cent. kill
of both insects and eggs at a temperature of 65-70° F.
an exposure of at least 18 hours is necessary and we are not
surprised at the poor results obtained by Mr. Holborn
~ in an experiment using an exposure of only 6 hours.
(2) Toxicity to man and animals.—Naphtha vapour has
an irritant action on the eyes and for this reason gas-masks
are worn during fumigation. The specification framed to
govern the supply of naphtha makes no attempt to ensure
the absence of mesitylene. A proportion of this, together
with its isomer pseudocumene, is present; but from the
results of an extensive series of toxicity experiments
with animals we are satisfied that danger to man from this
constituent, or the naphtha in its entirety, is not to be
apprehended.
(3) Fire and, explosion risk.—While all reasonable care
must be exercised when naphtha is being handled or
sprayed we are of opinion that the concentration of vapour
which might be expected to leak into adjoining premises
would not inflame when brought into contact with a naked
light. In regard to explosion risk, the vapour concentration
at 65° F. is only one-eighth of the lowest explosive con-
centration. ;
(4) Odour.—The odour of naphtha vapour is penetrating
but not unpleasant, and few complaints have been received
from the occupants of adjoining houses.
We should like to emphasise that whilst naphtha
is also a contact insecticide, it is the lethal property
of the vapour which makes it so efficacious for the
destruction of bed-bugs in infested houses. Since
our original publication we have improved the
technique of distributing the vapour in rooms by
the use of blankets wetted with naphtha and sus-
To these criticisms we offer the following
OBITUARY
[JUNE 12, 1937 1435
pended near the ceiling and down the walls. In
this way all likely harbourages, including ceiling
cracks, will receive a lethal concentration of vapour.
Mr. Holborn points out that the quantity of naphtha
used is ten times the lethal dose, and it may be stated
that this amount is necessary to allow for loss of
vapour through diffusion, absorption, and air changes.
Mr. Holborn, and later Mr. Mellanby, indicate
the possibilities of contact insecticides for use
in occupied houses. Such measures are helpful
in dealing with a light infestation, but in our opinion
a heavy infestation can only be dealt with success-
fully by a fumigation process. The premises must
be vacated but the furniture can be treated in
situ with heavy naphtha. Experiments have been
carried out which promise well for the use of heavy
naphtha for van fumigation, and further research
in this direction is in progress.
We agree as to the desirability of knowing the
nature and amounts of the toxic constituents, and
would point out that research into this question is
in hand. If and when this information is available
it must not be forgotten that the isolation of the
lethal constituent or constituents would give a
product of greatly increased price, and unless possessed
of exceptional properties, this would hardly be
expected to replace naphtha for practical fumigation
purposes.
We are, Sir, yours faithfully,
S. A. ASHMORE,
Government Laboratory, Clements Inn Passage; and
A. W. McKENNY HUGHES,
Dept. of Entomology, British Museum (Natural
June 5th. . History).
OBITUARY
WILLIAM FRYER HARVEY, M.B. Oxon.
Dr. W. F. Harvey, who died on June 4th at his
home in Letchworth at the age of 52, was an Oxford
medical graduate, qualifying belatedly in 1917
after a period of ill health. But his chosen profession
early surrendered him to letters, where his heart
was from the beginning. One of a family of seven
brothers and sisters in a household full of intellectual
stimulus, he was always reading widely and desul-
torily, and even as a child was rarely to be seen
without a pencil in his hand. His book entitled
‘ We were Seven” which appeared less than a
year ago, contains a series of contemporaneous
pictures of his youth; for he was able apparently
in writing it to reproduce his own feelings at the
time of the happenings, so that the book is neither
a biography nor a psychological study, but is an
inquiry into the mind of the child in a happy family
circle. Not that he lacked the faculty of judging
Parenthood, as is evident to those who noted his
initials at the foot of a bogus report of the Hampstead
branch of the Parent Study Association (Lancet,
May 6th, 1933) when the “ problem parent” was
submitted to careful analysis ; and yet kindly analysis,
for Harvey’s great interest was in the foibles of good
people, and as a satirist of the Society of Friends,
to which he belonged, he did it a valuable service.
Accounts of his life in the daily press have laid stress
on an act of heroism when he was surgeon-lieutenant
in the Navy and completed an amputation on a
wounded fellow officer in the engine-room of a sinking
destroyer. For this act he was awarded the high
distinction of the Albert medal; but the incident
almost escaped record because Harvey forgot about
it himself, taking it simply in his stride as part of
war-time medical work. Pacific himself in thought
and in practice he was always unwilling to accept
security at the expense of others’ danger and hazard.
Dr. Harvey married Miss Margaret Henderson.
He leaves two children, a boy and a girl.
CHARLES H. SHORNEY WEBB, M.S. Lond.,
F.R.C.S. Eng.
On June Ist Mr. Shorney Webb died of infective
endocarditis in the Middlesex Hospital where he
received his medical education and where for a dozen
years, before the breakdown that crippled his life,
he had been a briliant member of the honorary
surgical staff. Webb, writes a former surgical
colleague, had a fine academic career, gaining honours
and distinctions not only in the Middlesex school
but also in the University of London; he was only
the fourth Middlesex student to secure the M.S.
degree, and obtained marks qualifying for the gold
medal on that occasion. During his tenure of a
‘surgical registrarship at the hospital the wanderlust
seized him, and he served in the Balkan campaign
of 1912; in 1914 the first day of the late war saw
him eager alike for adventure and to place his talents
at the disposal of the British wounded. Webb
landed in the original Expeditionary Force with the
fourth casualty clearing station, a unit with which
he remained until 1918, when he was appointed to the
charge of a surgical division of the 24th general
hospital at Etaples. At a time when opinion was
still divided as to the desirability of exploration for
gunshot wounds of the abdomen, he was one of the
first to operate for this type of injury. To Owen
Richards, of course, belongs the credit of demonstrat-
ing and of urging the need of surgery in these particular
1436 THE LANCET]
wounds of warfare, but the first considerable com-
munication dealing with the subject was written by
Webb and Milligan.
Elected in absentia to the honorary staff of his old
hospital during the war years, he did not assume his
duties until after the armistice. Possessed of a far
greater operative experience than usually belongs
to a newly appointed assistant surgeon, Webb proved
himself also a fine teacher, acquiring a popularity
with the students akin to that which he had enjoyed
among his colleagues in his early days and in France,
while his surgical advice and services were sought
by his colleagues and their families. And later,
PUBLIC HEALTH
[JUNE 12, 1937
when he was again able to lead an active life, he
became a valued operating surgeon to the Middlesex
county council.
Webb’s gifts were many. He was a fine linguist ;
a lover of music, he played piano and organ; he
loved churches and old ecclesiastical architecture ;.
and the memory may still linger in the minds of his
war-comrades of the strains of some church organ,
by strange caprice intact, pealing forth from a ruined
church without roof, with walls wide open to the air,
an anthem perchance strange to the rude ears of that
time, and within a debonair surgeon playing intently
and with an exquisite skill. G. G.-T.
PUBLIC HEALTH
The New Scottish Maternity Services
Tuts. week local authorities of Scotland have been
called upon to submit schemes under the Maternity
Services (Scotland) Act, 1937, which: came into
operation on May 16th. The schemes must secure
that there are available to every woman who is to
be confined in her own home and who applies to the
local authority, facilities for :—
(a) the services of a certified midwife before and during
childbirth and until the end of the lying-in period ;
(b) medical examination and treatment during preg-
nancy, including at least three prenatal examinations ;
(c) medical supervision during childbirth and the lying-
in period ;
(d) medical examination at least once after the expiry
of one month after childbirth ;
(e) the services of an anesthetist when recommended
by the medical practitioner ; and
(f) the services of an obstetrician where necessary and
practicable.
The general object of the Act is to provide, for
women who are to be confined in their own homes,
care and treatment based on the team-work of doctor,
midwife, and consultant. This is a much wider
object than that of the English Act of last year, which
provided only for a service of midwives. The
maternal death-rate is much higher in Scotland than
in England and the conditions of midwifery practice
are different, doctors engaging in it to a greater
extent. A Government grant, equivalent to half
the additional expenditure involved but scaled up
or down according to the needs of the area, will be
payable on the new schemes. Fees will be paid by
the women in so far as they are able to pay, but no
charges will be made to the necessitous, and insured
women, the wives of insured men, and others in like
economic circumstances are likely to obtain the whole
range of services for an inclusive fee that will be little,
if at all, more than they pay at present for a midwife
alone. Local authorities are asked to aim at giving
the women as wide a choice as is practicable of
doctor and midwife. Though they must provide
the services specified in the Act, they will have a
fairly free hand in the actual arrangements they
may make. Thus they may arrange to have the
midwifery service provided through voluntary associa-
tions, or they may themselves pay midwives in private
practice on a fee basis, or they may employ a whole-
time salaried staff of midwives. As regards the
medical services, the Department suggest that
probably most authorities will throw this service
open to all general practitioners who desire to take
part in it. The Department, however, will be pre-
pared to consider alternative proposals. The
remuneration of the doctors to be employed is under
discussion.
Consulting obstetricians, the Department say,
should be obtainable in the four teaching centres and
surrounding areas and in places where maternity
hospitals employing resident obstetricians have been
established. ‘If. obstetrical specialists are made
widely available throughout Scotland, a great step
will have been taken towards raising the standard
of domiciliary midwifery. Accordingly, the Depart-
ment will expect local authorities to make every
reasonable effort to overcome any difficulties with
which they may be faced ” in obtaining this expert
service.
Compensation will be paid to midwives who,
within a specified period, surrender their certificates
either voluntarily or by direction of the local authority.
Half the cost of this compensation will be refunded
by the State.
INFECTIOUS DISEASE
IN ENGLAND AND WALES DURING THE WEEK ENDED
MAY 29TH, 1937
Notifications.—The following cases of infectious
disease were notified during the week: Small-pox,
0; scarlet fever, 1477 ; diphtheria, 916; enteric
fever, 28; pneumonia (primary or influenzal), 765 ;
puerperal fever, 39; puerperal pyrexia, 138 ; cerebro-
spinal fever, 24; acute poliomyelitis, 9; polio-
encephalitis, 1 ; encephalitis lethargica, 5; continued
fever, 1 (St. Pancras); dysentery, 26; ophthalmia
neonatorum, 94. 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 June 4th was 2948 which included: Scarlet
fever, 750; diphtheria, 843; measles, 84; whooping-cough,
485; puerpera fever, 23 mothers (plus 14 babies) ; ; encephalitis
letbargica, 282; poliomyelitis, 1. At S et’s Hospital
there were 27 babies (plus 18 mothers) vith opht
neonatorum.
Deaths.—In 123 great towns, including London,
there was no death from small-pox, 2 (0) from enteric
fever, 16 (0) from measles, 4 (1) from scarlet fever,
11 (4) from whooping-cough, 25 (4) from diphtheria,
60 (15) from diarrhoea and enteritis under two years,
and 22 (5) from influenza. The figures in parentheses
are those for London itself.
Tottenham and Nottingham each had one death from enteric
fever; Birmingham 3 deaths from measles. There were 3 fatal
cases of diarrhoea at Croydon, Liverpool, Bir » and
Stoke-on-Trent.
The number of stillbirths notified during the week was
307 (corresponding to a rate of 39 per 1000 total
births), including 41 in London.
CENTENARY OF CARDIFF ROYAL INFIRMARY. —
During last week as part of the centenary appeal of this
hospital for £250,000 a special service was held at St. John’s
Church and a centenary commemoration dinner at the
City Hall, at which Lord Horder was the principal guest.
On June 6th Lord Dawson broadcast an appeal for the
hospital on the National Programme,
THE LANCET]
[JUNE 12, 1937 1437
MEDICAL NEWS
University of Oxford
Dr. A. H. T. Robb-Smith, lecturer in morbid anatomy
and histology at St. Bartholomew’s Hospital, has been
appointed assistant director of pathology under Lord
Nuffield’s benefaction as from Sept. Ist.
Dr. Robb-Smith was educated at Epsom College and
- St. Bartholomew’s Hospital. He graduated M.B. in 1930 and
after holding resident appointments at St. Bartholomew’s
was made junior demonstrator of clinical pathology ; in
1933 he became senior demonstrator of pathology. The following
ear he wasawarded a Dorothy Temple Cross research fellowship
y the Medical Research Council and was granted leave for a
year’s work abroad under Prof. Ludwig Aschoff at Freiburg
and under Dr. del Rio Hortega in Madrid. On returning to
England in 1936 he became lecturer in morbid anatomy and
histology at St. Bartholomew’s and in the same year wasawarded
the university gold medal for his M.D. thesis on hyperplasia and
neoplasia of the lympho-reticular tissue.
University of Cambridge
Prof. H. R. Dean, F.R.C.P., Master of Trinity Hall,
has been elected vice-chancellor of the University. |
Titles of degrees have lately been conferred on the
following :—
M.B., B.Chir.—J. C. Drury.
M.B.—M. E. Barnard, D. M. Norman-Jones, and O. K.
Wilson.
An announcement will be fọund in our advertisement
columns of an E. G. Fearnsides scholarship for clinical
research on the organic diseases of the nervous system which
is open to men or women who have passed the Third M.B.
examination or Part II of the natural sciences tripos.
Applications should be sent to university registrary before
July 12th.
University of London
At recent examinations the following candidates were
successful :— i
THIRD EXAMINATION FOR M.B., B.S.
A. S. Aldis, B.Sc. (e), Univ. Col. ; M.S. Campbell (a), Middlesex;
H. W.C. er (a, b, d, and University medal) and A. J. Heriot (b),
King’s Coll. ; Å. N. G. Hudson (b), Middlesex; Josep
Ketcher (b), London ; C. J. Longland (a), St. Bart.’s ; Elizabeth J.
Rooke (e), Univ. Coll.; F. H. Scadding (a), Middlesex; and
R. C. Wofinden (c, e), St. Mary’s (all with-honours). H. I. C.
Balfour, St. Bart.’s ; J. D. Ball, Middlesex; Marjorie Bolton,
Roy. Free; E. R. Bowes, Guy’s; M. A. Carpenter and J. E.
Cates, St. Bart.’s ; Norah H. C. Clarke and May D. C. Clifford,
Roy. Free; P. R. K. Coe, Westminster; J.C. Colbeck, Guy’s ;
W. J. C. Crisp, Univ. Coll.; J. A. Currie, St. Thomas’s; J. B.
Cuthbert, St. Bart.’s ; Mary D. Daley, Roy. Free; H.J. Davies,
Univ. Coll. ; G. S. W. de Saram, St. Bart.’s and Ceylon Med.
Coll.; W. R. S. Doll, St. Thomas’s ; I. A. Donaldson, Middlesex ;
A. C. Dornhorst, St. Thomas’s; G. H. H. Dunkerton, King’s
. A. Dunlop Katherine W. Dunn-
Pattison, Roy. Free ; Hi. J. Eastes, Univ. Coll. ; Gwendoline M.
A.M. Herford, Roy. Free; J. R. Hill, S D. N. Hill,
T. H. Hils, Guy’s; Jacob Horowitz, Univ.
Coll. ; T. E. Howell, Guy’s; Sybil M. Hum hreys, Univ. Cou
Jenkins, Univ. Coll.; Mary Kane, Univ. Coll., Cardiff; J. W.M.
Leslie, St. Thomas’s : Oswald
Lloyd, Middlesex ; D. de la C. MacCarthy and T. O. McKane,
. J. Mann, Univ. Coll. ; . E. y
Roy. Free: A. E. Miller, Middlesex ; A. G. Moore, St. Thomas’s ;
Reilly, St. Mary's: Eliz
f . Roualleand L. J. Sandell, St. Bart.’s ; R.S. P. Schilling,
Sarah C. B. Walker, Roy. Free;
A. J. N. Warrack, St. Thomas’s; Lilian H. Walter and Joan M.
The following students have passed in one of the two
groups of subjects :—
Group I.—Laura M. Bates, John Bleakley, Katharine M. H.
Branson, F. J. Brice, K. C. Brown, Margaret M. Burton, Dorothy
R. Clarke, A. L. Collins, G. H. Darke, Cecile R. Doniger, Gertrude
L. E. Dudderidge, Mary N. Fawcett, W. B. Foster, J. P. Fox,
W. A. J. Fox, Audrey U. Fraser, Rachel Goldenberg, J. H.
Goonewardene, Douglas Graham Brown, A. G. Hemsley, George
Herbert, K. R. Hil, Jack Hoadley, J. G. Humble, Harry
Jackson, S. J. Johnson, Arthur Jordan, Harry Josephs Gladys E.
Keith, A. R. R. Kent, B. S. Kent, G. M. Kerr, Iris M. Lamey,
- Myer Lubran, W. H. McDonald, H. A. C. Mason,
J. D. Laycock, O. C. Levine, B. G. A. Lilw A. E. Loden,
. W. Moynagh,_
Mary G. Murph , J. H. F. Norbury, M. G. O'Flynn, A.C. D.
Parsons, Edith A. S. Parry-Evans, V. G. Peckar . M. Philip,
R. E. A. Price, Nancy E. G. Richardson, A. C. Ricks, G. ro
Tresidder, P. W. Vilain, R. R. Willcox, and M. R. Woods.
Group II ae J. Allardice, D. R. Ashton, D. W. Beynon, |
T. K. Bradford, J. D. Bradley-Watson, D. W. J. Cohen, Montague `
Curwen, P. H. Denton, J. E. Ennis, E. H. Hambly, D. H.
Harrison, R. Jones, E. R. Mountjoy Dakara roppillat
Ponnampalam, S. H. Raza, Mary C. Rowe, C. P. Sames, J. A.
Seri E. R. Smith, G. R. Steed, G. A. van Someren, and G. R.
aterman.
to) distinguished in forensic medicine and hygiene. (d) distin-
Arpi in surgery. (e) distinguished in obstetrics and gynæ-
Applications are invited not later than July 1st for the..
Laura de Saliceto studentship for the advancement of
cancer research which is worth £150 a year and is tenable
for not less than two years. Further information may be..
had from the academic registrar of the University, W.C.1.
Society of Apothecaries of London
The following candidates have satisfied the examiners.
for the Mastery of Midwifery :—
Isobel McA. Brown, Henry Canwarden, M. S. B. A. Hamid,
Bessie Hatherley, Stanley Henderson, Isabella A. Milne, Margaret
C. O’Brien, and A. A. Weinbrenn.
Royal College of Physicians of Edinburgh
On Thursday and Friday, June 17th and 18th, at.
5 P.M., Dr. R. Q. Gordon will deliver the Morison lectures.
to the College. He will speak on the neuropsychological,
basis of conduct disorder. :
Royal Faculty of Physicians and Surgeons of Glasgow.
At a meeting of the faculty held on June 7th, with Prof.
Archibald Young, the president, in the chair, the following
candidates were admitted to the fellowship :—
Mohamed Salleh Bin Abdul Hamid (London) ; James Holmes
Hutchison and Herbert Derek Brown Kelly '(Glasgow); Bal
Krishna and Kedar Nath Sinha (London); and Helen Frances
Wingate (Glasgow). f
Oxford Ophthalmological Congres s
The twenty-sixth annual meeting of the Oxford Ophthal.
mological Congress, founded by the late Robert W. Doyne,
`- will be held on July 8th, 9th, and 10th, at Keble College,
Oxford. The members will be welcomed by Mr. C. G.
Russ Wood (Oxford), the master, and afterwards Mr.
N. Bishop Harman (London), and Mr. Arnold Sorsby.
(London), will open a discussion on the problem of myopia,
and Mr. T. Harrison Butler (Birmingham) will read a
paper on lenticonus posterior and allied anomalies at the.
posterior pole. In the afternoon Group-Captain W.
Guilfoyle will describe the experiences of an uniocular.
pilot of aircraft and Wing-Commander P. C. Livingston
will discuss the same subject. Mr. Bernard Chavasse.
(Liverpool) will speak on the transconjunctival approach
to the inferior oblique. On the second day of the meeting
Sir Walter Langdon-Brown will read a paper on hormones.
and vitamins in ophthalmology. Dr. Arthur J. Bedell
will give a demonstration of photographs of the fundus.
in colour with a clinical digest. The Doyne memorial lecture.
was to have been given by the late Dr. David James Wood
(Cape Town), who died suddenly on March 18th. He had
completed his paper on night blindness, shortly before.
his death, and it will be read to the meeting by his colleague.
Dr. R. C. J. Meyer (Johannesburg). Papers will be read in
the afternoon by Prof. Joseph Imre (Budapest) on plastic
surgery of the eyelids, by Dr. Joseph Dallos (Budapest),
on the individual fitting of contact glasses, and by Mr.
J. W. Tudor Thomas (Cardiff) on the technique of corneal,
transplantation, with recent modifications. After the.
annual general meeting on the morning of July 10th,
Dr. Bernard Samuels (New York) will speak on the histo-
pathology of papilledema, Mr. E. F. King (London) on
the classification of the ocular melanomata, and Dr. D. V.
Girl (Eastbourne) on a new method of advancement.
with a single one-armed suture. The annual dinner of the.
congress will take place on Jtly 8th. Further information |
may be had from the secretary of the congress, Dr. F. A.
Anderson, 12, St. John’s-hill, Shrewsbury.
1438 THE LANCET]
University College Hospital
Men students of University College Hospital who have
held a resident appointment there are invited to apply for
a Bilton Pollard fellowship of an annual value of £650.
Further particulars will be found in our advertisement
columns.
London Hospital
The King has consented to become patron of this
hospital. Queen Mary will continue to hold the office
of president. As a memorial to the late Sir Ernest Morris,
it 1s proposed to extend the clinical laboratories, towards
the cost of which he had collected £3000.
St. Bartholomew’s Hospital
Particulars are given in the Medical Diary in another
column of a post-graduate course which will be held at
this hospital on June 17th, 18th, and 19th. The course
is open to all medical men but early application should be
made to the dean of the hospital. ;
Pharmaceutical Society of Great Britain
At the June council meeting Mr. Thomas Marns was
re-elected president, Mr. E. T. Neathercoat was re-elected
treasurer, and Mr. Thomas Guthrie was elected vice-
president, Mr. J. H. Franklin was codpted a member
of the council to fill the vacancy caused by the death
of Mr. E. H. Simmons.
Joint Tuberculosis Council
At the May meeting it was announced that 750 copies
of the Councils: memo on Tuberculosis Among Nurses
had been printed and that the Medical Research Council
were considering the republication of the memos by
Drs. W. H. Tytler and Peter Edwards on The Micro-
scopic and Cultural Examination of Sputum. After a
discussion on the Empire Conference on the Care and
After Care of the Tuberculous it was decided to form a
committee—comprising Dr, S. Vere Pearson (convener),
Profs. W. W. Jameson and S. Lyle Cummins, with
Drs. Jane Walker, J. B. McDougall, F. R. G. Heaf, and
F. W. Goodbody—‘ to consider what help this council
can give the colonies in their effort to control tuber-
culosis.” The question of holidays with pay was placed
on the agenda for the next meeting.
Medical Tour to Russia
The Society for Cultural Relations is this year again
organising a tour for medical visitors to the Soviet Union.
The group will leave London on July 17th and visits will
be paid to Leningrad, Moscow, Kharkov, and Kiev.
They will return to London on August 8th. Opportunities
will be given to members to visit hospitals, dispensaries
attached to factories, venereal disease clinics, and prophy-
lactoria (preventive clinics). A member of the society’s
medical and public health section will lead the group,
and if possible arrangements will be made for members
to see any specialised branch of medicine in which they are
interested. Further information may be had from the
secretary of the society, 98, Gower-street, London, W.C.1.
Fellowship of Medicine and Post-Graduate Medical
Association
An all-day course in gynecology will take place at the
Chelsea Hospital for Women from June 14th to June 26th.
Courses have been arranged for M.R.C.P. candidates in
neurology at the West End Hospital for Nervous Diseases,
in the afternoon (June 2lst to July 3rd); in tuberculosis
at Preston Hall, Maidstone, on July 3rd. Other courses
will be held in proctology at St. Mark’s Hospital (July 5th
to 10th); in dermatology at the Hospital for Diseases of
the Skin, Blackfriars (afternoons, July 12th to 24th);
in urology, at All Saints’ Hospital (afternoons, July 12th
to 3lst). Week-end courses will be given in general surgery
at the Prince of Wales’s Hospital (June 19th and 20th) ;
in diseases of the heart and lungs at the London Chest
Hospital, Victoria Park (July 3rd and 4th); in medicine
and surgery at the Miller General Hospital (July 10th and
llth). Courses are open only to members, and full
particulars may be had from the secretary of the Fellow-
ship, 1, Wimpole-street, London, W.1.
MEDICAL NEWS.— APPOINTMENTS
| [JUNE 12, 1937
St. Thomas’s Hospital
On Tuesday, June 29th, at 3 p.m., Sir Farquhar Buzzard,
regius professor of medicine in the University of Oxford,
‘will distribute the prizes at this hospital.
Birmingham Hospitals Centre
It is thought that a portion of this great centre may be
open next spring. The foundation stone was laid in
October, 1934. The first part of the scheme comprises .
a general hospital of 500 beds complete with all services,
a nurses’ home, and the medical school buildings. The
nurses’ home will accommodate 350,
A Fever Hospital in Spain
In view of the increasing danger of epidemics in Spain
the Holborn and West Central London Committee for
Spanish Medical Aid (6, Gordon-square. W.C.1) was
asked a month ago to provide a bacteriologist and equip-
ment for a fever hospital on the Madrid front. Withia
a fortnight it had sent out to Valencia a doctor, a bacterio-
logist, and an assistant, with enough material for a small
laboratory. An hotel has been taken over at Cuenca, 70
miles from Madrid, which will hold 150-200 patients, but it
lacks equipment, Beds, bedding, and linen can be bought
cheaply in Spain, and money for this is urgently needed.
The initial outlay was £300, and the bacteriologist has now
called for a further £200 for buying additional equipment
in Spain. The committee is at present able to send only
£50 and is trying to raise the further £150 within a week.
Prostitution and Venereal Disease
The International Abolitionist Federation held a congress
in Paris from May 20th to 22nd, when a number of dele-
gates, both French and foreign, paid tribute to the Minister
for Public Health, M. Henri Sellier, for taking responsi-
bility for the first Bill introduced by a French Government
which forbids traffic in women in all its manifestations.
After hearing reports from Dr. Hermans (Holland), Prof.
Geméhling (France), and Miss Alison Neilans (general
secretary of the Association for Moral and Social Hygiene),
the congress adopted resolutions pointing out that prosti-
tution cannot in itself constitute a punishable offence,
but that public authorities cannot be. indifferent to its
public manifestations. The measures adopted to stop
street solicitation must be applied to men as well as to
women; their enforcement should be entrusted to the
common-law police and must not be arbitrary. A service
of women police should be everywhere established, with
the special duty of assuring the protection of children
and to give assistance to women who need their help.
The réle of the law, in combating prostitution, should
consist, above all, in forbidding procuration in all its
forms. The modern struggle against venereal diseases
must be based on liberty; treatment must be voluntary,
free, and confidential, and it is unjustifiable to impose
coercive measures on certain sections of the population.
Appointments
Boyrp, M. R. E., M.B. Dubl. oy Resident Medical Officer
at the Ilford Maternity
CRAIG, JENNY D., M.B Yfanch., Assistant School Medical
Officer for Huddersfield.
DIGGLE, W. S., M.Ch. Orth. Liverp., F.R.C.S. Eng., Hon.
Orthopsedic Surgeon to the Bootle General Hospital.
FLEMING, H. T., M.B. Dubl., F.R.C.S. Eng. and Irel., Surgeon-
Superintendent at the Fermanagh County ’ Hospital,
Enni aay ce
GRAY, S. T. G., M.B. Aberd., D.P.H., Assistant County Medical
Officer and Assistant "School ‘Medical Officer for West
Sulfolk.
MoGuckIN, FRANCIS, M.D. Durh., F.R.C.S. Edin., Hon. Assistant
to the Throat and Ear Department of the Royal Victoria
Infirmary, Newcastle-upon-Tyne.
Rackow, A. M., M.B. Lond., D.M.R.E., Hon. Radiologist to
the Princess Louise Kensington Hospital for Children.
Rose, I., M.B. Leeds, Resident Medical Officer at the St. Helen
General Hospital, Barnsley.
SAINT, J. H., M.D. Durh., M.S. Minn. F.R.C.S. Eng., F.A.C.5.,
Hon. Assistant Surgeon to the Royal Victoria Infirmary,
Newcastle-upon-Tyne.
SCHOLEFIELD, JOHN, M.B. Le eds, F.R.C.S. Eng., Resident
Surgical Officer at the Prince of Wales's Hospital, Plymouth.
Core lag Surgeon under the Factory and Worksho ies
J. L. HILL (Newport, District, Monmouth) ; r. J.
NOORE (St. Austell District, Cornwall).
THE LANCET]
[JUNE 12, 1937 1439
PARLIAMENTARY INTELLIGENCE
HEALTH AND HOUSING
IN committee of the House of Commons on June 8th,
on a supply vote for the Ministry of Health, Sir
KINGSLEY Woop, Minister of Health, said that
the estimates for health services amounted to over
£22,000,000, and the total for all the departmental
services reached £166,000,000. There was an increase
of over £500,000 compared with the current year.
The slum clearance campaign was responsible for an
additional sum of £500,000 in respect of new houses,
and a new item in the estimates was £207,000 for
grants under the Midwives Act which would come
into operation in a few weeks. Considerable activity
had been displayed by local authorities in the pro-
vision and extension of sewers and the disposal of
sewage, and there had been increased provision
for public recreation. In 1926 the total amount of
loans for public recreation was £1,260,000; last
year it was £3,200,000.
THE PUBLIC HEALTH BALANCE-SHEET
Taking the credit side of the public health balance-
sheet, he could say that motherhood was safer than
it had been for 16 years, inasmuch as maternal
mortality for every 1000 live births was the lowest
recorded since 1922. The tuberculosis death-rate
continued to decline, and there had been a steady
decline in mortality from infectious disease. There
had also been a substantial decrease in the prevalence
of diphtheria. There was, however, another side to
the balance-sheet—cancer. While many more lives
were now being saved by early diagnosis of the
disease, cancer remained one of the most deadly
enemies of mankind, and was the single heaviest
item on the debit side of the national health balance-
sheet. Colds and influenza still accounted for nearly
a guarter of the absences from work in this country,
and while it was true that last year’s influenza
epidemic was what was called clinically mild, he
could assure the committee, on the best authority,
that there was not likely to be a further visitation on
the same scale for two years.
MOVEMENTS OF POPULATION
The estimated mid-year population in 1936 of
England and Wales was 40,839,000, an increase of
194,000 over the estimated mid-year population
figure for 1935. The total number of births was
605,292, the birth-rate per 1000 living being 14'8,
or 0°1 per cent. higher than for 1935 and 0'4 above
that of 1933, the lowest on record in this country.
There were 495,764 deaths, and the crude death-rate
per 1000 of the population was 12°1. This was 0°4
per 1000 higher than in 1935 and 0°7 above that of
1930, the lowest on record. The problem of population
in this country was engaging increasing public
attention, and was a vital matter. Certain facts
were already known in connexion with it but before
they could properly consider it they would certainly
need to know many more. The birth-rate, which
in 1875 was 35°4 per 1000 living, had now fallen to
14°8. He was told that to-day mothers had about
half the number of children which their grandmothers
had, and they knew, for instance, that in the next
15 years the total number of children aged five and
over in public elementary schools might fall by as
much as 1,000,000. The population in the immediate
future would contain a much larger proportion
of older people. They could not, of course, say if
all those conditions would continue; it was not
necessary to be pessimistic about the matter as to
whether, for instance, they would have to take into
account a stationary or a declining population.
Two inquiries were in progress on this matter, one by
the Registrar-General, and the other by the Popula-
tion Investigation Committee, a voluntary body
under the chairmanship of Prof. Carr-Saunders.
There was close coöperation between the two inquiries,
The present methods of obtaining and keeping
important vital statistics concerning this matter were
unsatisfactory and incomplete, and further informa-
tion was undoubtedly necessary in connexion with
fertility. The existing birth-rate statistics showed
the number of children born in the population as a
whole, but fertility statistics must relate to births of
particular parents, and show the kind of parents and
in what conditions they produced many or few
children. Other particulars required were the ages of
the parents, the duration of the marriage, the dates
and order of the births, and matters of that kind.
If those facts were available it would be possible to
investigate much more adequately the conditions
and circumstances which appeared to encourage or
discourage the production of children. He was
considering the best steps that could be taken to
see that these particulars were procured with due
. regard to their confidential and personal nature.
BUILDING PROGRAMME
There had been a record total in house building
with the erection of some 346,000 houses, compared
with 325,000 last year and 329,000 in 1934-35. Rural
housing presented its own special problems, and rural
district councils were now concentrating on slum
clearance, and their original programmes had been
increased by approximately two-thirds. The present
programme covered some 55,000 houses, of which
nearly 23,000 were to be dealt with under clearance
orders. He had asked the central advisory council
to consider further steps so far as rural housing
was concerned. He hoped to receive a report soon
and would then consider what further action might be
necessary in the light of the report. He would ask
the House to approve at a later date the extension of
the present rate of subsidy both for slum clearance and
for the abatement of overcrowding so as to apply it
to houses completed up to Dec. 31st, 1938.
NOTES ON CURRENT TOPICS
Milk-supply and Animal Diseases
On June 7th in committee of the House of Commons,
on a vote for the Ministry of Agriculture, the Minister,
Mr. W. S. Morrison, said that the milk scheme had,
so far, rendered possible a start on the great question
of improving the quality and increasing the con-
sumption of this vital food. In the last financial
year the amount of milk sold in the liquid market
increased by 12,500,000 gallons and the quantity for
manufacture had increased by 8,000,000 gallons.
There had been an immense increase in the number of
persons producing milk which reached an accredited
standard. Before the scheme was introduced there
were only 800 Grade A licences, but now there were
nearly 20,000 producers of milk of accredited standard.
With regard to poultry disease, the technical :
committee which had been set up was considering
the present methods of distribution of hatching eggs,
day-old chicks, and feeding stuffs. Strenuous efforts
were being made to lessen the toll of mortality among
the chickens. The utmost research into the pathology
of diseases which had caused the losses among poultry
was being continued by the scientific bodies concerned.
Any further measures which might be taken would be
of an administrative character when the new central
veterinary service came into being. Referring to the
immense burden of animal diseases, which cost the
industry something like £14,000,000 a year, the
right hon. gentleman said that a great deal of work
had been done in the past by local authorities and
by the Ministry’s veterinary service, and practical
results had been obtained. During the last financial
year there were 13 centres of infection from foot-
and-mouth disease, and these comprised 66 separate
premises, The policy which had been carried out had
had the result that the disease had not become
1440 THE LANCET)
PARLIAMENTARY INTELLIGENCE
[JUNE 12, 1937
endemic in this country, as it had in some of our
continental neighbours. It could be regarded as a
hopeful sign that the incidence of this disease on the
Continent seemed to be declining. There was a slight
increase in the incidence of anthrax, but a satisfactory
decrease in swine fever and sheep scab. There were
still diseases like tuberculosis, contagious abortion,
mastitis, and others which took an immense toll of
‘our cattle. The proposals which he had recently
announced would involve legislation, and repre-
sented a very much bigger step forward and a much
more resolute attack on this problem than had yet been
made. He hoped, with the codperation of those
concerned, that it would yield substantial results in
freeing the industry from a wasteful burden.
Replying to the debate which followed, Mr.
Morrison said that the Ministry of Agriculture had
under investigation a diagnosis by which it might be
possible to detect Johne’s disease in its early stages
and not only effect a cure but prevent infection.
This was being tried out, and they. hoped in a short
time to know whether it was a good thing or not.
Some Colonial Health Problems
In the House of Commons on June 2nd on a Colonial
Office vote Mr. Ormsby-Gore, Secretary of State for
the Colonies, referred to social conditions in Hong-
Kong and the Straits Settlements. The reports, both
majority and minority, of the mui-tsai question had,
he said, been sent to the governors of these two
colonies asking for their considered views. In both
colonies the predominant element was a shifting
Chinese population among which for centuries there
had been social customs repugnant to British ideas.
The British Government has set its hand to eradicate
or mitigate the evils from these customs and was not
going to turn back. But despite all its efforts mui-tsai
and other customs went on, and devices such as
adoption were resorted to in order to get round the
law. There was, however, a growing public opinion
of a more Western character, and it was essential for
A success to carry the Chinese population with
em.
Mr. LUNN said there was no method of dealing
with the buying and selling of human beings except
by total abolition. He went on to deplore the con-
ditions of health in the West Indies, where malaria
and typhoid were common, food was poor and
lacking in nutritive value, sanitation was bad, people
were living in overcrowded conditions, wages were
low, and unemployment rife.
Mr. DE ROTHSCHILD recalled an investigation made
by the Ross Institute showing that on the seisal
estates in East Africa the work performed by native
labourers was only a sixth of the value of that done
by Malayan labourers. This could be attributed to
defective sanitation, lack of malarial control, poor
nutrition, and bad working conditions in general.
Miss HORSBRUGH said while they could not abolish
_ the system of mui-tsai all at once, there should be
immediate notification of the transfer of children
under the age of 12 and a register of all who were
pie away from their family, up to the age of 16
or 18.
Sir ERNEST GRAHAM-LITTLE compared the state of
hygiene in East Africa with that on the West Coast,
where the land was largely held by the natives. In
Kenya the density of population in the native
reserves, up to 250 to the square mile, exceeded that
in British India. Most unfortunate was the inability
of the native to pay the land tax in Nyasaland,
where 50 per cent. of the adult males had left the
district to work in other parts of British Africa and
the tribal system had broken up. He went on to
compare health conditions among the Masai and the
Kikuyu, whose diet had weakened their resistance
to disease, and to cite the alarming incidence of
disease in certain parts of Kenya, where climatic
conditions were favourable and venereal disease
infrequent, but anæmia, malnutrition, yaws, pyorrheea,
malaria, hookworm, and tuberculosis were rife. These
were preventable diseases and it was a grave indict-
ment against British rule for preventable diseases to
prevail on this scale. The primary difficulty might
be lack of funds, but the research laboratory in Nairobi
provided pathological data which would cost at the
ordinary price over £20,000 a year. He hoped it would
be possible for the Colonial Office to provide further
assistance for medical research.
Mr. SORENSEN noted the decline in physical well-
being of the natives mentioned in recent reports
from the Gold Coast, where the medical staff had
declined and less personal attention could be given.
In 1929, he said, 90 medical officers attended to
250,000 patients, whereas in ]935 there were only
66 medical officers for 273,000 patients. There was a
shortage of staff for the treatment of ‘leprosy and
nothing being done to investigate the incidence of
silicosis and tuberculosis. A class of native capitalists
now growing up unaccustomed to stringent public
health and other restrictions might easily create
conditions in which ill health was bred. He under-
stood that only 10 per cent. of the children of school
age were receiving education.
Mr. ORMSBY-GORE, replying to the debate, claimed
that on the whole conditions were better in the
British colonial empire than in any other, and that
remarkable progress had been made in the last ten
or fifteen years. Before incurring expenditure for
medical research he must take advice from the Medical
Research Council. The causes of most tropical
diseases were known; the only way to deal with
malaria was to kill the mosquitoes, and remarkable
work in controlling yaws was being done by the
British medical staff all over Africa.
On June 8th, in the House of Lords, the Widows’,
Orphans’, and Old Age Contributory Pensions
(Voluntary Contributors) Bill passed through Com-
mittee. The Poor’s Allotments in Walton-upon-
Thames Bill was read the third time, and passed.
QUESTION TIME
WEDNESDAY, JUNE 2ND
Eradication of Animal Diseases
Mr. HENDERSON STEWART asked the Minister of Agri-
culture if any provision was being made in his long-
term policy for the eradication of disease in livestock,
for reducing the mortality caused by grass sickness in
horses, disease in poultry, and swine fever among pigs.—
Mr. RamssorHaM replied: The Government’s policy for
the eradication of disease in livestock, which my right hon.
friend announced last Thursday, will extend, as circum-
stances permit, to all classes of farm animals, including
poultry, although efforts will be mainly directed in the
first instance to the eradication of disease among cattle.
It is impracticable, in the present state of knowledge, to
recommend immediate measures for reducing the mortality
caused by grass sickness in horses. As regards poultry
diseases, my right hon. friend is considering what steps
can usefully be taken pending the report of the Technical
Committee, which is examining methods of distribution
of breeding stock, hatching eggs, and day-old chicks, with
particular reference to mortality. The policy now in
force for the control of swine fever will continue. Research
in all matters is being actively pursued under the auspices
of the Agricultural Research Council in collaboration
with the Agricultural Departments.
THURSDAY, JUNE 3RD
Drunkenness in London during Coronation Week
Sir ALFRED Brit asked the Home Secretary the number
of persons arrested for being drunk and disorderly in the
County of London during Coronation week; and the
number so arrested during the corresponding week of
1936.—Sir SamvuEL Hoare replied: I regret that the
particulars asked for by my hon. friend could not be
-
THE LANCET]
extracted without a considerable expenditure of time and
labour. I can, however, inform him that the number of
persons charged with drunkenness of all kinds in the whole
Metropolitan police district during Coronation week was
492. The figures for the corresponding week in 1936 are
not available, but the figure for the week preceding
Coronation week was 405.
Watered Milk
Mr. JENKINS asked the Minister of Health if his attention
had been called to the report of the analyst for the county
of Monmouthshire in which it was stated that the composi-
tion of a large number of milk samples was highly unsatis-
factory, as in a number of cases a large percentage of
water had been added, and in other cases the amount of
fat removed was extremely high; and what steps he
ia ag to take to ensure to the public that milk available
or sale should be of the highest quality and free from
adulteration.—Sir Kinastey Woop replied: My attention
had been called to this report and I am in communication
with the county council in the matter.
MONDAY, JUNE TTH,
Ventilation of the House of Commons
Mr. Bossom asked the First Commissioner of Works
whether, seeing the great advances made in recent years in
the science of ventilation, he would cause an investigation
to be made to ascertain if the ventilation of this chamber
could be made more satisfactory during the recess this
summer.—Sir Pure Sassoon replied: I will send my
hon. friend a copy of the note which was circulated to
Members in July of last year. The investigations described
in that note are proceeding, but I do not anticipate that
they will be concluded in time to enable improvements to
be effected during the coming long recess.
Tuberculin-tested Herds
Mr. KELLY asked the Minister of Agriculture the number
of approved tuberculin-tested herds in Great Britain.—
Mr. Brrnays, Parliamentary Secretary to the Ministry
of Health, replied: On March 3lst last there were 1795
herds in England and Wales licensed for the production of
tuberculin-tested milk. I am informed by my right hon.
friend the Minister of Agriculture that there are at present
in England and Wales 293 attested herds (which are
tuberculin-tested) on the register kept by his Department.
This number includes 84 herds which are also licensed
for the production of tuberculin-tested milk. —
Health of Spanish Refugee Children
Miss CazaLet asked the Minister of Health what was
the present position regarding the health of the Basque
children who had been brought into this country.—
Mr. BERNays replied: According to the information in
my possession the general health of these children is
satisfactory ; but my right hon. friend is advised that it is
highly desirable on grounds of public health that the
number of children in the camp at North Stoneham
should be reduced as speedily as possible, and he under-
stands that the National Joint Committee for Spanish
Relief are in accord with this view. Evacuation is in
progress, and about 900 of the 4000 children have already
been transferred elsewhere. . Five cases of typhoid fever,
two cases of diphtheria, and three cases of measles have
occurred among the children. The patients have been
isolated, and appropriate precautionary measures have been
taken against the spread of infection.
Nutrition and Minimum Income
Mr. Sanpys asked the Minister of Health whether His
Majesty’s Government accepted Mr. Seebohm Rowntree’s
recently published estimate of the minimum income
required to provide the essentials of life to which his
attention had been drawn ; and, if not, whether his depart-
ment had made any such estimate of its own.—Mr.
Bernays replied: No, Sir. My right hon. friend is advised
that this estimate involves certain features that are very
conjectural, and no sufficient official material for the
PARLIAMENTARY INTELLIGENCE.—VACANCIES
`
[JUNE 12, 1937 1441
preparation of an estimate of this kind is at present
available.
Milk Rations for Enlisted Boys
Mr. GRAHAM WHITE asked the Secretary of State for
War the present amount of the daily milk ration for
enlisted boys.—Sir V. WARRENDER, Financial Secretary
to the War Office, replied: The daily ration of milk for
enlisted boys is half a pint a day in addition to a variable
quantity required for hot beverages, puddings, &c. The
boys at the Army Technical School, Beachley, receive three-
quarters of a pint a day in addition to one-quarter of a pint
for other purposes.
‘TUESDAY, JUNE 8TH
Ex-Service Men in Mental Hospitals
Mr. KELLY asked the Minister of Pensions the number
of ex-Service men under treatment in mental hospitals
in this country for whose maintenance his department was
responsible.—Mr. H. RamssBoruHam replied: The number
of officers, nurses, and other ranks for whose treatment in
mental institutions my department was responsible at
end of May, 1937, was 5770.
`
_ Scientists Employed by Ministry of Health
Mr. MARKHAM asked the Minister of Health how many
scientists were at present employed in the Minis
and how this figure compared with that of 1930. —Šir
KINGSLEY Woon replied : On April lst, 1937, the scientific
staff of the Ministry other than the medical and dental
stafis totalled 13. This figure included a chemist, chemical
inspector, alkali inspectors, and pharmacists. The corre-
sponding figure at April Ist, 1930, was 13. The medical
and dental staffs at the same dates were respectively :—
Medical staff 1930 104 1937 .. 115
Dental staf .. 2 12 a 16
In addition, the department’s establishment in both
years included a post of serologist, which was temporarily
vacant on Spa lst last and will shortly be filled. '
Vacancies
For further information refer to the advertisement columns
Aberdeen Royal Infirmary. —Two Hon. eae Ophth. Surgeons.
Acton Hosp., W .—Cas. O., at rate of £
Ashford Hosp.,, Kent —Res. M.O., £150
Barnsley, Beckett Hosp. and Dispensary.— Jun. H. S., £200.
Bath, Royal United Hosp.—H.P., at rate of £150.
Bedford County Hosp.—Second H. S., at rate of £15
Birmingham and Midland Eye Hosp A. S., at rate of "5180-2150.
Birmingham Maternity Hosp.—H.S8., at rate of £75.
Birmingham, Selly Oak Hosp.—J un. M.O, *g, each at rate of
£2
Bolton Royal Infirmary.—H.P. and Two H:S.’s, at rate of £200
and £150 respectively.
Bradford Children’s Hosp. Yy. S., £150.
Brighton Municipal Hosp. —Third Res. Asst. M. O., £300.
Bradford Royal Eye and Ear Hosp.—Two H.S.’s, each £180.
Brighton, Royal Alexandra Hosp. Pad Sick ees hea —H.P., £120.
Brighton Royal Sussex County Hosp.—Cas. H.S
l General Hosp.—Two H.P. et Three H.S.’s, Res. Obstet.
H.S. to Spec. Depts, each at rate of £80. Also Cas. H
at rate of £100.
British Red Cross Society Clinic for Rheumatism, pee
N.W.—Hon. Dental Surgeon.
Cardiff City Lodge Hosp.—Jun. Res. M.O., £150.
Cardiff, King Edward VII ean National Memorial Assoc. —
Res. Asst. Tuber. M.O., . Also Res. M.O. for South
Wales Sanatorium, Baai.
Carlisle, Cumberland Infirmary.—H.S., ge rate of 2155.
Central London Throat, Nose, and Ear Hosp., Gray’s Inn-road,
W.C.—Hon. Assts. to Out-patient Dept.
Charing Cross Ho. W.C.—Hon: Orthopedic Surgeon. Also
Hon. Clin. Asst. to X Ray and Electrotherapeutics Dept.
Chelmaford C.C. —Temporary Tuber. O., £15 per week.
Che and North Derbyshire Royal ” Hosp —Res. Surg. O.,
£300. Also H.S., at rate of £150.
Chichester, Royal West Sussex Hosp.—Jun. H.S.,
City Hr London Mental Hosp., ‘Stone, Nr. Dain. any M.O.,
pincer. Essex County Hosp.—H.8., £175.
Connaught Hosp., E.—Hon. Surgeon.
Coney ana. Warwickshire Hosp.—Res. H. S. and Res. Cas. O.,
eac
pown aaa Mental Hosp., Downpatrick.—Jun. Asst. M.O.,
Dreadnought Hosp., Greenwich, S.E.—Receiving Room Officer,
at rate of £200. Also H. È. and H.S., each at rate of £110.
1442 THE LANCET] VACANCIES.—BIRTHS, MARRIAGES, AND DEATHS [JUNE 12, 1937
Durham County Council.—Deputy County M.O.H., £960. Also
Asst. Welfare M.O., £500.
Durham County Hosp.—H.S., at rate of £150.
Dunes ane Galloway Royal Infirmary.—Res. H.S., at rate
o .
East Ham Memorial Hosp., Shrewsbury-road, E.—Hon. Surgeon
to Orthopædic Dept. Also two Anæsthetists, each 1 guinea
per session.
Elizabeth Garrett Anderson Hosp., Euston-road, N.W.—Hon.
Asst. Phys. Also H.P., First and Second H.S.’s, and
Obstet. Asst., each at rate of £50.
Erith U.D.C.—Asst. M.O.H. and Asst. School M.O., £500.
Exeter, Royal Devon and Exeter Hosp.—H.S., at rate of £150.
Gloucestershire Royal Infirmary and Eye Institution.—H.8.
and H.P., each at rate of £150.
Hampstead General and North-West London Hosp., Haverstock-
hill, N.W.—H.S., at rate of £100.
Heron and Isleworth Borough.—Asst. M.O.H. and School M.O.,
Hospital of St. John and St. Elizabeth, 60, Grove End-road, N.W.—
es. H.P., at rate of £100.
Hosp. for Sick Children, Great Ormond-street, W.C.—Res. M.O.
for Country Branch, at rate of £200.
Hosp. for A FORGA Diseases, Gordon-street, W.C.—H.P., at rate
of £120.
Hull Royal Infirmary.—Second H.P. and H.S. to Ophth. and
Ear, Nose and Throat Depts., each at rate of £150. Also
H.S. for Branch Hospital, at rate of £160.
Ilford, King George Hosp.—Two H.S.’s, each at rate of £100.
Institute for the Scientific Treatment of Delinquency, Portman-
street, W.—Med. Reg., £300.
Ipswich, East Suffolk, and Ipswich Hosp.—Cas. O., H.S. to
Orthopedic and Fracture Dept., and H.S. to General
Surgeon and Genito-Urinary Surgeon, each £144.
Keltering and District General Hosp.—H.S. and H.P., at rate of
£160 and £140, respectively.
Lancaster County Mental Hosp.—Asst. M.O., £506.
Leeds General Infirmary.—Hon. Asst. Physician.
Leeds, Mension Mental Hosp.—Asst. M.O., £350.
Leicester Royal Infirmary.—Res. Radiologist, at rate of £200.
Liverpool County Mental Hosp., Rainhill.—Second Asst. M.O.,
£650. Also Asst. M.O., 7 guineas per week.
se A seal Hosp., Hope-street.—Res. M.O., at rate
of £ ;
Liverpool Royal Children’s Hosp.—Two Res. H.P.’s and two
Res. H.S.’s for City Branch, each at rate of £100. Also
Res. M.O. and Res. Surg. O. for Heswall Branch, each at
rate of £120:
London University.—Examinerships.
Manchester, Ancoats Hosp.—Cas. O. £250.
Manchester, Crumpsall Hosp.—Res. Asst. M.O., at rate of £200.
Manchester Park Hosp., Davyhulme.—Second Res. M.O., at
rate of £225.
Manchester Royal Children’s Hosp.—Sen. M.O., £300. E
Manchester Royal Infirmary.—Technical Asst. for Clinical
Laboratory. Work, £200. Also Jun. Asst. M.O. (Locum)
to Radiological Dept., 8 guineas per week.
M le a Salford Hosp. for Skin Diseases.—H.5S., at rate
o ;
Marie Curie Hosp, 2, Fitzjohn’s-avenue, N.W .—Asst. Director,
from £500. Also Res. M.O., £100.
Middlesbrough, North Riding Infirmary.—Sen. H.S. and
Tbird H.S., at rate of £175 and £140 respectively.
NO General Hosp.—Two H.S.’s and H.P., each at rate of
£150.
Newcastle-upon-Tyne, Royal Victoria Infirmary.—Registrar to
Throat and Ear Dept., £100. é
- Northampton General Hosp.—H.S., at rate of £150.
North Middlesex and' County Hosp., Edmonton.—Asst. M.O.,
at pave of £350. Also Jun. Res. Asst. M.O., at rate of
£250.
Nottingham General Hosp.—Res. Cas. O. and H.S. to Ear, Nose,
and Throat Dept., each at rate of £150.
Oldham Municipal Hosp.—Res. Asst. M.O., at rate of £200.
Paddington Green Children’s Hosp., W.—H.S., at rate of £150.
Plymouth City Hosp.—Deputy Med. Supt., £450.
Plymouth, Prince of Wales’s Hosp., Greenbank-road.—H.S., at
rate of £120.
Pontefract General Infirmary.—Jun. Res. M.O., at rate of £150.
Preston and County of Lancaster Royal Infirmury.—Two H.S.’s,
each at rate of £150. =
Princess Louise Kensington Hosp. for Children, St. Quintin-
avenue, W.—H.S., at rate of £120-£150.
PUMN gropa Lower Common, S.W.—Jun. M.O., at rate of
£1
Queen Charlottes Maternity Hosp., Marylebone-road, N.W.—Res.
M.O. for Isolation Hosp., at rate of £200.
Reading, Royal Berkshire Hosp.—Cas. O., at rate of £150.
Rotherham Hosp.—H.S. for Ophth. and Ear, Nose, and Throat
Depts., £120. a.
Royal Air Force Medical Service.—Commissions.
Royal Dental Hosp. of London, 32, Leicester-square, W.C.—
Anesthetists.
St. Helens County Borough.—Asst. M.O.H., £500.
St. Paul’s Hosp. for Urological and Skin Diseases, Endell-street,
W.C.—H.S., at rate of £100.
Salford, Hope Llosp.—Asst. Res. M.O., at rate of £200.
Salford, Infectious Diseases Hosp.—Jun. Asst. Res, M.O., £200.
Salisbury General Infirmary.—Res. M.O., £250. Also H.P.,
at rate of £125.
Sheffield Children’s Hosp.—_.S., £100.
Southampton Borough General Jlosp.—Res. Obstet. M.O., £350.
Southampton, Itoyal South Hants and Southampton _Hosp.—
Cas O., and Res. Anesthetist and H.S. to Ear, Nose, and
Throat Dept.,cach at rate of £150.
Southend-on-Sea General Hosp.—Res. Obstet. O., at rate of £100.
Southern Rhodesia Medical Service.—Government M.O., £600-
£750.
Stamford, Rutland and General Infirmary.—H.S., at rate of £250.
Stoke-on-Trent, Burslem, Haywood, and Tunstall War Memorial
Hosp.—Res. H.S., at rate of £175.
Stoke-on-Trent, Longton Hosp.—H.S., £160.
Stoke-on-Trent, North Staffordshire Royal Infirmary.—H.S. for
Aural and Ophth. Dept., at rate of £150.
Sunderland Children’s Hosp. —H.P. and H.S., each £120.
Sunderland Royal Infirmary.—H.S., £120.
Surrey County Mental Hosp. Service.—Jun. Asst. M.O.’s,
each £350.
Tilbury Hosp., Essex.—H.5S., at rate of £140.
Tunbridge Wells, Kent and Sussex Hosp.—H.S. and Cas. O., £150.
University College Hosp., W.C.— Bilton Pollard Fellowship, £650.
Wakefield, Clayton Hosp.—Sen. H.S., £250. i
Warwick, King Edward VII Memorial Sanatorium, Hertford Hill.
Jun. Asst. M.O., £250.
Watford and District Peace Memorial Hosp.—H.S.,atrate of £150.
West Ham Mental Hosp., Goodmayes.—Jun. Asst. M.O., £350.
Westminster Hosp., Broad Sanctuary, S.W.—Dental Surgeon.
Willesden General Hosp., Harlesden-road, N.W.—Cas. O., at
rate of £100.
Wolverhampton County Borough.—Asst. M.O.H., £650.
Wolverhampton Royal Hosp.—Hon. Asst. Surgeon and Hon.
Asst. Gyneecologist.
Worcester Royal Infirmary. H.S. to Gynecological Dept.,
£140.
York County Hosp.—H.P., £150.
The Chief Inspector of Factories announces vacancies for
Certifying Factory Surgeons at Hanley (Staffs), Tunbridge
Wells (Kent), and Wool (Dorset).
Medical Referee under the Workmen’s Compensation Act,
1925, for ophthalmic cases arising in the Sheriffdom of
Lanark. Applications should be addressed, the Private
Secretary, Scottish Office, Whitehall, London, S.W.1,
before June 30th.
Births, Marriages, and Deaths
BIRTHS
BATEMAN.—On June 3rd, at Eton-avenue, N.W., the wife of
Mr. Geoffrey H. Bateman, F.R.C.S., of a son.
BAYNES.—On June 5th at West Byfleet, Surrey, the wife of
Dr. H. Godwin Baynes, of a daughter. me
CoRRY.—On May 29th, the wife of Mr. Cedric Corry, F.R.C.S.,
of Oxford, of a son.
KONSTAM.—On June 4th, at Wildwood-rise, N.W., the wife of
Dr. Geoffrey Konstam, of a daughter.
MACLEAN.—On June 3rd, at Devonshire-place, W., the wife of
Dr. D. Maclean, of Harpenden, of a daughter.
MUMMERY.—On June 5th, at Welbeck-street, W., the wife of
Dr. Raymond Mummery, of a daughter.
MuURTAGH.—On June Ist, the wife of Dr. Harold Murtagh,
of Ripponden, of twins (a girlanda boy; boy stillborn).
PERCIVAL.—On June Ist, the wife of Lt.-Col. E. Percival,
D.S.O., R.A.M.C., of Fleet, Hants, of a son.
SADLER.—On June 3rd, at West Wittering, Chichester, the wife
of Dr. C. R. Sadler, of a daughter.
WAYNE.—On June 4th, the wife of Prof. Edward J. Wayne,
I’.R.C.P., of Shetlield, of a daughter. .
WOODHOUSE.—On May 30th, at Royal Naval Hospital, Portland,
the wife of Surg.-Comdr. G. W. Woodhouse, of a son.
MARRIAGES
Boyp—PEART.—On June 3rd, at Hungerford Parish Church,
Douglas Herbert Stuart Boyd, M.B., to Margaret, younger
daughter of Mr. A. R. Peart, of Hungerford, Berks.
LAURENT—BAKER.—On June 3rd, at Hampstead Town Hall,
Louis Philippe Eugene Laurent, M.D. Lond., to Phyllis
Margaret, only daughter of C. H. Collins Baker, C.V.O.,
of the Huntington Library, California.
ROBERTSON—W aTT.—On June 3rd, at St. Paul’s-street Congre-
gational Church, Aberdeen, Capt. Hamish Gordon Grant
Robertson, R.A.M.C., to Marjorie Mary Watt, eldest
daughter of the Lord Provost of Aberdeen.
W ARNER—MICHELSON.—On June 4th, Frederick Sydney
Warner, M.R.C.S., L.D.S., to Cicely Florence Michelson.
DEATHS
BARBER.—On June 4th, at Haywards Heath, Halford Vaughan
Barber, M.A. Camb., L.R.C.P. Lond., aged 83.
BARKER.—-On June 2nd, at Woking, the residence of bis sister-
in-law, Percy Duckworth Barker, M.R.C.S. Eng., aged 63.
BENNETT.—On June 3rd, Claude John Eddowes Bennett,
M.R.C.S. Eng., D.P.H., of Inglewood, Melksham.
CHUBB.—On May 31st, at Pitt-street, W., William Lindsay
Chubb, M.B.E.. M.D. Durh., formerly in practice at
Sandgate, Kent, and Farnborough, Hants.
Epa@ar.—On June Ist, at Troy-court, Kensington, W., Peter
Galston Edgar, M.B. Edin., aged 68.
HaRVEY.—On June 4th, at Letchworth, William Fryer Harvey,
M.B. Oxon., aged 52.
RoBERTSON.—On June 4th, at Wellington, New Zealand,
Alexander Robertson, M.D. Glasg.
N.B.—A fee of 7s. 64. is charged for the insertion of Notices of
Births, Marriages, and Deaths.
THE LANCET]
PROTAMINE INSULIN
WRITING last January Dr. P. Wolff? of Geneva
was already able to review 140 papers on the new
insulin compounds with a slow action. The con-
clusions he draws from these and from his own
experience may be summarised as follows.
(1) The treatment of severe diabetes is both safer and
simpler with the new compounds than with ordinary
(2) Absorption being slower, wide changes in blood-
sugar are prevented, and hypoglycemic reactions are less
common and milder. T
(3) A high fasting blood-sugar is the special indication
for protamine insulin, since it is of great advantage to the
diabetic to begin the day with an approximately normal
metabolism. l
(4) Insulin-sensitive patients can be more satisfactorily
controlled with protamine insulin because frequent
reactions are avoided.
(5) Young diabetics respond more favourably to prota-
mine than to ordinary insulin.
(6) The dosage as well as the number of injections can
often be reduced by using protamine insulin, and some
patients are able to abandon insulin altogether after
treatment with it.
(7) Diabetics coming under care for the first time should
be given protamine insulin, for in this way their treatment
can be stabilised satisfactorily with a single dose daily.
(8) There are no important disadvantages in the new
preparations as compared with the old, but in acute cases
they are unsuitable, and in pre- and post-operative con-
ditions, coma, acidosis, and injections they should be
only gradually substituted for the old.
(9) Protamine insulin offers a great advance towards
giving the diabetic a completely physiological nutrition.
These conclusions sound more favourable to protamine
insulin than those contributed to our last issue by
Dr. Izod Bennett and his colleagues at the Middlesex
Hospital. But Dr. Wolff is himself doubtful whether
any form of retard insulin has yet been sufficiently
studied to warrant general use outside the clinic ; their
administration must be adjusted to individual cases,
and not applied by any rule of thumb. The possi-
bility that they may offer a better control of the
disease aS a whole is nevertheless a high one, and a
more continuously normal level of the blood-sugar
must be of advantage. E. P. Joslin, who has already
treated over 700 diabetics with the new preparations,
speaks of the new “ Hagedorn era’’ and hopes that,
especially, the risk to vessels, nerves, and eyes of
diabetics may at last be overcome.
HOSPITAL LIBRARIES
MANCHESTER has an advantage over London in
the organisation of a hospital library service as
hospitals and libraries are both under the control
of the same local authority. Mr. C. Nowell, chief
librarian of Manchester, gave to a meeting included
in the annual conference of the Library Association
at Scarborough last week an admirable account of
what has been accomplished under his direction.
Starting with the proposition that a hospital library
service is more than the supply of books to patients he
described its value to nurses and maids as well as to
doctors, engineers, porters, and administrative staff.
In one hospital belonging to the corporation, but
many miles from Manchester, with a staff of two
hundred a collection of books is maintained for
their use as well as for the patients, and any book
specially required by a doctor or other member
of the staff can be obtained on request. In London
the County Council have an arrangement with the
British Red Cross library which by the terms of
1 Uber einige neue Arzneimittel. II. 5. Insulinpriparate
mit verzégerter Wirkung. By P. Wolff. Reprinted from the
Schweiz. med. Jahrbuch. Basel: B. Schwabe and Co. 1937.
NOTES, COMMENTS,
[JUNE 12, 1937 1443
AND ABSTRACTS
its trust is limited to patients. For the hospitals
in Manchester whether council or voluntary there
is a special committee working in the closest codpera-
tion with the Corporation Libraries Committee. |
The organisation is under professional direction
with voluntary helpers drawn from a wide range of
organisations, including the Dickens Fellowship who
have been particularly excellent in one hospital.
The libraries department is responsible that all books
issued are good of their kind, in good condition, and
cared for at least as much as the general library stock.
The repair and binding of the books is also supervised
by the public library staff. In order to have the
assistance of the central committee it is essential
for a hospital to have a recognised supervisor in charge
belonging preferably to an already existing organisa-
tion, created for some wider purpose, which gives
strength to the team and provides the very necessary
reservists for substitutes. Members of Toc H and the
League of Women Helpers have been particularly
acceptable on this account.
The qualifications of the library helper were
described by Mr. Nowell to be: ‘‘ A book-lover but
no highbrow, a pleasing personality with not too
much of the bedside manner, the capacity for not
just taking on a job of work, but for sticking to it;
loyalty to the service and a love of it for its own sake.”
The principal difficulty has been to find suitable
rooms for library purposes and Mr. Nowell entered
a plea that for all new hospitals a library department
—centrally situated—will be planned. Special refer-
ence was made to mental hospitals and Mr. Nowell
expressed his conviction that this work to be successful
must be in the hands of a trained librarian; though
at the same time he did not regard the service as
highly specialised but rather that the patients should
be catered for exactly in the same way as the general |
reader in the public library.
It is clear that under professional direction the
work of voluntary helpers can be rendered more
efficient and the service more beneficial to the patients
and staff whether in general or mental hospitals.
THE BIOCHEMISTRY OF MILK SECRETION
ON May Ist we referred to the intensive study of
milk production now being made at the National
Institute for Research in Dairying, at Reading—
a study which must stimulate analogous thought
on human lactation. In a paper since read before
the Royal Society of Arts, Prof. H. D. Kay, now
director of the Institute, described the influence
on lactation of various factors, including hormones,
The parts played by hormones in bringing about
mammary development and lactation, long suspected,
are now sufficiently understood for the processes to
be induced in the male of some animals by means of
cestrin, progestin, and prolactin; but the effects of
hormones—of oestrin and thyroxine in particular—
on established lactation in the cow are not what would
be immediately guessed from clinical experience.
If a sufficient dose of cestrin is administered to a
lactating cow the animal is brought into season within
a few hours, and there is also a moderate fall in the
milk volume. This accords with most farmers’
experience that the quantity of milk often falls
when a cow comes into season. But the fall caused
by cestrin is succeeded by a rise to the previous level
or even above, and at the same time an increase,
of the order of 10 per cent.,in the proportion of fat
and non-fatty solids in the milk. The increase, if
the dose of cestrin is large, may persist for consider-
able periods, having been observed in two cows for
two months, Perhaps the minor digestive disturb-
ances that commonly affect infants when their
mothers menstruate during lactation may be attribut-
able to an enrichment of the milk comparable to the
enrichment seen in these cows, |
Thyroxine and dried thyroid were dramatic in their
effect on cows, the milk yield increasing by 25-30 per
1444 THE Lancer]
MEDICAL DIARY
[JUNE 12, 1937
cent., the fat by 16 per cent., and the total yield of
butter fat per day by 50 per cent. Ifa similar effect
is obtained in women it will seem that the anxiety of
some types of mother, which is traditionally a cause
of failure to breast-feed, is not related to excessive
thyroid secretion.
Speaking of the excretion of individual constituents
of milk Prof. Kay said that the amount of phosphatase
in milk may be taken as an index of the efficiency of
the gland; its concentration is least in the milk
at the height of normal lactation and is also low in the
abundant and rich secretion of milk after thyroid
administration. In mastitis, on the other hand, the
phosphatase concentration is high.
Comparison of the venous and arterial blood of the
gland has shown that in all probability the lactose
of milk is derived from blood glucose, the several
phosphorus compounds from the inorganic phosphate
of the plasma (and not from the much larger quantities
of organic phosphorus compounds in the blood),
and part of the casein and the albumin from circulat-
ing amino-acids.
NUTRITIONAL RETROBULBAR NEURITIS.—Dr, Fitz-
gerald Moore asks us to say that in his paper published
in our issue of May 22nd a sentence on p. 1226 under
the heading of Aitiology should read: ‘‘ Thus it
has not been possible yet for me to prove thera-
peutically that ophthalmological response is due to
vitamin-B, treatment exclusively, but other general
evidence is so strong that I believe this certainly to
be only awaiting confirmation in this respect.”
In the article as printed the word italicised appeared
as vitamin-B.
E Medical Diary
Information to be included in this column should reach us
én 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, June 15th.—5.30 P.M.,. general meeting of
fellows.
THURSDAY. ;
Dermatology. 5 P.M. (Cases at 4 P.M.). Dr. Elizabeth
Hunt: 1. Rodent Ulcer. Dr. H.C.Semon: 2. Poikilo-
dermia. 3. Case for Diagnosis. ? Sarcoid Simulating
Rhinophyma.
FRIDAY.
Obstetrics and Gynecology. 8 P.M. Annual general meeting.’
Dame Louise McIlroy: Results of Radium Treatment
on Carcinoma of the Uterus and Uterine Hemorrhage.
Mr. A. C. Palmer: The Treatment of the Prolapse
Syndrome and Reconstruction of the Pelvic Diaphragm
and Vaginal Hysterectomy in One Operation. (Cine-
matograph film.)
Laryngology and Otology. 9.30 a.m. (Norfolk and Norwich
Hospital, Norwich), Mr. E. D. Davis, Dr. S. H.
Mygind (Copenhagen), Mr. G. H. lis, and Mr.
F. C. W. Capps:
tion and its Treatment. Dr. J. H. Ebbs (Birmingham) :
Early Bronchiectasis in Children, and its relation to
Ear, Nose, and Throat Diseases of Children. Dr.
Branford Morgan (Norwich): The Relation of the
Ear, Nose, and Throat to the Diseases of Children.
Mr. F. C. Ormerod: Tubercular Ulcerations of the
Mouth and Pharynx. 2.30-4 P.M., Demonstration and
Discussion of Cases.
SATURDAY.
Laryngology and Otology. 9.30 a.M. Dr. S. H. Mygind :
Problems of Aural Medicine. Dr. Phyllis Kerridge:
Hearing and Speech in Deaf Children. Mr. Hamblen
Thomas: Physical Aspects of Tinnitus. Dr. M.
Sourdille (Nantes): The Present State of the Surgical
Treatment of Otosclerosis.
Disease in Children. 1.30 P.M., Visit to Royal Manchester
Children’s Hospital, Pendlebury. Tour of the new
Zachary Merton Convalescent Home and Isolation
Block. 2.15 P.M., Demonstration of cases in the wards
of the Hospital. 4.15 P.M., demonstration of cases at
the Duchess of York Hospital for Babies.
EUGENICS SOCIETY.
TUESDAY, June 15th.—35.15 P.M. (Linnean Society, Bur-
lington House, Piccadilly, W.), Prof. W. G. Miller:
Veterinary Eugenics.
RESEARCH DEFENCE SOCIETY. f
TUEspvay, June 15th.—3 P.M. (London School of Hygiene,
Keppel-street, W.C.), Prof. G. Grey Turner: What
Research Owes to the Paget Tradition. (Stephen
Paget memorial lecture.)
Howe
Orbital Cellulitis due to Sinus Infec- |
ROYAL SOCIETY OF TROPICAL MEDICINE AND
HYGIENE, Manson House, 26, Portland-place, W.
THURSDAY, June 17th.—8.15 P.M., annual general meeting.
8.30 P.M., Mr. Henry Foy (Salonika): Blackwater
Fever in Macedonia. Dr. N. Hamilton Fairley and
Mr. R. J. Bromfield: Pseudo-methsmoglobin in
Blackwater Fever and its Clinical Significance.
LECTURES, ADDRESSES, DEMONSTRATIONS, &c.
BH POSTGRADUATE MEDICAL SCHOOL, Ducane-
road, $
TUESDAY, June 15th.—4.30 P.M., Dr. D. Hunter:
tional Diseases.
WEDNESDAY.—Noon, clinical and pathological conference
(medical). 2 P.M., Dr. J. Gray: Cerebral Hemorrhage
and Softening. 3 P.M. cal and pathological con-
ference (surgical). 4.30 P.M., Prof. M. Greenwood,
F.R.S.: Experimental Epitomlology
THURSDAY.—2.15 P.M., Dr. Duncan te: Radiological
. Demonstration. 3 P.M., operative obstetrics. 3.80 P.M.,
Mr. A. K. Henry: Demonstrations of the Cadaver on
Surgical Exposures.
FRIDAY.—3 P.M., clinical and pathological conference
' (obstetrics and gynecology).
Daily, 10 A.M. to 4 P.M., medical clinics, surgical clinics,
and operations, obstetrical and gynæcological clinics
and operations.
WEST LONDON HOSPITAL POST-GRADUATE COLLEGE,
Hammersmith, W.6.
MoNDAY, June 14th.—10 A.M., Dr. Post: X Ray Film .
Demonstration. Skin clinic. 11 A.M., surgical wards.
2 P.M., operations, surgical and gyneecological wards,
medical, surgical, and gyneecological clinics. 4.15 P.M.,
Mr. Arnold Walker: Antenatal Care.
TUESDAY.—10 A.M., medical wards. 11 A.M., surgical wards.
2 P.M., operations, medical, surgical, and throat clinics.
4.15 P.M., Dr. Hugh Gordon: Treatment of Common
Skin Complaints. ,
WEDNESDAY.—10 a.M., children’s ward and clinic. 11 A.M.,
medical wards. 2 P.M., gynæcological operations,
medical, surgical, and eye clinics. 4.15 P.M., Mr.
Harvey Jackson : Diseases of the Rectum.
THURSDAY.—10 a.M., neurological and gynecological
clinics. Noon, fracture clinic. 2 P.M., operations,
medical, surgical, genito-urinary, and eye clinics.
FRIDAY.—10 A.M., medical wards, skin clinic. Noon, lecture
on treatment. 2 P.M., operations, medical, surgical,
and throat clinics. 4.15 P.M., Mr. Vlasto: Minor
Problems on Oto-laryngology. f
SATURDAY.—10 a.M., children’s and surgical clinics. 11 A.>f.,
medical wards. :
The lectures at 4.15 P.M. are open to all medical prac-
titioners without fee.
FELLOWSHIP OF MEDICINE AND POST-GRADUATE
MEDICAL ASSOCIATION, 1, Wimpole-street, W.
MONDAY, June 14th, to SUNDAY, June 20th.—CHELSEA
HOSPITAL FOR WOMEN, Arthur-street, S.W. All-day
course in gynscology.—BROMPTON HOSPITAL, S.W.
M.R.C.P. course in chest diseases, 5 P.M., twice weekly.
—LONDON CHEST Hospital, Victoria Park, E.,Wed.and
Fri. 6 P.M., M.R.C.P. course in heart and lung diseases.—
NATIONAL TEMPERANCE HOSPITAL, Hampstead-road,
N.W., Tues. and Thurs., 8 P.M., clinical and patho-
logical course.—PRINCE OF W4ALES’S GENERAL Hos-
PITAL, Tottenham, N., Sat. and Sun., course in general
y surgery.
Courses are open only to members of the fellowship.
ST. BARTHOLOMEW’S HOSPITAL, E.C.
THURSDAY, June 17th.—1.30) P.M., medical cases.
surgical cases. 4.30 P.M., X ray demonstrations.
FRIDAY.—10 a.M., Dr. A. E. Gow: Treatment of Chronic
Diarrhcea. 1] A.M., Mr. G. L. Keynes: Carcinoma of
the Breast. Noon, Dr. A. C. Roxburgh: Demon-
strations of cases of diseases of the skin. 1.45 P.M.,
Dr. H. F. Brewer: Blood-grouping and the Patho-
logical Physiology of the Aneemias. 2.45 P.M., Mr. H. J.
Burrows: Treatment of Sacro-iliac Pain. 4 P.M.,
Mr. R. Foster Moore: Some of the Common Externa}
Diseases of the Eye.
SATURDAY.—10 a.M., Mr. Sydney Scott: Treatment of
Common Disorders of the Middle Ear. 11 a.M., Mr.
C. K. Vartan: The Indications for and the Technique
of Induction of Labour. Noon, Dr. D. E. Denny-Brown :
Treatment of Migraine. Mr. ©. Naunton Morgan :
The Treatment of Pruritus Ani and Hesemorrhoids.
2.45 P.M., Dr. A. W. Franklin: The Artificial Feeding
of Infants. 4 P.M., Mr. B. Rait-Smith: Pre-operative
Medication and Induction of Anesthesia.
This course is open to all medical men.
Mo TAL FOR SICK CHILDREN, Great Ormond-street,
THURSDAY, June 17th.—2 P.M., Mr. James Crooks : Deafness
in Childhood. 3 P.M., Dr. D. N. Nabarro: Inter-
pretation of Fæcal Bacteriology.
Out-patient clinics daily at 10 A.M., ward visits at 2 P.M.
ST. MARY’S HOSPITAL, W.
TUESDAY, June 15th.—5 P.M. (Institute of Pathology and
P on TOD ), Prof. J. A. Gunn : Treatment of Arrest of the
cart.
SOUTH-WEST LONDON POST-GRADUATE ASSOCIATION.
WEDNESDAY, June 16th.—4 P.M. (St. James’ Hospital,
POE S.W.), Mr. E. A. Lindsay: Painful
eet.
MANCHESTER ROYAL INFIRMARY.
TUESDAY, June 15th.—4.15 P.M., Dr. J. F. Wilkinson :
Achlorbydria. l
Occupa-
3 P.M.,
THE LANCET]
[JUNE 19, 1937
ADDRESSES AND ORIGINAL ARTICLES
CHANGE IN THE AGE OF MORTALITY
FROM DIPHTHERIA
By R. M. F. Picken, M.B., B.Sc., D.P.H.
MANSEL TALBOT PROFESSOR OF PREVENTIVE MEDICINE, WELSH
f NATIONAL SCHOOL OF MEDICINE
THIRTY years ago Murphy (1907) drew attention
to variations in the age of mortality in London from
. certain diseases, including diphtheria. His charts
will still repay study. For diphtheria he showed
that in the years of high prevalence from 1861 to
1865 the mortality at ages 4, 5-10, and 10-15 was
low as compared with the average rates at these ages
over the whole period 1859-1905, that the relative
immunity at these ages gradually disappeared as the
. years progressed, and that, when high prevalence
recurred in 1896-1900, it had been replaced by
excessive susceptibility in relation to the average
over the whole period. At younger ages the reverse
had occurred. Briefly, diphtheria appeared to be
attacking and killing children of school age to an
increasing extent. He saw evidence of a waning of
this movement with falling prevalence in 1901—05
and said of the increasing part taken by older children
up to the end of the nineteenth century “I think
this may probably be a natural increase, although
it may have been accentuated by increase in aggrega-
tion of children at school. However this may be,
I should expect to find the first evidence of recurrence
of epidemic prevalence of diphtheria in increase of
relative incidence upon ages 4, 5-10, and 10-15.”
He hoped that the figures for subsequent years would
help to determine whether these changes were
rhythmical, —
Since Murphy wrote, the question has received
a good deal of attention. Chalmers (1913) described
a similar failure of the mortality at ages 5-10 to
decline at the same speed as at younger ages in the
death statistics of Scotland for groups of years from
1860-62 to 1909-11, and identified a progressive-
transference of notifications in Glasgow from ages
under 5 to ages 5-10 during the years 1903 to 1912.
Collis (1925), comparing the specific death-rates
in England and Wales for 1901-10 with those for
1861-70, demonstrated a decline at all ages over
10 but an increase in both sexes at ages 0-5 and 5-10,
the latter being the greater. Woods (1928) expressed
these specific death-rates for England and Wales
as percentages of the standardised death-rates from
diphtheria for decennia from 1861 to 1910 and for
the four-year period 1921-24, and showed con-
clusively that fatal diphtheria in 1921-24, as compared
with 1861-70 and 1871-80, was concentrating on the
age-group 5-10 while remaining stationary or tending
to decline at younger and older ages.
In a very full discussion of the mortality from
diphtheria in England and Wales and in London
Forbes (1932) brought the records up to 1929, and
traced from period to period since 1871 the changes of
mortality in five-year age-groups up to 20-25 years.
He tentatively confirmed Murphy’s observation that
‘diphtheria tended to become relatively more fatal
in the later age-groups during times of high prevalence,
especially in London. He suggested further that
there was evidence that this process was extending
even to young adult ages in recent years. The
Registrar-General (1934), in an illuminating table,
compares the rates of mortality at single ages up to
5938 .
5 and at ages 10-15 with those at ages 5-10 for
individual years 1901-34. He shows that through-
out the whole of this century there has been a pro-
gressive shifting of mortality risks toward school age,
and mentions a similar change in Prussia. His
table indicates that the risk at ages 10-15 in post-
war years had been, on the whole, greater than pre-
war, even when expressed in terms of the rapidly
rising risk at ages 5-10.
MORTALITY AFFECTED BOTH BY INCIDENCE AND BY
FATALITY
With the exception of Chalmers these writers have
each confined their attention to mortality, reasonably
assuming that age-mortality was a measure of age-
prevalence. Chalmers’s table of notifications in
Glasgow expressed the cases in each age-group as a
percentage of the total at all ages in each year, taking
no account of changes of age of the population; the
transference of notifications to school age appeared
to be taking place too rapidly to be explained entirely
by such changes. It has seemed to me that the
respective factors of incidence and fatality might be
worthy of further exploration. The most satisfactory
way of doing so would possibly have been to investigate
the age-fatality of hospital cases, but unfortunately
it is impossible to get such statistics of sufficient
magnitude in satisfactory age-groups over a long series
of. years without putting others to labour which
hardly seems justifiable. Woods (1933) discusses at
some length the value of notification records and of
hospital fatality-rates, and concludes that they both
have their defects. She points to the obvious fallacy
arising from increased bacteriological diagnosis of
diphtheria in recent years, swelling the toll of mild
cases. Indeed this, among other problems, has caused
the London County Council to issue a special report on
the nomenclature of diphtheria (1936) and to include
the special designation “‘ bacteriological diphtheria ”
in its tables of hospital discharges. Nevertheless
the graph of notification rates in England and Wales
for diphtheria and scarlet fever (which tend to run
in harness) shows little divergence throughout the
period since 1911 for which these figures are available,
suggesting that bacteriological methods have not
greatly increased the number of notifications in
recent years throughout the whole country. It is
not possible to determine whether other changes of
fashion have raised the notification rates for both
diseases. In London, however, with which this
paper is largely concerned, there does seem to have
been an exceptionally high notification rate for
diphtheria since 1921, a fact upon which the Registrar-
General has commented from time to time. A part,
therefore, of the apparently great fall in fatality
in recent years is probably artificial, and the fact
that it is demonstrable in hospital statistics does not
detract from this conclusion since very few notified
cases nowadays fail to be admitted. The picture is
still further confused by the exceptionally large pro-
portion of wrong or doubtful diagnoses of diphtheria.
The important question for practical purposes is
whether these fallacies may be differential as regards
age-groups. As a test of the validity of placing
(certified deaths against notifications, rates have been
calculated and compared with hospital fatality-
rates so far as these are available, as shown in Table A.
The age-distributions of the fatality of all cases and
of hospital cases were somewhat different in the first
ten years of the century, In this connexion it may
BB
1446
be noted that the proportion of hospital admissions
to notifications was only 65 per cent. in 1901-05
and 67 per cent. in 1906-10, whereas in 1935 it was
99 per cent. (if all the cases admitted and classed
as ‘‘ bacteriological diphtheria ’’ were included among
the notified; even if they were all excluded the
TABLE A—London: Diphtheria Fatality at Certain
Ages as Percentage of Rate at 5-10 Years (Rates based
on all Notifications and Deaths compared with Hospital
Rates).
10-15
All cases.. ws 224 100 36
1901-05 .. { Hospital cases .. 188 100 42
All cases.. ei 240 100 28
1906-10 .. { Hospital cases .. | 191 100 53
1932-35 All cases.. os 125 100 49
1935 us Hospital cases .. 131 100 39
percentage of admissions was 88). In the earlier
years, then, it is likely that the fatality at ages over
5 was weighted in hospital by the admission of a pre-
ponderance of grave cases, and it is also possible that
a large proportion of the rapidly fatal cases under 5
used to die at home. However this may be, the
indices are reasonably similar in magnitude and
trend; it seems that no very great fallacy will
arise from studying specific fatality-rates based on
notifications and deaths,
SOURCES OF INFORMATION
In pursuing an investigation of this kind one has
to take data where they can be found. Notifications
for England and Wales are available only since 1911
and they are not classified by age and sex. The
material has therefore been derived from London,
Manchester, and Glasgow. At the outset it should
be said that what has happened in these large towns
is not necessarily true for other parts of the country.
There is some evidence that it is not. Unfortunately
most of the annual reports of medical officers of health
group together the notifications and deaths from
infectious diseases at all ages from 5 to 15, and the
Registrar-General classifies local deaths in the same
way. For the diseases predominantly affecting child-
hood such classification is of little value, and it
is therefore difficult to carry the inquiry into many
areas. |
AGE-MORTALITY IN ENGLAND AND WALES
In order to test whether the movement of specific
death-rates in London is comparable with that in
England and Wales rates have first been calculated
for the whole country. These differ from the figures
given in the papers quoted above, as they apply to
groups of five years around censuses commencing
in 1901. Earlier data have not been used because
comparisons between the records of diphtheria of
last century and the present are questionable. In
the early days of registration scarlet fever was
imperfectly differentiated from diphtheria and croup
was only diphtheria to an undetermined extent,
although it has been customary to combine the two
causes, Moreover, notification, with its stimulus to
diagnosis, became universal only in the last decade
of the nineteenth century and almost immediately
thereafter antitoxin treatment began to affect
mortality. In spite of the increasing influence of
bacteriological diagnosis the figures of the past
37 years have probably a more uniform meaning
than formerly. In all the tables in this paper deaths
THE LANCET] PROF. R. M. F. PICKEN: CHANGE IN AGE OF MORTALITY FROM DIPHTHERIA
TABLE [*
England and Wales: Diphtheria Deaths and Death-rates
per Million f at Certain Ages in Certain Periods
ŮŮ
Period. | — | -0- | 5- | 10-15 | 0-15
MALES | n
1890-1003 {| Bonthe. 112.550 |. 5008 ol OTE al apei
1909-13.. £ Dr | are £40 7300-415] 71 +6| 3924 8
1919-23... {| DR S. | 640 119442416 1068| 388+ 9
1929-33.. {| DROS: | i2117 331a] 8817| 2784 7
FEMALES
1899-1903 {| peatte. hagas or [o2is, a DOS | arg sae
1909-13.. { DROS | 7638-418 tSossre| 80-7 417= 9
1919-23.. { Dah. God 219 t5217 12d £8 414+ 9
1929-33.. { po 2,868 3
[JUNE 19, 1937
; 191 807
388 +16| 388415| 101+8| 291+ 8
PERSONS
1899-1903 | D.R... | 1,369419! 713414] 124+6| 75748
1909-13 .. | 657413! 453411] 76+43| 40546
1919-23 .. | 632414) 482412] 114+6] 40146
1929-33 .. | ,, 406 +12] 362+10| 93-+45| 28545
*In this, and the other main tables, rates in age-and sex-
groups over raft bere have been omitted.
calculated, but
to give rates of significance.
They have been
e numbers of cases and deaths are too smalt
The actual numbers of cases and
deaths in the three age-groups of childhood are included in
some tables because they are not very easily found elsewhere.
t In Tables I, II, and III this is based on census populations
of the central year in each period.
D.R.=Mean annual death-rate.
from croup—which are very small in number—are
ignored.
Table I bears out the general observation that
diphtheria has greatly declined in England and
Wales as a cause of mortality at all ages under 15
years, and that there has been little difference in this
respect as between the sexes. Males, however, as
has been frequently noted, have succumbed to a
greater extent at ages under 5, the reverse being
markedly the case at ages 5-10 and 10-15, so that the
TABLE B—England and Wales: Diphtheria Mortality
at Certain Ages as Percentage of Rate at 5-10 Years
10-15
Period.
1899-1903 192 215 173 100
1909-13 .. | 145 169 126 100
1919-23 .. | 131 145 119
24 24 23
1929-33 .. | 112 127 100
100
P.=persons ; M.=males; F.=females.
death-rate among females at the combined ages is
consistently higher. The relations between the
specific rates may be expressed as in Table B. |
THE LANCET]
When the death-rate at ages 5-10 is represented
as 100 for males or females or both sexes, the index
for children below these ages is seen to have fallen
from about 200 to a figure approximating to 100.
For females the two rates have become identical.
TABLE II
London: Diphtheria Deaths and Death-rates per Million
` at Certain Ages in Certain Periods
Period. | — 0- | 5- | 10-15 | 0-15
MALES
Deaths. | 2,275 766 123
1899-1903 { D.R. .. | 1,835 +86 |694 +55 | 120 +24| 936 +36
Deaths. | 862 314 26
1909-13... { R... | 733456 |292 +37| 25411) 369 +24
Deaths. |1,342 740 172
1919-23... { D.R... |1408 +86 |739 +61 |167 +29| 759 +36
FEMALES
Deaths. |2,248 972 120
1899-1903 { D.R. .. |1817 +86 | 872 +63| 113 +23 | 980 £38
Deaths. 818 398 51
1909-13 .. { D.R... | 700 +55 |367440| 49415] 387 +24
Deaths. | 1,267 838 198
1919-23 .. { D.R. .. | 1,362 +86 | 842 £65|194+31| 780 +36
PERSONS
1899-1903 | D.R... |1,826 +61 | 786 +41|117 +17| 958 +26
1909-13.. „œ... | 719438 |327 +27| 37+ 9| 379417
1919-23.. „ «es |1,388 +61 |790 +44|181 +21! 769425
1929, 30, Deaths. 773 540 107
32, & 33 D.R... | 649447 |412435| 84416] 375 +20
At ages 10-15 mortality is increasing in importance
even as compared with the rate at 5-10 years and
therefore much more in relation to the rate under
5 years. Death is sparing the very young far more
than those of later ages.
SPECIFIC RATES OF MORTALITY, INCIDENCE, AND
FATALITY IN LONDON
In Table II corresponding rates are given for
London. The deaths for 1931 are not available in
the required age-grouping and those for the sexes
separately cannot easily be obtained for any of the
last group of years. The relations of the specific
rates may be summarised, as before, in Table C.
TaBLE C—London: Diphtheria Mortality at
Ages as Percentage of Rate at 5-10 Years
Certain
0-5 5-10 10-15
Period. ge ee
P M | F. — P M F
1899—1903 .. | 232 264 208 100 15 17 13
1909-13 220 251 190 100 11 9 13
1919-23 .. | 176 190 162 | 100 23 23 23
1929, 30, 32,
a3) 3 X 157
In London the movement has been the same as in
England and Wales, although children under 5 years
have been, and continue to be, relatively more affected
than in the country generally. So far as the comparison
extends, the mortality under 5 years has again
PROF. R. M. F. PICKEN: CHANGE IN AGE OF MORTALITY FROM DIPHTHERIA [JUNE 19, 1937
1447
exceeded that at ages 5-10 to a greater extent among
males than females.
Whether this movement and these relations are
attached to incidence or fatality remains to be
examined. Using notifications as a measure of
TABLE III ‘
London: Diphtheria Notifications and Rates per Million
at Certain Ages in Certain Periods
Period. | | 0- | 5- | 10-15 | 0-15
MALES
1899- Cases 10,794 8,157 2,799
1903 | G.R...| 8,709 £187 | 7.404 +183 !2°695+114'6,435+ 97
1909- { Cases | 6,659 5,523 1,765
13 C.R...| 5,679 4155 | 5,117 +154 /1,7744+ 94|4,294+ 80
1919- f Cases |19,375 11,011 4,746
23 C.R...|10;900 +238 |10,993 +233 |4, (064.151 87, ,96+121
FEMALES
1899- Cases 10,281 9,907 3,602
1903 1| C.R.. .| 8,300 £182] 8,907 +199 13.3994 12616,977 +100
1909- { Cases | 6,015 6,613 2,359
13 O.R...| 5,166 £149] 6,077 £166 |2,325+107|4,586+ 84
1919- f| Cases | 9,236 ` 12,475 6,068
23 C.R...| 9,945 +230 |12,503 +249 |5,896+ 16919,3994 125
PERSONS
18997 >| C.R...| 8,505 +130 | 8,160 +135 |3,051+ 84]6,7074 70
1909-13] ,, 5,423 +120 | 5,597 +113 |2,052+ 714,4414 57
1919-23} ,, ..(10,429 +165 11,747 £173 '5,284+113/9,097+ 87
1929- Cases |17,050 19,199 557
33 C.R.. [11,476 +195 |11,722 +188 8535 +11119,036 + 97
C.R. = Mean annual case-rate.
incidence I have prepared Table III for the periods
covered by Table II. It shows the specific case-
rates. Their relations are exhibited, as before, in
Table D. ‘
Selective incidence among males under 5 years
seems to follow their selective mortality, and indeed,
as will be shown later, may be the main explanation
of it. The notification rates for the combined sexes
at ages under 5 and at 5-10 have not been very
different from one another in each period. Such
decline as has occurred in the relative importance
of the younger ages is moderate and uncertain and
has not been carried on to the most recent period.
TaBLE D—London: Diphtheria Incidence at Certain
_ Ages as Percentage of Rate at 5-10 Years
0-5 5-10 10-15
Period.
P M F — P M F
1899-1903 104 118 93 100 37 36 38
1909-13 .. 97 111 85 100 37 35 38
1919-23 .. 89 99 79 100 45 42 47
1929-33 .. 98 — — 100 35 — —
When the case-rates in the age-group 0-5 are com-
pared with the corresponding rates at ages 5-10
practically all the differences lie within errors of
random sampling. The tendency of the mortality at
later ages to assume increasing importance may have
1448 THE LANCET] PROF. R.M. F. PICKEN: CHANGE IN AGE OF MORTALITY FROM DIPHTHERIA [JUNE 19, 1937
been partly due to a shift of incidence, but this
explanation does not apply to the most recent years
when this shift has been less pronounced than in
the two preceding periods. It may be noted that
the first and third of the four periods included
TABLE IV
London : Diphtheria, Percentage of Deaths to Notifications
at Certain Ages in Certain Periods
Period. | 0- | 5- | 10-15 | 0-15 —
MALES
1899-1903 | 21°08 40°38 | 9°39 40°31 | 4°39 +0°39| 14°55 40°24
1909-13 .. | 12°941+0°40 | 5°68 40°31 | 1°47 +0°29| 8°62 40°24
1919-23 .. | 12°93 40°33 | 6°72 40°24 | 3°62 +027 | 8°62 40°17
FEMALES
1899-1903 | 21°86 +0°41 | 9°81 40°30 | 3°33 40°30 | 14°0440°22
1909-13 .. | 13°60 40°44 | 6°02 40°29 | 2°16 40°30 | 8°45 +9°23
1919-23 .. | 13°72 40°36 | 6°72 10°22 | 3°26 40°23; 829 +0'16
PERSONS
|
1899-1903 | 21°46+0°28 | 9°62 +0°22 | 3°80 +0°24 | 14°28 +0°16
1909-13 .. | 13°25+0°30 | 5°87 +0'21 | 1°87 40°21] 853+0°16
1919-23 .. | 13°30 40°24 | 6°72 40°16 | 3°42 40°17) 8°45+40°12
1929, 30, l : ; : . , . . ;
32, & 33 f 5°50 +0°19 | 3°30 +0'14 1°94 +0°19| 3°95 0'10
years of exceptionally high prevalence, but they are
least in accord as regards the relative incidence at
early and later ages.
In Table IV the proportions of deaths to notifica-
tions in age- and sex-groups in London are shown
for the same periods of years as before. Diphtheria
has tended to be less fatal among all female children
than males, but if there is any real difference it is
due to the relative exemption of females from attack
at ages under 5, for the fatality at this age and at
ages 5-10 is, if anything, greater. Over the periods
under review the proportion of deaths to notifications -
has fallen greatly. So probably has the real fatality,
although it would be difficult to determine the influence
of increased bacteriological diagnosis on these rates.
If diagnosis were assumed to have been more thorough
TaBLE E—London: Diphtheria Fatality at Certain Ages
as Percentage of Rate at 5-10 Years
0-5 5-10 10-15
Period.
P M. | F. | — | P. IM. |F
1899-1903 .. | 223 | 224 |223 | 100 | 39 | 47 | 34
1909-13 .. | 226 | 228 |226 | 100 | 32 | 26 | 36
1919-23 .. | 198 | 192 |204 | 100 | 51 | 54 | 48
1929, 30, 32, ENE LOPES Z
A yy 167 100 | 59
in 1919-23 than in 1909-13 then diphtheria must
have been definitely more virulent in the later period,
for the fatality, even as here measured, was slightly
greater in each of the three five-year age-groups
under 15 years. The relations between: the rates
at different ages throughout this series of years may
be expressed, as before, in Table E.
The post-war shift of mortality to later ages is
seen to have been accompanied by a very similar
change in the fatality relations. In this case the
figures, so far as they go, indicate that the change of
fatality from the disease has not been different as .
TABLE V
London: Diphtheria, Percentage of Deaths to Notifications
at Certain Ages in Certain Pre-war and Post-war Periods
Period. | — | 0- | 5- | 10-15 0-15
MALES
f C. 8,899 6,275 2,155
1901-05 D. i
F. | 16°96 +0°40 | 8°00 +0°33 | 2°92 +.0°36 11°97 +025
C. 7,498 5,604 1,742
1906-10 D. 1,162 358 1 :
F. | 15°50 40°42 | 6°39 +0°33 | 1°78 +0°32 10°45 +0°25
C. 11,764 10,207 4,614
1921-25 D. ; 144
F. | 10°38 +0°28 | 5°39 +0°22 | 3°12 +0°26 7°20 +0'16
C. 8,890 9,229 2,934
1926-29 D. 506 248 44
F. | 5°69+0°25 | 2°69 40°17 | 1°50 40°22) «3°79 +0°13
FEMALES
C. | 8,250 7,767 2,763
1901-05< | D. 1,497 598
F. | 18°14 +0°42 | 7°70 +0°30 | 2°71 +0°31 | 11°55 40°23
C. 7,022 6,939 2,358
1906-10 D. 1,055 440
F. |1502 +0°43 | 6°34 40'29| 1°78 +0'27 | 9°42 +0°23
C. 10,178 11,249 5,838
1921-25< | D. 1,099 654 170
F. | 10°80 +0°31 | 5°81 +0°22 | 2°91 +0°22| 7°05 40°15
C. 7,662 9,846 2,621
1926-29 | D.
F. | 6°00 £0°27 |314 +018 | 1°75 +0'26| 4'05 40°14
PERSONS
1901-05 | F. | 17:53 +0°29 | 7°83 40°23 | 2°81 +0'24|11°75 +0°17
1906-10 F. | 15°27 +0°30 | 6°36 40°22 | 1°78 40°21! 9°91 +0°17
1921-25 | F. | 10°57 +0°21 | 5°61 +0°16 | 3°00 +.0°17| 7°13 40°11
C. 21,114 24,127 8,038
1926-30 D. 1,223 702 121
F. | -5°79 +0°16 | 2°91 +0°11 | 1°46 4013| 3°82 +008
C 12,705 14,707 5,271
1932-35< | D 637 111
F 5°43 +0°20 | 4°33 40°17 | 2°11 +020 | 4°40 +0°11
C.=cases; D.=deaths; F.=fatality.
between males and females. When. read in con-
junction with the movement of incidence rates,
the above table indicates that in the last period the
movement of mortality to later ages is entirely due
to the increasing importance of the fatality at these
ages.
The comparison is carried further in Table V which
covers two almost continuous series of years from
1901-10 and from 1921-35. The most impressive
features of the table are the fall of fatality at ages
under 5 years, and the recent arrest of the decline
at later ages. This is especially striking in the last
four years when a rise at ages 5-10 and 10-15 has
been sufficient to increase the rate at all ages under
15, although that at ages under 5 years has continued
to fall slightly. These points are epitomised in
Table F.
As there is no pronounced or uniform difference
in the sexes, it is perhaps of little importance that
THE LANCET].
the rates for males and females separately are not
available for 1932-35. Although fatality at ages
5-10 has been relatively more important during the
whole post-war period, the movement has fluctuated.
The figures on which the rates are based are reason-
TABLE F—London: Diphtheria Fatality at Certain Ages
as Percentage of Rate at 5-10 Years
0-5 5—10 | 10-15
Period.
p | {m| vr | —|p| md] F
1901-05 .. 224 212 236 100 | 36 36 35
1906-10 . 240 243 237 100 28, 28 28
1921-25 .. 188 193 186 100 53 58 50
1926-30*.. 199 211 191 100 50 56 56
1932-35... 125 — — | 100 49 — —
* For the sexes separately the period is 1926-29.
ably large and the irregularities are probably real.
It can readily be understood that variations in the
social classes affected by the disease from time to
time might heavily influence the fatality at older
ages. Such
100 variations can-
not easily be
50 ascertained.
The period
1932-35 is
unique in the
importance
assumed by
the age-group
5-10 years.
The point is
also illustrated
in the Chart,
showing the
rate at each
age-period as
a percentage of
the rate at
ages 0-15 in
three groups
of years.
Mean Rate 0-15
PER CENT.
=)
1921-30
PER CENT.
(=)
193235
FATALITY-
RATES IN
MANCHESTER
In order to
test whether
these changes
are peculiar
to London,
attention may
be turned
elsewhere. The
annual report
of the medical officer of health of Manchester
has included tables of the cases and deaths of
each of the important infectious diseases in short
age-groups (sexes undistinguished) since 1891. In
his report for 1933 Dr. Veitch Clark commented
upon the change of age-incidence of diphtheria
in the last twenty years. Table VI presents an
analysis of the figures of cases and deaths since the
beginning of the present century, excluding the
decade in which the war occurred. The proportion
of deaths to notifications at all ages under 15 years
PER CENT.
O
o= 5s
AGES
London. Diphtheria fatality at certain
ages as percentage of rate at ages 0-15,
lO-15
has usually been more than twice as high as in London,
‘Ages 10-15:
PROF. R. M. F. PICKEN: CHANGE IN AGE OF MORTALITY FROM DIPHTHERIA [JUNE 19, 1937 1449
It is difficult to believe that this great excess. can
have been entirely due to less observance of notifica-
tion in á large town which has a vigorous health
department, and is also a teaching centre in medicine,
TABLE VI
Manchester: Diphtheria, Percentage of Deaths to Notifica-
tions at Certain Ages in Certain Periods
Period. | — o oo | s- 10-15 | 0-15
c.| 1,040 040 975 - | 254 2,169
1901-052 | D. | 18 593
F. | 36° 3 oe 49'22°06 fae 40| 7°09 +1°61| 27°34 +0°96
ric. 1,316 874 225 2,415
1806-104 D. "400 120 11 531
F. | 30°39 +1°27 (13°73 +1°16] 4°90 +1°43| 21°99 +0°84
c. 1,185 1,602 663 3,450
ot { D. 00 11 32
F. | 16°88 +1°09| 7°24 +0'65| 4°83 +083 | 10°09 +0°50
ae D. 218 50 18 386
F. | 14°50 +0'91| 6°90 +0°54| 2°51 +-0°58| 878 +0°43
c. 957 1,717 764 3,438
I { D. 132 174 41
: F. | 18°79 £1°11 (1013 £0°73, 5°37 £0°81| 10-09 £0°50
Part of it may be due to deliberate exclusion of
unverified cases. This, however, is not the main
point at issue. The relative importance of the
fatality at ages may be tested, as before, in Table G.
The movement is not quite the same as in London.
The smaller numbers for Manchester make the
comparison less valid. By chance the relationships
in any one of the quinquennia might have been
very different, but it is probably more than a mere
TABLE G—Manchester: Diphtheria Fatality at Certain
Ages as Percentage of Rate at 5-10 Years
Period. 0-5 -10 10-15
1901-05 166 100 32
1906-10 221 100 36
1921-25 233 100 |. 6
1926-30 210 100 36
1931-35 136 100 53
coincidence that here also the fatality at ages 5-10
has become more important in the last ten, and
especially the last five, years. Indeed, when the
specific rates of deaths to notifications over the
whole series of years from 1891 to 1930 are calculated *
and compared with the rates in 1931-35 they show
a significantly different relationship between the
rates for the two lower age-groups from that which
holds at the present time.
FATALITY-KATES IN GLASGOW
From records given by Chalmers (1913), and others
contained in the annual reports of the medical officer
of health of Glasgow, specific proportions of deaths
to notifications can be calculated for certain years,
and these are set out in Table VII. Expressed as
before, the fatality-rates are related as in Table H.
The proportions of deaths to notifications at all
ages under 15 years have been comparable with those
in London but much lower than in Manchester,
although the social circumstances and medical
standards of the two industrial cities are not dissimilar.
es 0-5:
* Ag 8645 cases, 2463 deaths, fatality 28°49 per cent.
Ages 5-10:
8792 cases, 1048 deaths, fatality 11°92 per cent.
2924 cases, 132 se a fatality 4°51 per cent.
BB
1450 THE LANCET) PROF. R. M. F, PICKEN: CHANGE IN AGE OF MORTALITY FROM DIPHTHERIA [JUNE 19, 1937
TABLE VII
Glasgow : Diphtheria, Percentage of Deaths to Notification
at Certain Ages in Certain Periods
Period. | — | o- 5- 10-15 | 0-15
C. 2,141 1,240 | 386 3,767
1903-074 | D. 443 95 | 14 552
F. | 20°69 +0°87 | 7°66 £0°75 ` 3°63 40°95! 14°65 10°58
c. 3,772 2,765 886 7,423
ee f D. 17 = 29 897
F. |1827 +0°63| 6°47 40°47! 3°27 40°60 | 12°08 +0°38
ipis c. 3,997 3,863 1,438 9,298
Ze D. 465 134 11 610
F. | 11°63 0°51 | 3°47 40°29 0°76 40°23] 6°56 £0°26
pases c. 3,430 4,507 1,666 9,603
A D. 358 175 ` 514
F. | 10°44 £0°51 | 3°88 +0°29 2°46 +0°38| 5-98 £0°24
|C. 1,377 1,979 876 4,232
a i D. 147 93 18 258
F. | 10°67 +0°83 | 4°70 +0°48 2°05 +048] 6°10 +0'37
Since 1924 the fatality at these combined ages seems
to have fallen little, if at all, and at ages 5-10 the
tendency has been upward although the numbers
are too small to establish the movement definitely.
Here, again, it may be said that the relative importance
TaBLE H—Glasgow: Diphtheria Fatality at Certain Ages
as Percentage of Rate at 5-10 Years
Period. 0-5 5-10 10-15
1903-07 .. ss 270 100 47
1908-12 .. bs 282 100 50
1924-28 .. as 335 100 22
1929-33 .. Ss 269 100 63
1934-35 .. ia 227 100 44
of the fatality at ages has varied from time to time, but
that there is the same recent tendency for the ages
5-10 to count more heavily, especially in the last
two years.
DISCUSSION
The fall in the death-rate from diphtheria through-
out the present century has been great and fairly
continuous in England and Wales. As would be
expected local fluctuations are more pronounced,
but the trend is downward. Like scarlet fever the
disease is generally thought to be no less common
than formerly, and notifications, for what they are
worth, and especially in their contemporaneous
fluctuation with those of scarlet fever, support this
view. If it is correct, diphtheria is following scarlet
fever in becoming a less fatal disease, and this
amelioration may not be entirely due to better,
earlier, and more frequent treatment in hospital.
If it is, as in the case of scarlet fever, a process not
dependent upon ad-hoc measures, other changes in
the behaviour of the two diseases might be expected
to agree. Woods (1928) has shown that diphtheria
mortality has reacted less at ages 5-10 than at other
ages, although the general tendency of death to be
transferred to still later ages observed in scarlet
fever was not demonstrable for diphtheria over the
period with which she dealt. The Registrar-General
(1934) does, however, indicate that this movement
is extending into ages 10-15. The specific death-
rates shown in this paper for England and Wales and
for London confirm this tendency. There is, there-
fore, some ground for believing that a process common
to the two diseases is at work.
-will hardly bear examination.
The assumption that these changes in the specific
rates of mortality are due to changes of incidence
seems to be only partly justified. Incidence rates,
and the proportions of deaths to notifications, at
ages in London indicate that the state of affairs is
more complex. On the whole there may have been
a relative reduction in the case rate at ages under
5 years, as compared with later ages, until recently
but it is not specially notable in the quinquennial
period around the census of 1931. On the other hand,
since the beginning of the century the decline of the
fatality under 5 years of age in London has been
much more rapid than at later ages. This also has
not been a perfectly continuous movement, but it is
revealed to a most striking extent in the rates for
1932-35 in comparison with earlier years and
especially with the first decade of the century. In
Manchester the fatality under 5 years has figured
much less prominently in 1931-35 than in any
other post-war period or in the quinquennium 1906—10,
but an exceptionally high fatality at ages 5-10 in
1901-05 served to reduce the relative importance
of the younger ages. The movement is somewhat
similar in Glasgow over the period for which data
are available, but it may have set in later and it
certainly has not gone so far as in London or
Manchester. In all three cities the most prominent
factor in the recent increase, or.arrest in the decline,
of fatality at all ages under 15 years has been a
rise in the fatality at ages 5-10, although the small
changes in Glasgow are equivocal.
It seems unlikely that this shift of the fatality is
artificial. The educational period of life is that at
which detection is likely to be most complete and
notifications, indeed, to be inflated, so that the
apparent fatality at ages 5-15 should have fallen
most since the inception of the school medical
service. Again, it is probable that immunisation
in London and Manchester (it has not been extensively
practised in Glasgow) has reached a higher proportion
of school than of pre-school children. A table
contained in the annual report of the medical officer
of health of Manchester for 1935 indicates that this
is especially true of the age-group 5-10 in that city.
As protection is a matter of degree it might have been
expected to lead to an increase in the proportion
of less fatal cases of diphtheria at these ages, and
so to reduce the average fatality-rate at the period
of life when the reverse appears to have happened.
Incidentally, the suspicion expressed by Dudley and
others (1934) that immunisation, by creating carriers,
would increase the risk for pre-school children is
not so far confirmed by the incidence or mortality
in London or Manchester. '
The theory tentatively mentioned by Murphy
and quoted by other writers, that the relative
hesitancy of the mortality at ages 5-10 to fall at the
end of the nineteenth and the beginning of the present
century was due to aggregation of children in school,
It has been con-
tinuous over a long period without any increase
in the aggregation, and it has apparently not been
mainly a change of incidence. The excess incidence
on females as compared with males at ages 5—15
hardly seems to lend itself to the explanation that
they are brought more into contact with younger
infective children.
It is interesting, but perhaps not very profifable,
to speculate on the natural processes that might
account for the movement. Such differences are not
peculiar to diphtheria. They can be seen in the
comparison between epidemics of any infectious
THE LANCET] MR. J. BRUCE: MASSIVE SPONTANEOUS INTRAPERITONEAL HEMORRHAGE [JUNE 19,1937 1451
disease affecting urban and rural communities,
notably those which, like poliomyelitis, are sporadic
over long periods but occasionally take on epidemicity
(Friedemann 1928, and Aycock 1928). The age-
variation of Schick immunity by class and locality
is now a matter of common observation and is
associated with differences of age-mortality. The
relative infrequency of patent or latent infections
in a community might allow its herd-immunity
to decline (Dudley 1936), so leading to a change in
the relative susceptibility of the population at later
ages to contract the disease and die of it. Considerable
periods of low prevalence of diphtheria do occur in
localities and it would be interesting to compare the
a@ge-incidence and age-fatality of the disease during
the months of rise and the period of decline in the
aggregate of a series of epidemics; if numbers of
sufficient magnitude could be observed. So far as
the data in this paper go, they do not indicate that
exacerbations of incidence are the governing factor,
although the point may have been obscured by the
periods chosen for analysis.
The most striking instance of unusual age-mortality
of a disease in modern times was afforded by the
influenza epidemic of 1918-19. It'seems to have
been due less to departure from the usual age-incidence
of the disease than to a change in the ages affected
by its chief mortal complication (pneumonia),
accompanied by a change in the age-fatality of that
complication (Collins 1931, 1934). No explanation
but an alteration in the nature of the virus or its
symbiotics seems to meet this case. In connexion
with diphtheria the most notable observation in
modern times has been the differentiation of the
corynebacterium into types. In a summary of the
position Cooper and others (1936) comment on the
fact that a change of predominance from intermediate
to gravis strains occurred in Manchester between
1933 and 1934, but less detailed information is
available as to the position in London and Glasgow.
In neither of these towns does there seem to have
been an excess of gravis strains at any time when
examinations were made during the years 1933 to
1935, but the proportion of mitis strains was low in
London. The association of mitis strains with
laryngeal diphtheria is now generally recognised
(Cooper and others 1936). A reduction in the
prevalence of these strains might therefore be attended
by a fall in the fatality among very young children
who succumb most readily to laryngeal involve-
ment, while a rise of the more toxic gravis or inter-
mediate strains might increase the risk for those a
little older. I understand that such a reduction of
laryngeal diphtheria in recent times has been noted
in London.
PRACTICAL CONSIDERATIONS ©
The present policy of health departments is to
concentrate on the immunisation of children in the
second year of life. This is no doubt sound, in
theory, as a means of gradually building up an
immune population. The argument often used,
however, in support of the practice—viz., that
diphtheria is specially fatal under 5 years—is less
valid at the present time than it used to be. It is
easier to persuade parents to accept immunisation
for school-children and much easier to organise its
administration at these ages. In view of the increased
part taken by the age-group 5-10, and to some
extent 10-15, in mortality there is much to be said
at the present time for adhering to the earlier policy
of making sure that the younger school population
is thoroughly dealt with, while using every possible
means of persuasion to induce parents to accept
immunisation also for infants at the end of the first
year of life.
SUMMARY
1. The well-known shift of diphtheria mortality
from pre-school to school ages in England and Wales
and in London is shown to have been continued up
to recent times. 7
2. In London it is apparently not due entirely,
. or even mainly, to a change of incidence.
3. There has been a shift of fatality to later ages
in London which is most striking in the period 1932-35.
It is probably not artificial.
4. A similar change in fatality can be traced in
Manchester and Glasgow but should not be assumed
to have occurred in other areas.
5. The explanation may possibly be found in
changes of strain of Corynebacterium diphtheria.
6. It is suggested that immunisation of the younger
school-children should not be neglected in favour of
infants at the end of the first year of life.
I am indebted for some of the records used in this paper
to Dr. W. Gunn, medical superintendent to the North-
Western Hospital, London, to Dr. R. Veitch Clark, medical
officer of health, Manchester, and to Dr. A. S. M. Macgregor,
medical officer of health, Glasgow; and, for making
extracts from many reports for me and advice on certain
statistical points, to Mr. W. T. Russell of the London
School of Hygiene and Tropical Medicine. None of them
is responsible for the way in which the figures have been
used,
REFERENCES
Aycock, W. L. (1928) Amer. J. Hyg. 8, 35.
Chalmers, A. K. (1913) Ann. Rep. of M.O.H., Glasgow, p. 234.
Collins, S. D. (1931) Amer. Publ. Hlth Rep. 46, 1909.
— (1934) Ibid, 49, 1.
Collis, E. L. (1925) J. State Med. 33, 201.
Cooper, K. E., Happold, F. C., McLeod, J. W., and Woodcock,
H. E. de C. (1936) Proc. R. Soc. Med. 29, 1029.
Dudley, S. F. (1936) Ibid, 30, 57.
. — May, IP. M., and O’Flynn, J. A. (1934) Spec. Rep.
Ser. med. Res. Coun., Lond. No. 195, p. 104.
ForS oa G. (1932) Diphtheria Past and Present, London,
p. A
Friedemann, U. (1928) Lancet, 2, 211.
London County Council (1936) Nomenclature of Diphtheria
Infections.
Murphy, S. (1907) Trans. epidem. Soc. Lond. 26, 99.
Registrar-General (1934) Statist. Rev. of Eng. and Wales, New
Ann. Series (Text), vol. 14, p. 57.
Woods, H. M. (1928) J. Hyg. 28, 147.
oo ae Spec. Rep. Ser. med. Res. Coun., Lond. No. 180,
p. 46.
MASSIVE SPONTANEOUS
INTRAPERITONEAL H#MORRHAGE
(SPONTANEOUS HEMOPERITONEUM)
By Joun Bruce, M.B., F.R.C.S. Edin.
TUTOR IN CLINICAL SURGERY AT THE ROYAL INFIRMARY,
EDINBURGH
(From the Department of Clinical Surgery, University
of Edinburgh)
MASSIVE intraperitoneal hemorrhage is occasion-
ally encountered as a sequel to trauma, malignant
disease, and in the female ectopic gestation. Apart
from such circumstances, spontaneous bleeding of
serious degree is one of the rarest of vascular acci-
dents, and certainly one of the rarest of acute abdo-
minal catastrophes. In individual experience it is
so infrequent that when it is discovered at operation
for acute abdominal symptoms, the surgeon is apt
to be embarrassed, and inadequate both in his
investigation and in his treatment.
1452
THE LANOET]
MR. J. BRUCE: MASSIVE SPONTANEOUS INTRAPERITONEAL HÆMORRHAGE [JUNE 19, 1937
The cases presented here have certain features of
interest which make them worthy of report; and
I have thought it well to review what has been
written on the subject, in an endeavour to determine
what exploratory procedures are likely to be useful
on such occasions.
SPONTANEOUS INTRAPERITONEAL HEMORRHAGE
IN THE FEMALE
Case 1.—The patient, a well-developed girl of 19, was -
admitted to hospital with a history that on the previous day
she was seized with spasmodic pain in the lower abdomen.
The pain was worse on the right side, and she thought
that at the beginning it radiated to the back. On the
day of admission she vomited on two occasions. There
were no urinary or bowel symptoms of note, and the
menstrual history was normal. She was, however, due to
menstruate on the day of admission.
On first examination the clinical findings were largely
negative save for some deep tenderness in the right iliac
fossa. A tentative diagnosis of mild catarrhal appendi-
citis was made, and it was decided to admit her for
observation. In the course of the forenoon, however,
her temperature, previously normal, rose a little, the pain
in the lower abdomen increased, and some lower abdominal
rigidity appeared. The diagnosis was apparently con-
firmed and operation was advised. By the time it was
carried out her condition had become further aggravated.
The pulse was rapid, thready, and her complexion was
greyish, her facies anxious, and she was very restless.
The abdomen was opened by McBurney’s method, and
at once there was an escape of bright red fluid blood
containing some clots. The appendix and cecum were
normal, and accordingly a paramedian incision was now
made and the pelvis inspected. It contained a large
quantity of blood, and after this was evacuated the
source of the hemorrhage was found to be a ruptured
cyst in the left ovary, which even then was bleeding very
profusely. The remainder of the ovary, the tubes, and
the uterus were all congested, probably because she was
due to menstruate. A left odphorectomy was carried out
and the wound closed without drainage. The recovery
was completely uneventful.
I had on several occasions operated on cases of
ruptured ovarian cysts in which there was a small
amount of blood in the pelvis. Indeed, along with
ruptured ectopic pregnancy, this condition consti-
tutes the bulk of intraperitoneal bleedings in the
female sex. Seldom, however, does the hemorrhage
attain the massive proportions which it did in this
instance, and it is rarely sufficient to be a source of
danger. Phaneuf (1924) has recorded 42 examples
of the condition and finds there is fairly equal
liability to the accident in the follicular and the
luteal varieties of cyst. A rarer and less well-
recognised cause of hzmorrhage in the female is
rupture of the dilated or varicose veins which are
occasionally found on the surface of a subperitoneal
fibromyoma of the uterus. Ernst and Gammeltoft
(1921) reported 23 cases of this kind, and pointed out
that the accident is apt to be fatal if the rupture
takes place into the broad ligament.
Spontaneous hemoperitoneum from rupture of an
ectopic gestation has a more serious prognosis than
the other varieties, for the blood remains sterile only
for a few hours. Thus, of 17 cases recorded by
Dudgeon and Sargent (1905) in only 7 was there no
infection after two hours. The usual infecting
organism was the Staphylococcus albus, and it is to
infection that the febrile course of the condition is
apparently due.
It is abundantly obvious that in the female the
source of intraperitoneal hemorrhage is usually to be
looked for in relation to the pelvic viscera. Never-
theless there are instances in which the bleeding
originates in conditions common to both sexes, and
these will now be considered.
SPONTANEOUS. HEMORRHAGE COMMON TO
BOTH SEXES
A variety of conditions that are common to the
two sexes may manifest their presence by severe
intra-abdominal hemorrhage, and their nature
is often obvious at operation. This is true of
spontaneous ruptures of the spleen (Baily 1929-30),
and liver (Bruce 1929), rupture of the splenic vessels
in cirrhosis of the liver (Pyrah and others 1929,
Ogilvie 1922), oozing from the liver in toxic hepatitis
(Peck 1905), and in undulant fever (Box and Bam-
forth 1925), and ruptured mycotic aneurysm in acute
bacterial endocarditis (Willius 1935).
Besides these, ‘two types of spontaneous hemorrhage
are of especial interest. In the first, the bleeding
occurs from an arterio-sclerotic vessel, and the con-
dition is generally and appropriately known as
abdominal apoplexy. In the second, the source of
the hemorrhage and the underlying cause have not
been discoverable at operation. It is on this latter
type, especially, that the following cases are thought
to have a bearing.
CasE 2.—The patient was an unemployed man 34 years
old, of muscular build. For two days he had suffered
from indefinite abdominal pain, and, six hours before
admission, while standing at the doorway of the “close ”
in which he lived, he was seized with violent epigastric pain
and with pain in the left shoulder. Both persisted in
acute form. Nausea was experienced shortly after the
pain began and he vomited within the hour. There were
no other significant features in the history, but he did
admit to suffering from chronic indigestion for an
unspecified number of years.
When I examined him he was very restless and looked
ill. He presented a curious plethoric or cyanotic appear-
ance, and was very thirsty. The temperature was sub-
normal, the pulse-rate, to begin with, only 76. The
tongue was dry and slightly furred. The abdomen
appeared to be distended, and the respiratory excursion
was limited. Palpation disclosed fairly generalised
tenderness, and muscular rigidity was present in the
epigastric area. The liver dullness was of normal extent ;
elsewhere percussion gave a rather dull note over the
major part of the abdomen, and especially in the flanks.
The other systems were not abnormal in any obvious way.
The diagnosis was somewhat in doubt, but was thought
to lie between an acute pancreatitis—which was favoured
by his rather cyanotic colour—and a leaking gastric ulcer,
the abdominal rigidity, the shoulder pain, and the former
history of digestive trouble seeming to support the latter.
Operation was advised and carried out within an hour of
admission, by which time the pulse-rate had risen con-
siderably. The abdomen was opened by a right para-
median incision, and immediately the peritoneum was
incised there was a gush of bright red fluid blood.
A very large quantity of blood was thereafter evacuated,
along with some large clots, and it was some time before
the viscera could be adequately inspected. The stomach,
duodenum, and pancreas were all normal. There was no
rupture of the liver or spleen and no definite bleeding-
point could be identified. The condition of the omentum
and the mesocolon was noted at the time. Each contained
several small discrete hematomata and appeared some-
what congested. The pelvis was investigated after the
incision had been enlarged, again with negative results.
Accordingly, a small rubber dam was left in situ and
the wound closed.
In the days pucci? operation an attempt was made
to identify the presence of any blood dyscrasia, but the
Wassermann test was negative, the blood counts within the
limits of normality, and the differential blood count
normal. The coagulation time and the platelet count
also gave the usual readings. His progress was interesting.
For the first six days vomiting was frequent; he could
retain nothing by mouth. After that he improved
markedly; the vomiting stopped and he had a very
-
THE LANCET] MR. J. BRUCE: MASSIVE SPONTANEOUS INTRAPERITONEAL HÆMORRHAGE [JUNE 19, 1937 1453
good appetite. In two weeks there was an intermittent
pyrexia, due probably to the absorption of the intra-
peritoneal blood ; thereafter the temperature settled and
his further recovery was uneventful. Seen at intervals
since, he has remained well and has had no further
abdominal trouble of any kind.
I have been able to trace only one exactly com-
parable case, previously reported in this journal by
Hartley and MacKechnie (1934).
Their patient was a labourer, aged 31, who experienced,
on rising in the morning, a sharp pain in the left upper
abdomen, which was relieved by vomiting. Some hours
later the pain recurred and he was admitted to hospital,
where his condition became so rapidly worse that laparo-
tomy was decided upon. The operation findings are of
great interest: there was a considerable quantity of
blood in the peritoneal cavity, and the omentum showed a
series of discrete hæmatomata in its substance. The
patient did not survive many hours, and autopsy con-
firmed the operative findings in that no definite source of
the hæmorrhage could be found.
Hartley and MacKechnie suggested, somewhat
provocatively, that the condition be caled
“ splanchnostaxis.”’
A case of Churchman’s (1911), though not exactly
comparable, has certain points of similarity.
His patient was a man of 48 who for some years had
suffered from constipation, with dull abdominal pain, and
who finally came under his care with acute abdominal
symptoms suggesting acute appendicitis. Shifting dullness
was present in the flanks, and it was accordingly assumed
that peritonitis had supervened. Operation revealed only
intraperitoneal hemorrhage, and the patient died in three
hours. At autopsy there was a hematoma in the rectal
wall, and some ecchymosis in the neighbourhood of the
pylorus and at other points in the small intestine. The
bowel wall, on section, showed dilatation of the subserous
vessels and intramural hemorrhage.
Churchman regarded these findings as in keeping
with hemophilia, largely because intraperitoneal and
intrapleural hemorrhages are known to occur in fatal
cages of this disease and in experimentally produced
“ hemorrhagic disease’? (Whipple and Sperry 1909).
This suggestion has not altogether been accepted, and
-indeed Osler and McCrae (1925) regard Churchman’s
case as an acute form of ‘ hemorrhagic peritonitis,”
of which disease they also recognise a chronic variety,
analogous to the hemorrhagic pachymeningitis
described by Virchow. The chronic form is localised
most commonly to the pelvis, and its pathological
manifestations take the form of the deposit on the
surface of the peritoneum of successive layers of
young connective tissue, containing numerous large
wide vessels, from which repeated hemorrhages take
place.
In my own case, and in the case of Hartley and
MacKechnie, the possibility of a hemophilic or a
hemorrhagic peritonitic cause was quite definitely
excluded, and in view of the complete recovery on the
one hand, and the absence of demonstrable visceral or
peritoneal post-mortem pathology on the other, it is
necessary to fall back on a vascular disturbance to
explain the bleeding.
Spontaneous hemorrhage from an arterio-sclerotic
vessel is always a possibility in the abdomen as
elsewhere. Nevertheless, considering the great fre-
quency of arterio-sclerotic vascular degeneration, and
the fairly common occurrence of gross visceral
aneurysm, the spontaneous rupture of visceral and
peripheral arteries is remarkably rare. The accident,
indeed, has been reported only on six occasions :—
Hilliard (1918).—Male aged 48.
abdominal pain with rigidity.
Sudden onset of
Laparotomy showed
hemorrhage, but definite bleeding-point not found;
General arterio-sclerosis.
Starcke (1923).—Spontaneous rupture of the gastro-
duodenal artery in a male, aged 60, with arterio-sclerosis.
Green and Powers (1931).—Sudden epigastric pain with
rigidity, after spontaneous rupture of the left gastric
artery, with a hematoma in the gastrohepatic omentum,
in a female aged 54, with a history of hemorrhages (nasal,
ocular).
Buchbinder and Greene (1935).—Spontaneous rupture of
a gastric artery in a male aged 57.
Moorehead and McLester (1936).—({1) Spontaneous
hemorrhage from junction of right and left gastrics, both
vessels being severely diseased. (2) Spontaneous rupture
of an aneurysm of the superior mesenteric artery. The
respective ages were 44 and 50 years.
From a study of the recorded cases two facts
emerge: (1) hypertension is an invariable accom-
paniment ; (2) the age-incidence is between 44 and 60
(average 52). In only one case is there positive
evidence of aneurysm formation, and on this account
the next case which I am reporting is of interest.
I am able to include it through the kindness of Mr.
C. F. W. Illingworth, under whose care the patient was.
Case 3.—For some days the patient, a man of 75, had
complained of being slightly off colour. Before this he
had had some difficulty in securing regular evacuation of
the bowel, and had required a daily aperient. On the day
of admission he was seized with sudden pain in the upper
abdomen, and for some hours this was attended by
repeated vomiting of food material. When examined after
admission he was found to have a subnormal temperature
and a feeble rapid pulse. His tongue was dry and furred.
and he looked ill. Investigation of his abdominal con-
dition revealed a prominent, ballooned, and tender cecum ;
the tenderness was continued over the whole distribution
of the colon, but there was no rigidity, and no swelling
could be detected. There was dullness in both flanks,
and a diagnosis of acute obstruction supervening on a
chronic malignant obstruction was made.
At operation a massive intraperitoneal hzmorrhage
was disclosed; a swelling could be discovered on palpa-
tion, apparently in relation to the aorta, and was taken to
be an aneurysm, and the abdomen was closed without
drainage. The patient died a week later from broncho-
pneumonia, and post-mortem examination showed an
extravasation of blood in the general peritoneal cavity
and in the transverse mesocolon. An aneurysmal dilata-
tion was present on the middle colic artery and was the
source of the hemorrhage. The abdominal vessels were
normal, and the aorta itself showed only slight
` atheromatous changes, with some degree of thickening of
the aortic valves.
At first sight it seems most likely that the aneurysm
in this case was secondary to arterio-sclerotic vascular
degeneration; yet the remainder of the abdominal
vasculature was healthy. It is a fact nevertheless
that abdominal aneurysm can occur in the absence
of degenerative changes in the arterial wall, for
Budde (1925) has recorded a case of fatal rupture of
an aneurysm of the left gastro-epiploic artery in a
man of 27, without evidence of arterio-sclerosis. -
In view of these findings it seems impossible to
exclude as a possible cause of these aneurysms a
congenital weakness of the vessel wall akin to that
which leads to aneurysm of the basal cerebral
arteries. Forbus (1930), in his classical account of
congenital aneurysms, has shown that they tend to
form at the points of branching of the arterial tree,
and their occurrence is favoured by the special mode
of formation of the arteries. In the development of an
_artery the larger trunks acquire a muscular coat,
while their smaller branches remain for a time as
simple endothelial tubes. Later on the branches
acquire muscular coats, not as outgrowths from the
muscle of the parent vessel but as independent
1454 THE LANCET]
developments in situ from the surrounding undif-
ferentiated mesenchyme. At the line of junction
between branch and trunk the respective muscular
coats meet, and should fuse solidly. It is in an
imperfection of the latter process that the explanation
of the aneurysm lies, for the persistence of a gap or
the occurrence of a “weak joint” creates a locus
minoris resistenttie, at which “ blowing out,” with
the production of aneurysm, may occur.
The rupture of a congenital aneurysm has attracted
most attention when the intracranial vessels are
involved. Forbus himself has drawn attention to
the possibility of a similar accident in relation : to
other vessels; and indeed his views of the origin
of the lesion were based on his studies of the
development not of the intracranial vessels but of
the mesenteric vessels. Reports of multiple miliary
aneurysms of this nature in the coronary and
mesenteric vessels have been made by Eppinger
(1887) and by Gee (1871), and in relation to the
pulmonary vessels by Wilkins (1917), and the renal
arteries by Forbus (1930).
While it is impossible to be dogmatic about the
third case, the probabilities favour such an .explana-
tion in the case of Budde; in the cases of Hartley
and MacKechnie, and in my own, it seems, in view
of the comparatively early age and the other con-
siderations, that the hzmorrhage may well have
originated in a miliary aneurysm, or in a spon-
taneous rupture at one of the numerous junctional
areas on the mesenteric arterial tree, and in these
two cases the clinical course offers a similar contrast
to that of the massive or apoplectic type of rupture,
and of the “leak” in the basal cerebral aneurysm.
The premise unfortunately cannot be held to be
proved, but the suggestion is made here in the hope
that it may lead to more detailed investigation if
similar cases are encountered by others.
It may also be of interest to record the mode and
results of treatment in hemoperitoneum from vascular
causes, as illustrated by the cases I have reviewed.
In the arterio-sclerotic cases ligation of the bleeding
vessel was undertaken and has always proved
successful, whereas in cases where the bleeding-point
was not definitely established, and where no treat-
ment was carried out, the patient died. Both cases
of established aneurysm were fatal, but in one of the
two cases in which definite aneurysm was not found |
the patient recovered.
CONCLUSIONS
In the female the likeliest source of spontaneous
hæmoperitoneum is the pelvic viscera, especially the
ovary and tube. In the male the most common
source is one of the mesenteric vessels, and a
systematic search for the bleeding-point should be
made, since ligation greatly increases the chances of
survival.
I am indebted to Sir John Fraser for the opportunity
of treating the first two cases and for permission to
record them. I am also grateful to Mr. Illingworth for
permission to refer to his case.
REFERENCES
Bailey, H. (1929-30) Brit. J. Surg. 17, 417.
Box, C. R., and Bamforth, J. (1325) Lancet, 2,1115.
Bruce, H. H. (1929) Ann. Surg. 90, 776
ae a J. R., and Greene, E. I. (1935) J. Amer. med. Ass.
it.
Budde, M. gen Münch. med. Wschr. 72, 1383.
Churchman, J.S. (1911) Amer. J. med. Sci. 142, ret
Dudgeon, L. S., and Sargent, P. W. (1905) Lancet, „47d.
Eppinger, H. (1887) Arch. Chir. a Supplement.
Ernst. H. and Gammeltoft, S. A. (1921) Act. obstet. gynec. scand.
4.
(Continued at foot of next column)
MR. A. L. D’ABREU ! DIAPHYSECTOMY IN ACUTE OSTEOMYELITIS
[JUNE 19, 1937
DIAPHYSECTOMY IN ACUTE
OSTEOMYELITIS *
By A. L. DABREU, Ch.M. Birm., F.R.C.S. Eng.
SENIOR ASSISTANT TO THE SURGICAL UNIT, THE WELSH
NATIONAL SCHOOL OF MEDICINE, CARDIFF
LOWER death-rates for acute osteomyelitis have
been recorded by those who prefer conservative and
limited measures to the old “gutter” operation
(Holman 1934, Tyrrell Gray 1934, Greene 1934).
This paper must not be misconstrued as an appeal
for radical treatment. Since the disease is a systemic
infection followed by a local lesion, death that in
the acute stage is due to septicemia or pyemia will
not be prevented by guttering, shaft resection, or
amputation: such measures indeed increase the
burdens of a critically ill patient. When the local
lesion predominates, suppuration in the metaphysis
spreads outwards to form a subperiosteal abscess ;
this sequence usually precedes a true myelitis. In
children and especially in infants extensive strip-
ping of the periosteum may not cause necrosis,
so adequate is the blood-supply from the nutrient
vessels. Exceptionally, early medullary infection
coincides with the periosteal abscess, but more usually
myelitis develops later as an inward spread along the
Volkmann’s canals from the subperiosteal abscess,
rather than as a direct extension from the metaphyseal
pus (Starr 1922).
CRITICISM OF THE GUTTER OPERATION
It is difficult to believe that the gravity of acute
osteomyelitis depends upon the rigidity of bone,
firstly because of the ease with which pus finds its
way into the subperiosteal space, and secondly
because in children the disease though arising within
more porous bone—because of its greater vasc ularity—
is far graver than in adults. It is more reason able
to ascribe the serious signs and symptoms of juvenile
osteomyelitis to rapid absorption of toxins from the
marrow, for the blood-vessels in growing shafts are
arranged in sinusoidal form to enable blood-cells—
and hence bacteria—to gain ready access to the
general blood stream. Such blood spaces are not
found in adult bones.
Sound treatment, as in the case of cellulitis, avoids
operation until there is a subperiosteal abscess.
At the first operation incision of this suffices; rest
to the patient and complete immobilisation of the
affected limb, preferably in plaster, follow. If at
operation the bone is bleeding there is no need to
* This paper is based upon a section of a thesis presented for
the degree of Ch.M. of the University of Birmingham.
nee continued from previous column)
Forbus, W. D. (1930) Bull. Johns Hone. Hosp. 47, 239.
Gee, S. J. (1 on St Bart’s Hosp. Rep. 7, 147.
Green, W. T., and Powers, J. a (1931) Ann. Surg. A 1070.
Hartley, H and MacKechnie, D oe ae Lane , 289.
Hilliard, J.W. (1918) Brit. med. J.
Moorehead, M. T., and McLester, J. a 1936) J. Amer. med. Ass.
s oid.
Ogilvie, W. H. (1922) Guy’s Hosp. Rep. 72, 219.
Osler, W., and McCrae, T. (1925) Modern Medicine, London,
1. 3, p. 813.
Peck, C. H. (1905) Ann. Surg. 42, 597.
Phaneuf, L. E. (1924) J. Amer. med. Ass. 83, 658. '
L. Ni. s asne F. R., and Garland, H. G. (1929)
Whipple, H., and R e e008) Bull. Johns Hopk.
Pies me 278.
Wilkens, G . (1917) Beitr. Klin. Tuberk. 38, 1.
Willius, F. E (1935) Proc. Mayo Clin. 10, 73.
re:
THE LANCET]
MR. A. L. D’ABREU : DIAPHYSECTOMY IN ACUTE OSTEOMYELITIS [JUNE 19, 1937 1455
ER ane al 2).—Left : radiogram 16 days after partial dapiyscotomy of femur: new bone is already FIG. 4 (Case 4).—
laid down;
at intervals during the nine months after the operation;
there is no deformity except for a little plete
Right: radiogram two years after operation ;
backward bowing.
drill or trephine since this sign indicates a healthy
marrow and the absence of myelitis; usually the
evacuation of the subperiosteal abscess will prevent
marrow involvement. The gutter operation would
only expose further bone to infection, while it adds
the risk of sequestrum formation. If however the
bone does not bleed even after drilling, extensive
FIG. 3 (Case 3).—Left:
sectomy, showing an apparent pseudo-arthrosis.
complete regeneration of fibula in cight months.
radiogram five months after diaphy-
Right:
guttering will not save it, for its blood-supply has
already gone, nor will it provide adequate drainage,
for the pus lies mainly without and not within
the shaft; while sequestrum formation will not be
prevented by so incomplete a removal if the shaft is
necrosed. In such conditions shaft resection is
superior to the gutter operation and may replace
amputation.
the wound is being irrigated through Carrel-Dakin tubes. Centre: radiograms
Radiogram seven
months after com-
diaphysec-
tomy of the fibula.
the new shaft is completely re-formed.
INDICATIONS FOR DIAPHYSECTOMY
Successful shaft resection by removing the diseased
area diminishes, though does not always prevent,
sequestration, and gives splendid drainage to the
subperiosteal space. The risk of non-regeneration
in children has been exaggerated ; it can be prevented
by care in the selection of cases (to be described later),
in the technique, and in the after treatment, where
adequate and prolonged immobilisation is essential,
The operation is unjustifiable in patients over 16,
for regeneration is too uncertain in adult shafts.
or in infants, when the most extensive periosteal
preys To Ty oer VET PERLE re
ål.
1 s ; S
MS, enar a ai RD o EE PEE E E was E EE ʻa
R eee
FIG. 2 (Case 3).— Portion of fibula removed.
stripping may not cause necrosis. In the fibula it is
the operation of choice even to the exclusion of simple
drainage, for non-regeneration is rare and does not
prevent a good functional result and rapid healing.
CHOICE OF PATIENTS
Apart from osteomyelitis of the fibula, resection
is unjustifiable until simple periosteal incision,
combined sometimes with metaphyseal drainage and
followed by plaster case immobilisation, has been
tried. If the temperature persists after four days
the wound is reopened and any abscesses drained.
If, however, the periosteum is widely stripped the
shaft is drilled by the technique described by Fraser
(1934). If no bleeding follows, the shaft is dead or
occupied by pus and will form a large sequestrum ;
1456 THE LANCET] MR. A. L. D’ABREU: DIAPHYSECTOMY IN ACUTE OSTEOMYELITIS [JUNE 19, 1937
FIG. 6 (Case 5)— Radiogram a year after operation showing
incomplete regeneration with pseudo-arthrosis.
FIG. 7 (Case 6).—Abscess cavity in the centre of a shaft which
shows chronic osteomyelitis.
it should therefore be removed in preference to
futile guttering. As already said, resection in the
presence of an adherent periosteum is unjustifiable,
for revascularisation of the shaft may follow.
THE CASE AGAINST DIAPHYSECTOMY
Greig (1933) correctly says that bone is at the
mercy of its blood-supply, being decalcified by the
hyperemia of infection. In acute osteomyelitis
the liberated calcium is redeposited within the
periosteum to form the new involucrum and failure
FIG. 5 (Case 5).— Wound after partial diaphysectomy of fibula.
of bone regeneration is to be expected after
diaphysectomy as the available calcium is removed ;
he says the shaft should not be removed until new
bone is well developed. Since dead and avascular
bone does not readily yield its calcium the argument
loses force, and even in the absence of a shaft the
inflamed periosteum, already rich in calcium and
osteogenic properties, rapidly lays down new bone.
Clinical Experience in Seven Patients
No account is given of the operation in the
phalanges, metacarpals, or metatarsals, but here
I have seen successful results. In all instances
diaphysectomy has been done before an involucrum
had formed.
CLAVICLE
In my first patient, complete bone regeneration
followed resection of an entire clavicle after periosteal
incision and bone drainage had failed (d’Abreu, 1933).
Case 1.—In a boy of 14 with acute osteomyelitis of
_the outer end of the clavicle, a subperiosteal abscess—
containing staphylococci—was opened. The temperature
fell, but three days later the length of the clavicle was
exquisitely tender. I operated again, found pus under
the whole length of the periosteum, and performed com-
plete diaphysectomy. Ten days later a large mass of
callus was palpable. The patient, who had been
immobilised with a long sand pillow between the scapule,
was then allowed to use the arm freely. A radiogram
taken 22 days after the diaphysectomy showed a massive
bone deposition. Five weeks after the operation the
function of the upper limb was normal. Palpation revealed
a normally outlined clavicle.
FEMUR
The second case is one of acute osteomyelitis of
the femur with diaphysectomy followed by recovery
and bone regeneration. (I am indebted to Mr. Geoffrey
Keynes for permission to include this patient upon
whom he operated.)
CasE 2.—A boy, aged 6, was admitted to St. Bartholo-
mew’s Hospital with acute osteomyelitis of the lower
end of the right femur; at 10 o’clock on the morning
of admission the lower end of the femur was exposed
and a subperiosteal abscess drained, but as at 7 P.M.
= on the same day he remained critically ill, a second opera-
tion was performed. To save amputation most of the
shaft of the femur was resected subperiosteally and a
8 9
FIG. 8 (Case 7).—Resected portion of shaft. Note the drill-holes
through which pus was located at the second operation, and
the original window drainage of the metaphysis.
FIG. 9 (Case 7).—Lateral radiogram of the regenerated tibia.
blood transfusion given; the wound was left widely
open and irrigated by the Carrel-Dakin method ; the pus
contained staphylococci. The limb was carefully splinted
with extension maintained by skin strapping.
Progress.—Sixteen days after the operation measure-
ment of both lower limbs did not detect any shortening
or lengthening. A radiogram taken on that day showed
fe Gy ora +a ee
THE LANCET]
that new bone was being laid down (Fig. 1). The
extension was maintained for eight weeks; at this stage
on measurement the affected lower limb was 1 cm. longer
than the normal side ; a radiogram showed good alignment
and a newly formed shaft. Progress was extremely
satisfactory although small sequestra had to be removed
on three occasions, a ring sequestrum being removed six
months after operation, one a year after diaphysectomy,
and the last a year and two months after the first
admission.
Result.—He was seen in July, 1929, when the wound
was soundly healed and again in 1932 when he was a
well-developed boy with a sound femur. MRadiograms
taken over a period of nine months after operation showed
excellent bone regeneration (Fig. 1).
Comments.—In the bone apparently most unsuit-
able for diaphysectomy owing to its massiveness, its
importance in weight bearing and lack of a companion
bone, an excellent result can be obtained; great
care in maintaining accurate extension and guarding
against backward -bowing prevented deformity.
The operation was an excellent substitute for amputa-
tion, giving adequate drainage in a critically ill
child. Diaphysectomy should have no place in the
routine treatment of osteomyelitis of the femur ;
but if after periosteal incision and drainage of the
metaphysis has failed, resection of an avascular shaft
is preferable to extensive guttering or amputation.
Rankin (1927) has published some splendid results
in the femur after resection.
FIBULA
There is no safer or more humane treatment of
acute osteomyelitis of the fibula than early excision
of the affected bone, and primary union of the wound
may follow (see Fig. 5).
CasE 3.—A boy, aged 12, provided a typical example.
He had severe pain over the lower end of the. left fibula
for five days before coming to hospital. On the day
before admission there had been a rigor. There was a
brawny red swelling over the fibula at its lower part.
Operation.—Through an incision over the lower third
of the bone, the peroneal muscles were displaced laterally
and posteriorly ; pus was found between the periosteum
and the bone for a distance of 24 in. The bone was
divided 3 in. above the epiphyseal cartilage and the lower
portion of the diaphysis avulsed; it separated easily
from the epiphyseal cartilage which was left behind and
intact (Fig. 2). The wound was lightly packed with
vaseline and the limb immobilised on a splint.
Progress.—On the 10th day the wound was healthy ;
a light plaster case having been applied he was discharged
well and free from pain; the wound was completely
healed within four weeks of the operation. He was
allowed to walk three weeks after the operation, the light
plaster being discarded six weeks after admission.
Result.—A radiogram taken 19 days after the resection
showed new bone. Six months later the shaft was almost
completely re-formed, but there was an appearance suggest-
ing a pseudo-arthrosis (Fig. 3). The gap, however,
disappeared and the bone regenerated completely (Fig. 3).
Case 4.—In a girl of 9, although regeneration was quite
satisfactory after an extensive diaphysectomy (Fig. 4.),
it was feared that since for some weeks she could not
extend the big toe, the external popliteal nerve had been
injured at the operation, but she recovered so rapidly that
it was probably due to temporary removal of the origin
of the extensor hallucis proprius. As the bone regenerated
so the power of extension returned. The wound has
remained soundly healed since operation.
Incomplete regeneration.—Although this was seen
once there was no loss of function ; this was in a boy
of 11 (Case 5).
At operation pus was found subcutaneously and had
burst through the periosteum which was found to be lifted
from the bone ; the lower quarter of the fibula was removed
MR. A. L. D’ABREU: DIAPHYSECTOMY IN ACUTE OSTEOMYELITIS [JUNE 19, 1937 1457
and avulsed from the epiphyseal plate. The wound was
wiped out with flavine and lightly closed. Progress was
entirely satisfactory and the wound healed almost by
the first intention, the boy being discharged 13 days after
peration and allowed to walk (Fig. 5). Bone regenerated
imperfectly, slowly, and irregularly, An ominous gap
existed two months after the operation. This gap,
though diminished, still existed six months later. A
radiogram taken a year after the operation showed per-
manent non-union (Fig.6). Union is impossible without
operation, but as there is no disability this is of course
unjustifiable.
Incomplete regeneration is difficult to explain.
Bisgard (1935) has shown that resection of periosteum
successfully prevents bony regeneration, and at the
operation on this boy I probably damaged a part
of it. Lorthioir (1935) also comments on the necessity
of preserving the integrity of the periosteum and
refers to unsatisfactory results following its damage.
x
Adults.—Since non-regeneration is not satisfactory —
in adults diaphysectomy should not be carried out
in these on any bone other than the fibula. The
operation has been done once in an adult.
Casz 6.—A man, aged 25, complained of painful swelling
in the mid-shaft of the left fibula. When he was 15 years
of age he had severe pain in the leg for a week which was
treated by hot fomentations until an abscess formed and
broke ; this abscess took six months to heal. After that
he had several recurrences of pain and of discharge.
There was a fluctuant swelling half-way down the fibular
shaft, the whole length of which was enlarged. A radio-
aes oe a Brodie’s abscess situated in the mid-shaft
ig. 7).
Operation.—A subcutaneous abscess was opened and
led down to greatly thickened bone; the portion of bone
containing the abscess was removed and after the wound
had been lightly packed with vaseline gauze, the leg was
immobilised in a plaster case.
Result.—The wound healed well. There has been no
bone regeneration but function is normal.
Comments.—In these cases of shaft resection of
the fibula, the disease was rapidly arrested, sequestrum
formation avoided and rapid healing obtained.
TIBIA
The following is a case of osteomyelitis of the
tibia in which metaphyseal drainage was performed
followed later by diaphysectomy. It resulted in
regeneration with some sequestrum formation.
CasE 7.—A boy, aged 12, had had severe pain above
the right ankle for some days; he was extremely ill,
flushed, and restless with a temperature of 102°F., a
pulse-rate of 112. |
First operation.—The lower third of the subcutaneous
surface of the tibia was exposed. On incising the
periosteum only a little pus escaped, and a window of
bone over the metaphysis was removed and pus was found ;
the marrow above the metaphysis was healthy and bled
normally. The wound was lightly packed with vaseline
gauze and the limb enclosed in a plaster case from above
the knee-joint to the heads of the metatarsals.
Since the temperature and pulse-rate remained high and
the boy was still ill, a second operation was performed
(eight days later). | ,
Second operation.—The plaster case was removed;
the wound was extended upwards and pus was found under
the periosteum reaching up to the proximal half of the
tibia. The tibia was drilled in three places; from the
lower two holes pus exuded, but healthy bleeding came
from the highest bone puncture. Because of the extensive
spread of pus both within and without the shaft, extensive
necrosis appeared inevitable, and more than two-thirds
were resected. The wide separation of the periosteum
from the shaft made the use of a raspatory unnecessary.
The bone separated easily from the lower epiphyseal
cartilage (Fig. 8). To prevent collapse of the lengthy
BB 3
1458 THE LAN CET] DRS, F. D. HART & P. O. ELLISON : MEDIASTINAL GANGLIO-NEUROBLASTOMA
periosteal tube, a glass rod was placed in its cavity. The
wound was lightly packed with vaseline gauze and the
limb encased in plaster.
Progress.—With the temperature and pulse-rate rapidly
falling there was a marked improvement in the general
condition. A radiogram taken 14 days after the operation
showed new bone around the glass rod which was then
removed under general anxsthesia. When the plaster
had been removed the large wound looked healthy, the
glass rod was lifted out and the whole limb again
immobilised in plaster. The further progress was satis-
factory, dressings being done at monthly intervals with
the limb rigidly immobilised throughout in plaster. At
the sixth dressing sequestra were removed from the upper
and lower ends of the wound, the former being a ring
sequestrum. At that time the shaft was well regenerated.
The boy was discharged on Sept. 29th in a plaster to which
was attached a Béhler’s walking iron; the wound was not
completely healed, but is now quite sound.
Result.—As seen on radiograms bone was being reformed
as early as on the fourteenth day after the diaphysectomy.
Iwo months after operation a new shaft had re-formed.
The lower part at this stage was not so well regenerated
as the upper. This deficiency coincided with a good deal
of residual infection in that area and was no doubt due to
the decalcifying effect of a local hyperemia. Six months
after diaphysectomy there was further bone formation
to be seen on the radiogram. At this stage a sequestrum
had appeared and was removed. Fig. 9 shows a lateral
radiogram of the newly formed shaft; although a cavity
is present this is symptomless.
Summary
Diaphysectomy is rarely required in the treatment
of acute osteomyelitis since the results of conservative
incision of a subperiosteal abscess are good when
combined with general and local rest; in common
with other radical measures it is unavailing when
fulminating septicemia overshadows the local lesion.
Extensive periosteal stripping does not imply
certain necrosis, but when combined with true myelitis
the shaft will largely die; in such patients resection
diminishes sequestrum formation and provides splendid
drainage of the pus in the periosteal tube. The
gutter operation is unsound for it does not save
sequestration nor provide adequate drainage; it is
based on the faulty assumption that bone rigidity
is the important factor in acute osteomyelitis. The
theoretical objection that a valuable source of calcium
is removed by diaphysectomy overlooks the inability
of avascular bone to yield or acquire calcium. The
operation is unjustifiable in infants and in adults,
the optimum age being from 6-16. The procedure,
except in the fibula where it is the operation of choice,
must not be adopted until simple periosteal and
metaphyseal drainage have failed and then only when
there is certain proof of myelitis. An adherent
periosteum requiring instrumental separation contra-
indicates resection.
The results in seven patients have been satisfactory.
The epiphysis must be conserved and the resection
need not proceed 1 inch beyond the affected portion
of the shaft. The periosteum must be meticulously
preserved from damage and adequate immobilisation
provided.
REFERENCES
Bisgard, J. D. (1935) Arch. Surg., Chicago, 30, 748.
d’Abreu, A. L. (1933) Lancet, 2, 1369.
Fraser, J. (1934) Brit. med. J. 2, 539.
Gray, H. T. (1934) Ibid, p. 272.
Green, W. T. (1934) Eng. J. Med. 211, 159.
Greig, D. M. (1933) Lancet, 2, 1263.
Holman, C. C. (1934) Jbid, 2, 867.
Keynes, G. L. (1937) Personal communication.
Lorthioir, P. (1935) J. Chir. Brux. 34, 169.
Rankin, W. (1927) Glasg. med. J. 107, 193.
Starr, C. (1922) Arch. Surg., Chicago, 4, 567.
[JUNE 19, 1937
MEDIASTINAL
GANGLIO-NEUROBLASTOMA
By F. DupLEY Hart, M.B. Edin.
MEDICAL REGISTRAR AT THE ROYAL NORTHERN HOSPITAL,
LONDON ; AND
P. O. ELLISON, M.B. Lond.
PATHOLOGIST TO THE HOSPITAL
In 1870 Loretz discovered a tumour containing
well-differentiated ganglion cells, and so established
the occurrence of neoplasms to which the term
ganglioneuroma was applied. Later, as a result of
further study of such tumours and increased know-
ledge of the anatomy and development of the sympa-
thetic nervous system, tumours were recognised which
were composed of undifferentiated sympathetic
formative cells. Such tumours are now called neuro-
blastomata. In between these two extremes (benign
and actively malignant) all degrees of intermediate
tumours were found, and Landau (1912) and von
Fischer (1922) have classified them under a variety
of different headings. Such tumours, although
commonly arising from undifferentiated sympathetic
tissue in the region of the adrenal medulla, may
also arise elsewhere from sympathetic nerve tissue‘in
the abdomen, thorax, brain, cranial and peripheral
nerves, and elsewhere. The neuroblastoma is well
recognised, and descriptions of the Pepper ahd
Hutchison types can be found in all comprehensive
text-books of pdiatrics. The ganglioneuroma ‘is
uncommon, but is carefully described. The inter-
mediate forms are rare, and so little attention has
been given to them in this country that the present
case is thought worthy of detailed description.
CASE REPORT
A boy, aged 6, was admitted to hospital on Jan. 25th,
1937, complaining of pain in the abdomen on and off
for one week, pain in both knees and the left side of the
face for one week, and small glands in the neck, painless
and discrete, for four weeks. Previously he had been
unwell for about a month. There had been no definite
tonsillar infection noted. The pain in the knees was not
acute but was made worse by movement. He had failed
to gain weight for four months before admission. There
was no history of cough, fever, or acute systemic upset.
He had slept well, remained fairly cheerful, and had a
normal appetite until one week before admission. He
had had measles and chicken-pox over a year ago.
Examination.—Temperature 102-7° F.; pulse-rate 124;
respiration-rate 26. A thin boy, somewhat flushed but
quite cheerful. Small discrete glands very slightly tender
both sides of the neck. Left tonsillar gland enlarged.
Small shotty painless glands in both axille. Examination
of cardiovascular and respiratory systems revealed nothing
definitely abnormal. Abdomen: slight tenderness in both
iliac fossæ, but no rigidity ; liver and spleen not palpable.
Joints: slight pain experienced on moving both knees,
also left hip ; otherwise no apparent abnormality. Central
nervous system normal; no rash. Blood: white cells,
8000 per c.mm. (polymorphs 54 per cent., lympho-
cytes 40 per cent., mononuclears 6 per cent.); no
abnormal red or white cells seen. Mantoux: negative
1 in 10,000, 1 in 1000, and 1 in 100.
Progress.—The temperature came down to normal in
four days but occasionally rose to 99°-100°. Pulse-
and respiration-rates also fell correspondingly. On
Feb. 16th temperature rose to 100°4°. Pains in the neck.
Glands much as before, but slightly more tender. Throat
normal. Blood: white cells, 6000 per c.mm. (polymorphs
60 per cent., lymphocytes 32 per cent., mononuclears
7 per cent., basophils 1 per cent.); 4 myelocytes and
2 normoblasts per 200 white cells. Sedimentation-rate
f
THE LANCET]
53 mm. in 1l hour (microscopical method). The urine
presented no abnormalities. The temperature had
settled by Feb. 22nd, when a radiogram showed an oval
mass behind the heart, alongside the vertebral column
in the posterior mediastinum (Fig. 1). Feb. 25th: blood
picture as before; general condition improved.
On March 6th he was very restless, with acute pain in
the left knee. Movements free and painless at the knee,
but much pain experienced on attempting to move the
left hip, where the muscles were in spasm. Adduction,
abduction, and flexion all equally painful. Nothing
abnormal noted in the spine. Spleen not palpable. Left
leg was put in extension. He rapidly improved but an
intermittent pyrexia persisted. Temperature 100°2°.
Pulse-rate 150. Later (March 12th) he had acute pain in
the other hip with similar findings.
Operation by Mr: F. D. Saner under general anzsthesia,
March 18th. Left side of chest explored with a needle.
No fluid found but some resistance offered to the needle.
A portion of the ninth rib was removed and an encapsulated
tumour removed without difficulty from the posterior
mediastinum, It was extrapleural with no adhesions, bar
~
PUT
IMAL 2i al
FIG. 2.—The tumour cut in half, showing the pale outer
ganlioneuromatous part and the ma t inner core of
neuroblastomatous tissue.
AHT
"altel! @h22 7
Sees se *:
a few loose connexions to the surrounding structures.
It was lying alongside the vertebral bodies opposite
thoracic vertebræ 7-11. There were no definite connexions
at its lower pole.
Pathology.—The tumour was encapsulated, with a firm
yellow-white ‘“‘ cortex” and a red ‘‘medulla”’ which
in places came near the surface ; irregular in shape, 2} in.
long, 1} in. wide, 1} in. thick (Fig. 2). Paraffin sections
were prepared from the solid outer portion of the tumour
and from the adjacent hemorrhagic area. “The stains —
used were Ehrlich’s hematoxylin, Anderson’s iron hemat-
oxylin, and eosin and van Giesen as counterstains.
The outer portion of the growth shows a groundwork
of very fine longitudinal fibrils accompanied by flattened
nuclei running in the same direction. This tissue is
arranged in rather ill-defined bundles with loose con-
nective tissue between them. Somewhat sparsely scattered
throughout there are -collections of pale staining cells
without any definite arrangement (Fig. 3). Some of
these cells are very large, others quite small, and there
are many intermediate forms. ‘These features are charac-
teristic of a ganglioneuroma and it may be noted that
the resemblance to sections of sympathetic nerve ganglia
is striking, though of course the histological picture is not
absolutely identical.
- The central portion of the tumour shows an active
neoplastic process, accompanied by hemorrhage and
necrosis. The growth consists of deeply staining cells
arranged in masses of varying size (Fig. 4). The cells
themselves are small and rounded and contain very little
With}
an y
DRS, F. D. HART & P. O. ELLISON : MEDIASTINAL GANGLIO-NEUROBLASTOMA [JUNE 19, 1937 1459
cytoplasm ;
they vary
somewhat
in size and
shape and
on careful
search all
stages
between
the small
undifferen-
tiated cell
and the
large pale
ganglionic
cell can be
found. In
addition,
rosette
forms ‘con-
sisting
of small
deeply
staining
cells ar-
ranged peri-
pherally
around a
fine fibrillar
stroma are
well shown
(Fig. 5).The
tumour,
therefore,
shows fea-
tures of
both neuro-
blastoma
and ganglioneuroma and is best described as ganglio-
neuroblastoma.
Further progress.—On March 23rd he was recovering
from the operation. Pale. A bloodcountshowed: hzemo-
globin, 45 per cent.; red cells, 2,600,000; colour-index,
0°9; reticulocytes, 3 per cent.; white cells, 7000 (poly-
morphs 60 per cent., lymphocytes 29 per cent., mono-
nuclears 6 per cent., eosinophils 4 per cent., basophils
1 per cent.); 4 megaloblasts, 1 normoblast, 3 myelo-
cytes, and ? 1 myeloblast per 200 white cells; many
hypochromic red cells; some anisocytosis and poly-
chromasia. f
May 3rd: the child is still anæmic, but is cheerful,
happy, and free from pain. He has latterly been allowed
up and walks well. He occasionally gets slight pain in
the left knee as before. His hæmoglobin, 65 per cent.
on April 23rd, is now 55 per cent. His red cells had risen.
as high as 4 millions per c.mm., but have now dropped to
3°3 millions. His colour-index has varied from 1 to 0'7.
Immature red and white cells persist as before. Radio-
graphy has shown nothing abnormal in the hips or spine.
It was thought his spleen could be felt following the
FIG. 1.—Radiogram (antero-posterior) showing
mass in mediastinum partly obscured by
shadow of heart.
Section shows large cells
(x 380.)
FIG. 3.—Outer part of tumour.
resembling those of ganglioneuroma.
1460 ‘THE LANCET]
FIG. 4.—Central part of tumour showing large pale pre-
g te te CoN and small deeply staining undifferentiated
ce x
transfusion, but at no other time. The glands on the
right side of his neck are definitely larger now. His
central nervous system seems normal. ,A histamine test-
meal reveals no abnormality. His temperature occasionally
rises and falls over an 8-18 day period (Fig. 6) and is
normal between, with occasional rise in the evening to
99°-99°7°,
Other treatment.—He has had one blood transfusion,
and is having a liver extract and iron.
DISCUSSION
The case is of interest because, although the tumour
is malignant, histologically and clinically, it comes
half-way between the benign true ganglioneuroma and
the highly malignant neuroblastoma, and corre-
sponds to the ganglio-neuroblastoma of Robertson
(1915) or the neuroblastoma gangliocellulare of von
Fischer. In the section the cells of different stages
of development are well seen, small round cells
resembling small lymphocytes, larger cells resembling
large lymphocytes with vesicular nuclei, and even
larger cells running up to immature ganglion cells.
These cell types correspond to the sympathogonia
and sympathoblasts described by Wright (1910).
Such a tumour is usually discovered later than the
highly malignant completely undifferentiated neuro-
blastoma, and sooner than the benign ganglioneuroma
which may, indeed, be entirely silent and discovered
unexpectedly at autopsy. Metastases occur, but the
whole picture is a slower, gradual one.
In this case metastases have almost certainly
occurred. The X ray appearance suggests a cord of
=
; N
S
FIG. 6.—Pulse, temperature, and weight chart.
DRS. F. D. HART & P. O. ELLISON : MEDIASTINAL GANGLIO-NEUROBLASTOMA
[JUNE 19, 1937
tissue running to the region of the left adrenal.
Pains in the lower limbs were noted in some of the
cases described by Frew (1911), and Stout (1924)
described a case of a child, aged 24, who complained
of weakness in the legs. Death followed attempts to
remove a left-sided adrenal ganglio-neuroblastoma,
and an ingrowth was found passing from the
tumour through the intervertebral foramen to
cause compression of the cord. The leg pains
in the case described here may be due to a similar
canse.
The anæmia is of interest. It differs from the
simple microcytic anæmia usually described in such
cases in having many immature red and white cells
in the circulation and many large red çells. The colour-
index has varied from 0-7 to 1. It appears to be a
leuco-erythroblastic anæmia, possibly due to secondary
deposits in bone. In view of the potential malignancy
of these tumours, even the more benign form,
removal is indicated.
this case.
The radiological findings allowed an early diagnosis
In a straight antero-posterior view
early
Even so, the prognosis is bad in
to be made.
FIG. 5.—Cells arranged in rosette form. (x 380.)
nothing was seen at the normal density as the tumour
was hidden behind the heart. An oblique view,
however, revealed it, and lateral and hard antero-
posterior pictures revealed the true extent and size
of the mass. Such a large mass, however, gave no
definite physical signs, and the X ray reports came as a
surprise. There is no radiological evidence of metastases
in the bones, but the glands in his neck are increasing
in number and size, and it is likely that they are
secondary to a lymphatic spread.
Our thanks are due to
Dr. Bernard Schlesinger for
his permission to publish this
case and for the great help
he has given us?
REFERENCES
von Fischer, R. F. ( 1922) Frank-
furt Z. Path. 28, 603.
ae wre S. (1911) Quart. J. Med.
Landau, M. (1912) Frankfurt. Z.
Path. 11, 26.
Loretz, W. (1870) Virchows Arch.
49 , 435.
Robertson, H. E. (1915) Ibid,
220, 147.
Stout, A. P. (1924) J. Amer. med,
488. 82, 1770.
ba a F. H. (1910) J. ezp. Med.
THE LANCET}
[JUNE 19, 1937 1461
“CLINICAL AND LABORATORY N OTES |
PANCREATIC CANCER WITH DIABETES
By F- Pycort, M.B. Liverp., D.P.H.
LATE ASSISTANT RESIDENT MEDICAL OFFICER, MILL-ROAD
INFIRMARY, LIVERPOOL
AND THE LATE
H. Ossory, D.M. Oxon., D.P.H.
PATHOLOGIST TO THE SOUTHERN GROUP, LIVERPOOL MUNICIPAL
HOSPITALS
CANCER of the pancreas and diabetes mellitus are
common diseases in medical practice, but it is rare
to meet both in the same patient. The usual
sequence is for the cancer to supervene on the diabetes ;
for clearly there is no reason to think that a diabetic
is any less liable to develop cancer of the pancreas
than an ordinary person. In the patient whose
history is given below this order was reversed and
the diabetic state was the result of the pancreatic
neoplasm.
Malignant disease of the pancreas most often
affects the head and/or body of the gland, leaving the
tail, which contains the greater part of the islet
tissue, uninvaded until a very late stage. Hence
the symptoms are the outward expression of biliary
and pancreatic obstruction and not of disturbed
carbohydrate metabolism. A neoplasm commencing
in the tail of the pancreas would not be likely to give
rise to any obstructive signs or symptoms, but
rather would show itself by an upset in the carbo-
hydrate balance.
The frequency of carcinoma of the tail of the
pancreas is about one-thirtieth that of the rest of the
gland. Ewing (1928) collected 358 cases of cancer
of the pancreas and in 12 of these the disease was
primarily confined to the tail. Futcher (quoted by
Osler) recorded 58 cases of pancreatic new growth
among 42,000 admissions to the Johns Hopkins
Hospital, the diagnosis being confirmed in 31 cases
at autopsy. On this basis one would expect one case
of cancer of the tail of the pancreas in about 30,000
hospital admissions.
CASE-HISTORY
The patient was a printer aged 58. For three or
four months before entering hospital he had been working
in another town some distance from his home.
this time he noticed increasing lassitude, followed later
by a sense of complete exhaustion. He said that at the
beginning of this period he had had slight swelling of the
legs lasting for afew days. For six weeks his thirst had
greatly increased and he had suffered from severe polyuria.
His appetite was very poor and he had lost weight. For
the last month he had noticed that he had a small
swelling in the left side of his neck and that his voice
had become hoarse. He gave a history of pneumonia and
pleurisy four years before. |
His nutrition was very poor; he had that laxity of the
skin which follows intense dehydration and loss of weight.
There was no icterus of the skin or conjunctive, no
cedema of the ankles, and moderate clubbing of the
fingers. There was no smell of acetone in his breath.
His pulse-rate was raised (100 per minute), but his tem-
perature and respiratory rate were normal. He had a
small ovoid swelling in the left lobe of the thyroid, which
had caused a slight deviation of the trachea to the
opposite side. His peripheral arteries were moderately
sclerotic. No abnormal physical signs were made out on
systematic examination. A specimen of his urine freely
reduced Fehling’s solution, but contained no acetone or
diacetic acid. A quantitative analysis the following day
showed 2°5 per cent. of glucose and a later examination
During |
‘were confirmed at necropsy).
3°3 per cent. The fasting blood-sugar was 250 mg. per —
100 c.cm. on the day after admission.
Sputum examination was negative for tubercle bacilli
and X ray films of the chest revealed no abnormality.
Unfortunately he was not well enough to submit to a —
laryngoscopy. He was put on to a diet of milk, 7 oz.
four-hourly, with water ad lib. No insulin was ‘given.
His lack of appetite and poor general condition prevented
the addition of solid food to the diet. He was entirely
confined to bed. Soon after entering hospital he com-
plained of abdominal pains which were not severe at first
but later increased in intensity. Nothing apart from
slight generalised abdominal tenderness could be found to
account for them. His bowels were acting normally. On
the seventh night after admission he was kept awake by
an intolerable desire to have a bowel action. In the
early hours he called for a a pan, suddenly began to
sweat, collapsed, and died.
An autopsy was performed the same day. A large mass,
the size of a grape-fruit, occupied the site of the tail of
the pancreas; the head and body were not involved.
The left lateral portion of the tumour was necrotic and a
loculated cavity had been formed by adhesions between it,
the splenic flexure of the colon, and a portion of the peri-
toneum of the lesser sac. The cavity was filled with old and
recent blood clot. The left kidney had two small secondary
deposits beneath the capsule. The liver was normal and
there was no biliary obstruction. The thyroid was
enlarged mainly on the left side due to secondary meta-
stases. The larynx was normal in appearance. The lungs
were oedematous, and the heart showed some degree of
myocardial degeneration.
Microscopic sections of the primary growth and of the
secondary deposits in the kidney and thyroid showed the’
same characters. Dr. Osborn’s report was: ‘‘ The histo-
logical appearances are typical of the more embryonic
type of carcinoma of the pancreas, having a superficial
resemblance to lymphosarcoma. Tlie cancer cells are
small, darkly staining, with little cytoplasm, and arranged
loosely in masses.” The islets in the adjoining portion of
pancreatic tissue seemed normal in structure.
HISTORICAL SURVEY
Gerard, Kissel, and Pétry (1932) record a case of
moderately severe diabetes with pancreatic deficiency
in a male aged 45. At autopsy the pancreas was one
mass of growth and metastases were present in the
liver, left kidney, colon, and mesocolon. Urmy,
Jones, and Wood (1931) describe a case of diabetes .
with fatty diarrhcea due to carcinoma of the pancreas.
Velazquez (1932) records another case of pancreatic
diabetes complicating cancer of the head of the
pancreas.
The frequency of cancer of the pancreas in diabetics
was studied by Marble (1934), who followed the after-
histories of 1000 diabetics. Of these, 256 died of
cancer—in 35 cases from cancer of the pancreas (21
No case was found in
which the head was not involved. In 4 cases the
whole gland was affected, but the tail to a less extent
than any other part. In every case the neoplasm
supervened on the diabetes.
Gibbs and Logan (1929) reported the results of
147 autopsies on diabetic patients. No mention is
made of growth being found in the pancreas on any
occasion. Incidentally, they found apparently normal
islets present in 11 cases.
SUMMARY |
A case of diabetes mellitus and carcinoma of the
' tail of the pancreas is reported. The history and
findings at autopsy make it clear that the diabetes
was the result of the pancreatic new growth.
Unfortunately the patient’s condition did, not allow
1462 THE LANCET]
ROYAL SOCIETY OF MEDICINE: THERAPEUTICS AND PHARMACOLOGY |
[JUNE 19, 1937
us to perform a glucose-tolerance test, which might
have produced an interesting curve.
We feel impelled to publish this case, not only
because of its rarity, but also to stimulate interest
in the collection of further post-mortem evidence
in diabetes mellitus, a disease whose etiology from
a pathological point of view is still incompletely
worked out.
I greatly regret that owing to the untimely death of
Dr. Osborn it has been impossible to produce an adequate
photomicrograph of the sections.—F. P.
REFERENCES
Ewing, J. (7928) oN eo pianto Diseases, p. 746.
Futcher, T. B. (19 a Pred in Osler’s Principles and Practice
of Medicine, p. 6
Gerard, Kissel, and Petry (1932) Rer. méd. Est, 60, 373.
Gibbs, W. F. . and Logan, V. W. (1929) Arch. intern. Med.
376
, Marble, A. 81934) New Engl. J. Med. 211
Urmy, T. V., Jones, C. M., and Wood, J. C. OSI) Amer. J. med.
Nei. 182. 662.
Velazquez, B. L. (1932) Arch. Fac. Méd. Zaragoza 1, 288.
THE USE OF STENT COMPOSITION
RADIUM TREATMENT OF CARCINOMA
OF THE VAGINA AND URETHRA
By: CLIFFORD WHITE, F.R.C.P. Lond., F.R.C.S. Eng.,
F.C.0.G.
SENIOR OBSTETRIC SURGEON TO UNIVERSITY COLLEGE
HOSPITAL, LONDON
' Excrsion of a carcinoma of the vagina or urethra
is generally agreed to be a most unsatisfactory
operation and one which can only be attempted
in unusually early cases. The results of operative
treatment have been so depressing that most gynæ-
cologists now prefer to use radium, although the
growth is not of.a type which is usually very radio-
sensitive, In using interstitial radiation for a carci-
noma of the vagina by inserting radium needles of
suitable length into the growth the immediate
IN.
difficulty is that only short needles can be used without
a grave risk of penetrating the bladder, urethral
canal, or rectum, An exception is when the carcinoma
happens to be low on the posterior wall of the vagina ;
but this is rare and such cases are suitable for treat-
ment by excision. Short needles inserted into vaginal
growths almost always fall out even if the vagina is
thoroughly plugged, and in the case of a carcinoma of
or near the urethral orifice plugging is not feasible,
Thus attempts have been made to secure the radium
needles or the boxes containing the radium needles
to the wall of the vagina or urethra by catgut sutures.
This is technically not easy to do, as superficial sutures
cut out of the tissues and deeply passed sutures may
perforate the adjacent viscera thus accelerating
fistula formation.
To avoid some of the above difficulties, I have used
Stent’s Dental Composition (Porro and Co., New
Cavendish-street, London, W.1) in some six cases
during the last three years. The wax composition
is heated till it can be moulded to the length and size
of the vagina—a small senile vagina takes about one
of the tablets and a capacious vagina will require
three. Having thus got an obturator which fits the
vagina from the cervix to the urethra, the radium
needles are embedded into that part of the surface
of the obturator which will lie opposite to the growth
—i.e., in the case of an epithelioma of the urinary
orifice, the needles are inserted into the upper part of
the external end of the obturator and may extend more
to the left or right according as the spread of the
growth is more to one side or the other. The whole
obturator is then covered with a piece of rubber
glove which is tied at both ends with thick thread ;
the ends of the threads are left long to facilitate
removal of the obturator by traction on them. I have
usually inserted 30 to 45 mg. of radium element
according to the size of the growth and given a dose
of about 1250 milligramme-hours which may be
repeated. So far this dosage has not resulted in
early fistula formation.
A self-retaining catheter is essential.
MEDICAL SOCIETIES
ROYAL SOCIETY OF MEDICINE
SECTION OF THERAPEUTICS AND
PHARMACOLOGY
AT ai Meeting of this section on June 8th, with
Dr. Dorotuy Hare, the president, in the chair, a
paper on
Hyperthyroidism and the Thyrotropic Hormone
of the Pituitary
was given by Dr. ARNOLD LOESER (Freiburg i. Br.).
He said that in animals the’ typical symptoms of
hyperthyroidism could be produced by administering
thyroid' hormone or by increasing the production
and liberation of thyroid secretion by giving the
thyrotropic hormone. After injection of the thyro-
tropic hormone into a young guinea-pig the thyroid
showed definite changes: macroscopically it was
enlarged and filled with blood; microscopically
there was a decrease in the amount of stainable
colloid, with growth of the acinus cells which became
first cubical and then columnar; the lumen of the
follicles became smaller and the picture resembled
that of the human gland in Graves’s disease. The
changes could be observed in from 30 minutes to
12 hours after the injection and were also apparent
when living thyroid tissue was treated with thyro-
‘and gonadotropic hormones.
tropic hormone in vitro. The hormone was therefore
believed to act directly on the gland cells; it was
inactive when given by mouth and could be separated
from other anterior pituitary substances, the grawth
The hormone was
estimated by the changes induced in the thyroid and
had been found to be present in very different amounts
in the pituitary of different species. Estimated in
Junkmann-Schoeller units per gramme the com-
parative figures were: ox, 250-500; sheep,
about 1000; rat, 4000-8000; pig, 300; horse, 70;
and man 150-1000. The content in human pituitary
gland was greater in patients suffering from tuber-
culosis and allied chronic infections than in
those with other pathological conditions. The
histological changes in the thyroid gland were
accompanied by a reduction of iodine content,
whereas the iodine content of blood and urine
increased ; after treatment with thyrotropic hormone
the metabolic rate was also raised in guinea-pigs
and humans on the first day, but reached a maximum
after 6-10 days; the glycogen content of the liver
was lowered only after about four days, as it was after
administration of thyroxine. Injection of thyrotropic
hormone also caused hypertrophy of the adrenals and
a fall in their vitamin-C content, increased appetite,
loss of hair, loss in weight, tachycardia, changes in
THE LANCET]
the metabolism of the heart muscle, and finally the
characteristic tremor seen in humans. These symp-
toms were not observed in thyroidectomised animals ;
on the other hand exophthalmos could be produced in
the absence of the thyroid, and Marine and Rosen
therefore thought that the thyrotropic hormone
irritated certain centres in the mid-brain which
controlled the sympathetic nerve to the eye..
Many observers had been unable to maintain the
high rate of production and excretion of thyroid
hormone in normal animals; in fact all the changes,
except exophthalmos, retrogressed to normal or even
subnormal even though the administration of thyro-
tropic hormone was continued; lethal thyrotoxi-
cosis was not produced, apparently because the thyroid
became refractory to the hormone. Loeb in America
had attributed this to an inhibitory action of the
thyroid hormone acting on the thyroid to prevent
further action of the stimulator; certainly the
simultaneous administration of thyroid substance
reduced the effect of the pituitary hormone, but
_ according to Kuschinsky the thyroxine acted on the
hypophysis) Dr. Loeser pointed out however that
hypophysectomised animals also developed a refractory
thyroid under the continued influence of thyrotropic
hormone ; for this reason he concluded that there must
be a second factor in which the pituitary played no
part. Collip and Anderson had first shown that such a
second factor existed ; they had found that the blood
of rats which had been injected for many weeks with
thyrotropic hormone was able to inhibit the action
of the thyrotropic hormone in another animal. The
origin of this substance in the body was unknown
but appeared not to be the pituitary, thyroid,
adrenals, or ovaries. This antithyrotropic principle
had been found in the blood of rats, guinea-pigs,
rabbits, dogs, sheep, and horses after 4-9 weeks’
treatment with thyrotropic hormone ; it had also been
found in normal blood of animals and man, but not in
thyroidectomised animals nor in Graves’s disease,
Loeser and Trikojus had succeeded in concentrating
the antithyrotropic principle and obtaining a stable
powder, 25 mg. of which would suppress the action.
of at least 10 units of thyrotropic hormone, The
extracts were active when given by mouth; their
action was not type-specific, for the thyrotropic
hormone from one species (cattle) could produce in
a second species (sheep) factors which could suppress
in a guinea-pig the activity of a thyrotropic hormone
obtained from a third species (pig). The antithyro-
tropic principle was produced only if thyroid tissue or
thyroxine was present ; inorganic iodine was without
effect in this connexion; the principle was effective
only against the thyrotropic hormone.
The refractoriness of the thyroid in pituitary hyper-
thyroidism seemed to be an adaptation process to
protect the thyroid against the thyrotropic hormone,
It might work by limiting production of the hormone
and its excretion from the pituitary or by barring
the thyroid from the effect of the thyrotropic hormone.
In either way the over-excretion of thyroid hormone
did not occur; experimentally both were feasible for
the excretion of hormone from the pituitary could be
limited by giving thyroxine; encagement of the
thyroid might be achieved by a substance, or sub-
stances, normally present in the blood the amount of
` which might be increased in hyperthyroidism. The
principle seemed to act directly on the thyroid
The thyrotropic hormone therefore had not only the
property of activating the thyroid gland but owing
to the enhancement of the latter's function, of
bringing counter-regulatory processes which pro-
tected the organism against further stimulation from
ROYAL SOCIETY OF MEDICINE: THERAPEUTICS AND. PHARMACOLOGY [JUNE 19, 1937-
1463
the pituitary hormone, eventually . reproducing the
original state of the gland.
Dr. Loeser had found, however, that the organism’s
dual capacity to protect itself could be broken through
by giving progressively increasing doses of the
pituitary hormone; in this way he had been able to
maintain and develop the signs and symptoms of
hyperthyroidism until death supervened. He had
shown this by giving equal total quantities of pituitary
hormone to two series of animals, one receiving uni-
form doses, the other doses which were doubled every
three days until ‘death occurred; in the first group
moderate changes which retrogressed were developed.
In the latter group the thyroids of all the animals were
much enlarged, being on average five times as large as
normal ; the adrenals were also enlarged and there was
fatty degeneration and diffuse necrosis in the liver
and kidneys ; these effects were observed only when
the hormone dosage was progressively increased and
indicated a pronounced thyrotoxic damage since
they were a feature of Graves’s disease. Dr. Loeser
thought therefore that a continuous state of hyper-
thyroidism could be produced in two ways. The first
was continual animation of thyroid activity with the
normal protective function still preserved—ie., true
pituitary hyperthyroidism. The second was failure of
the protective mechanism with a constant or increasing
animation of thyroid activity. The possibility of
treating Graves’s disease with highly active antithyro-
tropic factor was worth consideration in certain cases.
Dr. C. L. Corer said that the thyrotropic hormone
was unfailing in its action. Since he first heard of it
he had wondered what its relation was to the etiology
_ of Graves’s disease. He had tried to find out whether
the hormone circulating in the blood was increased
in that condition. The serum of patients with Graves’s
disease appeared to contain an antithyrotropic effect.
In order to discover whether the thyrotropic hormone
appeared in the urine in Graves’s disease, he had
developed a chemical means of concentrating it, but
even when large quantities of urine were used he had
found no evidence of increased excretion. In the
literature there was extraordinarily little agreement |
as to whether the hormone was present in the blood
in Graves’s disease; the balance of opinion seemed to
be that if it were present it was rather below normal,
and that it was slightly increased in myxedema.
On the whole it seemed that the hormone was behaving
more as a friend than a foe to man in Graves’s disease ;
there was little evidence so far that in that illness the
hormone was produced in excess or was an xtiological
factor.
Dr. RUSSELL BRAIN had been atrai in cases
of exophthalmos with ophthalmoplegia. In some
of them the exophthalmos progressed after partial
thyroidectomy, although the basal metabolic rate
was lowered ; these observations supported the views
put forward by Marine and Rose.
Dr. A. W. SPENCE had been unable to find any
evidence of increased thyrotropic hormone in Graves’s
disease or in two cases of spontaneous myxedema.
In the literature the results were conflicting. Graves’s
disease had been divided into two groups, the larger
due to primary hyperthyroidism, the smaller to
hypersecretion of thyrotropic hormone. The.serum of
patients might serve as an indication for diagnosis and
treatment; some workers claimed success from
deep X ray therapy on the pituitary. Dr. Spence had
found antithyrotropic substances to be present in
normal serum but not in the serum of Graves’s
disease ; he thought that that disease might be due to
lack of inhibiting substance rather than to excess of
thyrotropic hormone.
1464 THE LANCET]
SOUTH-WEST LONDON MEDICAL SOCIETY
[JUNE 19, 1937
Mr. A. S. PARKES, F.R.S., said that the term
“ anti-hormone”’ had first come from Montreal. Its
meaning was not clear and he preferred to speak of
antithyrotropic serum. He asked Dr. Loeser whether
he had made immunological tests with that serum, to
which Dr. LOESER replied that he had not. Dr.
Parkes had been unable to find any antithyrotropic
factor in the blood of six normal sheep. ,
Dr. LOESER said he thought Graves’s disease might
be due to too much thyrotropic hormone or to too
little antithyrotropic principle.
SOUTH-WEST LONDON MEDICAL SOCIETY
AT a meeting of this society held at the Bolingbroke
Hospital on June 9th, with Dr. T. A. CLARKE, the
president, in the chair, the Bolingbroke lecture was
delivered by Dr. CHARLES E. Lakrn who took as
his title
Physical Signs: Are Fhey Worth While?
Dr. Lakin said that his experience as a teacher and
an examiner had convinced him that physical signs
were receding from the important position once held
in the minds of students. Radiology was to blame,
for with its increasing use physical signs were regarded
as unreliable, and time spent in gaining proficiency
in examination as wasted. To argue in terms of
radiology versus physical signs was an error, since
radiology only provided another set of signs, con-
firming those found on physical examination or sup-
plementing them. The X ray apparatus could not
be carried in the waistcoat pocket, and anyone who.
had studied under the old masters knew how much
information and certainty could be attained through
physical examination alone. Interpretation of radio-
grams was often difficult and sometimes misleading,
and he quoted a case where a patient had been kept in
bed for many weeks on the strength of an X ray
shadow (thought to indicate fluid) at one lung base,
when physical examination would have shown no
evidence of a pleural effusion. ate
Physical signs revealed the physical conditions of
the organ studied, for example the volume, density,
expansibility, conductivity, and moisture of the
lungs. To determine the nature of the process at
work physical signs had to be correlated with morbid
anatomy, another field of study now declining in
‘importance. Dr. Lakin agreed with Dr. R. A. Young
who had recently deplored the present tendency of
the young physician to avoid post-mortem work.
The year 1761, he said, was notable for the publica-
tion of two books, the first being the five-volume work
of Morgagni, then in his eightieth year, on the seats
and causes of disease. The letters of which the book
consisted gave accounts of the history, clinical
condition, and post-mortem findings of cases side by
side. Dr. Lakin read the account of a case of menin-
gocele to illustrate the pleasant way in which the
carefully observed facts were recorded. The book
was the first real attempt to correlate post-mortem
findings with what had been observed in life, and
marked not only the beginning of morbid anatomy,
but the beginning of modern clinical medicine.
Another book published in 1761 was a treatise in
Latin on a new device for percussing the chest by
Leopold Auenbrugger. The son of an innkeeper of
Graz, Auenbrugger applied to the human chest the
principles of tapping on casks to determine their
content. The published results of his seven years of
observations on patients, checked in the post-mortem
room, attracted little attention, although Stoll of
Vienna used the method. Corvisart, having read
of it in Stoll’s lectures, republished the book in 1808
with his own notes, and immediately percussion took
its place as one of the most valuable clinical methods.
Cullen (1784) was the first to write of percussion in
England, but he never practised it. The reason for
this neglect lay in the fact that the anatomical con-
ception of disease had not crystallised. Physicians
thought in terms of symptomatic nosology, similar
symptoms of widely differing etiology being grouped
together. Corvisart extended the use of percussion
to cardiac disease and aneurysm of the aorta; he
first described the presystolic thrill of mitral stenosis.
What the historians called the pathologico-anatomical
school of Paris, of which Corvisart was a distin-
guished member, was in reality a clinical school
where the importance of correlating physical signs
with morbid anatomy was recognised. Amongst
the students attracted to Corvisart was Laennec,
inventor of the stethoscope. Dr. Lakin told the
story of this discovery, based on the use of the trans-
mission of sounds by solids in physical examination.
Laennec’s ‘“‘Traité de JTAuscultation Médiate ”’
(1818), filled with his own careful observations, was
one of the greatest books in medicine. Another
name to be remembered in this connexion was Joseph
Skoda of Vienna. ‘Trained in medicine, physics,
and mathematics, he had applied the laws of sound
to physical diagnosis, and had established physical
signs on a logical basis with definite laws, to. which
faith could be pinned.
In the use of physical signs there were many
difficulties, some, such as extreme scoliosis, being
insuperable. It was possible to be much misled, but
in only a small proportion of cases. In the vast
majority physical signs could be relied on, and a
method should not be discarded because it was diffi-
cult. The younger generation wanted results in a
hurry without labour or sweat. It had to be remem-
bered that radiologists had difficulty in interpreting
radiograms, which often failed to elucidate difficulties.
The logical basis of physical signs was that examina-
tion showed the physical condition of the organ
examined. The next step was correlation with
morbid anatomy. In a case with the signs of a cavity
at the base of a lung, morbid anatomical experience
showed that it would be unusual for a tuberculous
cavity to appear at a base unless there was one higher
up. Percussion gave information about lung density,
solid lung giving a higher pitched note than spongy
lung. A musical ear was necessary, especially as
there was so little tone about percussion notes com-
pared with those of musical instruments. A high-
pitched note resulted from solid lung or lung com-
pressed by fluid. With fluid there was a greater feeling
of resistance on the finger. Conductivity was tested
by auscultation ; the presence of bronchial or tubular
breathing indicated solid lung, absent breath sounds
that something intervened. Breath sounds arose in
the larynx, solid lung conducting the sound better
than spongy lung, which gave vesicular sounds.
Sometimes there was bronchial breathing over fluid,
and in such anomalous cases the signs could be inter-
preted in the light of displacement of the apex-beat.
Expiration was prolonged when elasticity was lost,
as in emphysema. Cavernous breathing resulted
from air passing over the opening of a cavity.
A great deal could be learned from the study of
physical signs without X rays. Dr. Lakin could not
help wondering whether those who decried physical
signs had ever got into the way of eliciting them.
Perhaps they lacked a musical ear; perhaps they
suffered from some defect of the organ of hearing.
\
THE LANCET]
SOCIETY OF MEDICAL OFFICERS OF HEALTH
[uNe 19, 1937 1465
SOCIETY OF MEDICAL OFFICERS OF
HEALTH
AT a meeting of the fever hosprtals medical service
group of this society on May 28th, with Dr. E. H. R.
Harries, the president, in the chair, a paper on the
Heart in Diphtheria
was read by Dr. H. Mason LEETE (Hull City Hospital).
Diphtheria, he said, had been especially severe in
Hull during the past six years, and the numerous
toxic cases gave opportunity for a study of the toxic
myocardium. He had attempted to classify in a
roughly quantitative manner the varying degrees of
cardiac dysfunction. A clinical distinction was
drawn between general toxic death in the first week
of disease and cardiotoxic death in the second and
third weeks. Changes in the relative intensities of
the heart sounds could be recognised fairly constantly
during the progress of a severe case, together with
extrasystoles and reduplications, and it was possible to
place these phenomena in a scale which shows increasing
or decreasing cardiac impairment. Proteinuria is an
almost constant accompaniment in cardiotoxic cases.
Dr. M. Mitman (Eastern Hospital, L.C.C.) said
that Dr. Mason Leete’s clinical stages of diphtheria
were substantially similar to his own. In the first
week there was evidence of local lesions and general
toxemia, but electrocardiographic changes were
rare. In the second week there was clinical and
corresponding electrocardiographic evidence of cardio-
vascular damage in the more severe cases. Of the
electrocardiographic signs the most common were
changes in the form and voltage of the QRS
complex, changes in the direction of the T wave in
significant leads, and evidence of conductive lesions
in the bundle and its branches. He believed that
lengthening of the P-R interval was not common,
and that when damage to the main bundle occurred
it produced a complete heart-block. Complete
heart-block sometimes occurred with a normal
pulse-rate. An indication of serious cardiovascular
damages could be obtained not only from the quantity
of albumin in the urine but also from the diminution
in the quantity of urine passed. He believed that
the cardiovascular phenomena in the paralytic stage,
as well as the paralyses themselves, were of central
nervous origin. He had inquired of physiologists if
the cardiac irregularities and the tachycardia of this
stage could be due to damage to the central nervous
system, and had been assured that they could.
Dr. H. S. Banks (Park Hospital, L.C.C.) said that,
of the various factors concerned in the production
of the heart lesion in diphtheria, not the least impor-
tant was the dosage and route of injection of the
antitoxin. He noted that none of Dr. Leete’s cases
had received more than 60,000 units of antitoxin,
some as little as 16,000 units divided between the
intramuscular and the. intravenous routes. The
division of the dose in this way was in his opinion
unnecessary and wasteful. The effective dose in
toxic diphtheria was the intravenous dose, and he
advocated larger intravenous doses as a means of
preventing or modifying the heart lesion. He knew
the financial and mechanical difficulties involved in
such a system of dosage, but believed that it paid
handsomely. He asked whether any member had
followed up the late W. E. Dixon’s work on the
prevention of the heart lesion by preliminary adminis-
tration of large doses of digitalis, He'had not so far
been able to determine what cases, if any, were
suitable for this method,
Dr. E. James (Romford) expressed the view that
gravis strains were not always responsible for a high
case-fatality. In a series of some 800 cases of diph-
theria admitted to hospital from Dagenham, Horn-
church, and Romford during the past 2} years,
approximately 70 per cent. were classified as gravis
and 20 per cent. as intermediate strains, yet the
latter had been nearly twice as lethal as the gravis.
What was the explanation ?
LONDON ASSOCIATION OF THE
MEDICAL WOMEN’S FEDERATION
AT a meeting of this society on May 25th, with
Miss E. C. Lewis, the president, in the chair, a
paper on
Recent Advances in Obstetrics
was read by Miss KEREN Parkes. She said that in-
no branch of medicine did practice vary so much
among reliable authorities as in obstetrics. ‘New
principles were very slow to.be universally estab-
lished, and what was taught as an advance in one
school might be condemned whole-heartedly in
another, But during the last few years some impor-
tant changes of outlook had been very general.
For instance, in the study of the toxsemias of preg-
nancy, a subject always abounding in theories,
there was now an emphasis on the primarily meta-
bolic nature of these disorders, any actual “ toxins ”
being considered as only the result of the disordered
metabolism. In the treatment of minor degrees of
disproportion in primigravide, the fashion for.
| Surgical induction during the last month had given
way to the almost universal practice of trial labour
at term, with the lower-segment Cesarean operation
to follow if necessary. In general, the overwhelming
importance of the conduct of labour itself was gain-
ing recognition, now that the first enthusiasm for
antenatal care had subsided. Even the most skilled
and thorough antenatal treatment could not avoid
all the dangers and difficulties to be dealt with
during the course of labour. For purposes of
discussion clinical obstetrics could be divided into the
antenatal, intranatal, and postnatal periods.
ANTENATAL
Antenatal care could not be limited to the nine
months of pregnancy, since the woman’s adjustment
to this would depend on the state of her health and
nutrition for years past. The province of the ante-
natal doctor thus covered almost the whole field of
medicine, For early diagnosis the Aschheim-Zondek
and the Friedman tests had a high degree of accuracy
and had other uses, notably in diagnosing the intra-
uterine death of a fœtus, the presence of a vesicular
mole, and the onset of chorion-epithelioma. A state
of pregnancy having been diagnosed, the next problem
was to maintain it. In cases of repeated abortion
extracts of corpus luteum were now given. Since
this extract was unfortunately still very expensive,
an alternative method was to give large doses of a
substance stimulating luteal activity which was
found in the urine of pregnant women, marketed as
Antuitrin S or Progynon. regnancy being well
established there were three main objects in ante-
natal work: (1) the avoidance of difficult labour.
due to malpresentation and disproportion, (2) the
avoidance and treatment of toxzmias, (3) the educa-
tion of women in mothercraft and the hygiene of
pregnancy. In each of these fields there had been
some advance, c -
1466 THE LANCET]
(1) By means of X rays in pelvimetry it was now
possible to compare the actual diameters of the
pelvis and of the foetal head. Unfortunately esti-
mates based on these elaborate measurements were
all static and failed to allow for the alterations in
flexion and the moulding of the head which took
place under the influence of uterine contractions,
whose strength and efficacy were quite unpredictable.
In cases of breech presentation external version was
now undertaken slightly earlier than used to be the
custom—from 32 to 34 weeks, instead of from 34 to
36. Where version failed and the legs were extended,
it was no longer customary to bring down a leg when
pelvic measurements were normal unless there was
delay in the second stage. In cases of acute hydram-
nios where X rays revealed a normal foetus the tension
of the liquor caused severe abdominal pain. It had
been found possible to tap the amniotic sac through
the abdominal and uterine walls, if necessary on
several occasions, without disturbing the pregnancy.
(2) The toxæmias of pregnancy were now regarded
as arising primarily from disturbed metabolism. The
best protection against toxæmia was a good mixed
diet, containing fresh foods, with plenty of iron,
calcium, and vitamins, but it was still necessary ‘to
be constantly watching for early signs of toxemia.
Routine urine tests and blood-pressure readings were
now the rule, but in the estimation of odema an
interesting advance had been the recognition that
much help could be obtained from regularly weighing
patients, ‘“‘ occult edema’ being revealed by exces-
sive gain in weight. It appeared from Dame Louise
Mellroy’s work that the normal gain was greatest
from the 24th to the 28th week, being on an average
3 lb., while in toxic cases the maximum gain occurred
rather later, from the 28th to the 32nd week, and was
about 44 lb. Miss Grace Jones had drawn attention
to the state of the retinal arteries as an index of the
condition of the arterioles elsewhere in the body,
particularly in determining when the changes were
such that permanent renal damage was likely to result.
Any sign of retinal exudate or hemorrhage was an
indication for the immediate induction of labour.
(3) Great changes were going on in the maternity
and child welfare services. The supply of domestic
help was an aspect of domiciliary midwifery which
did not, Miss Parkes thought, always receive the
attention it deserved. A supply of reliable home
helps under the supervision of the local authority,
who would guarantee them an adequate wage,
would go far to encourage women to be delivered at
home. :
INTRANATAL
As to the intranatal period, the general trend was
to minimise interference of every kind, and to realise
that the passage of the head through the pelvis was
a dynamic problem—i.e., the uterine forces were
quite as important as the relative sizes of passage
and passenger. A few years ago the induction of
premature labour was very popular for cases where
disproportion was feared at term, but now induction
had no place in the treatment of primigravide with
suspected disproportion. Doubtful cases of dispro-
portion should all be submitted to a trial labour at
term. If after some hours of good pains and rupture
of the membranes the head was not satisfactorily
in the pelvis, Cesarean section must be performed.
The lower-segment operation could safely be under-
taken much later in labour than the classical opera-
tion. The routine use of anzsthetics in labour was
becoming more general, and for the normal delivery
self-administration of gas-and-air was considered
LONDON ASSOCIATION OF THE MEDICAL WOMEN’S FEDERATION
_ best in combining safety and efficiency.
[JUNE 19, 1937
Anzestheties
were important as a possible factor in the production
of the condition known as ‘obstetric shock,’ a
sudden and alarming collapse. The most ellective
treatment appeared to be intravenous saline, with
stimulants such as Coramine or Icoral, and warmth,
One complication of labour which had received more
attention lately was the contraction ring, which
occurred in otherwise perfectly normal cases, causing
prolonged delay, and ultimately obstructed labour,
It might arise at any stage of labour. When this
was diagnosed early in the first stage the treatment
was lower-segment Czsarean section. Later, when
infection. had occurred and the child was dead,
morphia, deep anesthesia, and constant traction
by weights attached to the perforated head were the
only methods available to relax the ring. Should
the contraction occur only in the second stage,
delivery might be accomplished by forceps under
deep anesthesia, and with amyl nitrite. In the third
stage, when fortunately the complication was rare,
treatment was by manual removal of the placenta
after dilatation of the ring—a very dificult pro-
cedure. In the intranatal period the baby also had
to be considered. The resuscitation of the shocked
or asphyxiated baby by lobeline had recently been
recommended.
POSTNATAL
Finally, speaking of advances in the puerperal
period, Miss Parkes referred to prophylaxis against
sepsis, the importance of droplet infection, of septic
foci in the patient herself, and of conditions such
as tonsillitis or ear discharges in other members of
the family, when'the mother was being delivered
in her own, often overcrowded home. Hæmolytiec
streptococci were now known to be the important
organisms, but had been differentiated into twenty-
two different types, varying in virulence, the eleventh
being the worse. Prontosil Album (p-aminobenzene-
sulphonamide) seemed to be an effective drug against
hemolytic streptococci, and its use provided an
enormous advance in treatment. A complication
which might arise during treatment with this drug
was sulphemoglobinemia, which was manifested by
cyanosis, especially of the lips, without any cardiac
or respiratory distress. The condition appeared to
be harmless as long as prontosil was stopped as soon
as the cyanosis was noticed. Epsom salts should
not be given to patients on prontosil, nor, in fact,
any drastic purgative, for even those not containing
sulphur increased the sulphides in the bowel by their
irritating action. Another drug fostered by Queen
Charlotte’s was the widely used antiseptic Dettol.
An electrically driven breast-pump was a fairly
recent innovation, and increasing interest was being
shown in the reconditioning of weakened abdominal
and pelvic muscles by massage and exercises. More
practical advice was being given to women about
the proper spacing of their pregnancies, and patients
with heart or kidney disease were given careful
instruction in birth control rather than a vague state-
ment that they must not have any more babies.
The available clinics giving advice on contraception
were still woefully overworked and overcrowded,
and there were large areas without any, but the need
for them was being recognised, and their numbers
were increasing. Miss Parkes illustrated her address
with some Kodak films of a type of lower-segment
Cesarean operation, of difficult cases of breast-feeding,
and of a case of pseudo-pregnancy, showing the
disappearance of the phantom tumour under
anesthesia,
THE LANCET]
THE LANCET
LONDON: SATURDAY, JUNE 19, 1937
SECOND BEST CARE OF THE EYES
THE Northern Counties Association for the Blind
has issued a warning against the indiscriminate
sale of spectacles. The Association is not, so far
as we are aware, dominated by registered medical
practitioners ; its advice may therefore be listened
to by the general public without any fear that it
is an insidious attempt to bolster up a monopoly
of professional practice. The Association expresses
doubts of the wisdom of allowing a patient to
select for himself a pair of spectacles from a tray
on a street stall or in a multiple shop. The spec-
tacles thus sold may be cheap, and the properly
prescribed spectacles obtained from an optician
may be dear ; but any reasonable or even generous
expenditure on the care of the eyes and the preserva-
tion of the sight is justified. Local authorities have
power under Section 66 of the Public Health Act of
1925 (to be replaced next October by Section 176 of
the new Act of 1936) to make any desirable arrange-
ments for assisting in the prevention of blindness
and for treating local residents who suffer from
disease or injury of the eyes. The Northern
Counties Association suggests that this statutory
power might well be exercised so as to enable the
poorer members of the community to have the
best appliances. What has evidently impressed
the Association is the twofold danger that inexpert
selection from a tray may fail to correct defective
vision and lead to the neglect of the disease under-
lying the defect. The insidious onset of chronic
glaucoma, for instance, needs considerable skill to
diagnose ; failure tó secure skilled examination
of the patient’s eyes may mean that a fair chance
of preventing blindness is thrown away. Voluntary
agencies are doing what they can. In addition to
the clinics and the free services of specialists in
the great hospitals the National Ophthalmic
Treatment Board enables anyone with an annual
income of less than £250 to obtain examination
of the eyes and the prescription of glasses by
recognised ophthalmic medical practitioners at a
much reduced fee. If the fee is still out of reach
of the poor patient, the local authority might
make use of its power under Section 66. Blind-
ness has become a special concern of the com-
munity. It is a false economy that leaves the
layman to be his own expert. No one wants to
overstate the danger; it is on record, however,
that the departmental committee on the Optical
Practitioners Bill of 1927 reported itself satisfied
that the number of cases in which the patient
might miss the opportunity of remedial treatment
if the patient were not examined by an oculist
was by no means negligible.
SECOND BEST CARE OF THE EYES
[JUNE 19, 1937 1469
Just at this moment, as it happens, the National
Health Insurance Joint Committee has issued
some amendments of the Additional Benefit
Regulations of 1930 in relation to ophthalmic
treatment and optical appliances. There is to be
a new committee, representing the approved
societies and the opticians, to administer oph-
thalmic benefit. After next September an approved
society may adopt a scale of charges drawn up
by this committee for the provision of optical
appliances of a defined standard, and in particular
for allowing as a separate item ‘‘ any charge for
services rendered by an optician whether an
optical appliance is supplied or not.” Article 25
of the 1930 regulations defined the provision of
optical appliances as including “any service
rendered by an optician incidental to the provision
of the appliance.” The recent amendment seems
to contemplate that the optician shall perform the.
“ophthalmic examination ’’ which in the 1930
regulations meant “an examination of the eyes
by a medical practitioner having special experience
of ophthalmic work.” If by its new regulations
the Ministry of Health is giving official recognition
to a form of unqualified medical practice, it is a
curiously unobtrusive method of reversing the
conclusions of one Royal Commission and two
departmental committees. The latest annual
report of the National Ophthalmic Treatment
Board dealt faithfully with those apologists for
the sight-testing optician who claim that, when
glaucoma is present, he ‘‘may be considered
absolutely capable in detecting the condition and
thus safe from the public point of view.” However
admirable the education of opticians, their work
has been the correction of errors of refraction.
Their curriculum is not designed to equip them
with the knowledge of physiology and pathology
needed to detect the beginnings of disease.
-` The Minister of Health, in notifying the issue
of. the amending regulations, announces that they
` were framed after consultation with members of
the medical profession. It would be interesting
to learn what those representatives told the
Ministry and how far the Ministry paid attention.
Are those whose sight is defective going to get the
best service ? In a recent letter to the Times Dr.
G. C. ANDERSON justifiably criticised the Ministry
for encouraging the patient to seek what is ad-
mittedly the second best. Sir KinesLEy Woop is
himself satisfied that the ultimate ideal is for all
persons to go to medical eye specialists, and his
plea that the number of these is insufficient has
been denied by Sir Joun Parsons. The new
regulations seem to deserve longer considera-
tion than they have received. Issued by a
procedure based on the sometimes overworked
allegation of departmental urgency, they are |
technically Provisional Regulations. This
should mean that, so far as England and Wales
are concerned, though the regulations take effect
forthwith, there will be an opportunity for any
public body to object to them before they finally
are published as Statutory Rules, The opportunity
should not be neglected.
1470
THE LANCET]
FRACTURE CLINICS
[JUNE 19, 1937
FRACTURE CLINICS
In a number of hospitals throughout the country
a special department has now been set up for the
treatment of fractures and the practice is extending.
The public health authorities are beginning. to
recognise the importance. of these clinics and to
be interested in their organisation as a matter of
public benefit and public economy. For this
reason, as we noted last week, the committee
appointed last year by the Ministry of Health to
inquire into the rehabilitation of persons injured
by accidents has thought well to issue.an interim
-report.' The committee is anxious to ensure
that the organisation of fracture clinics shall
proceed along the right lines, so that individual
clinics shall be efficient and established with due
regard to local needs, while overlap is avoided.
The report therefore deals with (1) the type of
treatment and plan of clinic that should give the
best results, and (2) the distribution of fracture
services so as to put them in reach of all patients
in towns and rural districts. The committee
bases its scheme on the assumption that the
clinics will be established at and as an integral
part of existing hospitals. The principle is that
all fracture cases shall be concentrated in one depart-
ment and under a single control to ensure con-
tinuity of treatment and supervision of all stages
of recovery right up to the re-establishment of full
working capacity.
The type of fracture clinic planned by the com-
mittee has at its head a surgeon who is paid for
his services. The prime responsibility is his and
he is expected to devote a considerable proportion
of his time to the work. The remuneration sug-
gested is £500 for a surgeon-in-charge at a hospital
of 500 to 1000 beds dealing with 2000 to 2500
fractures in the year, £300 where the hospital
has 200 to 500 beds, with a proportionately smaller
number of fracture cases. In the small hos-
pitals, of 50 to 200 beds, the salary is propor- .
tionately reduced. For all the larger hospitals
the scheme provides for one or two full-time assis-
tants, who are senior members of the resident
staff, for the services of a resident radiographer,
and for clerical assistance. The efficient keeping
of records is an essential part of the work. The
services of two resident house surgeons, already
on the staff of the hospital, are called on as required.
For the small hospitals, the appointment of full-
time assistants may not be justified, but arrange-
ments would be made to secure the part-time
service of the existing staff. It will be seen that
this scheme departs in one main particular from
the ordinary policy of voluntary hospitals in that
it involves the payment for services of a member
of the visiting staff. The committee points out
that the time and service that will be required
from the surgeon and the fact that knowledge of
fracture treatment is of small financial advantage
in private practice means that, without payment,
hospitals cannot expect to secure the man best
1 Interim Report of the Inter-Departmental Committee on
the Rehabilitation of Persons Injured by Accidents. H.M.
Stationery Office. Pp. 20. 4d.
qualified for the work. One paragraph of the
report suggests the possibility of fracture clinics
becoming part of a general accident service which
would no doubt include the supervision of all exten-
sive injuries of the soft parts and ensure the skilled
treatment of tendon injuries. Under the purview
of such a service would naturally come the equip-
ment and training of the ambulance corps. In
the future the accident work of hospitals is likely
to be divided off more sharply from the treatment
of sickness, from which it differs profoundly. It
is not good for a patient with a fractured leg or
arm to be treated side by side with ill patients,
whether in wards or in out-patient clinics. He is
not ill, and what he needs is healthy competition
in recovery with other patients like himself.
Malingering is rare in a fracture clinic.
The report cites four criteria of correct reduction
of fractures : (1) the limb must be the right length ;
(2) the bone must be in correct line; (3) there
must be no rotation or twisting ; (4) joint surfaces
must be correctly restored. Fixation by plaster-
of-Paris applied next to the skin is the general
method advised. ‘Traction is mentioned as the
method of choice for fractured femurs. The
importance of early use is emphasised as the basis
of the modern treatment of fractures. In the
planning of the routine work of the clinic arrange-
ments are made for immediate treatment of
casualties, for a session at which every case
can be seen daily for the first few days, and for a
weekly session at which attendance is arranged of
all out-patient cases of fracture under treatment,
all former in-patient cases of fracture, and cases
reporting at varying intervals for follow-up pur-
poses. This clinic is conducted by the surgeon-in-
charge. It is strongly recommended that special
wards be provided for fracture cases which require
admission, and that they shall be placed under
the care of the surgeon in charge of the clinic.
Special arrangements may be made for fractures
of the pelvis and for head injuries, and also for
cases in which the fracture is.a complication of an
abdominal injury. That the equipment of the
department need not be very expensive was
shown by the report we recently published ? of
the municipal accident service at Cardiff. THe
covering letter sent with the report to the county
councils and county borough councils expresses
the hope that if these bodies are intending to
establish clinics for themselves they will refer to
the detailed scheme given in the appendix. Evi-
dently the Ministry of Health expects local authori-
ties to shoulder the responsibility for the efficient
treatment of accidents. Suggestions are made
for the treatment of patients in outlying districts
by codperation between small cottage hospitals
and larger centres. The establishment of accident
services is in many cases held up by lack of money.
Last October a conference on the treatment of
accidents was held in Manchester by the General
Federation of Trade Unions. Employers’ organisa-
tions are also showing interest in the efficient
treatment of their workers. Could these bodies
2 Lancet, Jan. 9th, 1937, p. 107.
THE LANCET]
not induce the great insurance companies to con-
tribute ? It is they who stand to gain most by
the quick and complete recovery of the injured
person. The numbers concerned are large. At
825 hospitals (724 voluntary and 101 municipal)
which replied to the committee’s inquiries nearly
202,000 new fracture cases were treated in the
year 1935. 7
SUPERANNUATION IN THE LOCAL
GOVERNMENT SERVICE
THE fact that local authorities are not obliged
to make provision for their retired employees,
though most of them, including the more important
ones, have made such provision, has long been a
matter of discontent. The Local Government and
Other Officers’ Superannuation Act, 1922, has been
adopted, according to Sir KinasLEy Woop, by
nearly 950 local authorities, and some 25 have
Local Act schemes; but 587 authorities have
made no arrangements for superannuation. It is
not only to protect the employees of the last group,
but to encourage free migration throughout the
country in a service where varied experience is of
high value to senior administrative officers, that
an extension of superannuation provision is
urgently needed. Hitherto, again, even those
local authorities which have made such provision
have been free to decide which of the posts in their
service are designated as “established,” and only
the employees occupying “established ” posts are
superannuable. A Bill now introduced? is designed
to ensure this privilege for all whole-time officers ;
as regards part-time officers and servants there is
no compulsion, their inclusion in the scheme being
left to the discretion of the authority. The normal
age of retirement will remain at 65, except for
female nurses, midwives, and health visitors, who
will retire at 60, or if they wish, at 55, provided
they have then completed 30 years of service.
This permissive clause brings the scheme to some
extent into line with the Federated Superannuation
Scheme for Nurses and Hospital Officers, adopted
by most of the voluntary hospitals of the country,
which makes 55 the age of retirement; but a
more fundamental difference unfortunately remains
which will complicate any attempt in the future
to follow up the coédrdination of the superannuation
practice of local authorities by linking it with that
of the voluntary institutions. The difference is
that whereas under the Federated Superannuation
Scheme the employer pays annually double the
contribution of the employee (10 per cent. and
5 per cent. respectively), the local authority pay
only the same proportion of the remuneration as
do their officers and servants. Hitherto this has
been 5 per cent., but the Bill proposes that in view
of the change in interest rates since 1922, when
Parliament last dealt with the matter, the contri-
bution in respect of officers shall in the future be
6 per cent. from either party. The Bill in its
present form offers only one small concession to
those officers who may wish ‘to seek experience in
1 Bill 141. H.M. Stationery Office. 18.
SUPERANNUATION IN THE LOCAL GOVERNMENT SERVICE
[JUNE 19, 1937 1471
institutions other than those under local authorities ;
12 months is substituted for 6 as the period con-
stituting a disqualifying break of service. Migra-
tion between the services of all local authorities
throughout the country, however, which was
formerly. liable to be penalised by loss or grave
diminution of superannuation prospects, will
involve no handicap if this Bill becomes law.
Reciprocal arrangements are now for the first
time introduced between authorities, such as the
London County Council which have local Acts
and not only between those which have adopted
the Act of 1922, and this applies to transfer values
as well as to the reckoning of previous service.
A criticism made of the Bill at its second reading
concerned the fact that the inclusion of servants
in the superannuation scheme remains optional ;
and Captain ELLISTON expressed disappointment
that no provision was made in the Bill for the
optional addition of a number of years, not exceed-
ing ten, to those which professional officers had
actively served. His plea for special consideration
of the position of medical officers, in view of
the late entry into the service due to long
undergraduate and post-graduate training, was a
cogent one. The debate recorded on another
page was clearly only the first skirmishing round
on a complicated issue.? The relief that legislation
has at last been introduced on the lines recom-
mended by the departmental committee under
Sir AMHERST SELBY-BIGGE as long ago as 1928
will not prevent a careful scrutiny of the provi-
sions of a Bill which will affect an increasing
number of medical officers, nurses, midwives, `
health visitors, and other employees as the service
of local authorities expands.
ANTIBODIES AGAINST HORMONES —
A NEw and fertile field of research was thrown
open when COLLIP and ANDERSON proved that
animals can develop resistance to hormones
administered to them over long periods.’ It has
been established that the thyrotropic and gonado-
tropic hormones of the pituitary evoke such a
resistance, and it is reported that the growth and
ketogenic factors of the pituitary also do so.
Clinically this observation is important, first,
because it may explain why patients become
refractory to further treatment,.and, secondly,
because an antagonistic substance produced in
animals might be used to relieve disorders caused
by excess of hormone. That such a substance can
exist is shown by the fact that the serum of resistant
animals will inhibit the action of the hormone in
other animals, whether this hormone is secreted
by the animal or injected by the investigator.
The hormones known to call forth this resistance
to themselves are protein-like bodies, and it has
been suggested that, like many proteins, they act
as antigens, provoking an immunity due to the
formation of antibodies. Clearly there is: an
analogy at least between the well-known mechanism
2 A memorandum (Cmd. 5452) a Dart the Bill has been
issued and can be obtained from H.M. Stationery Office, 3d.
3 Collip, J. B., and Anderson, E. M., Lancet, 1934, 1, 76, 784.
1472 THE LANCET]
of acquiring immunity to proteins and the formation.
of protective substances against hormones, and it
is credibly reported that the intensity of precipitin
reactions and complement-fixation reactions run
parallel to the protective properties of the sera in
the animal. One difficulty has been to distinguish
between reactions due to hormones and those
due merely to specific proteins, It has, however,
been shown that if antiserum to ox pituitary is
precipitated with ox serum, the supernatant
liquid contains protective factors against ox pitui-
tary, and this rules out the possibility of the anti-
genicity being bound up with the specific proteins.
On the other hand, there is no known mechanism of
auto-immunisation by which an animal becomes
immune toits own pituitary; the hormone, to produce
an antiserum, must come from a different species.
This implies generally, in the present state of pitui-
tary hormone chemistry, that it must contain
heterologous protein, but it would appear that a
greater zoological difference between the species
from which the extract is made and the species
which receives the injections is necessary for the
formation of antisera to hormones than for the
formation of antisera to serum proteins. The
activity of hormone antisera against hormones: is,
' again, subject to species- and source-specificity ;
for antiserum to gonadotropic hormone from
pregnant-mare serum is only partially effective
against other forms of gonadotropic hormone, and
antiserum to extract of human pregnancy urine
is not effective against ordinary pituitary extracts,
whilst antiserum to ox pituitary is only partially
effective against extract of human pregnancy
urine. The immunological phenomena are con-
sistent with the existence of gonadotropic hormones
that differ in each species of animal but have less
intricate and distinctive patterns, and structures
less differentiated from species to species, than
the serum proteins. Alternatively, the same
gonadotropic hormones may serve a group of
related species. The hormonal activity may be
conceived as due to a prosthetic group common
to all species, but so far it has not proved possible
to separate a simple active compound containing
such a group, in the way that thyroxine has been
separated from thyroglobulins. The determinant
groups responsible for serological reactions must,
however, be independent of the hormonal pros-
thetic group, for antisera to gonadotropic hormone
may be prepared with extracts of pregnancy urine
whose potency has been lost after storage, or even
from a fraction from normal male urine having
negligible hormone activity. Logical as the scheme
may seem, it may not be the whole story, and
various considerations remain to be taken into
account, especially in the case of the thyrotropic
hormone. Dr. A. LOESER, whose work carries
great weight, dealt with some of these in the dis-
cussion reported on p. 1462. His most striking
discovery is that antithyrotropic activity is present
in normal sheep’s serum, and it is claimed that
this activity can be concentrated into a particular
fraction. Confirmation of these results would
lead to modification of the straightforward immuno-
logical concept according to which an animal
ANTIBODIES AGAINST HORMONES
[JUNE 19, 1937
does not form antibodies to its own protein-like
hormone. |
Another provocative contribution to these
problems is made by Prof. Junius BAUER and his
collaborators in Vienna,* who find that injection
of thyroxine into rabbits produces a resistant
state, as judged by the disappearance of the fall
in serum-lipase and of the loss in weight which
are regarded as typical thyroxine efiects. When
this resistant state is reached, the serum shows a
positive complement-fixation reaction if thyroxine
is used as antigen. Normal rabbit serum does not
give this reaction. When the sera of human
patients are examined, it is found that this com-
plement-fixation reaction with thyroxine is given
by a large proportion of those with hyperthyroidism
whereas the sera of those with other diseases are
usually negative. Operation on hyperthyroid
patients followed by cure is accompanied by a
disappearance of the thyroxine complement-
fixation reaction. These observations are poten-
tially of great clinical importance and of theoretical
interest in that they suggest that resistance to
thyroxine is bound up in some way with a
mechanism that is on the borderline of recognised.
immunological reactions. A full immunological
effect this cannot be, for the sera of thyroxine-
resistant rabbits does not confer resistance on
normal animals. This work has been extended to
the demonstration that not only thyroxine but also
di-iodotyrosine, adrenaline, sympatol, insulin,
tyrosine, and phenol can act as antigens, the sug-
gestion being that the phenol group is the centre
of a group of more or less unspecific serological
reactions. More definite conceptions of these
reactions must await further study. The comple-
ment-fixation reaction itself is little understood,
and both immunology and endocrinology stand
to gain from closer examination of these
resistance phenomena.
THE MODERN MENTAL HOSPITAL
IN opening the new Runwell Mental Hospital (briefly
described on p. 1487) Sir Kingsley Wood, the Minister of
Health said that the national outlook towards mental
disease had in recent years completely changed, and in no
branch of public health services had there been such
striking improvements in methods of treatment. The
provision in the Mental Treatment Act of 1930, whereby
voluntary patients could be admitted to public mental
hospitals, had already had remarkable results. Of the
25,000 patients admitted to such hospitals last year
nearly 27 per cent. were received on a voluntary footing.
He did not think there was proof that the incidence of
mental disorders in this country was rising. Nevertheless
the problem was a considerable one and there were some
150,000 persons in this country at present under care by
virtue of the Acts providing for Mental Treatment, whilst
there were of course many more who suffered from mental
instability and nervous disorders. Probably something
like a third of all sickness, apparently physical, was in
fact nervous in origin. He was glad to say that increasing
numbers were voluntarily seeking treatment in the early
stages of the disease and while they were still able to
coéperate with the doctors.
4 Bauer, J., Kunewdalder, E., and Schachter, F., Wien.’ klin.
Wschr. 1936, 49, 399; 1937, 50,83. Bauer, J., and KunewAdlder,
E., Wien. klin. Wschr. 1937, 50, No. 12.
THE LANCET |
[JUNE 19,1937 1473
ANNOTATIONS
STATISTICAL TACT
THs week we publish in the form of a slender book 1
of under 200 pages Dr. Bradford Hill’s pithy articles
on the application of statistical principles to medical
investigations. Those who followed these articles
in the pages of THE LANCET in the early months of
this year will find in the book some useful practical
additions—notably a set of simple definitions of
commonly used statistical terms and standard
errors; a note of the precise meaning of certain
expressions sometimes loosely used; and the con-
ventions which are usually followed in expressing
certain rates—e.g., maternal mortality-rate, attack-
or incidence-rate, fertility-rate.
also, by permission of Prof. R. A. Fisher, F.R.S.,
and Messrs. Oliver and Boyd, a table constructed by
him which is particularly useful for testing the
presence or absence of association between character-
istics which, like so many characteristics in medical
work, cannot be quantitatively expressed.
Dr. Bradford Hill in his preface repudiates with
some warmth any suggestion that the statistician
is a cold-blooded organism who enjoys either refuting
other workers’ conclusions, or explaining that though
these may well be true valid evidence of their truth
is sadly lacking. He does not fancy himself in the
rôle either of the armchair critic or of the confirmed
“sceptic, and he resents being forced into the ungracious
position of having to turn down as inconclusive
another man’s sincere and serious work. The
proper solution is for the worker in medical problems,
clinical: as well as preventive, himself to learn
something of statistical technique, both in experi-
mental arrangement and in the interpretation of
figures. Dr. Bradford Hill has shown that, contrary
to the general idea, no special mathematical ability
is needed to grasp and apply elementary statistical
principles and he has certainly illustrated precept
by example. These examples make it clear that it is
not only the senior worker surveying case notes
collected over a long period with a view to extracting
their statistical message who will find here the
help he needs. Whoever is writing an article, prepar-
ing a university thesis, planning a series of experi-
ments, contemplating the issue of a questionnaire,
or concerned with deductions from samples typical
(he hopes) of a larger population will gain from its
study ; and most of all, perhaps, the doctor anxious
to use the opportunities of general practice to solve
some clinical or epidemiological problem.
The main lessons the book teaches is that it is
before an investigation is started rather than after
it is completed that the principles underlying the
collecting and interpreting of numerical evidence
should be grasped, and that far from being a trivial
and time-wasting ingenuity, the application of the
numerical method to the subject matter of medicine
is an important stage in its development,
THE 'ORUG TRAFFIC IN EGYPT
THE report of the Narcotics Intelligence Bureau 2
to the Egyptian Government for 1936, if less dramatic
than the seven previous annual reports, yet affords
1 Principles of Medical Statistics. By A. Bradford Hill,
D.Sc., Ph.D., Reader in Epidemiology and Vital Statistics in
the University of London (London School of Hygiene and
Tropical Medicine); Fellow and Member of Council of the
Towo, e Society. London: The Lancet Ltd. 1937.
p. . 68.
2 Egyptian Government, Central Narcotics Intelligence
Bureau. Annual report for the year 1936. Govt. Press,
Bulaq, Cairo, 1937. l l
There is included °
invaluable evidence of successful vigilance in dealing
with illicit traffic in noxious drugs. T. W. Russell
Pasha, the active director of the Bureau, claims that
Egypt has for years had more drastic legislation
against illicit traffic than such as is provided for
by the last convention on the subject drawn up at
Geneva. While the general situation in Egypt is
now said to be “fair to medium ” it is claimed that
a vast improvement has been effected since 1930
and the number of convicted traffickers and convicted
addicts continues to fall. Indeed ‘ under the post-
treaty régime, the possibility of an almost drugless
Egypt” is foreseen by the indefatigable Pasha.
Internationally however the picture is not so reassur-
ing. ‘The situation at Suez is ‘“‘ disturbing.” It is
reported that ‘“ the majority of the Manchukuo heroin
destined for America is now being routed from the
Far East ports through the Suez Canal’? Commerce
in opium and heroin in Manchukuo appears to be
entirely uncontrolled. ‘‘The world source of illicit
white drugs to-day is China north of the wall and
for some distance south of it. These areas are either
under direct or indirect Japanese control.’ The
chief market for this Chinese heroin is said to be
America, no longer via the Pacific to Western ports,
but through the Suez Canal to European ports for
trans-shipment to New York. According to Russell.
“ Ships’ personnel and passengers can buy a kilo
of heroin in Tientsin for 5000 franes; at Suez and
Port Said they can find ready purchasers at 12,000
francs for the kilo who will dispose of their goods
eventually with a very big profit to themselves.”
The report concludes by urging the closest possible
coéperation with Great Britain and the United States
so that the good work done by the League of Nations
“ shall not be undone and the world re-poisoned solely
and entirely for the monetary profit of a mob of
international rascals living under the protection of
the political chaos of the Far East.”
SECOND INTERNATIONAL CONGRESS FOR
MICROBIOLOGY
So many and so diverse were the subjects under
discussion at the meeting of the International Congress
for Microbiology held in London during July of last
year! that even the final issue of the papers could
only be given in the form of abstracts. The report
of the congress has now reached us in book form ?
under the editorship of Dr. R. St. John-Brooks, the
honorary general secretary of the congress. Micro-
biologists throughout the world will find the volume
full of interest and instruction as much of the work
was chosen for presentation on the grounds that a
clear international understanding of it was desirable.
The discussions range through all the branches of
parasitological and economic microbiology but \no
doubt, as with all really “live”? meetings, the most -
important part of the transactions were in the
personal conversation and demonstrations which took
place during the congress. Among the questions of
medical interest discussed were filtrable viruses,
malaria, the diagnosis of enteric fevers, the prophy-
laxis of diphtheria and whooping-cough, and the
serum treatment of diphtheria, staphylococcal, pneu-
mococcal, and meningococcal infections, enteric fever,
and so forth. The communications on these practical
1 Lancet, 1936, 2, 274 and 331.
2 Second International Congress for Microbiology, London,
1936. Report of Proceedings. Edited for the executive com-
mittee by R. St. John-Brooks (honorary general secretary).
London, 1937, pp. 579.
1474 THE LANCET]
subjects give a good idea of present methods and
tendencies in immunological forms of treatment.
Prontosil and its congeners in the treatment of strepto-
coccal infection came under review. Other sections
covered microbiology in relationship to dairying and
water-supplies, ensilage production, the destruction
and preservation of timber ; problems of the fermenta-
tion and canning industries also received attention.
From such a wide selection it is almost invidious to
select any special subject as of outstanding interest ;
but in the account of advances in virus study one
reads with something of a shock the announcement
of Prof. A. R. Dochez that he and his colleagues have
kept the viruses of influenza and common cold
alive and infections for as long as a year in chick-
embryo medium. The novelty has not yet worn off ,
the experience of watching filtrable viruses emerge
from being mysterious and impalpable ‘ qualities ”’
to reach their present status as cultivable micro-
organisms, with a defined morphology and a compli-
cated and polymorphic life-history. All classes of
microbiologists will be interested too in the discussions
on the methods of maintaining the viability and
virulence of bacteria, on selective bacteriostasis,
the preservation of immune sera, the chemistry of
antigens, and the chemical activities of micro-organisms.
Among matters of more popular interest were the
investigations recorded by Mr. B. E. Proctor of
Cambridge, Mass., on the microbiology of the upper
air, With the aid of an apparatus which he calls the
bio-aerocollector, successive samples of air can be
collected by aeroplane and submitted to microbio-
logical examination. Viable bacteria, moulds, and
yeasts were found to be present at altitudes of 20,000
feet or more during all seasons of the year and even
pollen grains could be collected at very high altitudes.
The volume will appeal to readers who wish to gain
some idea of current activities in the world of micro-
biological research.
DR. JEKYLL DIAGNOSES MR. HYDE
THIs was Sir Walter Langdon-Brown’s witty title
for his Cavendish lecture to the West London
Medico-Chirurgical Society on June 3rd. He began
by saying that to the inheritors of nineteenth
century materialistic medicine it was not a welcome
discovery that the psyche was a causal factor in
disease. The Freudian attitude to the uncon-
scious was perhaps apt to give it too dark and
depressing an impression. He himself started,
therefore, from a biological standpoint as Rivers
would have done. Structurally numerous vestiges
of earlier evolutionary phases were to be recog-
nised in the human body, and the human psyche
from this point of view was likewise a product of
evolution which showed many archaic features.
Rivers did not accept Freud’s conception of a censor-
ship; he regarded the fantastic and symbolic forms
in which hysteria and dreams manifested themselves
as a regression to a lower level which was natural
to the infantile stages of human development, indi-
vidual or collective. We reached the higher levels
ef our nervous system on the stepping-stones not
only of our dead selves but of our long dead ancestors.
The lecturer could not doubt that medicine would
have to become increasingly psychological in its
approach. The new psychology was a compromise,
a selection from the doctrines of different schools,
but it was the needs of the present time that had
led to its development. If some academic psycho-
logists scoffed at it, the simple reply could be made
that it worked, Although it was only in its infancy
SOYA BEAN OR SKIM-MILK FOR INDIA ?
[JUNE 19, 1937
its influence was overflowing beyond the confines
of medicine into many other fields of thought, just
as did Darwin’s exposition of the principle of evolu-
tion. A compact body of well-informed medical
opinion on the subject could be a much-needed educa-
tive influence in a world which seemed to be steadily
growing more psychologically sick. At the present
time, added Sir Walter Langdon-Brown, the darker
side of the collective unconscious was assuming a
volcanic energy. If it was not to prevail we must
live up to the Greek maxim, ‘“ Know thyself,” or
Caliban would reconquer the island he inherited from
Sycorax his mother. “Dr. Jekyll must diagnose
Mr. Hyde by recognising his origin. Am I too opti-
mistic in hoping that the profession to which Jekyll
belonged can by psychological insight play an impor-
tant part in leading the way to a calmer, humaner,
and more rational world ? ”
SOYA BEAN OR SKIM-MILK FOR INDIA?
THE difficulty of securing proper nutrition for the
people of Europe seems great enough, but it shrinks
into insignificance compared with the difficulty of
- securing proper nutrition for the people of India. The
nutritional laboratory of the Indian Research Fund
Association at Coonoor was already busy with
practical problems when it was directed by Sir
Robert McCarrison, and its fine traditions are being
carried on by Dr. W. R. Aykroyd (who passed straight
to it from the Health Section of the League of Nations)
and his Indian colleagues. One of the many qtestions
tackled is what foodstuffs, of those available, can
best be used to supplement inadequate Indian diets,
and a fruitful inquiry of this sort has just been
reported.1 Two methods of investigation were
followed.. One method was to weigh and measure
groups of suitable children of whom some received
the supplements to be tested while others acted as
controls, and the second method was to reproduce
as exactly as possible the supplemented and unsupple-
mented diets and to compare the growth-rate of rats
receiving these. Excellent coöperation was obtained
from missionary hostels for children where the diet
was similar to, but rather better than, that consumed
by the children at home. The supplements chosen
were 1 oz. of dried (equal to 8 oz. liquid) skim-milk
daily, or 14 oz. of soya bean daily. The result was
very striking and was confirmed by the animal
experiments. There was an impressive increase in
weight and height among the children receiving
skim-milk, compared with the negative controls, but
no benefit to those receiving soya bean. An improve-
ment in general condition, a lessened liability to
illness, and an increased vitality were also con-
spicuous. The outcome of the test is surprising,
because cultivation of the soya bean has been
advocated as being perhaps the key to the nutritional
problem of India. Certainly the supply of protein.
of good biological value in such diets as those under
consideration, described as ‘‘ poor Madrassi’’ or
“ poor Hindu,” is low, and one would have expected
that the comparatively good protein of the soya bean
would have gone some way to remedy it. It is of
course possible that it did do so, but that the
coexistence of some second grave deficiency in the
diet was a limiting factor which prevented the benefit
from appearing. If the skim-milk provided both the
good protein and the other limiting factor a double
benefit would appear. Aykroyd and Krishnan
suggest that this second factor supplied by the skim-
1 Aykroyd, W. R., and Krishnan, B. G., Indian J. med. Res.
1937, 24, 1093.
`
THE LANCET]
milk and not by the soya bean is some constituent
of the vitamin B, complex. A great problem of
national housekeeping in many European countries
is the disposal of a vast surplus of skim-milk, India
could use this if it were dried, and Aykroyd and
Krishnan discuss the practical politics of this
suggestion. To-day, they find, dried skim-milk
imported into India is too expensive to be used by
the people but not enormously too expensive. It is
subject to a 30 per cent. import duty, and if this
impost could be abolished the cost would no longer
be prohibitive and a big step would have been taken
towards rescuing the children of South India from
“a poor ‘state of nutrition, with their physical
potentialities largely undeveloped,”
BENZEDRINE
THE many and curious effects of benzedrine,
which remained unnoticed for twenty years after
Barger and Dale described it in 1910, continue to
attract the attention of investigators, both of the
dilettante variety, who take a dose or two of the
drug out of curiosity or under the stress of approaching
examinations, and of the more serious kind, who
write papers about it. An annotation in these columns!
last year drew attention to its main effects—namely,
a rise in blood pressure, a relaxation of gastro-
intestinal spasm, and a striking mental change
involving euphoria, loss of fatigue, heightened
intellectual activity, and talkativeness. Since then
Davidoff and Reifenstein 2 have reported the effects
of a 10-14 days’ course of benzedrine on normal
subjects, and on several groups of psychotic patients.
The manifestations observed, both subjectively and
objectively, are extraordinarily numerous and varied ;
it is abundantly clear that benzedrine acts very
differently on different people. In the ten normal
subjects, elevation of mood, over-talkativeness, and
an increase in motor activity and general efficiency
were the most frequent changes; if fatigue had
been present it disappeared. But five of the
ten developed a state of irritable restlessness
which they did not relish, and from the case
reports we learn that the increase of activity and
efficiency sometimes involved a dangerous degree of
disrespectfulness to superior officers on telephones.
Fatigue sometimes appeared ‘in subjects who had not
felt it before taking the drug. A host of minor bodily
sensations, pleasant and otherwise, are mentioned.
In a number of the subjects, all effects diminished
after the first few days, and little abnormality was
observed in the second half of the period of administra-
tion. The action of the drug in the psychotic patients,
many of them in depressed states, was roughly similar
in kind but less in degree, and there was the same
great variability. A detailed analysis led to the
tentative conclusion that more stimulation occurred
in patients depressed from toxic or organic causes
(such as alcoholism) than in those with purely psycho- `
genic disorders, and to the suggestion that the drug
may be of value in making the minds of depressed
or self-absorbed patients more accessible to investiga-
tion or psychotherapy. No use for it, comparable
to that in narcolepsy, has emerged. On the other
hand, Solomon, Mitchell, and Prinzmetal* have
produced a fair case for its beneficial effect in post-
encephalitic parkinsonism. They treated 28 patients,
some with benzedrine alone, and some with benze-
1 Lancet, 1936, 2, 1475.
2 Davidoff, E., and Reifenstein, E. C., J. Amer. med. Ass.
May 22nd, 1937, p. 1770.
Solomon, P. » Mitchell, R. S., and Prinzmetal, M., y Ibid,
Pp.
CORRELATION BETWEEN INTELLIGENCE AND SIZE OF FAMILY [JUNE 19, 1937
1475
drine and hyoscine or stramonium. Nearly all of
them experienced a decrease in drowsiness, when
this had been present, and an increase in energy and
well-being, which was therapeutically well worth
while. No clear effect on rigidity or tremor could be
demonstrated, but—most strikingly—six patients who
suffered from oculogyric crises lost this distressing
symptom completely, and two others almost com-
pletely, under the influence of benzedrine. Since
inhibition of sleep is the conspicuous central effect of
benzedrine, this observation accords prettily with
Sir Arthur Hall’s thesis * that oculogyric crises are
really episodes of partial and disintegrated sleep.
Solomon and his colleagues found, by contrast, that
the drug was of no use in arterio-sclerotic parkinsonism
or in psychotic patients with conspicuous asthenia,
and out of their large experience they join other
authors in giving warnings against its indiscriminate
use. Its action varies so much, and the effects of
its repeated use are still so little known, that caution
is clearly advisable, especially in its administration
to normal or relatively normal people, as distinct from
those with chronic and incurable disorders.
CORRELATION BETWEEN INTELLIGENCE AND
SIZE OF FAMILY
AN investigation into the correlation between
size of family and intelligence was recently under-
taken > by Mr. R. B. Cattell, Ph.D., with a subsidy
from the Eugenics Society. Specially designed non-
verbal intelligence tests were applied to two groups
of children of ten years of age, who went to school.
in the urban area of Leicester and a rural area com-
prising the villages to the north and south of Dartmoor.
The urban group comprised 2873 children and the
rural 861. Briefly Dr. Cattell found that the stupider
the children the larger were their sibships. In, the
urban area, the mean number of children per family
was 3:36; in the rural, 3-63. The urban children
of an intelligence quotient of 170 belonged to families
wherein there were on average 2:35 children; those
with a quotient of 70 to families whose average size
was 4:13. Comparable figures for the rural children
were 1-80 and 4:21. Children with quotients between
these extremes belonged to families whose size was
roughly in inverse proportion to their intelligence.
Dr. Cattell draws from this data the conclusion that
our national intelligence, being very largely hereditary,
is declining at the rate of about three points in a
generation or a point a decade. In a foreword he
asks that his results and conclusions be submitted
as early as possible for confirmation to a competent
commission of social psychologists and economists
and that, if confirmed, they should be taken into
account by the Ministry of -Health and the Board of
Education,
The facts adduced by Dr. Cattell are unquestion-
ably interesting and suggestive; but the informed
reader will feel that they hardly support the crushing
superstructure of social and philosophical theorising
which is built on them. The technical basis of the
inquiry receives but the scantiest discussion. No
details are given of the specially designed non-
verbal intelligence tests which were employed ;
the reader is not told whether group tests were used ;
and the all-important question of sampling is
dismissed in a footnote. The confident quality
of the generalisations and the boldness of the
Ae J., Brit. med. J. 1931, 2, 833.
5The Fight For o National Intelligence.: By Raymond
B. Cattell, M.A., B.Sc., Ph.D., Psychologist to the Telceater
po ance Authority. London: P. . King and Son. 1937.
p 8
1476 THE LANCET]
recommendations might even have been excessive if
they had been based on hundreds of thousands of cases
drawn from every county in England. Dr. Cattell
deduces from his figures that a real deterioration of
our race is going on here and now, day by day, hour
by hour. To increase the medical and social services
of to-day, without at the same time demanding
restriction of births by those who use them is, we
are told, as. damnable a piece of wickedness as has
ever been condemned by moral law. The husband
should, indeed, be imprisoned for bringing into the
world children beyond his means and, in all probability,
below average intelligence. In discussing remedies,
military similes are used. The presence of deteriora-
tion, having now been clearly proved, can be attacked.
In this generation, the fight has been launched :
the fight is on, and will be won by men and women
fit for the hand-to-hand fighting of committees,
with stamina to carry the struggle into the dust and
heat of social welfare work in sordid cities, and with
courage to face what may at first be a withering
fire from strongly entrenched ignorance and sloth.
Dr. Cattell’s book suffers from language such as this,
SULPHANILAMIDE
EVIDENCE that »-aminobenzenesulphonamide
(= sulphanilamide) protects mice against meningo-
cocci! has led to its trial not only in meningococcal ?
but also in gonococcal infections. R. M. Fry and
also Buttle and his colleagues have found that it is
as effective against small numbers of gonococci as it is
against meningococci in broth medium in vitro, and
although therapeutic tests on animals cannot be carried
out with the gonococcus the experimental evidence
seems to justify its further trial in this infection.
Dees and Colston è of the Johns Hopkins Hospital,
Baltimore, report that since February of this year
they have used sulphanilamide in 47 cases of gono-
coccal infection of the genito-urinary tract. In
36 of these the gonococci and the urethral discharge
disappeared in less than five days, and in only 3
was there no demonstrable response. ‘‘ The most
striking feature of our experience,” they write,
“has been that in no instance has there been a
progression of the infection, even in cases which
showed no response to treatment.” It is not stated
how many of the patients returned for examination,
but in only 3 of those who did so was there any
recurrence, and these were all men who had dis-
continued treatment after a prompt response. Some
patients tolerated a daily dose of 1 gramme per 20 Ib.
of body-weight for as long as a month without serious
ill effects, ‘but dizziness and lassitude were some-
times noticed at first, and sulphemoglobinemia was
recognised in 1 of the first 19 cases (the remainder
are not fully reported). It is not surprising therefore
that Dees and Colston sound an ‘‘ emphatic warning ”
about the possibility of unpleasant reactions, and
though they are profoundly impressed by the prompt
response, and especially by the way in which the
spread of infection was checked—their object in
presenting a report at this stage is to stimulate the
careful use of sulphanilamide in clinics where large
numbers of gonococcal infections can be closely
studied. Such tests are already in progress in
England, but we understand that the results so far
obtained are less encouraging than those of Dees and
Colston.
1 Buttle et Lanet, 1936, 1, 1286;
Jan. 2nd, 1937,
2 Sce D ezt, May 15th, 1937, p. 1183.
E., and Colston, J. A. C., J. Amer. med. Ass.
3 Dees, J.
May 29th, 1937, p. 1855.
SULPHANILAMIDE,—ARTIFICIAL HANDS THAT WORK
oar? H., Ibid, ©
[JUNE 19, 1937
The latest paper by Rosenthal and his colleagues
of the United States Public Health Service * describes
further observations on sulphanilamide and related
compounds in experimental pneumococcus, strepto-
coccus, and meningococcus infections. These workers
have prepared a new compound, disulphanilamide,
which on subcutaneous administration (but not by
mouth) proved slightly more effective than sulphanil-
amide against streptococcal infections in mice,
though its ‘ acute toxicity ” was only one-fifth that
of sulphanilamide. It was also more effective against
meningococcal infections of mice. In this country
Gray et al. ë have also prepared disulphanilamide
and report that (when given by mouth) it is slightly
more effective than sulphanilamide against strepto-
coccal infection of mice, while its toxicity is half that
of the sulphanilamide by this route. The formula of
disulphanilamide is i
HN >SO,NH £ > SO,NH.
and it is interesting to compare its effect with that
of diaminosulphone as described by Dr. Buttle and
his colleagues ê
H,N <> S0,< NH,
In the streptococcal infections of mice diamino-
sulphone proved 25 times as toxic as sulphanilamide
but 100 times as effective,
ARTIFICIAL HANDS THAT WORK
Baron Larrey relates in his memoirs that after the
battle of Brezina he lay in bed, too exhausted to sleep,
for on that day he had done more than 200 amputa-
tions; and as he lay there the thought came to him
that it should be possible to use the muscles of the
stump to provide motive power for an artificial limb,
Some ninety years later Vanghetti, an Italiay physio-
logist, made the first experiments on these lines ;
but the idea did not find practical application until
the late war, first in Italy and then on a larger scale
in Germany. V. Putti described some of these kine-
plastic operations at the Royal Society of Medicine
in 1918,7? and in 1923 came a brilliant monograph
from Sauerbruch of Berlin.® First, a tunnel lined with
skin is made through the triceps behind and another
through the biceps in front. (If the amputation
has been below the elbow-joint, then the tunnels
are made in the extensor group of muscles behind and
in the flexor group in front.) When healing is
complete each tunnel is traversed by a removable
ivory peg from each end of which a string passes to
the artificial limb. The hand itself has four fingers
acting as one unit, and the’thumb acting as a second
unit, and movement of the units is effected by
contraction of the flexor or extensor muscles of the
arm. At the end of his Macewen memorial lecture
delivered in the University of Glasgow last week
Prof. Sauerbruch showed a film illustrating the
remarkable activities possible for patients who
had lost both arms; several of the patients shown
were in good employment as telephonists. The
film opened with a view of two men fitting their
own limbs without assistance. One of them then
dressed himself, being able to carry out the finer
movements necessary to button up trousers and
coat. Another man, wearing his artificial hands,
emptied a box of matches on a table and then with
4 Rosenthal, S. M., Bauer, H., and ,branham, S. E., Publ.
Mith Rep., Wash. May 21st, 1937, p. 662
5 Gray, W M Buttle, G. A. H. od Stephenson, D., Biochem.
J. May, 1937, 724.
ê Buttle et al. fy Lancet June 5th, 1937, p. 1331.
$, 19
8 Sauerbruch, F. (1923) Die willkürlich bewegbare künstliche
Hand. Berlin.
THE LANCET]
fine . dissecting forceps picked up each individual
match and replaced it in the correct position in the
box. The film next showed an exhibition of writing
by two patients, one of whom had also lost an eye.
Another two patients made a combined demonstration
. in which one entered carrying a pail of water which he
poured into the empty pail carried by his colleague.
This manœuvre completed, they offered each other
cigarettes and lit up in the usual way.
there was a close-up of two artificial hands in action,
a shot which had esthetic as well as technical value.
THE FERMENTATION OF PASTEUR AND
CLAUDE BERNARD
It is perhaps some consolation for ordinary men
to behold great ones occupied by little quarrels.
Generally speaking the great figures in the history of
science have afforded fewer opportunities for us to
reap this kind of consolation than have those who
were great in literature and in the arts. Lawyers, too,
and certainly politicians, provide more frequent and
more violent exhibitions of invective called out by
trivial causes than do the leaders of science. These
considerations heighten the interest of the story
which Dr. J. M. D. Olmsted relates! under the title
“ Claude Bernard’s attack on Pasteur.” The title is a
little misleading, for the “ attack ” is to be found in
notes which Bernard had never published and in all
probability never intended to publish, at any rate in
the form in which they were found. The two men
were close friends in their lifetime, Bernard being
some nine years older than Pasteur whose career he
actively encouraged. Pasteur it was, however, who
was instrumental in gaining much needed improve-
ments in facilities for scientific work in Paris, and it
was through his polemics that the Emperor was
interested and that a suitable laboratory was provided
for Bernard." The two scientists were, as is well
known, both interested in the phenomena of fer-
mentation, and engaged in experiments to find out its
nature and causation and to demolish the theory
of spontaneous generation. Their attitude to the
question was, however, not the same. Bernard
believed that the process of fermentation was purely
a physico-chemical one, while Pasteur maintained that
it was a form of life and did not occur without the
presence of some living organism however minute.
Bernard had actually helped Pasteur to demonstrate
the truth of his contention by supplying the blood of
a dog, which Pasteur sealed in clean glass vessels and
kept in an oven at 30°C. for six weeks. At the end
of this time Pasteur was able to demonstrate to the
Academy of Science that even blood would not
ferment out of contact with germ-laden air. Bernard
nevertheless continued his own experiments, hoping
always to be able to demonstrate the presence of
some soluble ferment which caused the phenomenon
of fermentation without the necessary presence of
any living thing. Notes describing these experiments
and the conclusions at which he was arriving, contrary
of course to those of Pasteur, were the cause of the
quarrel which arose after Bernard’s death. D’Arsonval,
Bernard’s pupil and disciple, who had been given the
task of going through his dead master’s papers, took
certain notes, with Paul Bert and Dastre, to Berthelot.
They appeared soon after in the Revue Sctenttfique
with a preface by Berthelot, who had previously
attacked Pasteur on the subject of fermentation.
The fat was in ‘the fire. How Pasteur found in the
notes ‘contradiction of the facts and conclusions
which he had presented before the Academy,” and
1 Ann. med. Hist. March, 1937, p. 114.
` THE FERMENTATION OF PASTEUR AND CLAUDE BERNARD
Finally -
[JUNE 19, 1937 1477
“ absolute condemnation without any restriction of
my views on fermentation in general and on alcoholic
fermentation in particular,” how he did not believe
at first that the notes were genuinely those of the
dead Bernard, and how he triumphantly produced
new and convincing evidence in support of his own
view, should be read in Dr. Olmsted’s lively account.
In a sense both the great men were right. Fermenta-
tion is a physico-chemical process as Bernard main-
tained, and its cause is an enzyme which is provided
by a living organism, as Pasteur asserted. Moreover,
at present no one has succeeded in producing the
enzyme synthetically without the aid of living cells.
THE PAGET TRADITION
EvERY year the Research Defence Society com-
memorates its founder and first secretary by a lecture
delivered at the annual meeting. On Tuesday
last Prof. Grey Turner was the lecturer and in speaking
on the debt of research to the Paget tradition he paid
tribute to both father and son. Stephen Paget
owed his belief in experiment and his zeal for
science to his upbringing in the home of one of
the leaders of medicine—an untiring worker who
combined every day clinical practice with careful
measurement, observation, and collection of facts ;
a surgeon steeped in the history of surgery
who knew what experiment had done for his art.
Sir James Paget’s idea of the doctor’s aim is
reflected in his presidential address to the Inter-
national Congress of Medicine of 1881: “ We had
better not compete where wealth is the highest
evidence of success ; we can compete with, the world
in the nobler ambition of being counted among
the learned and good who strive to make the future
better and happier than the past.” . And again in an
address in 1863 to students at Bart.’s: ‘‘ That which
will most harass you in your practice will be the
apparent success of dishonesty. You must be
prepared for it, for it will not cease in your time, if
indeed it ever does.” To Stephen Paget, his father’s
biographer, James Paget was a continuing inspiration,
and, as Prof. Grey Turner said, the most valuable —
of all the father’s work for the promotion of research
was the stimulus he gave to his son. As secretary
of the Research Defence Society from its foundation
in 1908 till his death in 1926, Stephen Paget was
. indefatigable in serving the cause of experimental
medicine, Prof. Turner recalled his labours during
the late war when attempts were being made to dis-
courage antityphoid inoculation and Paget worked
to the limits of his strength in delivering
lectures to the troops in training. Poor health
again interrupted his service as director of the Anglo-
Russian Hospital in Petrograd, but up to the end of
his life he used all his energy in the work he had
chosen—work in which his object “ was always to
see fair play, to put the real facts squarely before his
hearers and to inform them of what was often
unknown and ill-understood.” That is essentially
the honesty of which his father spoke, and it is the
enduring honesty of science. l
INTER-DEPARTMENTAL COMMITTEE ON ABORTION.—
This committee, which has been set up under the chair-
manship of Mr. Norman Birkett, K.C., “‘ to inquire into
the prevalence of abortion and the law relating thereto,
and to consider what steps can be taken by a more effective
enforcement of the law or otherwise, to secure the reduction
of maternal mortality and morbidity arising from this
cause,” has held a preliminary meeting and will shortly
proceed to hear evidence. Communications may be
addressed to the secretary, Committee on Abortion, ©
Ministry of Health, Whitehall, S.W.1.
—
1478 THE LANCET]
[JUNE 19, 1937
SPECIAL ARTICLES
THE LISTER INSTITUTE
A YEAR’S INVESTIGATIONS
(Concluded from p. 1422)
New growth factors in aqueous yeast extracts.—
Dr. Macrae and Miss C. E. Edgar have shown that
aqueous yeast extracts contain two factors, besides
vitamin B, and lactoflavin, necessary for the growth
ofrats. One of these may be distinct from vitamin B,,
as described by György.
Chemistry of vitamin B, .—Extending their earlier
work in Edinburgh Dr. Toad and Dr. F. Bergel have
completed a synthesis of aneurin (vitamin B,).
The synthetic product was identified with the natural
vitamin by chemical and biological methods and the
synthesis of a number of related compounds has been
undertaken with a view to determination of the
structural features essential for antineuritic activity.
Essentials for reproduction.—Miss Hume and Miss H.
Henderson Smith have continued their study of the
dietary deficiency in rats which affects their breeding
capacity, the full-term young dying in utero or failing
to survive after they are born. Preliminary work
by Dr. Todd and Dr. Bergel having confirmed the
value of rice-germ oil as a starting material for the
isolation of the anti-sterility factor (vitamin E),
the investigation of the unsaponifiable fraction of
this oil as well as of the more commonly used wheat-
germ oil has been taken up in collaboration with
Dr. H. Waldmann and Dr. T. S. Work. From rice-
germ oil several crystalline alcohols have been isolated
and the various products are at present being tested
biologically. It is not yet possible to state definitely
whether or not any one of them represents the pure
vitamin.
Vitamin-O requtrements——Mr. S. S. Zilva, D.Sc.,
has studied the relationship of the intake of ascorbic
acid to the vitamin-C content of the “selective ”
‘organs and other tissues of guinea-pigs, to their
susceptibility to scurvy, to the urinary excretion
of ascorbic acid, and to their general well-being.
He found that in order to attain the maximum concentra-
tion in the tissues ten times the protective dose had to
be given. Only traces of the vitamin were established in
the ‘selective ” tissues when a daily dose 2—3‘times as
great as the protective dose was administered. Guinea-
pigs, the tissues of which contained these minimum amounts
of vitamin C, were, however, observed to live for a number
of years, during which time they attained very high weights.
Furthermore, the time taken by guinea-pigs to succumb
to scurvy when placed on a scorbutic diet was not appreci-
ably different, whether the tissues carried their maximum
load of ascorbic acid or whether only traces of it were
present in them, prior to the animals being deprived of
the vitamin. The accumulated vitamin C in the body
of the guinea-pig, therefore, does not act as a store in
the true sense of the word.
The results of this investigation are in accord with
the general observation made by Zilva and 8. W.
Johnson some years ago on human beings and lend
support to the view that there is a wide margin of
“ unsaturation ” with vitamin C which has no obvious
detrimental effect on the health of the individual.
Vitamin C and cataract.—The presence of vitamin C
in the aqueous humour and lens in relatively high
quantities has attracted the attention of those
interested in the etiology of cataract and contradictory
views are held concerning the significance of this
fact. Dr. Johnson has devoted his attention to the
fate of the ascorbic acid in the humours and lens of
the eye of the guinea-pig in the process of depletion of
vitamin C, but his results suggest that the depriva-
tion of guinea:pigs of vitamin C has no direct bearing
on the stiology of cataract in these animals.
Synthetic ascorbic acid in . canning fruits and
vegetables.—It has previously been shown that it is
possible to add ascorbic acid to fruits and vegetables
before canning without incurring serious destruction
of ‘the acid during the process. Preliminary work
by Dr. Zilva and Mr. T. N. Morris has been carried
out on the stability of the acquired antiscorbutic
potency of these final products. Apples canned
in January, 1935, were tested in September, 1936,
by the biological method, and no perceptible loss
in activity during storage was recorded.
CALCIFICATION
Calcifying mechanism of bone.—Previous work has
shown that the activity of the calcifying mechanism
of the hypertrophic cartilage of the bones of rachitic
rats is generally lower than in that of normal
embryonic bones. Is this decreased activity merely
a sequel to the failure of the cartilage to become
calcified or is it partly responsible for this failure ¢
Prof. R. Robison, F.R.S., and Miss J. Barnett have
observed a very striking increase in the activity of
the calcifying mechanism in bones of rachitic rats
which have received a single moderate dose of calciferol
(5-30 international units vitamin D) within 24—48
hours of death. Calcification of these bones in vitro
occurs at unusually low levels of calcium and phosphate
concentrations, even lower than those required for
normal bones.
It has been shown by other workers that the type
of rickets induced by addition of beryllium salts
to the diet does not respond to vitamin-D therapy.
In agreement with this it has now been fdund that the
administration of very large doses of calciferol
(up to 100,000 I.U.) shortly before death produces
no increase in the very low activity of the calcifying
mechanism of the bones.
Calcification of the aorta.—Prof. Robison and
Dr. M. Laskowski (Warsaw) have completed their
experiments on changes in the aorta in hyper-
vitaminosis D). Calcification of this vessel occurs
very rapidly in rats receiving large doses of calciferol
with a diet of high calcium content but may remain
absent if the calcium intake is sufficiently reduced.
Experiments made with the aortæ of these rats have
failed to produce any evidence of changes in the
organic tissue before deposition of calcium salts but
facilitating such deposition, analogous to the effects
observed’ in bone. The results must be taken as
supporting the view that calcification of the aorta
in hypervitaminosis D is primarily the result of
supersaturation of the blood with calcium salts.
Lactatton.—Dr. G. A. Grant has investigated the
influence of certain hormones in reinstating lactose
synthesis in vivo in regressing mammary glands of
female guinea-pigs which have just ceased lactation.
The lactogenic factor, prolactin, induced these
regressed glands to produce only a limited secretion
of a milk-like fluid of very low lactose content
(0-2-0-4 per cent.). However, active secretion of
milk containing 2-5 per cent. lactose is produced by
prolactin, if the secretory cells of the acinar tissue
have undergone a reconditioning process through
treatment of the animals with ostradiol and pro-
gesterone. Certain substances, for example diphenyl-
a«-naphthylearbinol, which do not possess the phenan-
threne nucleus characteristic of the sex hormones,
THE LANCET]
also caused mammary growth in male animals,
though the possibility of this being an indirect effect
on the general endocrine system requires further
examination.
| SERA AND VACCINE
Specific antigen of Shtga’s bactllus—At Elstree
- Mr. W. T. J. Morgan, Ph.D., has continued his
investigations into the nature of the specific antigen
of B. dysenteriæ (Shiga). It has proved possible
to recover the bacterial antigen in a form which can
be considered to be its natural state. It is a poly-
saccharide-lipoid complex, which readily engenders
in the rabbit specific agglutinins and precipitins for
B. dysenteriae (Shiga). The polysaccharide represents
about 40 per cent. of the antigenic complex; an
account of its chemical structure was given in last
year’s report.
Spore-bearing anaerobes——Mr. D. W. Henderson,
Ph.D., has continued his study of the protective
substances in specific antibacterial sera which control
experimental infection with Clostridium æœdematis
maligni. His observations suggest that antibacterial
prophylaxis may find practical application in the
. control of infections associated with this organism.
Meningococcal infectton.—Dr. G. F. Petrie has
confirmed the statement that an inoculum containing
a comparatively small number of living meningococci
suspended in a solution of mucin is lethal to mice by
intraperitoneal injection. It is now possible to
estimate without difficulty the relative virulence of
meningococcal strains by means of the mucin tech-
nique. Thus a Group I culture maintained under
routine conditions for the past three years has proved
to be as virulent as several freshly isolated strains.
It is intended soon to investigate the therapeutic
action of antimeningococcus sera in mice with the
aid of mucin. |
Type-spectfic antistreptococcus sera.—Dr. Petrie
and Dr. Henderson have immunised rabbits and
horses with three serological types of streptococcus
which are often present as pathogenic agents in a variety
of streptococcal infections in man. The rabbits
have responded satisfactorily, as judged by their
agglutinin titres, but the horses have yielded sera
of much lower titre. Experiments are to be carried
out in mice to ascertain whether the protective action
of the experimental antistreptococcus sera is strictly
type-specific.. Preliminary tests indicate that the
limits of error are wider than those of similar tests
in use for titrating antipneumococcus serum, Type I.
Stabilising action of glycerin on toxins and sera.—
The experience of the past fifteen years at the serum -
department has proved that the addition of 50—60 per
cent. glycerin to tetanus toxin has a remarkable
stabilising action on it and thus facilitates its use as
a laboratory standard in routine tests of samples of
antitoxin,
Within recent years the principle has been extended to
the toxin of Cl. welchit and to dysentery toxin (Shiga).
Technical difficulties have hitherto precluded the applica-
tion of the method to diphtheria toxin but Dr. Petrie
has now prepared a glycerinated toxin by a simple method
which permits of some degree of purification and of a
threefold concentration of the lethal toxin. The L+ dose
of this preparation is 0°0133 c.cm. and the average lethal
dose is 0°0002 c.cm. for guinea-pigs of 250 grammes. The
addition of glycerin to antitoxic and antibacterial sera
is known to have a stabilising influence on the specific
antibody and the method has been applied to most of
the laboratory serum standards in use in the department.
Glycerinated preparations of this kind possess the great
advantage that they can be stored at —10° C. |
Dr. Petrie and Dr. Morgan have made further
observations on the rate of destruction of the protective
UNITED STATES OF AMERICA
‘in the dermis by Besredka’s
[JUNE 19, 1937 1479
antibody in batches of natural and concentrated
antipnewmococcus serum, Type I, on storage. The
concentrated product loses potency much faster than
the natural serum, and the loss takes place mainly
during the first year. Dr. Petrie has begun similar
observations on the stability of the specific antitoxin
in antt-dysentery serum (Shiga).
Elementary-body suspensions in Jenmertan prophy-
laxts.—Behrens and Neilson in 1935 described a
method for purification of vaccinia virus by iso-
electric precipitation of the associated proteins in a
suspension of vaccine pulp. Dr. D. McClean has
studied this method and its application to the produc-
tion of bacteria-free suspensions of elementary bodies
suitable for intracutaneous injection in Jennerian
prophylaxis. It appears that the storage of elementary-
body suspensions of vaccinia prepared for clinical
use is unlikely to present serious difficulties.
TISSUE PERMEABILITY AND LOCAL IMMUNITY
Dr. McClean has completed the observations begun
by Dr. Favilli (Perugia) and himself on the relation
between tissue permeability and local immunity
to infection.
The inhibition of the diffusion of crude testis extract
’s “ antivirus,” plain broth, and
various substances known to reduce the permeability of
the cell, was reported by Favilli and his collaborators ;
this has been confirmed, using purified preparations of the
diffusing factor from the testis. Culture filtrates from
certain invasive bacteria cause a dramatic increase in the
permeability of the tissues and it has been shown that the
diffusion of the purified spreading factors obtained from
these filtrates is similarly inhibited by the same agents.
The mechanism of this inhibition has been investigated
and it appears that it is the inflammatory cellular response
provoked by the injection of “‘ antivirus,” plain broth, and
other substances, which renders the tissues less permeable
to these diffusing factors, whether they are derived from
the testis or from bacteria. These observations supple-
ment the work of Menkin on the local fixation of inflam-
matory processes, and they indicate that ‘‘ localimmunity ”’
may be explained, at least in part, by a non-specific
reduction in the state of permeability of the tissues. They
also indicate the importance of the balance between the
diffusing activity of invasive bacteria and the reduction
in local permeability that results from the inflammatory
response by the host.
Apart from the purely local reaction, it is known
that the diffusing factors of bacterial origin are anti-
genic and provoke the appearance of neutralising
substances in the serum. Preparations are being
made for a serological investigation of the relation
between purified diffusing factors derived from
different bacterial species such as staphylococcus,
Cl. welchti, and Cl. chauvoet.
UNITED STATES OF AMERICA
(FROM AN OCCASIONAL CORRESPONDENT)
TOWARDS A NATIONAL PUBLIC HEALTH POLICY
AN important step in the direction of an agreed
programme between organised medicine and the State
for the care of the indigent sick was taken on May 24th
when the house of delegates of the Medical Society
of New York accepted a report of its committee on
the provision of medical care. The report accepts as
a principle that the health of the people is a direct
concern of the Government, and a national public
health policy directed toward all groups of the
population should be formulated. This extension is
to be governed by the approval of the local medical
profession and is to incorporate to the greatest
possible extent the services of the general practitioner
1480 THE LANCET]
in preventive medicine. Among the practical proposals
designed to carry out these principles are the following :
“ That the first necessary step toward the realisation of
the above principles is to minimise the risk of illness by
increasing preventive efforts through extension of public
health services, federal and local.
“That an immediate problem is provision of adequate
medical care for the medically indigent, the cost to be met
from public funds.
“ That public funds should be made available for the
support of medical education and for studies, investiga-
tions and procedures for raising the standards of medical
practice. If this is not provided for, the provision of
adequate medical care may prove impossible.
“That public funds should be available for medical
research as essential for high standards of practice in both
preventive and curative medicine.
“That public funds should be made available to hos-
pitals that render service to the medically indigent and for
laboratory diagnostic and consultative services. That
these consultative and laboratory diagnostic services shall
be established only in regions where the medical profession
approves the need for same, and after consultation with
the local medical profession in the area affected.
** That in the allocation of public funds existing private
institutions should be utilised to the largest possible extent
and receive support so long as their service is in con-
sonance with the above proposals.”
These proposals, along with a request for a working
definition of the term “adequate medical care,” were
before the house of delegates of the American Medical
Association when it met last week.
THE TRAILER
The automobile trailer, like the house-sparrow, is
said to have been imported from England. In recent
years these mobile homes have manifested a remark-
able crescive faculty. Since Mr. Sherman, whose
money came from his father’s vaccine laboratory in
Detroit, exhibited the first trailer at a Detroit auto-
mobile show in January, 1930, his business has grown
by leaps and bounds. Last year he sold 6000 ‘‘ covered
waggons.” Total factory production was about
35,000, and the Automobtle Datly News estimates that
160,000 trailers were on the road.
A survey of the American Municipal Association,
the Society of Planning Officials, the American Public
Welfare Association, and the National Association of
Housing Officials arrives at the estimate that this
summer there will be 400,000 automobile trailers in
use, housing 1,250,000 persons. It is not necessary
to accept Roger Bahson’s forecast that within twenty
years half of the population of this country will be
living in trailers before we convince ourselves that trailer
housing constitutes a genuine public health problem.
When its a trailer a house? When its wheels
have been removed (as one of our recent ordinances
decrees) or when it has stood for a specified number of
days in one particular spot? Most trailers have no
refrigeration—what happens to the food and milk
carried on board? The common solution of this
problem has led to the nickname of “‘ tin-can tourists ”
being applied to trailer folk. Above all, how shall
the trailer dispose of its garbage and sewage ?
Florida welcomes trailers and provides comfortable
sanitary trailer camps equipped with running water,
sewerage connexions, electric current, shower- baths,
and toilet facilities. Rates for a site in such camps
vary from one to ten dollars a week. If the trailer
contains children Florida charges a licence fee of
12 dollars towards the cost of their education. In
some of the camps doctors, themselves living in trailers,
are licensed to practise medicine among the rheumatic,
bronchitic, sinus-infected refugees from northern cold
and snow. On New Year’s Day trailers crossed the
State line into Florida at the rate of 25 an hour,
IRELAND
[JUNE 19, 1937
Northern and western States have not all proved
themselves as adaptable to the refugees from summer
heat. Municipal ordinances, it is whispered, have
been devised ostensibly to protect the public health
but actually in the interests of hotel proprietors and
real estate firms. Unable to rely on finding a camp
with sewerage provisions, the trailer builders have
resorted to a number of ingenious devices. There is
the chemical toilet, of course, whose treated effluent is
probably harmless ¢f it is properly treated. Or there
may be a simple container with provision for “‘ deo-
dorising ”? until opportunity for decent burial occurs.
A modern contrivance makes use of a waterproof
paper bag which can be securely sealed after use and
disposed of at leisure.
There is at least one travelling tuberculosis sani-
torium that provides a perpetually ideal climate and
the distraction of travel, as well as all modern medical
care and (it is said) adequate rest for the patients.
IRELAND
(FROM OUR OWN CORRESPONDENT)
A SEQUEL TO INOCULATIONS : THE JURY’S VERDICT
THE inquest at Ring, co. Waterford, on a girl of
12, who had died from generalised tuberculosis follow-
ing an immunising injection against diphtheria
(see Lancet May 29th, p. 1305), was continued
on June 10th and concluded at the district hospital,
Dungarvan, on June 12th. Dr. Walsh, the acting
coroner, put the following questions to the jury:
(1) when, where, and from what cause did the deceased
die? (2) Was the ulcer on her arm a tuberculous
ulcer? (3) If it was a tuberculous ulcer did the
general tuberculous condition from which she died
spread from this? (4) If it was a tuberculous ulcer,
did the microbes causing it enter the body at the time
the child was inoculated against diphtheria? (5) If
they did enter it at the time what was their source
and how did they come to be injected ?—With regard
to his last question the coroner said that the lines for
an investigation with any hope of reaching a solution
seemed to him to be almost endless. It must needs
be a long, searching, and highly scientific one, more
properly carried out, in his opinion, by a body of
scientists than by a coroner’s jury. ‘“‘ If you believe,”
he said to the jury, “ that you are not in a position
to give an opinion as to the origin of the tubercle
And I cannot see how you
The jury then brought in a
bacilli, you will say so.
are in such a position.”
verdict as follows :—
“ That we unanimously agree with the medical testimony
that Siobhain Kennelly died at Kmnockenpower on
April 20th, 1937, from toxzmia and purpuric hemor-
rhage consequent to general miliary tuberculosis infection,
and that we are of opinion, according to the evidence
placed before us, that the tuberculous condition was
originated by the inoculation of prophylactic into the
right arm of Siobhain Kennelly in November, 1936,
and that we are of opinion that the contents of the 25 c.c.
bottle of prophylactic labelled ‘T.A.F. Burroughs Well-
come,’ from which a portion of the material was extracted
by Dr. Daniel McCarthy for the purpose of the aforesaid
inoculation, contained tubercle bacilli, and that the
inoculation was carried out by Dr. McCarthy according
to the most approved surgical technique. Every pre-
caution was taken by him and by those who assisted him
to guard against infection arising from contaminated
surgical applications, and we exonerate them from any
blame in this matter.’
Giving evidence about other children at Ring College
who suffered after a similar injection, Dr. P. Kiely
(Cork) said he had examined 10 of the original 11
THE LANCET]
children and found practically all the primary lesions
healed, and in all the condition of the glands greatly
improved. Replying to counsel he said that in his
opinion the future development of the children would
be entirely favourable.
TREATMENT OF TUBERCULOSIS
Speaking at the annual. meeting of the Royal
National Hospital for Consumption for Ireland on
June 10th, Dr. T. G. Moorhead drew attention to
the recent addition of a fully equipped operating
theatre. The facilities for operative work were now
as good as in any hospital in Great Britain or Ireland.
He added that it had been stated that it was proposed
to establish sanatoriums in every county in the
Irish Free State. He thought that if that were so
they should limit their activities to incurable cases.
If they were to compete with such institutions as
those at Newcastle and Peamount they would do
more harm than good. He understood that there
was also a project to establish a central surgical
hospital for tuberculosis. That might be a good
thing but it was a better thing to have treatment
carried out in one institution.
MEDICINE AND THE LAW
Dismissal of Officials under Lunacy Act
THE tenure of officers appointed under the Lunacy
Act has been examined afresh by the Court of Appeal
in McManus v. Bowes. Section 276 of the Act requires
the visiting committee of every mental hospital to
appoint a medical officer, and adds that ‘‘ the com-
mittee may remove any person appointed under this
section.” Does the word ‘“‘ remove ” mean ‘‘ remove
at the committee’s pleasure”? If a statutory
authority has power to appoint and remove officers,
is it entitled to dismiss at a moment’s notice? This,
_ said Lord Justice Slesser, is a matter of great impor-
tance because it goes to the root of the tenure of
everyone employed under the Lunacy Act.
` Dr. Hugh McManus, formerly assistant medical
officer of the Park Prewett Mental Hospital, Sher-
borne St. John, Hampshire, claimed damages against
the Hampshire Joint Mental Hospital Committee
for wrongful dismissal and also sued for the return
of his superannuation contributions. He had origin-
ally sued Dr. R. F. B. Bowes, the former medical
superintendent of the hospital, on the ground that
Dr. Bowes had unlawfully procured the committee
to dismiss him. At the trial before Mr. Justice
Macnaghten it was held that there was no evidence
to go to the jury in support of the allegation against
Dr. Bowes. On appeal the Court of Appeal likewise
released Dr. -Bowes from the proceedings for want of
evidence against him. The case was then dealt with
on the issue of the power to dismiss without notice.
It was argued for Dr. McManus that there was
nothing in the reported cases which should incline
the court to interpret ‘‘remove’”’ as ‘“‘ remove at the
committee's pleasure.” Lord Justice MacKinnon
was puzzled by the fact that the committee had
purported to give Dr. McManus three months’ salary
in lieu of notice.. Under what power did the com-
mittee do so? Could the district auditor have sur-
charged this sum as an illegal overpayment? Lord
Justice Slesser asked whether, if an official had a two-
year contract, he could still be dismissed at pleasure ?
After full argument the Court of Appeal was unani-
mously of opinion that the committee had power
under the Lunacy Act to remove one of its servants
at will. The judge at trial had ruled that the plain-
\
MEDICINE AND THE LAW
‘her and struck her on the head.
[JUNE 19, 1937 1481
tiffs claims were barred by the Public Authorities
Protection Act, 1893, because they were not brought
within the statutory time-limit of six months. The
Court of Appeal declined to interfere.
Substantial Damages for Release of Mental
Patient j
As the medical profession is well aware, there can
be heavy damages against a doctor whose certificate
causes a mental patient to be confined or retained in
an institution. The substantial award of £3500 has
now been given in the converse case of a too early
release. At Liverpool assizes last week Mrs. Bertha
Holgate, with her husband, successfully sued the
Lancashire Mental Hospitals Board and two doctors
of the Calderstones Institution near Blackburn. The
defendants, she contended, had committed a breach.
of statutory duty and had been negligent in licensing
John Lawson, a mental defective, to be absent from
the institution. Lawson had attacked her at her
home and she had suffered serious injuries. Sir
Patrick Hastings, K.C., who opened the plaintiffs
case with characteristic vigour, stated that Lawson,
aged 29, was a dangerous criminal who had been
charged with housebreaking, larceny, assault,
attempted rape, and robbery with violence. Lawson
had been an inmate of Rampton Asylum. From this
State institution he was transferred to Calderstones
on the assumption that his condition was improved.
Lawson’s brother (described by counsel as a working
man with very little leisure to look after anybody
else) applied for his temporary release on licence
and assured the committee that the patient would
remain under his personal supervision. John Lawson
went to Mrs. Holgate’s house, said he was hungry,
and asked for a cup of tea. When her back was
turned, he picked up a piece of wood, came up behind
Her skull was
fractured and her wrist and hand were also injured.
One year of her life had been wiped out and no one
could say how many more years she might not lose
through her injuries. The two defendant doctors,
Dr. F. A. Gill and Dr. G. S. Robertson, were respec-
tively the superintendent and deputy superintendent
at Calderstones. Dr. Robertson had signed the
licence ; Sir Patrick Hastings emphasised that only
the superintendent had authority to sign.
Counsel for the defendants reminded the jury that
Dr. Gill had spent a lifetime in the care and treat-
ment of mental deficiency, and Dr. Robertson had
12 years’ experience of such work. There were seven
offences on record against Lawson, but on five of
these occasions he was either bound over or put on
probation ; all the cases except the last had occurred
before he was 18. He had shown no signs of violence
at Rampton Asylum; his transfer to Calderstones
indicated a progressive improvement, and it was
reasonable, in view of his recent history, to let him
out for a short time to see how he behaved under
proper supervision. The committee had seen and
questioned the brother; it considered the accom-
modation and supervision would be adequate. Finally
it was urged that the two doctors had acted upon
honest belief based upon their medical skill and
experience. Error of judgment was not negligence.
The jury, however, awarded £3500 to Mrs. Holgate
and £708 to her husband. The.defendants had paid
£2000 into court with denial of liability. This sum
was ordered to be paid out to Mrs. Holgate in part
satisfaction of her award, and judgment was given
in accordance with the jury’s findings. As the judge
observed in the course of his summing-up, it is easy
enough to be wise after the event.
1482 THE LANCET)
[JUNE 19, 1937
GRAINS AND SCRUPLES
Under this heading appear week by week the unfetiered thoughts of doctors in
various occwpations.
Each contributor is responsible for the section for a month;
his name can be seen later in the half-yearly index.
BY TWELFTH MAN
III
Sir Auckland Geddes advised his medical audience
in Edinburgh to cease ‘their fear of the non-
rational.” Such advice might be thought superfluous
in our day when the behaviourists maintain that
there is no non-material element in our make-up,
when determinists declare that we are impelled by a
vis a tergo which is both incalculable and irrational,
and when the Freudians insist that our conduct is
determined not by reason or free-will but simply
by our instinctive desires. He was not, however,
urging the claims of irrationalism as a satisfactory
philosophy but pointing out that there are many
facts and many phenomena which reason cannot
elucidate. Such a view has become a commonplace
of twentieth-century science. Modern men of science,
says Bertrand Russell, ‘“ believe that ascertainable
truth is piecemeal, partial, uncertain, and difficult.”
It is possible to be grateful for this new-found
humility of the scientists while still believing that
reason remains man’s guide to as much truth as is
ascertainable, that lis reason is free and may still be
used to control his instinctive desires.
x x *
G. K. Chesterton in his autobiography has an
amusing description of the discussion which took
place in the village of Beaconsfield concerning the
nature of the proposed war memorial. G. K. C., as-
might be expected, argued strongly for a cross but
the ‘local doctor, an admirable physician but a
sceptic of rather a schoolboy sort, observed warmly,
If you do put up a thing like this, I hope yow UU
stick a light on it, or all our cars will smash into it
in the dark.”
This is a perfect illustration of the practical, the
materialist approach to life’s problems which is the
normal attitude of the doctor. There is no need to
defend this outlook in a medical journal; its virtues
shine for us like a good deed in a naughty world.
The limitations of such an approach are less obvious,
for we are mostly “sceptics of rather a schoolboy
sort.” We were trained to believe that the intangible
was non-real, the invisible non-existent, and what
we could not explain was not merely inexplicable
but irrational also.
It is difficult to slough off habits of thought which
have dominated us for generations, but if, while still
retaining unrepentantly our belief in rationalism as
a working-day philosophy, we could acquire something
of the spirit of our modern physicist-philosophers, we
might get with it incalculable gain. ‘‘ Come down to
brass tacks,’ declares our Beaconsfield doctor,
“ granted that there is this new spirit in modern
science, what can it profit clinical medicine which
has no concern with the fourth dimension ?”’ While
we await an answer to this pertinent question from
some undiscovered clinical genius, let me attempt an
inadequate reply. I believe that in each age there
are a few dominating ideas which permeate and
fashion the thought of the day. These ideas are
valuable not because they enunciate fresh truth but
because they reveal new aspects of truth. I believe
that clinical medicine stands to-day in urgent need
of such reinterpretation. There are hosts of new
facts, imperfectly digested, which demand new
generalisations and such generalisations would alter
profoundly our conception of disease processes in the
individual, But even if this new comprehension is
denied us, I think the modern scientific spirit might
still do much for us. It would make us more receptive
of new ideas in medicine and more distrustful of new
remedies, It would make us less satisfied with the
diagnostic labels which we attach to patients and less
disappointed if a piece or two of the jig-saw puzzle
is Missing, as it so often is. It would help us to look
at disease constitutionally, to regard it as a reaction
of the whole man, mind and body—an individual
reaction. It would. kill forever those monstrous
text-books of differential diagnosis that depend on
an analysis of symptoms—katabolic and not anabolic.
. It would give us a juster appreciation of the results
of laboratory research and an enhanced ability in the
fitting of these new facts into the mosaic of our
clinical conceptions. It would make us more critical
of our own dogmatism, more aware of our enormous
capacity for self-deception. It would keep Cromwell's
cry ringing in our ears, ‘‘ Gentlemen, I beseech you,
by the bowels,of Christ, to remember that you may
be mistaken.” This would be no mean harvest.
I may be wrong, but I think it has been possible to
see the stirrings of this new spirit during this last
decade. $ ” £
The recent death of Miss Moberley recalls an
incident which illustrates well our changed attitude
to non-rational experiences. Thirty-six years ago 1
Miss Moberley and Miss Jourdain were on holiday in
Paris. They were women of high intelligence and
the successive principals of St. Hugh’s College,
Oxford. Neither of them had any specialist knowledge
of French history. They were walking one afternoon
in the grounds of the Petit Trianon at Versailles when
they were met and addressed by persons wearing the
costume of 1789; some of those persons were visible
to one of them, others to both. They passed by woods
that no longer exist; saw a man sitting by a kiosk
which has disappeared long ago; and were accosted
by a footman who emerged from a door in the palace
which, through the destruction of a staircase, was
built up nearly a hundred years ago. At the time the
ladies noticed nothing peculiar in their experiences
beyond a strange feeling of depression. It was only
when discussing some weeks later the events of the
afternoon that they became impressed by the
strangeness of what they had seen. Patient research
in the years that followed revealed that the geography
of the place, as they described it, was as it had been
in the days of Marie Antoinette, that the lady seen
by Miss Moberley was Marie Antoinette herself ;
that the dresses were in detail what they would have
been in 1789. There is much quietly described
corroborative detail in the book ; it makes fascinating
and unusual reading.
It is not difficult to imagine what the general
reaction to this recital would have been thirty years
ago— but to-day J. W. Dunne, in an introduction to
the book, writes, ‘“ Hence, if Einstein is right, the
1** An Adventure.” ByC. A. E.Moberley and E. F. Jourdain.
London. 1931.
THE LANCET]
contents of time are just as ‘real’ as the contents
of space. Marie Antoinette, body and brain, is
sitting in the Trianon garden now. What does that
‘now’ mean? It is a four-dimensional ‘ now,’ such
as would be employed by a super-mind which could
perceive Marie Antoinette and you (who are reading
this) as equally present to perception. . . A
dreamer’s attention can travel to and fro in the
physicists alleged four-dimensional ‘time’ ... .
Granted this absorption in that particular part of
the past, anyone who is capable when awake of
mental ‘time-travelling’ combined with telepathy
would be likely to see what these two ladies saw
through the eyes of any persons who walked in that
garden in the year 1789.”
$% * *
This adventure has one curious interest for the
physician. It resembles the sort of visual and
auditory aure which sometimes accompany an epi-
leptic fit. James Collier described thus the aura
of a patient of his ‘“ who suddenly found himself
approaching a level-crossing in a picturesque village
in high sunlight. Out of the little guard-house on
the farther side came a woman dressed in the conical
beaver-hat and scarlet cloak of the Welsh national
dress, who greeted him with a smile. He hastened
forward to meet her but found the gates rapidly
closing upon him. As they closed, but before they
touched him, he lost consciousness. In this case the
hallucination was always the same in every detail and
in each fit.” Moreover, both Miss Moberley and Miss
Jourdain experienced an ‘extraordinary depression
during the incident which in spite of every effort
steadily deepened.” I am not suggesting that both
these ladies had epileptic attacks with an identical
aura and at the same moment, but would our
physicist-philosophers regard an epileptic attack as an
explosive escape into fourth-dimensional time ?
* * *
The rôle of the expert in human affairs becomes an
increasingly important one. With its increasing
importance comes a distressing tendency for the
expert to pontificate outside his own subject. When
I read statements taken from experts found wandering
but still capable of speech, I recall the remark of
Hanoverian George as he surveyed his troops before
battle: ‘“ I don’t know what they'll do to the enemy
but, by God, they frighten me.”
The expert who uses his reputation to buttress an
Opinion which does not rest on the foundation of his
special knowledge sins against the light. Examples
of this occur readily to the mind. Doctors err
frequently in the law courts, where the expert medical
witness is easily tempted. One of the less offensive
instances was that of a distinguished forensic patho-
logist who gave his opinion as to whether or not the
sound of a falling body could have been heard by the
driver of a car. It matters not at all whether the
medical jurist was right or wrong because his evidence
on such a matter is of the same value as the least
intelligent layman—neither more nor less. But to-day
the opinion of doctors is invited, both individually
and collectively, on many matters outside a court of
law which are of national, social, and political
importance. An enumeration of such subjects would
include malnutrition, population, the _ birth-rate,
birth control, noise, tests for drunkenness, road acci-
dents, the campaign for physical fitness, corporal
punishment, euthanasia, war and peace, and many
another problem, even when specific questions of
public health are excluded.
GRAINS AND SCRUPLES
[JUNE 19, 1937 1483
If doctors are to express aN opinion on these and
kindred subjects there will be general agreement that
they should abide by the rules governing the conduct
of experts on such occasions—viz.: (1) they should
have a specific contribution to make; (2) this contri-
bution should rest on facts within their own know-
ledge and that of their colleagues ; (3) if their opinion
should not coincide with informed medical opinion
it should be so stated; (4) if the subject should be
one on which they have no expert knowledge it
should be made clear that they are expressing an
individual opinion which is of equal value with the
opinion of Mr. Smith. Although no one will quarrel
with these rules, I think it could be shown, if one
had the time and a gift for patient research, that
doctors, both individually and collectively, have
published on all the subjects mentioned above,
opinions which are no more than the expression of a
personal bias. I recall two recent examples of this.
* x a
There is a suggestion, as all my readers know, that
the level of the alcohol in the blood should be used
as a test of incapacity to drive in persons charged
with being drunk in charge of a car. Some years ago
an eminent surgeon, who is also an ardent temperance
propagandist, wrote to the Times a letter which
introduced this subject for the first time to the
general public. The Times, obviously impressed with
our colleague’s surgical distinction, printed his letter in
the place of honour on the middle page and his
readers were, no doubt, equally impressed by his
propaganda on behalf of this test. They did not
know, for he did not tell them, that while biochemical
assays are sufficiently difficult to interpret in the
courts of medicine, in the courts of law they darken
counsel and confuse judgment. They did not know,
nor did he tell them, that as a test for driving
incapacity such examinations have, in the opinion of
many doctors, about the same value as the olfactory
evidence of an anosmic constable. Nor was he
content with this, but he popped nimbly over a
neighbouring hedge into the lawyer’s field and said —
that any man who refused to have such an examina-
tion made when charged with such a misdemeanour
stood almost self-convicted ! This remark must have
caused laughter in the Inns but terror in the public-
houses—which was perhaps what our temperance
propagandist intended.
* x *
A well-known physician wrote to the Times a few
weeks ago insisting that the cause of gastric disorders
in London busmen was an insufficiency of vitamin B
in their diets. This I should take to be in flagrant
disregard of rules 2 and 3 quoted above. Let the
busmen eat brown bread. Their ulcers would be
prevented and, we might infer, the buses would
quickly be rolling down Regent-street again. Vita-
min B not only cures constipation, prevents intestinal
cancer, but it is also a dramatic solvent of industrial
disputes. Next day, to his great indignation but to
my great delight, he was confronted by another
gentleman also straying from his own field. A dis-
tinguished member of the advertising business (not,
let me hasten to assure the cynical, of our own
profession) replied to him in a letter which outlined
concisely orthodox medical opinion on the subject.
Sir A. B., a physician of repute,
Went out to settle Bevin’s bus dispute.
Too bad. He met Sir Advertising Jim,
Who, without much ado, did settle him.
a
1484 THE LANCET]
[JUNE 19, 1937
CORRESPONDENCE
THE OVER-TREATMENT OF GONORRHGA
To the Editor of THE LANCET
Sir,—Mr. Nicholls’s letter in your issue of March
20th was one that has long required writing, and I
should like therefore to congratulate him on his
courage in attacking an evil which we all recognise.
I fear however that unless a miracle happens his
voice will be as ‘‘the voice of one crying in the
wilderness,” for the root of the evil lies rather in the
system of treating venereal disease than in the indi-
viduals practising it. He puts his finger on the
weak spot when he says: ‘gonorrhea has been
withdrawn from the circle of hospital life and wedded
to syphilis (an unhappy and incompatible match),
and they live apart in a dark and uncritical world of
their own.”
The trouble is the training of the venereal specialist,
and it is a curious irony of fate that this odd hybrid,
whom Mr. Nicholls so justly condemns, should have
been made possible by John Hunter, the greatest
name in British surgery, and the greatest name on
the staff of Mr. Nicholls’s own hospital. Hunter,
experimenting on himself in 1767, persuaded the
world that syphilis and gonorrhea were the same
disease. It was therefore logical for one man to
specialise in this disease. Philippe Ricord exposed
the fallacy in 1837, yet we still talk about ‘‘ venereal
disease ” in the singular; and we still seem to think
that two dissimilar diseases—one, according to Osler,
requiring the widest possible knowledge of internal
medicine, the other obviously needing an expert
acquaintance with urology—can be adequately
treated by a junior official with very limited experience
of either. |
Venereal disease has always been the cinderella of
medicine, and the only hope of rescuing it and its
exponents from this lowly position is to restore
syphilis to general medicine and add gonorrhea to
urology, the branch of surgery to which it logically
belongs.
At present the treatment of venereal disease is’ a
blind-alley occupation. Those in charge have no
chance of promotion to the medical or surgical stafi
of their respective hospitals. They have no incentive
to enlarge their horizon, and as a consequence the
following is the sort of thing that happens. A patient
was treated for six months with sounds as a case of
stricture. At the end of this period, getting no
better, he was seen by a urologist who passed a cysto-
scope without any difficulty, and discovered he had
cancer of the bladder which by this time had become
inoperable. Anyone with the most elementary
knowledge of surgery could not have committed
such a tragic blunder; yet it happened at one of
our best known venereal clinics. It is inadequate
surgical training that makes possible the over-
treatment by irrigation and the mangling of urethras
with dilators that one now sees going on in so many
of our venereal clinics. Such treatment would not be
possible in any clinic where men with real surgical
minds are in control. A man professing to be an
expert on gonorrhea ought to be able to use a cysto-
scope, do an internal urethrotomy, or operate on a
prostatic abscess instead of allowing it to burst. He
ought to be able to do a salpingectomy or cure a
cervical tear when necessary.
How many of our so-called venereal experts are
capable of performing these simple operations ?
Hardly any. And the reason is that they have been
NS
trained on entirely wrong lines, acquired the mental
outlook of the old dead and gone regimental medical
officer instead of that of the urologist. Is it too late
to hope that the treatment of gonorrhma may be
rescued from the dead hands of this “service”
tradition, and allowed to develop on sound surgical
lines ? I am, Sir, yours faithfully,
J. JOHNSTON ABRAHAM,
Queen Anne-street, W., June 14th.
DIAGNOSIS AND TREATMENT OF GASTRIC
AND DUODENAL ULCER
To the Editor of THE LANCET
S1r,—I should like to suggest to Dr. Duncan Leys
that he should use a really delicate test for occult
blood for a year. I am convinced that he would
never go back to the rough methods used in most
English laboratories. There is no analogy between
the Fehling reaction for sugar and the tests for occult
blood, because normal urine contains traces of sugar,
so that a test is required which gives a positive
reaction only with a percentage of sugar greater than
normal. But normal stools contain no blood if there
is none in the food, so the more delicate the test the
more valuable is the information it gives. Every
year I see at least half a dozen cases of cancer missed
and numerous patients with an active ulcer said to
be healed because a report of no occult blood has
been received, although when the examination is
repeated with Dr. Ryffel’s technique! it is positive.
Properly done, a positive occult blood test is of more
value than a negative X ray examination, as it is
positive in every case of cancer of the alimentary
canal, and it rarely becomes negative with gastric
and duodenal ulcers until after the niche has dis-
appeared. It therefore shows the need for, further
investigations in suspected cases of cancer of the
stomach and colon when the first X ray report is
negative, and it gives the best indication we have as
to when an ulcer has healed—short only of gastro-
scopy in the case of gastric ulcer.
The guaiac test has the great advantage over the
benzidene test in giving no reaction with iron, whereas
the latter is useless in the many cases of ulcer in
which the presence of anemia calls for the adminis-
tration of iron, and the spectroscopic examination
of a fecal extract for hamatoporphyrin and acid
hematin gives additional information of the greatest
value. I am, Sir, yours faithfully,
ARTHUR F. HURST.
New Lodge Clinic, Windsor Forest, July 14th.
SULPHÆMOGLOBINÆMIA AND
METHÆMOGLOBINÆMIA AFTER
SULPHANILAMIDE
To the Editor of TuE LANCET
SIR;—In view of the communication of Dr. Paton
and Dr. Eaton in your issue of May 15th and their
letter published on June 5th, the following case in
which sulphemoglobinsemia and methamoglobinemia
developed after the administration of Prontosil
appears to be of interest.
A man aged 41 was admitted to. Guy’s Hospital on
March llth, 1936, for a chronic empyema of three months’
standing. A rib was resected on March 18th and 3 pints
of pus were drained off. The pus was sterile on culture.
The patient made satisfactory progress until March 27th
1 Vide Price’s ‘‘ Medicine,” 4th ed., 1933, p. 605.
THE LANCET]
when he developed an acute tonsillitis. Hemolytic
streptococci were grown from a throat swab. On March 31st
the patient had a venous ‘thrombosis in the left leg and
on April 3rd he began to have rigors. On April 4th he
developed arthritis of the right wrist and’a blood culture
at this date gave a heavy growth of hemolytic strepto-
cocci. On April 6th the hemoglobin was 58 per cent.
and the white count 11,000 cells per c.mm.
From April 6th to the 13th 5 c.cm. of prontosil was
given intravenously each day and 2 tablets of prontosil
per os t.d.s. After April 13th no further injection was
given, but the patient continued to take the tablets
per os for a further few weeks. On April 9th the tempera-
ture remained normal and the patient was very much
better. The white count rose to 22,000 cells per c.mm.
and a blood culture on Apri] 15th was sterile. During
the severe stages of the illness the patient had a livid
complexion, but this was attributed to the septicemia.
Progress continued to be satisfactory until May 16th
when the temperature began to rise again up to 100°F
each day. On May 20th the patient complained of pain
` in the right groin and later this spread to the knee. On
examination there was evidence of psoas spasm and tender-
ness in the right groin and right loin. The presence
of a psoas abscess was suspected. On June 10th treat-
ment with prontosil tablets was recommenced. The
patient then became obviously cyanosed, the lips, ears, and
facial venules being of a leaden-blue colour. There was
no dyspnea and the patient appeared unusually well in
himself. Enterogenous cyanosis was diagnosed and on
June 15th Dr. J. H. Ryffel examined the blood and
reported: ‘“‘ The laked blood shows an absorption band
in the red which gets smaller but does not disappear on
addition of: ammonium sulphide. The band appears to
be due to a mixture of methemoglobin and sulphemo-
globin.”
Besides prontosil the patient had been having, amongst
other drugs, magnesium sulphate and phenacetin. On
June 14th all these drugs were omitted. On June 2lst
the hæmoglobin was 27 per cent. At this date the patient’s
colour had much improved, although the cyanosis was
still marked. Dr. Ryffel again examined the blood on
June 26th and reported : “ The blood still shows a well-
marked band in the red not altered by ammonium sulphide.
Therefore sulphemoglobinemia only.” In the meantime
cedema developed in the right loin and right thigh and it
was thought desirable to perform an exploratory operation.
In view of the patient’s general condition he was given a
blood transfusion of 300 c.cm. on June 26th and a second
transfusion of 500 c.cm.on June 30th. On July 2nd a-
large psoas abscess was drained in the thigh. Hemolytic
streptococci were grown from the pus. Following this the
patient made satisfactory progress culminating in his
discharge from hospital.
I am indebted to Dr. E. P. Poulton under whose care the
patient was, and to Dr. Ryffel for permission to publish
this case.
Methzmoglobinemia and sulphemoglobinemia in
the same patient has also been described by L. P.
Garrod (Quart. J. Med. 1925, 19, 86). In this case
the methemoglobinemia was believed to be super-
added to the enterogenous picture by the excessive
use of headache mixture and cleared up immediately
on the discontinuation of the drug.
I am, Sir, yours faithfully,
J. A. J. HAMMOND.
Guy’s Hospital, S.E., June 9th.
“TREATMENT OF ACUTE OSTEITIS
To the Editor of THE LANCET
Srr,—Owing to absence from home I have only just
read Mr. Saint’s interesting lecture on Acute Osteitis,
published in your issues of May 22nd and 29th. His
reference to a contribution of mine on the subject
calls for some comment although I cannot here
discuss all the points raised. If anyone who is
interested will refer to my article they will find that
two of the three patients who died were suffering
TREATMENT OF ACUTE OSTEITIS
‘Southern Spanish Relief,
[JUNE 19, 1987 1485
from virulent septicemia, and that immediate
operation was undertaken because, at that time, I
did not realise the value of delay in such cases: I
am not suggesting that, with expectant treatment,
the outcome would have been different, but I do wish
to emphasise that the initial septicemia is by no
means always mild, as Mr. Saint appears to suggest,
and that a few days’ pre-operative treatment may be
a life-saving measure. In this connexion is there
no one who can find the records of Mr. Tyrrell-Gray’s
cases? They might be of great value. Since my
article was published I have treated nine more cases
on similar lines without a death.
On the exact extent of the local operation I do
not. wish to dogmatise, but I am convinced that
harm has been done in many cases by too radical
interference. Our first object, in a disease with a
mortality so potentially high, should be to save life.
The principles of treatment should be operation at
the right moment, which, in my opinion, should not
be within a few hours of diagnosis, adequate fixation
of the part, and infrequent dressing, which can be
secured by using B.I.P.P. As regards the latter
agent, I am in whole-hearted agreement with Mr.
Saint, having used it constantly after my first trial
of it in Mesopotamia in 1916.
The subject of acute osteomyelitis has been up
for discussion at medical meetings on many occa-
sions. I would suggest to Mr. Saint that a statistical
investigation by the Association of Surgeons, into
the results of various methods of treatment, would
be of considerable interest.
One final question, can Mr. Saint give us the
approximate duration of illness, in each case, before
he operated ?
I am, Sir, yours faithfully,
Northampton, June 14th. C. C. HOLMAN.
A DEBT OF HONOUR
To the Editor of THE LANCET
Sır, —The Southern Spanish Relief Fund, whose
hospitals for children in Almeria suffered severely
in the recent German bombardment, appealed through
your columns on March 13th for the voluntary
assistance of doctors. Five applications, in all,
were accepted, after irreproachable references from
colleagues had been received, and after two of the
applicants had been interviewed by a leading London
doctor. Pour of these five had successively to be
repatriated in their own and our interest, leaving us `
with liabilities which amount in all to over £200.
I honour the kindly reluctance of reference-writers
to give information that will prevent acceptance of
a colleague’s application, but I hope that your
readers may feel the same kindly reluctance to let
a compatriot suffer serious loss thereby. For I feel
it impossible to charge expenses of the character
incurred to a fund raised for the Spanish wounded,
women, and children. Failing help they will have
to be met from a private purse already depleted by
running, and raising money for, the hospitals. Any
subscriptions for the relief of this personal liability
should be marked ‘ medical” and addressed to:
E. T. Mardling, Esq., F.C.I.S., The Hon. Treasurer,
10, Old Jewry, E.C.2.
Should they exceed the total liability, subscribers will
be consulted as to the refund or redisposition of the
balance.
I am, Sir, yours faithfully, i
GEORGE YOUNG,
Director of British Hospitals, Almeria and Murcia.
1486 THE LANCET] |
PREGNANCY TOXAEMIA
To the Editor of THE LANCET
SIR, —I have read with some interest Dr. Theobald’s
paper in your issue of June 12th. Important as
minerals and vitamins are to the economy—even in
the non-pregnant—TI do not think their exhibition in
pregnancy plays the part which Dr. Theobald would
have us believe. From his own account these
substances do not prevent the occurrence of the
pregnancy toxemia, for signs appeared in 13 out of
50 cases treated. Since the incidence was much
greater—more than twice as great—in the 50 not so
treated, suggesting some effect, we must either
conclude that the doses in the first 50 were insuff-
cient, or that some other cause than a deficiency of
these substances is at work in the production of the
toxemia of pregnancy.
Unfortunately, in his present paper, Dr. Theobald
does not consider other possible causes. He talks of
the different protective substances associated with
toxemic symptoms. Attributing the difference in
the incidence of “ complications ” in his two groups
to the substances given in the one and withheld from
the other, he asserts that the results of the dietetic
treatment of these patients in the antenatal ward
strengthen his assumption. ‘The symptoms,” -he
says, ‘“‘cleared up in every case.” He believes,
apparently, that these cases cleared up because of
the dietetic treatment, and because of that alone.
But, presumably, these patients were kept in bed ;
if that were so, the effect of rest in bed, per se, finds
no place in his argument.
I do not propose to dissertate here on the effect
of rest in bed; it will be admitted that rest in bed
has some effect—even in patients suffering from the
toxemia of pregnancy. But it does not matter
whether Dr. Theobald’s patients were kept in bed
or not; I know from my own experience that putting
toxzmic patients to bed and feeding them on water
only—and in restricted quantity (to begin with
l pint, or 13 pints per 24 hours) flavoured with a
little lemon and given a little glucose—restores these
patients to the normal; the odema disappears, and
presumably the blood pressure if raised goes down.
I give them no especial vitamins and no calcium ;
yet they get well. The treatment is essentially
physical: combined with starvation. But to-day,
when every disease is attributed to some biochemical
aberration, and the patient is treated by the exhibi-
tion of some tablet or capsule, J do rather wonder
whether the effect of rest in bed will be allowed to
be a physical one. But if rest in bed acts physically,
how does it do so? I state categorically that rest
in bed, per se, prevents the toxemia of pregnancy.
It is for your readers to answer how it does so.
In line with this we find that dietary deficiency
in pregnancy occurs without the appearance of the
pregnancy toxemia. Anzemic pregnant women
appear immune from the toxemia of pregnancy.
Truly, eclamptic women are anæmic ; but that is a
result of the visceral impairment, not the cause of
that impairment. In the same way we see that
postpartum hemorrhage is never followed by post-
partum eclampsia. . .. How does venesection prevent
eclampsia—whether ante- or post-partum? By
producing an anemia? By its chemical or its physical
effect? The danger of removing too much blood
postpartum is puerperal sepsis; not the toxemia of
pregnancy (e.g., eclampsia). Truly, the biochemical
ingredients of the blood are of importance ; but not
in the prevention of the toxzmias of pregnancy.
PREGNANCY TOXÆMIA
[JUNE 19, 1937
May I remind your readers that man consists of a
mass of cells, &c..; that both the cells and the juices
possess very definite physical qualities; and that
not one of the vital functions goes on without the
play of physical forces which the cells of the body
engender; and that when these physical forces are
insufficient or too great, physiological processes are
disturbed, and interfered with. This is even so in
the pregnant woman ; it occurs irrespective of bio-
chemical (vitamin) influences; it is a factor which
those desirous of understanding the toxemia of
pregnancy and its prevention will be forced—by the
reductio ad absurdum argument if by no other—sooner
or later seriously to consider.
I am, Sir, yours faithfully,
Rugby, June 11th. | R. H. PARAMORE.
To the Editor of THE LANCET
Sır, —It is now over six years since I advocated
in the British Medical Journal the continuous
administration during pregnancy of calcium phosphate
15 grains thrice daily, together with a plentiful supply
of green vegetables. I was and still am of opinion
that the toxæmias of pregnancy are deficiency diseases.
The case for the continuous administration of
calcium during pregnancy seems unanswerable.
For nine months there is an enormous demand on the
mother to provide calcium phosphate for the bones
of the fœtus ; this demand has to be met in some way,
either by an increased intake of calcium or by
drawing on the mother’s reserve of calcium, with
disastrous consequences for both mother and child.
Another well-known fact is that there is a seasonal
variation of the phosphorus and -calcium content
of the blood, the percentages being highest during the
months of maximum sunshine; therefore during
the winter, and especially the months following the
winter, there is greater need of calcium than ever.
This need for calcium coincides with the greatest
incidence of eclampsia, according to Harrer of the
New York Lying-in Hospital, who has shown
graphically the incidence of eclampsia during ten
years, and considers that the increased incidence in
early spring is due to the cold and damp weather
prevailing at that time (Williams’s “ Obstetrics ’’).
We know that in chronic parenchymatous nephritis
the calcium content is low, that nephritis and edema
have been successfully treated with calcium, and
that calcium has a sedative effect on the nervous
system and diminishes the permeability of the blood-
vessels, and we know that in some cases of ursemic
convulsions the blood calcium is low. We know
also that one cause of tetany is calcium deficiency,
and curiously enough it has been noted that epidemics
of tetany usually occur in the spring. These and
. many other reasons seem to indicate that large
doses of calcium, in addition to the vitamins, are
required to make up the maternal deficiency, and to
prevent the so-called ‘‘ toxwmias’’ of pregnancy.
If in spite of these measures the patient shows
signs of hyperemesis I would advise, in addition to
the calcium phosphate and vitamins, giving dilute
hydrochloric acid, preferably in the form of betaine
hydrochloric and pepsin, of which there are several
preparations on the market.
I am a little disappointed that this treatment has
not been tried out on a large scale before. I had hoped
that someone would have given it an extended trial
before now, and I trust that Dr. Theobald’s interesting
paper will lead to a real and thorough test.
I am, Sir, yours faithfully,
Isle of Anglesey, June 14th. ` J. L. Morr.
THE LANCET]
MOYNIHAN MEMORIAL
To the Edttor of THE LANCET
Sir,—The board of the General Infirmary at Leeds
realise that the greatest memorial to the genius and
work of the late Lord Moynihan must always be
-advancement in the ‘art of surgery, which he did
so much to promote. They feel, however, that it is
their duty and privilege to perpetuate a record of
Lord Moynihan’s work for surgery and his labours
in and for the General Infirmary at Leeds by the
erection within its walls of a suitable memorial.
‘Already a ward has been named the ‘ Moynihan
Ward,” but much more than this is clearly required.
The board have appointed a committee to submit and
carry out a suitable scheme, and on behalf of this
committee I am able to state that the sum of £750
has already been received. More than this is needed
if the memorial is to be adequate and I am authorised
to invite subscriptions from medical and lay
sympathisers. It is suggested that one guinea would
be a suitable amount, though more or less would
be very acceptable.
Subscriptions should be forwarded to the General
Infirmary at Leeds in the name of the “ Moynihan
Memorial Fund” or to myself. They will all be
very gratefully acknowledged.
I am, Sir, yours faithfully,
CARLTON OLDFIELD,
Chairman, Moynihan Memorial Committee.
June 14th.
BICENTENARY OF THE BRISTOL ROYAL
INFIRMARY
To the Editor of THE LANCET
Sir,—Sunday next, June 20th, marks the
completion of 200 years’ work at the Bristol Royal
Infirmary : for on this day in 1737 the out-patient
department was opened for the reception of patients,
though the formal opening did not take place until
December of that year. We feel that the bicentenary
of the oldest provincial teaching hospital in the
Kingdom is a matter of more than local interest and
importance. To mark the occasion a carnival is
being held at the Clifton Zoo from July 7th to 10th.
The formal celebrations will take place later in the
year, probably early in October, when it is hoped that
former students and others associated with the
infirmary will make a special effort to be present.
I am, Sir, yours faithfully,
E. WATSON-WILLIAMS,
Hon. Secretary, Bicentenary Celebrations Committee.
Clifton, Bristol, June 14th.
THE LANCET 100 YEARS AGO
June 17th, 1837, p. 448. |
From an answer to a Correspondent.
Corporal Ward.—Were it a necessary consequence of
the inversion of images on the retina, that the mind
should perceive them to be upside down, then it might be
correct to speculate on the cause of their being recognised
in an upright state. But the upside-down result has not
yet been proved to be inevitable. Every theorist, however,
appears to have forgotten this. Be the image pictured in
whatever position it may on the retina, the mind clearly
recognises the lower end to be the lowest, and the upper
to be the highest, but why it does sd, it is as unnecessary
to debate as the question, how the mind comes to be
sensible that the representation of an object exists on the
retina at all. The opinion that the “change of flanks
is effected by the decussation of the optic nerves,” is not
new, but has often before been hazarded. Experiments
and not conjectures are needed in physiology.
THE LANCET 100 YEARS AGO
[JUNE 19, 1937 1487
A NEW MENTAL HOSPITAL
On Monday last, Sir Kingsley Wood, the Minister
of Health, opened the new mental hospital at Runwell,
Essex, which has been provided jointly by the county
boroughs of East Ham and Southend-on-Sea, Erected
at a cost of £650,000 it has been planned so as to
combine all the previous advances in mental hospital
design, including a separate admission hospital,
four research laboratories, a general library, and a
recreation hall equipped with gymnastic apparatus.
There is also a new feature—a detached “ closed
unit ’’ for disturbed cases. i
Everything has been done with the aim of convinc-
ing both patients and public that nervous and mental
disease must be treated with ‘‘ the same intensive
care, scientific means, and human understanding
as any physical disorder.” With a site of 500 acres
between Wickford and Rettendon (about 24 miles
from East Ham and 12 from Southend) the buildings
have been placed on a slight slope open to the south
and sheltered by rising and well-wooded ground
on the north. They are widely spaced, and “in
this way it is hoped that an atmosphere may be
engendered of light and airy buildings without
obtrusive restraint, and with a freedom from the
‘institutional’ feeling. Wide verandahs with large
solaria form a feature of the patients’ units, and
airy rooms with french windows enable them to
feel that they are in a sanatorium rather than a
great institution.”’ :
Occupational therapy is considered a very important
part of the treatment to be provided, and provision
has been made for teaching many different handi-
crafts, as well as upholstery, printing, tailoring,
boot-repairing, metal work, and carpentry. The
admission hospital is built in a single storey and
affords every facility for open-air treatment. In
this unit is the X ray department, the pathological
and biochemical research laboratories, a department
of hydrotherapy, and laboratories of experimental
psychology and clinical pathology. Two detached
villas, at a distance from the other buildings, are for
voluntary patients suffering from the milder forms of
mental disorder ; they allow of as much freedom and
privacy as possible and they are described: as the
first of their kind in a public hospital. Units for
quiet and employable patients are provided with
large gardens and are connected by covered ways
with the occupation therapy shops. There are
also three parole units for patients not needing
much supervision and able to enjoy more freedom
both inside and outside the grounds. They have
easy access to the kitchen garden, laundry, and farm,
where a certain number of the patients will be
employed, Finally there is the “ closed” unit,
situated well away from the other buildings,
accommodating 60 male and 100 female patients
suffering from the more severe forms of mental
disorder, This is planned to be unlike the old-
fashioned ‘‘ refractory block ” and will have a large
garden. 7
The hospital has room for 1010 patients, and
forms a community of perhaps 1400 people with
25-30 separate units. The physician superintendent
is Dr. Rolf Strém-Olsen, the deputy superintendent
Dr. S. M. Coleman, the senior physician Dr. S. L.
Last, and the assistant physicians Dr. M. B. Brody
and Dr. F. P. Haldane. There are also two resident
house physicians. The visiting consultant staff
are: Dr. T. Rowland Hill, Mr. Rodney Maingot,
Dr. I. Vitenson, Mr. J. Lyle Cameron, Dr. H. E.
Bonnell, Mr. G. G. Talbot, Dr. G. White Phillips,
and Mr. W. Milton Bull. The architects of the new
building are Messrs. Elcock and Sutcliffe.
1488 THE LANCET]
BRITISH ASSOCIATION OF
RADIOLOGISTS
AT a meeting of this association held at the British
Institute of Radiology on June llth and 12th,
under the presidency of Prof. J. M. WOODBURN
Morison, the Skinner lecture on the
After-care of Patients Suffering from Cancer
of the Breast
was delivered by Dr. F. HERNAMAN-JOHNSON. After
drawing attention to the increase in the death-
rate from carcinoma of the breast during the last
thirty years, the speaker gave it as his opinion that
little advantage was likely to accrue from the adoption
of heavy dosage methods of radiation therapy in this
field, and that radiation therapy should be employed
primarily as a palliative measure following radical
surgery. The objects to be attained in palliation
were first to free the patient from any external signs
of the growth, secondly to relieve pain and discomfort,
thirdly to delay the onset of and, if necessary, treat
metastases, and lastly to treat the patient from a
psychological point of view. In this respect attention
was drawn to the value of surgery where the patient
was more likely to feel that the growth had in fact
been completely removed. Reference was made to
Dr. A. T. Todd’s work, but Dr. Hernaman-Johnson
did not consider this suitable for hospital patients.
Referring to biochemical tests he was of opinion that
the differential sedimentation-rate, while not of
value in diagnosis, was useful in assessing the response
to treatment. Isolated skin recurrences should,
he thought, not be regarded as of grave importance ;
heavy dosage should be employed locally. Axillary
recurrences should be removed surgically, while
supraclavicular gland metastases should be dealt
with by heavy doses of X ray therapy. Metastatic
deposits in bones were worth.while treating, and in
such cases Todd’s method should be employed.
Thoracic invasion rarely responds and the prognosis
with liver metastases should be regarded as quite
hopeless.
Wave-length in Radiotherapy
Mr. G. F. STEBBING, opening a discussion on
wave-length as a factor in radiotherapy, emphasised
the fact that in this form of treatment results were
obtained only when the dosage was carried to a
level which produced a fairly severe reaction on the
skin, and that all factors which might contribute
to a lessening of this reaction were worthy of
consideration. It was almost universally accepted
that the same physical dosage measured in réntgens
(r) produces less normal tissue damage when delivered
by radiation of short wave-length. Despite this
lesser biological response of the normal tissues
Mr. Stebbing was of opinion that so far as malignant
cells were concerned the reverse was the case and
that using short wave-length rays a more lethal
effect on the tumour was obtained. This view was
based primarily on the belief that the action of the
radiation on the tumour cells is direct and not through
the tumour bed. In addition to this “selective”
action the use of short wave-length rays as produced
by higher voltages resulted in greater penetration
and so an improved depth dose which, though
numerically not of a high order, was in many cases
of very great value. Thus an absolute gain of 5 per
cent. per field resulted in a total gain of 30 per cent.
if six ports of entry were employed as in many cross-
fire methods.
BRITISH ASSOCIATION OF RADIOLOGISTS _
[JUNE 19, 1937
Dr. DoUGLAS WEBSTER, on the other hand, while
admitting that the use of higher voltages enabled
a greater depth dose to be obtained, pointed out that a
similar result could be obtained by the use of greater .
treatment distances. He did not consider that
there was any selective or specific action in relation
to wave-length, and in support of this view he pointed .
out that from the physical point of view ionisation
effects did not run parallel to the wave-length of the
radiation and that, from the practical aspect, the
measurement of, the r at the higher voltages was
a matter of some difficulty. On the biological side
he quoted a number of experiments in which the -
employment of radiation generated at widely different
voltages had failed to produce any different response
on the part of the biological medium. On clinical
grounds there was, as yet, no concrete evidence to
support the view that better results were obtained
by the use of higher voltages and that clinics employ-
ing X rays generated at potentials of 600 kv had
not produced results superior to those obtained at
200 kv.
Dr. RALSTON PATERSON, supporting Dr. Webster,
was of opinion that short wave-length rays were,
as a rule, to be preferred since their use entailed
less skin reaction for the same measured dosage.
This advantage, however, he considered to be due
not to any specific or selective action on malignant
tissue but to some physical factor as yet undetermined
and possibly related to a defect in our present
measurement methods.
Dr. STRUTHERS FULTON did not consider that
radiation effects were due to any specific or selective
action. Clinically similar and equally satisfactory
results were obtained in skin malignancy by the use
of long wave-length X rays on the one hand and
gamma rays on the other. The fact that with
X rays these results were obtained at relatively
lower dosage levels as measured physically in roéntgens
tended to support the view held by Dr. Paterson
that our present methods of measurement might,
in time, require to be revised.
Dr. R. E. ROBERTS, arguing against there being
any selective action, pointed out that if long wave-
length rays produced a greater effect on the skin it
was reasonable to assume that they would also
produce a greater effect on tumour tissue.
Dr. F. Erus cited a number of clinical and bio-
logical experiments from the literature, all of which
tended to show that no selective action in relation
to wave-length did’in fact exist.
Mr. STEBBING, replying, pointed out that skin
tumours were, as a rule, sensitive, and that care
must be exercised in drawing deductions from this
material. With deep-seated tumours the difficulty
was greater and it was in the treatment of such
cases that the value of short wave-length rays was
most apparent.
Low Voltage Near-distance X Ray Therapy
Dr. S. B. Apams, after outlining the particular
merits of this form of treatment, proceeded to
describe two special applicators which had been
devised at the Royal Cancer Hospital with a view to
providing a more homogeneous distribution of energy
on the skin surface than that obtainable with the
standard applicators. He discussed the question
of dosage, illustrating his remarks by slides of clinical
subjects successfully treated by this method. Clinical
and biological problems in relation to the factors of
time and intensity were being investigated, but it
was as yet too soon to put forward any definite
results.
THE LANCET]
Dr. J. F. BROMLEY considered the possibilities of
the method in the treatment of lesions in the mouth
7 and in carcinoma of the rectum. The particular
merit of this method in the treatment of skin
malignancy in the region of the eye was demonstrated
by a series of slides showing clinical results.
Dr. Bromley also briefly outlined certain biological
experiments on which he was engaged.
Prof. Morison emphasised the importance of
considering the dosage at the tumour level. The
profound effect which distance has in modifying this
was graphically demonstrated as was, also, the
comparatively small gain in depth dose associated
with the use of higher voltages. An interesting table
was shown comparing, from the point of view of
energy output and distribution, radiation from a
radium bomb, a radium applicator, an X ray tube
operating at 200 kv and a short distance X ray
tube operating at 60 kv. Prof. Morison discussed
“the possible difference in biological response to split
dosage, continuous and massive methods of treat-
ment. During treatment the tissues gradually
changed in their sensitivity to radiation. Tumours
tended to become radio-resistant and he was, there-
fore, experimenting with a method whereby the
daily dose was gradually increased throughout the
period of treatment. |
Dr. R. McWHIRTER thought that similar results
could be obtained by the employment of a tube
operating at the 200 kv level. He had, further,
found the single day massive dose method quite
satisfactory for the treatment of skin malignancy.
Dr. FULTON was of opinion that the near-distance
X ray therapy plant provided something which
could not be duplicated by any other apparatus at
present available. While approximating in energy
distribution to a radium plaque it gave a very much
higher output. On the other hand, a high voltage
X ray tube, while providing a high output, gave a
more profound depth dose effect. Two points had
to be borne in mind in using the short distance X ray
tube. First, the depth dose was small and for
this reason he felt that it should be used with dis-
cretion in the treatment of tonsillar lesions, and
secondly, the energy distribution is such that it
falls off rapidly towards the edge of the field. This
fact must be borne in mind in treating skin malignancy
and a correspondingly wider area be subjected to
radiation. Short distance X ray therapy had taught
us two important lessons. The first of these was that
permissible dosage is closely associated with the size
of the field irradiated, and with small fields it was
possible to administer doses measured in r similar
to those given by radium, The second point was
that dosage is also related to volume of tissue
irradiated, and here we find that as a result of the
superficial distribution of energy in the tissues it is
possible to deliver higher doses with the short distance
X ray tube than with an X ray tube generating rays
of- much shorter wave-length but operating at a
greater distance and so irradiating a larger volume of
tissue despite the fact that the ports of entry may be
similar in size.
Ventriculography
Dr. ERIK LYSHOLM of Stockholm gave an address
before a large audierice on radiological experience in
ventriculography, based upon 806 verified cases
examined by ventriculography and encephalography.
The use of the method was, he said, increasing.
In Stockholm air was now solely employed as the
contrast agent; with refined technique, it would
show all the details which could be elicited by opaque
BRITISH ASSOCIATION OF RADIOLOGISTS
[JUNE 19, 1937 1489
media, the use of which had proved inseparable
from risk. Arteriography was only employed when
a vascular lesion was suspected. For radiography
he used an apparatus whose constant focal-distance
at all angles enabled him to make a three-dimensional
reconstruction of the ventricular system. When
the reconstruction was superimposed upon an
anatomical chart, slight deformities were readily
appreciated, and the lesions could be accurately
localised. He demonstrated his new type of grid,
constructed entirely of metal, which absorbed its
own secondary and tertiary radiation. The grid
lines were so fine as to be almost invisible, and the
thickness could be adapted to varying conditions
and objects. The ventriculographic appearance of
supra-tentorial tumours he divided into three groups,
each with its characteristic picture :—
(1) Convexity tumour, causing lateral displacement,
with tilting of the upper end of the septum pellucidum
away from the tumour and flattening of the upper angle
of the lateral ventricle of the same side. The higher the
tumour, the greater the amount of tilting of the septum.
(2) Tumour situated laterally, at the level of the Sylvian
fissure, causing lateral displacement without tilting of
the septum or indentation of the outer angle.
(3) Temporal tumours: the typical picture was a
lateral displacement with a characteristic angulation of
the septum and third ventricle to one another. This
angle was open towards the side of the tumour; the
lateral ventricle on this side was narrowed, drawn out
into a point inferiorly, and showed an indentation on its
lower outer side. In this group it was essential to observe
the temporal horn. The direction in which it was dis-
placed would determine whether the tumour was superficial
or deep.
Filling of the third ventricle, of the aqueduct, and
of the fourth ventricle was accomplished by special
techniques. Characteristic filling defects were then
observed with intrinsic and extrinsic tumours of the
third ventricle. It was sometimes possible to
determine the operability of intraventricular tumours
by observing whether they were completely surrounded
by air or attached to the ventricular wall. He
demonstrated examples of very small cysts at the
foramen of Monro—an important type, of which
he had seen four cases—tumours of the anterior
middle and posterior parts of the third ventricle, and
pineal tumours. Posterior third ventricle tumours
could not always be distinguished from one another.
The pinealoma gave a well-defined filling defect
with more or less complete filling of the suprapineal
recess. Calcification in the tumour did not necessarily
signify that it was a pinealoma. Four such fumours
had proved to be gliomata, and one a tuberculoma.
Tumours of the lamina quadrigemina were often
hard ‘to distinguish from posterior tumours of the
third ventricle; in some cases both regions were
invaded. If the ventricular defect were small in
comparison with the degree of displacement of the
aqueduct, the tumour was likely to be quadrigeminal.
Careful observation of the aqueduct gave valuable
indications. Quadrigeminal tumours displaced it
towards the clivus, but not laterally. Upper vermis
tumours caused early compression of the aqueduct,
and in the lateral view have a typical picture—
namely, an angulation of the supratentorial part of
the aqueduct, the peak of which was directed back-
wards, together with a bowing of its infratentorial
part and of the fourth ventricle downwards and
forwards, unaccompanied by any lateral displacement.
This deformity did not occur with inflammatory
stenosis. Tumours of the cerebellar hemispheres
caused bowing of the aqueduct, towards the base,
with lateral displacement. They rarely obliterated
1490 THE LANCET]
the cavity of the fourth ventricle. Tumours of the
lower vermis pressed upon the lower part of the fourth
ventricle which, together with the aqueduct, was
dilated. Angulation of the aqueduct was rarely
seen. Intraventricular tumours, if large, might
completely obliterate the cavity of the fourth ventricle.
If small, they could be outlined: a rough or irregular
outline indicated a papilloma. Ependymomata and
medulloblastomata showed smooth surfaces.
Cerebellopontine angle tumours displaced the
aqueduct dorsally and towards the opposite side, and
often caused a depression of the lateral wall of the
fourth ventricle. Pontine tumours also displaced
the aqueduct dorsally, but lateral displacement did
not occur. Dorsal displacement of the aqueduct with
flattening of the floor of the fourth ventricle had been
observed in a few cases of meningioma of the clivus.
-Dr. E. W. TWINING, proposing a vote of thanks,
stressed the personal element in Dr. Lysholm’s
investigations. The brilliant results which he had
demonstrated resulted from the concentration of the
cases in one centre, and from the concentration of the
best brains upon that material. Routine radio-
PUBLIC HEALTH
[JUNE 19, 1937
graphy could not obtain equivalent results. Every
case involved careful and prolonged personal study.
Short Papers
Dr. H. W. A. Post outlined the technique and
normal and pathological salpingographic appearances
in the uterus and tubes.
Dr. E. Roman WILLIAMS indicated the value of
urography, ascending and intravenous, in demonstrat-
ing the physiological dilatation of the renal pelves
and ureters in pregnancy, and the cystographic
diagnosis of placenta previa.
The use of lipiodol in the localisation of spinal
tumours was described by Dr. H. M. WortH, who
gave details of the technique and showed a number
of cases diagnosed by lipiodol introduced by the
lumbar and cistern puncture respectively.
Dr. M. H. JUPE read a paper on cases of suprarenal
tumour, and described the clinical and radiological
appearances in the Pepper and the Hutchison types
of neuroblastoma of the adrenal medulla. He drew
attention to certain characteristic bone changes in
the latter type.
PUBLIC HEALTH
Refresher Courses
THE life of a medical officer in any branch of the
public health service is increasingly hard. The
enlarging scope of the public health department is
calling for a very high type of medical officer who
requires, in addition to medical knowledge, personal
and social qualities to which Sir Kingsley Wood
alluded at the last annual dinner of the Society of
M.O.H.’s. The imagination of the advertising agent,
the zeal of the missionary, the patience of Job,
the hide of the hippopotamus were among the
qualifications, ‘‘ coupled,” he added, ‘‘I suppose,
with medical knowledge.” On the same occasion
Dr. Ernest Ward spoke of the initiative taken by the
Society in promoting higher education, and its hope
for the advice and coöperation of the Ministry of
Health in arranging for it. The organisation of short
post-graduate courses for the various classes of
medical officers employed by local authorities was
the first step suggested. No time has been lost and
a circular now issued by the executive secretary of
the Society to local authorities tells of provisional
arrangements for a series of refresher courses. Three
such courses are announced ; |
(1) Sept. 28th to Oct. Ist, at Cardiff, for medical officers
of health, limited to 40.
(2) Week beginning Nov. 8th, at Manchester, for school
‘medical officers, limited to 30.
(3) Early in 1938, a course in infectious diseases, in
London, limited to 20.
No sanction, it seems, is required for expenditure
incurred on these courses by local authorities which
have the conviction that they will get an adequate
return for their money in the maintenance of efficiency
on the part of their staff. The Board of Education
has also expressed general agreement with the
principle and a syllabus of a school medical course
is now being drawn up. An attendance fee of two
guineas will cover the central organising expenses
and local fees for each course, and prompt application
is desirable in view of the strict limitation of numbers.
No other commendation of the scheme is necessary
than a mild expression of surprise that it has not been
put into execution before. All honour to the present
initiative. °
polio-en¢cephalitis, 1;
relapsing fever, 2 (Leatherhead, Wharfedale R.D.) ;
County Council on June lith was 2902, whic
fever,
lethargica, 282 ;
there were 24
neonatorum.
and 17 (4) from influenza.
at Darlington and Worcester.
INFECTIOUS DISEASE
IN ENGLAND AND WALES DURING THE WEEK ENDED
JUNE 5TH, 1937
Notifications.—The following cases of infectious
disease were notified during the week: Small-pox, 0;
scarlet-fever, 1517; diphtheria, 925; enteric fever,
39; pneumonia (primary or influenzal), 652; puer-
peral fever, 33; puerperal pyrexia, 124; cerebro-
spinal fever, 17; acute poliomyelitis, 3; acute
encephalitis lethargica, 5;
continued fever, 1 (Stockport); dysentery, 33;
ophthalmia neonatorum, 115. No case of cholera,
plague, or typhus fever was notified during the
week,
The number of cases in the Infectious Hospitals of the London
included: Scarlet
736 ; diphtheria, 830; measles, 91; whooping-cough,
446 ; puerperal fever, 22 mothers (plus 13 babies); encephalitis
oliomyelitis, 2. At St. Margaret’s Hospital
abies (plus 13 mothers) with ophtha a
Deaths.—In 123 great towns, including London,
there was no death from small-pox, 1 (0) from enteric
fever, 7 (0) from measles, 0 (0) from scarlet fever,
16 (6) from whooping-cough, 29 (4) from diphtheria,
46 (13) from diarrhoea and enteritis under two years,
The figures in parentheses
are those for London itself.
Four persons died at Birmingham of diphtheria and 2 each
There were 7 fatal cases of
diarrhea at Willesden and 4 at Leeds.
The number of stillbirths notified during the week was
313 (corresponding to a rate of 41 per 1000 total
births), including 52 in London.
NEw HOSPITAL AT IVER.—The new Iver, Denham,
and Langley Cottage Hospital will be opened on July 2nd
by the Duke of Kent.
RoyYAL EYE HOSPITAL, SOUTHWARK.—This hospital
is setting up a special committee to carry out research
with a view to preventing injuries to the eyes. A
museum of various devices intended to protect the
eyes of industrial workers is being prepared and the
committee is asking employers in South London to help
in the campaign. Plans are being prepared for two addi-
tional wards and accommodation for extra nursing staff
is to be provided. The cost of this, which is the first part
of the rebuilding scheme, will be about £50,000.
THE LANCET]
[JUNE 19, 1937 1491
PARLIAMENTARY INTELLIGENCE
THE HEALTH SERVICES
WE have already summarised (p. 1439) some part
of Sir Kingsley Wood’s important statement on
committee of supply on the health services. A few of
his chief points remain to be noted. Advances,
he said, had been made in the treatment of child-
bed fever ; the discovery that certain organic chemical
compounds could reduce both the mortality from this
disease and the incidence of complications had been
of outstanding importance. The epidemic of enteric
fever during the year at Bournemouth, Poole, and
Christchurch illustrated once again the difficulty of
ensuring a safe milk-supply otherwise than by
pasteurisation, where the milk was as in this case.
obtained from many sources and pooled before
distribution. ‘There had also been an increase in the
proportion of mortality caused by some of the
diseases whose prevalence was greatest among the
older part of the population; that was, he supposed,
a natural corollary of the decline in the great killing
infectious diseases which used to take a heavy toll
at all ages. The fixing of the date from which the
new overcrowding provisions were to operate in
particular areas was proceeding steadily ; up to the
end of March 1484 orders had been issued for fixing
the appointed day, leaving 52.to be fixed before the
end of the year. The same date marked the end of
the fourth year of the five-year programme of slum
clearance. It had more than kept its promise.
Four-fifths of that programme was _ represented
by 166,000 houses and already the houses in submitted
orders and purchase agreements exceeded that
number. In April last he asked the maternity and
child welfare authorities to review their arrange-
ments for the supply of milk and meals to nursing
and expectant mothers and young children; replies
from such places as Durham and Leyton had stated
that their services were already complete; 33
authorities had reported that they were taking further
action. During the past year he had urged on local
authorities the importance of the fullest supervision
over the health of children between the ages of 18
months and five years; at least 47 authorities had
established special clinics for toddlers, and 53 had
arranged for the school medical services to be available
for the younger children, while 64 had appointed
additional health visitors. He had been struck
with the fact that although we had perhaps the
finest social services in the world, they were by no
means fully utilised ; he hoped in the autumn of this
year, in connexion with the Board of Education and
the Central Council for Health Education, to organise
a national campaign to bring these health services
more to the notice of the people. The keynote of the
campaign would be: ‘‘ Use your health services.”
They would get a real advance, apart from the creation
of new services, in getting the people to utilise the
services already in existence. The establishment of
the Ministry of Health was the outward expression
of Parliament that national health was of supreme
and vital importance to the State, and it was
undoubtedly inspired by that new and wider humanity
which was so prevalent to-day. Their aim must
continue to be along those lines and it should be their
desire to the best of their endeavour and capacity
to make good health the birthright of every citizen.
Certainly this could be said, that the fight for good
health could not be successfully conducted with a
limited choice of weapons or on a narrow front.
We must more than ever use the whole armoury
which modern knowledge and medical science had
given us, and, if possible, broaden our front and deal
not only with the specific diseases of the individual
but more and more with the wider conditions, the
environment, the occupations, and the conditions
of our people. Although there was much to accomplish
it could be claimed that their efforts to build up a
healthy nation had not been in vain.
60,000 persons who last
CRITICISMS OF GOVERNMENT POLICY
-Mr. AMMON said that the block grant system
limited the full play of the health services. He
hoped that before it was too late the Minister would
turn his mind to the planning of satellite towns
and the location of industry; otherwise, when they
had got over the immediate needs, they would be
faced with greater social problems and difficulties
than in the past. The provision of public abattoirs
was urgent. .
Mr. HAMILTON KERR said there was still little
supervision of the child between the ages of two and
five years. A definite health policy should ensure
the regular medical supervision of every child up to
the age of 16. In every local centre a properly
organised file of the entire health history of each
boy and girl should be readily available.
Mr. LANSBURY contended that the necessity for
a range of services which the Minister of Health
controlled through local authority arose largely
because of poverty, and until poverty was dealt
with we should not make true progress. Until
children could get within their homes all the food
necessary for them, we should not obtain that healthy,
virile youth population that we all wanted to see.
Sir FRANCIS FREMANTLE dealt with the proposed
additional ophthalmic benefits. There was, he said,
a contest between the ophthalmic surgeon on the one
hand and certain persons in the benefit societies on
the other, as to what was the proper way of administer-
ing ophthalmic benefit. Obviously it was the most
convenient thing to allow opticians to prescribe
spectacles. But the departmental committee of
1922 had stated that “. .. an official register of
opticians would tend to mislead the public into
thinking that registered opticians were competent
to discharge functions which belong ret to those
who have had a medical training.” And the com-
mittee of 1927 said: ‘‘ We are not satisfied that even
those opticians who are most highly qualified in all
other respects are sufficiently trained in this respect.”
Since 1927 the Association of Dispensing Opticians
and the National Ophthalmic Treatment Board had
been set up, with inclusive charges well within the
means of those whose family income did not exceed
£250 per annum, That being so it was dangerous
to allow additional benefit to be given by persons
not qualified to find out the trouble at the back of
the eye.
The case for satellite cities was agreed, but the
difficulty was to.get them put into effect by local
authorities. It was not simply the establishment
of a garden: city here or there that was needed,
but the adaptation of the whole town-planning move-
ment in that direction. Meanwhile London was
sprawling over the countryside. Some authority
ought to take hold at once of the centres that were
being made by the arterial roads. They would be the
centres of the future communities, and yet they were
allowed to be taken up by petrol stations, breweries,
poo houses, and caravans. He hoped the Greater
ndon planning authority would be revived.
Sir FRANCIS went on to endorse a plea made by
Mrs. Tate for a trial of the Scandinavian experiment
in the treatment of venereal disease which had resulted
in almost complete immunity from syphilis and a
large reduction of other diseases, Here the position
had been improved by the scheme of treatment
centres, but a large number of persons failed to
pursue the treatment to the finish. Of the nearly
ear attended V.D. clinics,
only 22,000 had the final tests of cure, and nearly
20,000 ceased to attend before completion of their
treatment. The first essential was education and
the Ministry of Health ought to exercise pressure
on the local authorities to keep up their quota of
subscriptions to the Social Hygiene Council. They
also had to consider seriously whether it was not
1492 THE LANCET]
desirable to introduce some kind of compulsion either
in notification or in ensuring completion of treatment.
In Holland a voluntary system had given results
better than ours; last year they had only 11 fresh
infections per 100,000 of the population.
Mr. J. HENDERSON said that rheumatism was
startlingly prevalent in large portions of industrial
England. Several continental governments, backed
up by the municipalities, had established a network
of spas and clinics. In ,this country the leading
hospitals were not dealing as they should with the
manipulative treatment of this disease. He urged
the Minister to organise a national service of municipal
clinics in conjunction with the local hospitals.
Mr. G. GRIFFITHS urged the Minister to deal with
burning pit heaps in mining districts, the fumes of
which caused ill health. He commented on the
absence in the report of anything about diabetes.
We had in this country not fewer than 200,000
diabetics. A State-insured person who was a diabetic
got his insulin free; if the wife of such a person
was a diabetic and was prescribed insulin, her husband
had to pay anything from 10s. to 18s. a week for it.
Mr. GODFREY NICHOLSON said that the Ministry
were losing a sense of proportion with regard to
maternal mortality. Too much stress was being
put on antenatal treatment and not enough emphasis
on the importance of skilled attention at the actual
time of birth. An eminent gynecologist had said
to him that it was the specialist who should be looking
after the actual confinement and the practitioner
doing the antenatal care. The solution of the
problems of maternal and infantile mortality lay
in educating the whole population.
Miss WARD said that before embarking upon a
campaign of ‘‘ Use your health services” it was
important to know whether there were adequate
health services provided by every local authority.
We should have a detailed survey of what health
services were available to see whether local authorities
were taking advantage of the powers which they could
use, and whether they had the necessary finances to
enable them to do so.
MINISTERIAL REPLY
Mr. BERNAYS said that the figures in the latest
annual report of the chief medical officer of the
Board of Education were illuminating. They showed
that out> of 1,680,000 school-children examined,
only 0°7 per cent. were suffering from definitely bad
nutrition and only 10°6 per cent. from subnormal
nutrition. There was also the encouraging fact—
which gave the lie to the assertion about the deteriora-
tion of our national physique—that the general death-
rate had fallen by one-third during the last 25 years
and that the death-rate from tuberculosis in children
under one year of age had been reduced by a half
in the same period. Malnutrition was a problem
and the Government could legitimately claim that it
had been tackled with energy and effect in the last
few years. Reference had been made to the question
of satellite towns. This question was dealt with
by a departmental committee in 1924, which recom-
mended the establishment of a National Planning
Board. The main suggestion was that the larger local
authorities should be encouraged, and, if necessary,
compelled, to make further outward development
in the form of planned units outside the town,
separated by adequate areas of open land. The
instances of Welwyn and Letchworth garden cities
had been raised, and the Government had been asked
why we cannot apply experiments of that kind. These
garden cities were started by public utility companies,
and local authorities were doing much to secure the
same objects. After all, town planning was planning
to secure proper sanitary conditions, amenities, and
conveniences. The increasing use of joint committees
meant the extension of planning for larger units,
[Sir FRANCIS FREMANTLE: They are doing nothing
to marry factories to residences, and that is the whole
essence of the thing.)
PARLIAMENTARY INTELLIGENCE
[JUNE 19, 1937
Houses were being built, Mr. Bernays rejoined,
under healthy conditions on the outskirts of the
towns, and this policy would be continued and
encouraged, With the existing organisations, and
working with the sympathy of established authorities,
much was being and could be done.
Objection had been taken to the recognition of
opticians as having power to prescribe for defective
eyesight. While the Minister was satisfied that the
ultimate ideal was that all persons should go to a
medical eye specialist, he was satisfied that it would
not be practical politics under present conditions
to make this an invariable practice in all cases,
The reasons were that the supply of qualified medical
men was not sufficient to meet the needs of the whole
population and that the people had not been educated
up to recognising the advisability of this course in
what they regarded as ordinary, straightforward
cases of defective eyesight. The regulations, there-
fore, provided for either of the alternative courses
being followed. Every insured person was required
to visit his own insurance doctor before his application
for ophthalmic treatment was granted.
PENSIONS FOR LOCAL GOVERNMENT
OFFICERS
In the House of Commons on June 11th the Local
Government (Superannuation) Bill was read a second
time. In moving the second reading Sir KINGSLEY
Woop said that the main and general object of the
Bill was to secure such a measure of uniformity
as might reasonably be required in regard to the
provisions to be made by local authorities for pensions
for their staffs. It required provision to be made
for the superannuation of all whole-time local govern-
ment officers and facilitated similar provisions by
local authorities over and above that made by the
general law relating to pensions for their other
employees. The Bill brought the local government
service in this respect into line with the long-established
practice of the Civil Service and thus added another
measure of protection in old age to a further section
of the community. The present rate of contribution
for both officers and servants was 5 per cent. of their
remuneration with an equivalent contribution from
the local authority. It was estimated that in the
present circumstances the rate of contribution
needed to secure the benefits was in total 12 per
cent. for officers and 10 per cent. as at present for
servants, and the Bill accordingly proposed to increase
the rate for new entrant officers by 1 per cent. with
a similar increase in the authorities’ contribution.
The Bill contemplated the minimum of interference
with the various superannuation schemes established
under local Acts, but if the main purpose was to be
achieved it was essential that those schemes should
be extended to cover, when they did not already do
so, all whole-time officers.
DIFFERENTIAL TREATMENT
Captain ELLISTON expressed disappointment that
no provision was made by the Bill for the optional
grant of added years by local authorities in the case
of their professional] officers. He had'been advocating
that concession since 1922. He had some special
experience of the conditions of service of medical
officers. ‘They were men who spent five or six years
in acquiring their professional qualifications. At
the end of that period if they were wise, or if they were
fortunate, they took a period of service as house
physician or surgeon in a hospital and then they had
to acquire the further professional qualifications
which would enable them to take a public health
appointment. In view of the tremendously varied
character and importance of public health work in
these days, a medical officer who hoped to secure
an appointment had to acquire special experience
in a number of directions. He had to spend a period
of residence in hospital; he had in most cases to
spend a period in a tuberculosis sanatorium. He
+
THE LANCET]
had to acquire extra experience, perhaps, in diseases
of women and children, and so on. That meant that
he was usually 30 years of age, or more, before he
could obtain his first appointment. Owing to this
late entry at a higher salary level the contributions
of these officers in relation to their pensions were
much higher than those of non-professional officers,
many of whom entered the local government service
as soon as they left school. He (Captain Elliston)
was hopeful that it was not too late for the Minister
_ to consider whether he could make some concession
in this matter and give local authorities the power,
if they so desired, to add years, not exceeding ten,
to the number which professional officers, in such
circumstances as he had described, had actually
served. Alternatively, it was being suggested that
years spent in professional training should be allowed
to count as service years within the meaning of the
Act. He knew the anxiety of the Minister to promote
coöperation between the municipal hospitals and
the great voluntary hospitals. He (Captain Elliston)
was told that there were members of the House of
Commons who would like to see it made possible by
this Bill to provide for the interchangeability between
the federated superannuation scheme of the voluntary
hospitals and the superannuation scheme of the
local authorities. If that were practicable it would
undoubtedly facilitate the interchange of personnel
and would do a great deal to raise the standard of
the hospital services in this country. What he had
said also applied to other officers such as health
visitors, nurses, and so on.
Mr. W. H. GREEN said the London County Council
had 3400 nurses on probationary service and he
gathered that under this Bill those nurses would
immediately be placed under the superannuation
scheme. There was a great amount of coming and
going in the ranks of probationers, particularly in
the nursing profession, and a hardship would be
imposed if all the probationery nurses to whom he had
referred were compelled immediately to be placed
under the superannuation scheme. Another point
affected the health visitors engaged by local authorities.
He was delighted to think that at long last the
retiring age of health visitors was to be fixed at 60;
but that carried with it a great grievance, because
to qualify for the maximum pension health visitors
must have put in 40 years’ service. That would be
well-nigh impossible under the conditions of the
Bill. It was very seldom that a health visitor was
appointed under the age of 25. That meant that
at the most they could put in only 35 years’ service.
He wondered whether some compensation might
be provided in the Bill in regard to the 5 years’
service.
Sir FRANCIS FREMANTLE said among civil servants
they had men of the highest possible attainments.
Those interested in local government wanted to
get the same type of men into the local government
service. To attract them to this service they must
remove certain disadvantages, one of which had
been the absence of superannuation provision.
This Bill helped to meet that difficulty. There were
points in the Bill in which the transition from
voluntary service to public service might be made
more easy. The arrangements under the present
Bill were not satisfactory for bringing in the mid-
wives, who while working under voluntary associations
in villages where they were not employed for the
whole of their time were also under a contract with
the local authority under the Midwives Act to provide
a midwifery service. Sir Francis asked the Minister
to give the most earnest consideration to the require-
ments which would enable the midwives to secure
the full advantages of superannuation. It was
difficult to recruit midwives, yet it was on the mid-
wifery service that they depended very largely for the
improvement of the maternity services of the country.
He gave his cordial support to this Bill as a con-
structive measure for building up a great local
government service,
PARLIAMENTARY INTELLIGENCE
[JUNE 19, 1937 1493
MINISTERIAL REPLY
Mr. BERNAYS, Parliamentary Secretary to the
Minister of Health, said that the clause which dealt
with the position of nurses was based on the recom-
mendation of the Selby-Bigge Committee. Obviously
this was a matter which could very well be considered
when the Bill reached committee. The Minister
would be glad to receive any representations on the
part of the interests concerned between now and
the committee stage. As to the point raised by
Captain Elliston as to why there was a differentia-
tion in the rates of contribution between officers and
servants, a uniform rate of 5 per cent. was fixed by
the Act of 1922 for all employees brought within
its provisions. It was urged before the Selby-
Bigge Committee that the remuneration of an officer
usually increased automatically or by promotion
from the beginning to the end of his service, and he
was pensioned on the average remuneration of the
last five years of his service when his remuneration
was obviously at the highest. On the other hand,
a workman received wages which soon reached their
maximum and remained at the same level for many
years. Accordingly, a workman’s contribution paid
throughout on a flat basis of remuneration brought
into the superannuation fund a greater sum in relation
to the pension drawn than did that of an officer.
Since the same scale of pension was applicable to
both classes of employees a smaller percentage rate
of contribution should be sufficient in the case of a
workman than in the case of an officer.
THE SCOTTISH MEASURE
On the previous day Mr. ELLIOT, Secretary for
Scotland, moved the second reading of the Local
Government Superannuation (Scotland) Bill. He
explained that there were two specific points in which
the Bill differed from the English measure. In the
first place it was proposed that the minimum number
of officers to be covered by the scheme should be 50 ;
under the English Bill the minimum number was
100. In the second place, in the Scottish Bill they
also made provision for local authorities to act jointly
in cases where they had not themselves a sufficient
number of employees to make a separate scheme.
But all the ‘‘ small burghs ” had fewer than 50 whole-
time officers, so for this purpose they would be.
counted as employees of the county councils.
NOTES ON CURRENT TOPICS
Physical Training
In the House of Commons on June 11th the Physical
Training and Recreation Bill was read a third time.
On the motion for the third reading, Mr. LINDSAY,
Parliamentary Secretary to the Board of Education,
said that since the second reading action had been
taken on four points. The local organisations com-
mittee had done a great deal of preliminary work
and he hoped the local bodies would begin work
during the summer holidays. The committee on
propaganda intended to start an intensive campaign
in the autumn. It had given special consideration to
the use of films. The technical committee had been
considering the question of the National College
and had proceeded a long way. The question of
research was very important. The grants com-
mittee could begin to consider applications as soon
as the statutory powers were obtained. The aim
was to build up a new leadership of trained men and
women and to inspire the whole nation with the great
ideal of personal fitness. They could not rest content
until every child in the country had equality of
access to all that was meant by physical education
and had an equal chance to become a healthy citizen.
Mr. LEES-SMITH said he had come to the conclusion
that the part of the Bill which ultimately would
probably prove the most valuable would be that
which dealt with physical education, particularly in
the form of remedial exercises for those whose work
was deleterious to their health, rather than that
1494 THE LANCET]
which dealt with physical recreation. It must not
be taken for granted that because young medical men
engaged in active physical recreation up to the age
of 25 or so they did not need physical education.
One of the most striking observations which had
fallen from Lord Dawson of Penn was that when he
had watched hikers, tennis players, and even terri-
torials, he had noted that many of them were suffering
from defects of posture, stooping shoulders, and bad
chests, which would pay them out a little later when
the health and strength of youth had passed. He
(Mr. Lees-Smith) had never envied great athletes
from the point of view of permanent fitness for life.
When he read of the death of great athletes and
noted their age he came to the conclusion that they
were not quite as well off as the rest of the popula-
tion and he was reminded of an observation by
Plato that ‘‘ an athlete is on a slippery edge in respect
of health.” He hoped,it would not be thought,
therefore, that by providing facilities for great
athletic prowess they would be doing the work of
building up the physica] health of the nation.
Mr. WAKEFIELD said speaking for himself, and he
was sure also for his colleagues on the National
Advisory Council, their aim was to try to make the
great mass of the people, young and old, physically
fit. They did not want to get a few sprinters doing
100 yards in 10 seconds; they would far rather have
a million people doing 100 yards in 12 or 13 seconds.
The result of their work would not depend on the
success and ability of one or two outstanding athlete
but on the general excellence attained by all.
Mr. LINDSAY, replying to the debate, said that
` while they all wished to encourage the games which
were characteristic of this country there was a great
deal to be said for physical education as such. He
was told by experts that at the present time they
were all going about half dead, and that there were a
few very simple exercises which every member of
the House of Commons could take every day and
which would make a great difference to the health,
the physique, and the happiness of those who engaged
in them. They did not quarrel with that theory
at all. He had the greatest admiration for what
was being done in Germany, Czechoslovakia, Sweden,
Denmark, and elsewhere, but he was still convinced
that they had to proceed on the basis of our character-
istic British games. If they did that he was quite
certain they would make this organisation a complete
success,
School Medicine
On June 14th in committee of supply, Mr. KENNETH
LINDSAY, Parliamentary Secretary to the Board of
Education, said that the total increase in the vote
over last year was for £1,296,233. Part of the
increase was due to general maintenance charges,
and there was another item, provision for physical
training under the Government’s new scheme.
That provision would be made in a supplementary
estimate. During the last 18 months provision had
been made for the youngest children by way of
7500 nursery schools in 80 different areas. Fifty
new schools with playing fields attached were approved
in 1935-36, and during the last year 90 such new
schools were also approved. During the last two
years, 111 playing fields had been acquired for
separate schools, and 61 to cater for a variety of
schools had been acquired. Gymnasia had been
provided for 117 elementary schools. Mr. Lindsay
was glad to be able to report progress along many
lines of advance in regard to the School medical
service and physical education. Since the recent
circular was issued 34 new proposals and 5 proposals
for enlarging existing nursery schools had been
received. The present position was that 89 nursery
schools were recognised by the Board of Education,
and in addition 31 had been approved in principle
and 10 were under consideration. While the growth
was rapid in proportion the total was still compara-
tively small and there were still many areas where
local conditions would justify providing these schools
PARLIAMENTARY INTELLIGENCE
[JUNE 19, 1937
but where proposals had not been received. Their
object was to obtain for all children under five years
of age whose home conditions were unsatisfacto
light airy rooms, special playgrounds, play material,
and a happy environment which they needed for-
normal physical and mental development.
MORE STAFF NEEDED
The school medica] service was a wonderful service,
but it needed more staff. Since the recent circular
was issued 32 authorities had increased their staff
by the appointment of six whole-time and 29 part-
time medical officers; 12 authorities had appointed
aural and 8 ophthalmic specialists, and one a specialist
on rheumatism. One hundred proposals had been
received for building school clinics and extending
old ones and there were 13 new schemes for ortho-
peedics, 19 for aural treatment, and 15 for artificial
light treatment. These were examples of how the
staff was being increased, but there was still leeway
to make up. : At the time of the issue of the circular
it was estimated that there were less than two-thirds
of the number of school dentists required. He
was glad to say, however, that 61 authorities had
increased their staff by employing 62 full-time and
23 part time dentists. But the ideal they must
achieve was an annual inspection of all school-
children ; otherwise he did not see how they could
make good progress in this which was probably one
of the most important aspects of the health services.
There were also day open-air schools, residential
schools for delicate children, and the problem of the
feeble-minded was always with them. Itwas particu-
larly difficult to deal with in the countryside. For
some children the only solution was the residential
school and on that score one new proposal had been
received from a country district.
On June 11th in the House of Commons the Children
and Young Persons Bill, which has already passed
through the House of Lords, was read a second time.
QUESTION TIME
WEDNESDAY, JUNE 9TH
Milk Ration for Boys in the Navy
Mr. GRAHAM WHITE asked the First Lord of the Admiralty
the present amount of the milk ration for boys in the
Navy.—Mr. Durr Cooper replied: There is no fixed
ration of milk for boys in the Navy as they are victualled
under the general mess system and are provided with a
varied dietary without fixed rations of the various items
of foodstuffs. The average amount of milk issued daily
to each boy is estimated to be approximately $ pint.
Colonel GRarron: Will my right hon. friend say whether
the milk is fresh or tinned ?—No further answer was
given.
. Industrial Employment of Children at Home
Mr. DENMAN asked the Home Secretary whether his
attention had been called to the charges made of excessive
employment of children at home on industrial work ;
whether he could give any information as to the extent
of this practice; and what steps he was taking to stop
it—Mr. GEOFFREY Luoyp, Under Secretary, Home
Office, replied : I am obliged to my hon. friend for calling
attention to this matter, about which no complaints have
reached the Home Office. In 1931 as the result of an
inquiry it was reported by the education authorities that
652 boys and girls aged 12-14 were employed in industrial
work at home within the limits allowed by the law. My
right hon. friend is proposing to ask the education authori-
ties in the near future for information as to the application
of the law as amended by the Children and Young Persons
Act, 1933, and this information will include the point
now raised.
Royal Marines and Tuberculosis
Mr. RosBert TAYLOR asked the First Lord of the
Admiralty the number of Royal Marines invalided out
of the service owing to tuberculosis; the number who
THE LANOET]
PARLIAMENTARY INTELLIGENCE
[JUNE 19, 1937 1495
had applied for pension ; and the number of cases in which
pao were awarded during the last three years.—Mr.
UFF COOPER replied: During the period of three years
ended April 30th, 1937, 65 Royal Marines were invalided
out of the service on account of tuberculosis, of which
number 62 were pulmonary and 3 other forms; each
invalid was automatically considered for an award of
pension which was granted in 43 cases.
THURSDAY, JUNE 10TH
Health of Spanish Refugee Children
Mr. Lzeacu asked the Minister of Health whether the
Basque children who recently reached this country had
been vaccinated and inoculated before their arrival,
and, if so, against what diseases were they vaccinated or
inoculated ; and when were these operations performed.—
Sir KinastEy Woop replied: So far as I am aware no
special measures of vaccination or inoculation were taken
before the children’s arrival in this country, but approxi-
mately 50 per cent. were found on examination to have
been vaccinated against small-pox. I understand that a
first inoculation against typhoid has now been given to
nearly all the children in the camp at North Stoneham.
Sir ARCHIBALD SouTHBY asked the Minister of Health
how many Spanish refugee children had been admitted
into this country; and how many cases of typhoid or
suspected typhoid had occurred amongst them.—Sir
Kincstey Woop replied: According to the information
with which I have been supplied, 3881 children arrived
at the camp at North Stoneham on May 23rd and 24th.
Six cases of typhoid, including one not finally diagnosed,
and one of paratyphoid have occurred amongst them.
Three children are at present under observation for this
disease.
Sir A. Sournsy: In view of the risk of the spread of |
this disease would the right hon. gentleman give an assur-
ance that none of these children will be allowed to move
to other parts of the country until they have undergone
the full quarantine ?—Miss Wiixrson : Is it not a fact
that the arrangements in regard to quarantine have been
most admirably carried out by the voluntary service of
doctors ?
Sir Kinastey Woop : The responsibility for the conduct
of this matter rests with the voluntary committee. I
think that everyone will agree that my department have
given all the advice and assistance that can be given in
this matter, and we shall continue to do so. So far as the
question of the removal of children is concerned, I am
anxious. myself, subject to satisfactory medical conditions,
that these children shall leave the camp as soon as reason-
ably practicable and possible. Any assistance that my
medical officers can give to medical officers in districts
where they may have to go, in order to secure safety so
far as health is concerned, will be given.
Sir J. Lams: Will the medical officers of health be
informed before the arrangements are made to transfer
these children ?
Sir Kinestey Woop: Oh yes, Sir. It is obviously a
very important responsibility on the local medical officers
of health. 7
Sir Joun Hastam: Does the right hon. gentleman
realise that some of these children have already been
removed from the camp and that some of them are in
my own constituency ? Have the necessary steps been
taken between the Ministry of Health and the local
authorities to make sure that the children are fit to be
removed ?
Sir KinastEY Woop: The matter is one for the local
authority in the area and the medical officer concerned.
From my own knowledge and observation I believe that
the medical officers in the districts are fully alive to the
need for properly carrying out their duties.
Juveniles and National Health Insurance
Mr. THORNE asked the Minister of Health whether the
court of inquiry had come to any settlement in connexion
with the fees to be charged by the doctors when boys
and girls become employed after leaving school; and
whether the Government intended bringing in a Bill to
deal with the matter.—Sir Kincstey Woop replied :
Yes, Sir. The court of inquiry which was asked to con-
sider the doctors’ capitation fee to be paid as from January
next for all insured persons entitled to medical benefit,
on the assumption that employed juveniles would then
be included, has reported in favour of the present rate
of 9s. per annum. I shall introduce the necessary Bill as
soon as Parliamentary business permits.—Mr. THORNE:
Is it in consequence of their powerful organisation that
the doctors have got all that they wanted ?—Sir KINGSLEY
Woop: I would advise the hon. gentleman to consult the
doctors.
Health Insurance and Ophthalmic Treatment
Sir Ernest GRAHAM-LITTLE asked the Minister of
Health whether the National Ophthalmic Treatment
Board was taken into consultation by him in drafting the
Additional Benefits Amendment, 1937; and whether he
was satisfied that the arrangements made by these regula-
tions for permitting sight testing by recognised ‘opticians
would in no way interfere with the development of the
best possible ophthalmic medical service in this country.—
Sir KinGsLEY Woop replied: Before the regulations to
which the hon. Member refers were made the fullest con-
sideration was given to the views expressed on behalf
of doctors associated with the work of the National Oph-
thalmic Treatment Board. I see no reason why any
arrangements made under the regulations should interfere
with the development of a satisfactory ophthalmic medical
service.
Major Proctor asked the Minister of Health whether,
in connexion with the Additional Benefits Amendment
Regulations, 1937, he could say what steps had been
taken by him to obtain agreement between the sight-
testing opticians and the National Ophthalmic Treatment
Board with regard to the question of sight testing in con-
nexion with ophthalmic benefit.—Sir KinestEy Woop
replied: Repeated attempts have been made to obtain
agreement between the different schools of thought on
the subject referred to by my hon. and gallant friend
and I have myself received representative deputations
from both sides. Unfortunately it was not possible for
any agreement to be arrived at. | |
Unemployed Persons and Dental Treatment
Mr. WHITELEY asked the Minister of Health whether
his attention had been drawn to the increased cost of
public assistance committees due to dental treatment
and the provision of artificial dentures to persons in receipt
of allowances from the Unemployment Assistance Board ;
and whether he was prepared to arrange for such cost to
be met by the Board and thus relieve the local public
assistance committees of what should be a national charge,
—Sir KinastEy Woop replied: I have received a com-
munication from one local authority on this matter. I
am advised that under the Unemployment Assistance
Act the Board have no power to defray the cost of dental
treatment.—Mr. WHITELEY: Do I understand that the
public assistance committees will still have to bear the
burden of these additional costs ?—Sir KInasLEy Woop :
Yes, Sir; the provision of medical benefits remains the
responsibility of the local authorities under the Act,
MONDAY JUNE 14TH
Spanish Refugee Children
Mr. MITCHELL asked the Home Secretary whether he
could make any statement in regard to the future of the
Spanish refugee children in Great Britain in the event of
it being impossible to repatriate them in the near future.—
Mr. Luoyp, Under-Secretary, Home Office, replied: .
The committee responsible for the care and maintenance
of these children has given an undertaking to the Govern-
ment that they will be repatriated by the committee
as soon as circumstances permit. It is clearly impossible
to foretell when circumstances will permit of repatriation.
As my right hon. friend the Minister of Health stated
on June 10th, the responsibility for any arrangements for
moving them from the camp at North Stoneham rests
with the voluntary committee, which is, I understand,
making arrangements for their accommodation in groups
in private institutions and similar places.
Effect of Noise on Health
Sir RALPH GLYN asked the Minister of Health whether
- he would appoint a committee to inquire into the detri-
mental effect of unnecessary noise on the health of people
1496
living in large cities; and how far medical opinion sup-
ported the view that many instances of nervous break-
downs, &c., were due to causes which could be to a great
extent eliminated.—Sir KinGsLEy Woop replied : Research
into the effects of noise on workers carried out by the
Industrial Health Research Board of the Medical Research
Council, on which reports have been published, shows
that it is very difficult to detect and measure any specific
effects of noise on health, and it is hardly possible to assess
within the limits of a Parliamentary answer the influence
which medical opinion would assign to the part played
by noise in the increased strain of modern life. I will
send my hon. and gallant friend some references to medical
publications on this subject. As at present advised, I
do not think the subject lends itself to investigation by a
committee as suggested.
THE LANCET]
TUESDAY, JUNE 15TH
Nurses’ Hours in Scottish Mental Hospitals
Mr. ROBERT GIBSON asked the Secretary of State for
Scotland what was the total number of attendants and
nurses on the stafis of, or employed at, mental institutions
in Scotland as at May 3lst, 1937; how many of these
individuals had a tour of duty extending to 84 or more
hours, 78 and under 84 hours, 72 and under 78 hours, 66 and
under 72 hours, 60 and under 66 hours, 54 and under
60 hours, 48 and under 54 hours, 42 and under 48 hours,
and under 42 hours per week, respectively ; what were the
corresponding figures for the Smithston institution in
Greenock ; and if he had any statement to make regarding
the introduction of legislation to restrict the working
week of such individuals to a maximum of 48 hours.—
Mr. WEDDERBURN, Under-Secretary of State for Scotland,
replied: The information desired is not immediately
available but steps have been taken to obtain it and I
will communicate with the hon. and learned Member
when it is received.
Maternal Mortality
Mr. JAMES GRIFFITHS asked the Minister of Health the
maternal mortality-rate for each of the administrative
counties and county boroughs in Wales for the year 1936,
and the corresponding rate for England and Wales as a
whole.—Sir KrinesLey Woop replied: The following
table gives the information requested by the hon.
Member :—
Maternal mortality
deaths for 1936 per
1000 total (live and
still) bi
births.
Puerperal Other puer-
sepsis. peral causcs.
England and Wales 1-34 2°31
Cardiff C.B. a 2:55 z 1-13
Merthyr Tydfil C.B. 1:02 .. —
Newport C.B. T 0:59 .. 1-77
Swansea C.B. zi i 2-22 4°44
Administrative Counties:
Anglesey 1-30 5:20
Brecknock 1-25 4-99
Caernarvon 2:38 4:17
Cardigan 1-48 7:42
Carmarthen .. 1-54 5-01
Denbigh 0°83 2°91
Flint .. 2-04 3°58
Glamorgan 2°42 2°92
Merioneth — 1-82
Monmouth 2:96 3°52
Montgomery .. — 1-43
Pembroke 2:25 1:50
Radnor — 3:07
Housing Conditions in Scotland
Sir Tuomas Moore asked the Secretary of State for
Scotland whether, in view of the fact that over 250,000
houses were still required to replace unfit dwellings in
Scotland and that, owing to the present condition of the
building trade, it would not be possible to erect more than
some 25,000 houses per annum, he could state what
special steps he proposed to take to encourage temporary
reconstruction and reconditioning in order to improve the
present position.—Mr. WEDDERBURN replied: In view
of the present pressure on the supply of building trade
PARLIAMENTARY INTELLIGENCE
[JUNE 19, 1937
labour in Scotland, my right hon. friend is not satisfied
on the information at present before him that a policy
of temporary. reconstruction and reconditioning would
make any material contribution to housing needs, but
following representations made to him by the Convention
of Royal Burghs he is making further inquiries on the
subject.
Hospital Staff at Gibraltar
Lieut.-Commander: FLETCHER asked the Secretary of
State for War whether the normal hospital staff at
Gibraltar was too small to be able to cope with 35
unexpected patients, or whether there were other reasons,
and, if so, of what nature, for the dispatch of four nurses
to Gibraltar to nurse the wounded from the Deutschland.—
Mr, Hore-BetisHa replied: The staff of the Military
Hospital, Gibraltar, is adequate to deal with a normal
number of patients. The casualties from the
Deutschland were abnormal.
THE SERVICES
ROYAL NAVAL MEDICAL SERVICE
Surg. Comdr. A. G. Lee to Pembroke for R.N.B.
Surg.-Lt.-Comdr. T. G. B. Crawford to be Surg. Comdr.
Surg. Lt.-Comdr. V. J. Fielding retires at own request.
Surg. Lt.-Comdr. R. V. Jones to Wellington.
Surg. Lts. G. L.. Hardman, J. F. Meynell, W. S. Parker,
and W. B. Teasey to Victory for R.N.B.; and I. C.
Macdonald to Falmouth.
ROYAL NAVAL VOLUNTEER RESERVE
Proby. Surg. Lt. D. R. Maitland to be Surg. Lt.
ARMY MEDICAL SERVICES
Col. J. Heatly-Spencer, C.B.E., late R.A.M.C., having
attained the age for retirement, is placed on ret. pay.
Lt. Col. W. H. O’Riordan, M.C., from R.A.M.C., to be
Col.
Royal Army Medical College : Lt.-Col. and Bt.-Col. R. C.
Priest, K.H.P., R.A.M.C., to be Professor of Tropical
Medicine and Consulting Physician to the Army.
ROYAL ARMY MEDICAL CORPS
Maj. G. S. McConkey to be Lt.-Col.
TERRITORIAL ARMY
Capt. W. C. Armstrong to be Maj.
Lts. G. O. Brooks, F. G. Maitland, W. B. R. Monteith,
and J. B. Bishop to be Capts.
R. M. McGregor (late Offr. Cadet, Edinburgh Univ.
Contgt. (Med. Unit) Sen. Div., O.T.C.) to be Lt.
ROYAL AIR FORCE
Flight Lt. H. C. S. Pimblett is promoted to the rank
of Squadron Leader.
Flying Offrs, promoted to the rank of Flight Lt.: J. R. R.
Jenkins, E. W. R. Fairley, and R. C. O’Grady.
Flight Lt. T. J. M. Gregg to No. 4 Flying Training School,
Abu Sueir, Egypt.
Dental Branch.—B. Blackburne to Medical Training
Depôt, Halton, on appointment to a non-permanent
commission as a Flying Offr. for three years on the active
list.
AUXILIARY AIR FORCE
No. 600 (City of London) (Fighter) Squadron: J. H.
Attwood is granted a commission as Flying Offr. .
INDIAN MEDICAL SERVICE
The Commander-in-Chief in India has notified the
following appointments :—
Col. W. J. Powell, C.I.E., as Assistant Director of
Medical Services, Peshawar District, with effect from
March 27th last.
Col. W. L. Watson, O.B.E., as A.D.M.S., Kohat District.
Lt.-Col. H. C. D. Rankin, O.B.E., as specialist in
medicine, Deccan District.
Appts. made in India :—
A.D.M.S.: Col. T. C. C. Leslie, O.B.E., Brit. Serv.
D.A.D.M.S.: Maj. R. Murphy, R.A.M.C.
(Continued at foot of opposite page)
THE LANCET]
[June 19, 1937 1497
MEDICAL NEWS
University of Oxford
Dr. A. D. Gardner, director of the Standards Laboratory
of the Medical Research Council, Oxford, has been
appointed to a readership in bacteriology as from Oct. Ist,
and the title of professor has been conferred on him for so
long as he holds this office.
Dr. Gardner was educated at Oxford University and St.
Thomas’s Hospital, graduating in 1911. In the following year
he was admitted to the fellowship of the Royal College of
Surgeons of England and a year later he took his M.D. degree.
From 1914 to 1917 he held a Radcliffe travelling fellowship
and in 1923 he was awarded the prize for medice] research.
Dr. Gardner held the posts of demonstrator in morbid anatomy,
research assistant, and house surgeon at St. Thomas’s Hospital.
He is a fellow of University College, Oxford, and the author
of ‘ Bacteriology for Medical Students and Practitioners ”’
and of “ Microbes and Ultramicrobes.” He contributed the
section on the dysentery group of bacilli to the Medical Research
Council’s ‘‘ System of Bacteriology ” in 1929. His work on
whooping-cough has done much to introduce into this country
the cough-droplet method of early diagnosis which he described
in our columns in 1932.
Dr. E. S. Duthie has been appointed university demon-
strator in pathology for four years from Oct. lst.
University of Cambridge
On June llth the following degrees were conferred :—
M.D.—F. W. Shepherd, T. R. Thomson, and E. W. Taylor.
M.B., B.Chir.—*D. G. Levis, *N. B. Betts, and *Guy Rigby-
Jones, S. C. Buck, G. E. Loxton, A. E. M. Hartley, A. J. Moon,
R. G. Pulvertaft, J. H. Lankester, and F. S. A. Doran.
M.B. . G. F. Mackenzie, *T. V. Tattersall, J. S. Ellis,
A. L. Jackson, H. S. Mellows, J. M. Scott, E. F. W. Grellier, and
K. W. B. Rostron.
* By proxy.
Royal College of Surgeons of England
At a meeting of the council of the college held on
June l0th with Sir Cuthbert Wallace, the president, in
the chair, a letter was read from the Rockefeller Founda-
tion presenting the sum of £500 for one year towards
research work at the college. The honorary college
medal was awarded to Sir Frank Colyer, in recognition
of his many contributions to scientific odontology and to
the service of the college. Sir Holburt Waring, who has
been a member of the council since 1913, and who was
president of the college from 1932-35, presented a silver
cup to mark his retirement from the council. ,
Diplomas of fellowship were granted to the following :—
J. H. Mulvany, M.R.C.P. Lond., King’s Coll.; B. E. Fernando,
L.R.C.P. Lond., Ceylon and St. Barts; V. H. Barnett,
M.B. Lond., Univ. Coll. and Guy’s; H. G. Ungley, M.D. Durh.,
London Hosp.; H. W. Burge, M.B. Lond., King’s Coll. and
West London; A. H. Charles, M.B. Camb., St. George’s and
St. Thomas’s; A. B. Evans, M.B. Camb., Westminster and
St. Bart.’s; Ashton Miller, M.B. Camb., St. George’s and
St. Thomas’s; W. H. D. Trubshaw, L.R.C.P. Lond., St. Bart.’s;
C. F. Critchley, M.B. Lond., St. Thomas’s and Guy’s; S. G.
Mayer, L.R.C.P. Lond., London Hosp.; Guy Blackburn,
M.B. Camb., St. Bart's; W. A. Law, M.B. Camb., London
Hosp.; B. N. Sinha, M.B. Lucknow, Middlesex and London
Hosp.; A. J. Helfet, M.B. Liverp.; J. R. Rose, M.B. Camb.,
St. Thomas’s; W. R. Merrington, M.B. Lond., Univ. Coll. ;
B. L. Williams, M.B. Camb., St. Thomas’s; K. G. F. Mackenzie,
L.R C.P. Lond., Cambridge and St. Thomas’s; Amarnath
Mukerji, M.B. Calcutta, Middlesex and St. Bart's; R. T. K
Nayar, M.B. Madras, London Hosp. and St. Bart.’s; A. K.
Taiwaikar, M.B. Bombay, St. Barta; R. A. Hughes,
M.B. Liverp. ; N. B. Rao, M.B. Bombay; T. H. Ackland,
M.D. Melb., St. Bart.’s ; W.S. Campbell, M.B. Belf., London
Hosp.; H. G. N. Cooper, B.M. Oxon., Guy’s and West London ;
K. R. Cussen, M.B. Melb., St. Thomas’s and London Hosp. ;
(Continued from previous page)
Appts. vacated in India :—
A.D.M.S.: Col. A. E. S. Irvine, D.S.O., V.H.S., Brit.
Serv.
Embn. Med. Ofir. : Maj. A. J. Bado, R.A.M.C.
Capt. P. K. S. Gupta resigns his temp. commn.
COLONIAL MEDICAL SERVICE
Surg. Lt. P. H. Stone has been appointed Medical
Officer, Kenya. Dr. W. P. H. Lightbody (Palestine)
becomes Assistant Director of Medical Services (Health),
Sierra Leone; Dr. J. Naudi (M.O.), Senior Medical Officer,
Nigeria ; Dr. W. Nelson (Nigeria), Senior Medical Officer,
Gold Coast; Dr. R. Nicklin (Zanzibar), Medical Officer,
Nyasaland; and Dr. A. M. W. Rae (Gambia), Assistant
Director of Medical Service, Gold Coast.
I. G. L. Ford, M.B. Dubl., Guy’s and London Hosp.; A. N.
McCrea, M.B. Camb., St. Mary’s and St. Thomas’s; S. K.
Menon, M.B. Bombay, Guy’s; J. S. M. Pringle, M.B. Dub.
London Hosp.; H. J. Ross, M.B. Aberd., London Hosp. and
Middlesex; J. C. Scott, M.D. Toronto, St. Bart.’s and Radcliffe
Inf.; R. A. M. Yeates, M.B.Sydney; and F. R. Yousry, M.B.
Cairo, St. Bart.’s and Guy’s.
A diploma of membership was granted to Alan William
Woolley, and diplomas in anesthetics were granted
jointly with the Royal College of Physicians to the
following :—
C. D. Banes, R. P. Booth, Elva M. Chivers, R. T. V.Clarke, R.W.
Cope, Herbert Curtis, G. D. Drury, A. C. Fraser, A. H. Galley,
J. L. Hopkins, Ernest Landau, I. N. Lewis, H. J. V. Morton,
A. H. Musgrove, J. A. V. Nicoll, William Niven, Angela M.S. A.
Ofenheim, G. S. W. Organe, F. H. Pratt, A. C. R. Rankin, O. N.
Ransford, J. R. Ritchie, J. M. Savege (Major, R.A.M.C.), H. R.
Sheppard (Major R.A.M.C.), J. T. Turner, R. C. Walch, and
Doris E. C. Walker
At the recent primary examination for the fellowship
the following candidates were successful :—
P. Berbrayer, M.D. Manitoba, Univ. Coll. ; J. A. W. Bingham,
M.B. Belf., Middlesex ; Ruth E. M. Bowden, Roy. Free; A.C.
Brewer, M.B. Liverp.; A. J. Broomhall, L.R.C.P. Lond.,
Univ. Coll. and Middlesex; D. M. F. Carter, Guy’s; G. H. D.
Channing, Guy’s; L. P. Clark, M.B. N.Z., Univ. Coll. and
Middlesex; S. Eisenhammer, M.B. Edin., Cape and Univ.
Coll.; R. Ewing, M.B. Camb., Middlesex ; Frances V.
Gardner, Roy. Free; A. Gourevitch, M.R.C.S. Eng., Birm.
and Middlesex ; I. H. Griffiths, M.B. Lond., Middlesex; E. O.
Harris, M.B. Lond., Middlesex; E. C. Herten-Greaven, M.B.
Camb., Lond. Hosp. ; J. Heselson, M.B. Cape Town, Univ Coll.:
W. B. Highet, M.B. N.Z., Univ. Coll.; W. G. Holdsworth,
M.B. Melb.; A. H. Hunt, B.M. Oxon., Univ. Col. and St.
Bart.’s; A. J. Innes, M.B. Edin., Univ. Coll. and Middlesex ;
R. Ismail, M.B. Cairo, Univ. Coll. and St.-Bart.’s; E. S. James,
M.D. Manitoba, Middlesex and Univ. Coll.; A. B. King, M.B.
Lond., Univ. Coll.; G. H. Kitchen, M.D. Toronto, Univ. Coll.
and Middlesex; R. A. V. Lewys-Lloyd, M.B. Lond., St. Bart.’s ;
J. F. Lipscomb, M.B.Sydney, Univ. Coll. and Middlesex;
L. Lloyd-Evans, Edin. and Middlesex; T. G. Lowden, B.M.
Oxon., Univ. Coll. and Middlesex; S. D. Loxton, M.B. Brist.,
Univ. Coll. and Middlesex ; . M. McGladdery, M.B. Lond.,
St. Bart.’s and Middlesex; T. J. B. A. MacGowan, M.B. Glasg.,
Middlesex ; Rosamund M. I. Mackay, M.B. Lond., Univ. Coll. ;
H. E. . Martin, M.B. Dubl., Univ. Coll. and Middlesex ;
K. Mazhar, M.B. Cairo, Middlesex and Lond. Hosp.; A. M.
Minaisy, M.B. Cairo, Middlesex and Univ. Coll. ; B. P. Moore,
St. Thos.; B. L. Morgan, Middlesex; G. N. Morris, M.B.
Melb., Middlesex and Univ. Coll.; A. L. Newson, M.B. Melb.,
Univ. Coll.; H. R. C. Norman, M.D. Toronto, Middlesex and
Univ. Col.; M. D. M. O’Callaghan, St. Bart.’s; J. G.
O’Donoghue, M.B. Melb., Univ. Coll.; M. K. Parikh, M.B.
Bombay, Middlesex; W. D. Park, M.B. Lond., Middlesex and
St. Bart.’s; W. Parke, M.B. Liverp.; D. G. Phillips, M.B. N.Z.,
Univ. Coll.; J. G. Pyper, M.B. Belf.; S. C. Raw, M.B. Durh.;
M. J. Riddell, St. Thos.; A. F. Rushforth, Guy’s; M. L. A.
Samie, M.B. Cairo, Middlesex and Univ. Coll.; A. H. Sangster,
M.D. Dalhousie, Univ. Coll.; A. H. M. Siddons, M.B. Camb.,
Univ. Coll.; <A. J. Slessor, M.B. Aberd., Middlesex ;
H. A. Small, M.B. N.Z., Univ. Coll. and Middlesex ; R. Spencer,
M.B. Manch., Durham ; K. R. Thomas, M.B. N.Z., Univ. Coll. ;
D. M. Thomson, M.D. Manitoba, Middlesex and Univ. Coll. ;
G. M. Thomson, M.B. Sydney; A. J. Walker, St. Bart.’s;
A. Wardale, M.B. Lond., Univ. Coll.; D. Wynn-Wiliams,
Univ. Coll. and Middlesex ; J. F. Ziegler, M.B. Melb., St. Mary’s ;
and A. Zinovieff, Middlesex.
The following examiners were elected for the ensuing
year :—
Dental Surgery.—Surgical Section: Mr. C. P. G. Wakeley,
Mr. C. E. Shattock, Mr. P. H. Mitchiner, Mr. E. G. Slesinger,
Mr. Reginald Vick, and Mr. Basil Hume. Medical Section :
Dr. R. A. Rowlands, Dr. A. H. Douthwaite, Dr. R. A. Hickling,
and Dr. Charles Newman.
Primary Fellowship.—Anatomy: Mr. P. N. B. Odgers,
Prof. H. H. Woollard, Prof. R. B. Green, and Mr. E. P. Stibbe.
Physiology: Prof. Hamilton Hartridge, Prof. John Mellanby,
Prof. D. T. Harris, and Prof. A. St. G. J. Huggett.
Diplomas of .R.C.P., M.R.C.S.—Elementary Biology:
Mr. W. A. Cunnington, Mr. A. E. Ellis, Mr. S. R. B. Pask, and
Mr. Wilfrid Rushton, D.Sc. Anatomy: Mr. E. P. Stibbe,
Dr. A. J. E. Cave, Prof. W. J. Hamilton. Physiology: Prof.
A. St. G. J. Huggett, and Prof. Samson Wright. Midwifery :
Mr. A. C. Palmer, Mr. Victor Lack, Mr. Trevor Davics, and
Dr. Wilfred Shaw. Pathology: Prof. James McIntosh, Dr. W.G.
Barnard, Mr. B. W. Williams, and Mr. D. H. Patey.
Diploma in Public Health.—Part I: Major-General H. J. M.
Perry. Part II: Dr. Charles Porter. , ,
Diploma in Tropical Medicine and Hygiene.—Major-General
W. P. MacArthur and Dr. Hamilton Fairley.
Diploma in Ophthalmic Medicine and Surgery.—Part I:
Mr. Leighton Davies and Mr. Affleck Greeves. Part II: Mr.
Foster Moore.
Diploma in Psychological Medicine.—Prof. F. L. Gola.
Diploma in Laryngology and Otology.—Part I: Mr. Sydney
Scott and Mr. Edward Carew-Shaw. Part II: Mr. T. B.
Layton.
‘Diploma res eaat Radiology rere I: Dr. H. T. Flint.
Part II: Dr. Hug avies.
Diploma in Anesthetics —Dr. H. E. Gaskin Boyle.
Diploma in Child Health.—Dr. A. G. Maitland-Jones.
1498 THE LANCET]
MEDICAL NEWS
[JUNE 19, 1937
University of Wales
At recent examinations the following candidates were
successful in obtaining the tuberculosis diseases diploma :—
A. A. Azeez, M. P. Crowe, B. A. Dormer, M. C. Malkani,
C. F. McConn, K. P. R. Pillai, N. N. Sen, H. K. Surveyor,
G. R. Talwalker, and Helen Turner.
University of Sheffield
Dr. Gilbert Forbes has been appointed lecturer in
forensic medicine and Dr. J. M. Kennedy lecturer in
infectious diseases. Dr. J. Webster Bride has been
appointed examiner in obstetrics for the final M.B.
examination in September.
Middlesex Hospital Medical School
On Wednesday, July 2lst, at the Scala Theatre, Lord
Dawson will distribute the prizes gained during the past
year by students of this school. Dr. G. E. Beaumont
will deliver an introductory address entitled the Breath
of Life. The wards of the hospital, the medical school
and research departments, and the nurses’ home will be
open to inspection after the prize-giving.
Queen’s Hospital for Children, Hackney
This hospital is undertaking an extension and recon-
struction scheme which will cost £50,000. Of this £30,000
must still be raised if the buildings are to be opened free
of debt.
National Smoke Abatement Society
The offices of this society are being transferred from
Manchester to London, and after Thursday, June 24th,
the address to which all communications should be sent
will be: Chandos House, 64, Buckingham-gate,
Westminster, S.W.1. The society’s present London address
at 71, Eccleston-square will no longer be used except
where the personal attention of Sir Lawrence Chubb
is desired.
Forthcoming Congresses
Meetings which have been arranged for the future
include the following :—
June 19th- .. Journées Médicales de... Brussels.
23r ruxelles.
» 2lst- .. Silicosis Symposium. . Saranac
25th Lake, N.Y.
» 26th- .. Journées Médicales Inter- .. Paris.
30th nationales de Paris.
July ist- . National Association forthe .. Bristol.
3rd Prevention of Tuberculosis.
i 5th- . International Hospital Con- .. Paris.
llth gress.
» ŝth- . Oxford Ophthalmological .. Oxford.
10th Congress.
» 12th- .. International Short-wave .. Vienna.
17th Congress.
» 19th-— .. International Congress on .. Paris
24th Mental Hygiene.
5 Sb yea . British Medical Association. .. Belfast.
i 24th— .. International Congress of .. Paris.
Aug. Is Child Psychiatry
ed ae š Population Congrès . Paris.
ug. 8
Aug. 5th- .. Internationale Gesellschaft .. Stockholm.
ith für Geog ra nnigene Patho-
ogie.
» 29th- .. International Swiss Medical .. Interlaken
Sept. 4th eek. |
Sept. ain British Association . Nottingham.
ò 5th— .. International Union Against .. Lisbon.
9th Tuberculosis.
i 13th— .. International Congress of .. Chicago.
17th Radiology.
» i38th- .. International . Society of .. Paris
15th Gastro-enterology.
es 16th- .. International Congress on .. Vichy.
18th Hepatic Insufficiency.
» 2ith- .. International Child Welfare .. Rome.
30th Congress.
Oct. 2nd— .. International Congress for .. Copenhagen.
4th Psychotherapeutics.
j 9th .. International Rheumatism .. Paris.
Congress.
5 17th— .. International Society of .. Wiesbaden and
22nd Medical Hydrology. Frankfurt.
Dec. 8th- . International Congress of .. Cairo.’
lth Ophthalmology.
March 21st .. International Leprosy Con- .. Cairo.
ference.
4 26tb— .. International Congress on .. Oxford.
31st Rheumatism and Medical
Hydrology
September .. International Surgical .. Vienna.
Society.
Newbury District Hospital
This institution has been remodelled and extended at
a cost of some £24,000 and the new buildings were opened
lately by Mr. A. Thomas Lloyd, His Majesty’s Lieutenant
of Berkshire. Two wings have been added to form
new men’s and women’s wards and the accommodation
has been increased from 36 to 64 beds.
A National Dental Service
Sir Kingsley Wood, the Minister of Health, accompanied
by Mr. R. H. Bernays, parliamentary secretary to the
Ministry, on Tuesday last received a deputation represent-
ing the British Dental Association, the Incorporated
Dental Society, and the Public Dental Service Association.
The deputation emphasised the need for a compre-
hensive dental service, as an essential sequel to the school
dental service, which would provide dental inspection and
treatment for every insured person. This could only be
made possible by means of a statutory dental benefit.
The service should be organised on a panel system similar
to that in force for medical benefit, and the dentists, like
the insurance medical practitioners, should be remunerated
on a capitation basis. Sir Kingsley Wood said in reply
that over 10 million persons—two-thirds of the whole
insured population of England and Wales—were already
entitled to dental treatment as an additional benefit
and that the scope of the existing scheme would be
considerably extended by the new proposals for bringing
juveniles into National Health Insurance. It was clear
that the cost of providing dental benefit as a statutory
benefit would be very heavy and would raise the question
of an increase in the contributions paid by insured persons
and their employers. He was nevertheless much
impressed by the arguments put forward and promised to
give them careful consideration.
Harveian Society of London
At the Buckston Browne dinner held at the Connaught
Rooms on June 10th, Lord Hewart proposed the toast
of the Society and said he thought doctors had little to
fear from the Recording Angel. Dr. A. H. Douthwaite,
responding as president, announced that despite a doubling
of its subscription the Society now had over 400 members.
Its present stability would have been impossible but
for the ten years’ devoted work of Dr. de Bec Turtle,
whose latest benefaction was the gift of a cigarette box
and snuffbox in celebration of Coronation year; while
the dinner itself was one of the many manifestations of
the generosity of Sir Buckston Browne. Mr. M. F.
Nicholls having ingeniously proposed the Guests, Mr. H. L. -
Eason was led from thoughts of Harvey and the circulation
of the blood to speculations about other circulations—
of the port, of the press, and of London traffic, this last
being sadly impaired by arterio-sclerosis, ischemia, and
clots in all the main arteries, with an occasional coronary
thrombosis near the Bank of England. The next speaker,
appropriately enough, was Mr. Ernest Bevin, whose
feelings about the bus strike caused him to appeal for
closer relations between medicine and industry. He
wished that doctors would take less interest in incidence
and more in causation—that they would act as a look-out
brigade and not postpone action until disease had killed
a large number of people. The new chemical and machine
age, coming so suddenly, had produced a situation in
which all must codperate to find a remedy. There was a
growing desire to bring discovery and practice closer
together, and nowhere was this more necessary than in
medicine. The greatest sufferers from the gap were
the working people: they paid a very large proportion
of their income for medical service and were not quite
getting value for money. There was not yet the right
organisation for getting the right results; the service,
with its long waits at institutions and its failure to include
women and children, was not organised for the present
generation. ‘‘ What I resent more than anything else,”
said Mr. Bevin, ‘‘is the discrimination between those with
one salary and those with another. Why aman should be
classed as proletariat at £5 a week and as lower middle-
class at £5 1s. passes my comprehension.”
Mr. Derek Curtis-Bennett in the final speech of the
evening spoke of what everybody owed—“ not only in
pounds, shillings, and pence ”—to the medical profession.
THE LANCET]
MEDICAL NEWS.—-APPOINTMENTS.—VACANCIES
[JUNE 19, 1987 1499
Dr. Christopher Addison, on whom a peerage was
conferred in the Coronation Honours, has taken the title of
Baron Addison, of Stallingborough in the county of
Lincoln.
Salvation Army Mothers’ Hospital
Lady Baldwin, on June 8th, opened a new isolation
block at this hospital in Lower Clapton-road. The block
cost £8785.
Disposal of the Dead
The sixth joint conference of the National Association
of Cemetery and Crematorium Superintendents and the
Federation of Cremation Authorities in Great Britain will
be held at Torquay from June 28th to July Ist.
West London Hospital
Prince Arthur of Connaught presided at the annual
meeting of subscribers of this hospital and stated that
4441 in-patients were received last year. Maintenance
alone amounted to £65,300. The new buildings are to be
officially opened by Queen Mary on Oct. 18th and will be
named the Silver Jubilee extensions.
St. Thomas’s Hostel for Babies, Kennington
On June 7th Princess Helena Victoria opened the.
new nurses’ home attached to this institution. She also
received purses towards the £6,000 which is the cost of the
building.
Lady Tata Memorial Grants and Scholarships
The trustees of this fund have awarded scholarships
for research in blood diseases, with special referenge to
leukemia to: Dr. Jörgen Bichel (Aarhus, Denmark)
and Dr. Edoardo Storti (Pavia, Italy). They have also
awarded grants for research expenses or for scientific
assistance to the following: Dr. Julius Engelbreth-
Holm (Copenhagen); Prof. Karl Jármai (Budapest) ;
Prof. James McIntosh (London); Prof. Charles Oberling
(Paris); Prof. Eugene Opie and Dr. Jacob Furth (New
York); Dr. Georg Weitzmann (Leipzig); and Dr. Lucy
Wills (London).
British Association of Radiologists
After holding its first annual general meeting at
Birmingham in 1935 and its second at Manchester in 1936
this association came to London for its third annual
meeting which was held on June llth and 12th at the
Reid-Knox Hall, Welbeck-street, under the presidency
of Prof. J. M. Woodburn Morison, The discussions are
briefly reported on an earlier page. On the evening of the
11th some ninety members and their friends dined together
at the Hotel Splendide, Piccadilly ; the diagnostic and
the therapeutic groups were both well represented. In
proposing ‘“‘ The Association,” Mr. S. J. Worsley, acting
principal of London University, spoke of its aim to
combine the conservative outlook of medicine with a
quick adaptation to new ideas. London University, he
said, still had the only chair of radiology in this country,
and its diploma of medical radiology was now a going
concern, some eight of the London school being prepared
to take part in preparing for it.
preside next year when the Association meets in Belfast,
paid a tribute to the previous occupants of the presidential
chair who had done so much to improve the education
and status of the radiologist. He mentioned the decision
to establish a higher diploma and an intention some-
time to found a college of radiology. Dr. R. E. Roberts
(Liverpool) proposed ‘‘The Guests,” mentioning Miss
Skinner who had generously endowed a lectureship,
Sir Cuthbert Wallace, who was president of a college
on whose regulations for the fellowship the Association
had moulded its own, and Dr. Lysholm of Stockholm,
who was not only the fountain head of radiology in Sweden,
but also an expert yachtsman and engineer. Sir Walter
Langdon-Brown, in replying, suggested possible mottoes
for the Association, amongst them (1) “ What shadows
we pursue,” (2) ‘‘For now we see through a glass darkly.”
The President concluded by giving as an extra toast
‘ Absent Friends,” with a special message to Mr. Thurstan
Holland, prevented by his health from attending. Other
guests present were Mr. Rock Carling and Mr. Dickson
Wright.
- Aberdeen, Rowett Research Institute. —Biochemist, £300.
Dr. R. M. Beath, who will.
Appointments
BAKER, ALFREDA H., M.D. Belf., F.R.C.S. Eng., Temporary
Assistant Surgeon to the Elizabeth Garrett Anderson
Hospital.
BEAUCHAMP, GUY, M.B. Birm., Hon. Physician to the Charter-
house Rheumatism Clinic, London.
BURGE, H., M.B. Lond., F.R.C.S. Eng., Resident Surgical Officer
at King George Hospital, Ilford.
COOPER, H. G. N., B.M. Oxon., F.R.C.S. Eng., Resident Surgical
Officer at the Ancoats Hospital, Manchester.
HI, GLADYS, M.D. Lond., F.R.C.S. Eng., M.C.0.G., Temporary
Assistant Obstetric Surgeon to the Elizabeth Garrett
Anderson Hospital.
IRVINE, DUNDAS, M.R.C.S. Eng., Hon. Anesthetist to the
Charterhouse Rheumatism Clinic, London.
JONES, L. E., M.B. Lond., F.R.C.S. Eng., Resident Surgical
Officer at the Queen’s Hospital, Birmingham.
JONES-DAVIES, T. E., M.A. Camb., M.R.C.P. Lond., Assistant
Medical Officer for Surrey.
JORY, N. A., B.Sc. N.Z., F.R.C.S. Eng., Assistant Aural Surgeon
at St. Bartholomew’s Hospital.
KANE, WINIFRED A., M.R.C.S. Eng., Lady Assistant Medical
Officer for Coventry.
Mackiz, J. R. M., M.D. Aberd., M.R.C.P. Lond., Medical
Registrar at King George Hospital, Ilford.
MoLrL, H. H., M.D. Rome, M.R.C.P. Lond., Hon. Physician to
the Leeds General Infirmary.
ScowEN, E. F., M.D., M.R.C.P. Lond., Assistant Physician
and Assistant Director to the Medical Professorial Unit at
St. Bartholomew’s Hospital.
SHIELDS, CLIVE, B.M. Oxon., Physiotherapist to the Victoria
Hospital for Children, Chelsea.
Princess Alice Memorial Hospital, Eastbourne—The following
appointments are announced :—
Estcourt, H. G., M.B. Lond., F.R.C.S. Edin., Hon. Surgeon ;
HMGUE: A. G., M.D. Aberd., D.P.H., Hon. Assistant Physi-
cian; an
SNOWBALL, L. A. H., M.B., M.R.C.P. Lond., F.R.C.S. Edin.,
Hon. Assistant Surgeon.
Queen Charlotte's Maternity Hospital.—The following appoint-
ments are announced :—
MEEK, EDWARD, M.D. Toronto, L.B. Dubl., Senior Resident
Medical Officer ;
ane? OswaLD, M.R.C.S. Eng., Assistant Resident Medical
cer ;
Evans, E. P., M.R.C.S. Eng., Resident Anesthetist and
District Resident Medical Officer; and
GIBB, ANN, M.B. Edin., Resident Anesthetist.
V acancies
For further information refer to the advertisement columns
Also
Med. Grad. to assist in Research, £35-£45 per month.
Ashton-under-Lyne District Infirmary.—H.S., at rate of £150.
Also Cas. H. S., £180.
Barnsiey, Be Hosp. and Dispensary.—Jun. H.S., also H.P.
each :
Bath, Royal United Hosp.—H.P., at rate of £150.
Bedford County Hosp.—Second H.S., at rate of £150.
Bermondsey Borough.—Asst. Tuberculosis O., £600.
Birkenhead Education Committee.—Asst. School M.O., £500.
err am and Midland Eye Hosp.—H.S., at rate of £130
O :
Birmingham, Queen’s Hosp.—Res. Anesthetist, £70-£100.
Birmingham, Selly Oak Hosp. and Infirmary.—Supt. Matron,
£450. Also Jun. M.O.’s for Hospital, each at rate of £200.
Board of Education.—Medical Officer, £738.
Bolton Royal Infirmary.—Two H.S8.’s, each at rate of £150.
Bolton, Townley Hosp., Farnworth.—Asst. M.O., £225.
Brighton, New Sussex Hosp. for Women.—H.P., £104),
Brighton, Royal Sussex County Hosp.—Cas. H.S., £120.
Bristol Royal Infirmary &c.—Radio-diagnostician (Locum),
at rate of £500.
British Postgraduate Medical School, Ducane-road, W.—Cas. O.,
at rate of £150. oe
British Red Cross Society Clinic for Rheumatism, Peto-place,
N.W.—Hon. Dental Surgeon.
Cambridge, -Addenbrooke’s Hosp.—Res. Anesthetist and
Emergency O., at rate of £130.
Cardiff City Lodge Hosp.—Jun. Res. M.O., £150.
Cardiff, University College of S. Wales and Mon.—Asst. Lecturer
in Dept. of Anatomy.
Carlisle, Cumberland Infirmary.—H.S., at rate of £155.
Cassel Hosp. for Functional Nervous Disorders, Swaylands,
Penshurst, Kent.—Med. Director, £1200-£1500.
Charing Cross Hosp, W.C.—Hon. Orthopedic Surgeon. Also
lin. Asst. to X Ray and Electrotherapeutics
Hon. C
Dept.
Chelmaford Cc.C.—Temporary Tuber. O., £15 per week.
Cheltenham General and Eye Hosp —H.P., £150.
ld and North Derbyshire Royal Hosp.—Res. Surg. O.,
£300. Also H.S., at rate of £150.
1500 THE LANCET] - VACANCIES.—MEDICAL DIARY [JUNE 19, 1937
Coventry and ry Hosp.—H.P., £160, Res. H.S., and W. O ertfi
Cas. On each £15 pa one reed MORT Memorial Sanatorium, Hertford Hill.
Perono, Prince of ‘Wales's Hosp.—Jun. H.S., at rate of
Durham County Hosp.—H.S., at rate of £150.
Eastbourne Royal Eye Hosp., ’ Pevensey- road.—H.S., £100.
Elizabeth Garrett Anderson ’ Hosp., Euston-road, N.W. —Hon.
Asst. Phys. Also H.P. First and Second H.S.’ s, and
Obstet. Asst., each at Tate of £50.
Evelina Hosp. for Sick Children, Southwark, S.E.—H.P., Locum.
£4 4s. weekly.
Exeter, goual Devon and Exeter Hosp.—H.S.,
£15
Federated’ eee States, Central Mental Hosp.—Asst. Med.
u
Gateshead “Mental Hosp., Stannington, Northumberland.—<Asst.
Gloucestar shire Royal Infirmary and Eye Institution.—H.S.
.P., each at rate of £150.
Haifas, Royal Infirmary.—First H.S., at rate of £200.
Herefordshire General Hosp.—Res. Surg. O. and H.P., at rate
of £150 and £100 respectively.
Hospital of St. John and St. Elizabeth, 60, Grove End-road, N.W.—
Res. H.P., at rate of £100.
Hosp. for Sick Children, Great Ormond-street, W.C.—Res. M.O.
for Country Branch, at rate of £200
Hosp. for Tropical Diseases, 25, Gordon- street, W.C.—Ophth. Surg.
Hosp. for Women, Soho-square, W.—Hon. Clin. Assts.
Huddersfield, St. Luke’s Hosp. ——Res. M. O.,
Hull, Beverley- road Institution.—Asst. M.Ò A 0350.
Hull Royal Infirmary.—Second H.P. and H. S. to Ophth. and
Ear, Nose and Throat Depts., each at rate of £150.
Ipswich, East Suffolk, and I ‘pswich Hosp.—Cas. O., H.S. to
Orthopeedic and Fracture Dept., and H.S. to General
Surgeon and Genito-Urinary Surgeon, each £144.
Kettering and District General Hosp.—H.S. and H.P., at rate of
£175 and £150, respectively.
Kidderminster and District General Hosp.—Jun. H.S., £100.
King’s College Hosp., Denmark-hill, S.k:.—Asst. N eurologist.
Leeds, Killingbeck Sanatorium.— Asst. Res. M. O., £250
Leicester Royal Infirmary.—Pathologist (Locum), £10 weekly.
mer poe), Cleaver Sanatorium for Children, Heswall.—Res. M.O.
London Chest Hosp., Victoria Park, E.—Asst. Tuberculosis O.,
at rate of
London University. —Examinerships.
Manchester, Ancoats Hosp.—Cas. O., £250. Also H.S. to Ear,
Nose and Throat Dept., at rate ‘of £100.
Manchester kar Hosp., Grosrenor-square. — Res. H.S., £120.
Manchester Royal Children’ s Hosp., Pendlebury.—Res. M.O. and
Res. H.S., at rate of £150 and £100 respectively.
Manchester Royal Infirmary.—Technical Asst. for Clinical
Laboratory Work, £2
Marie Curie Pi oan 2, Fitzjohn’ s-avenue, N.W.—Asst. Director,
rom
salaries North Riding Infirmary.—Sen. H.S. and
T H.S., at rate of £175 and £140 respectively. -
Middlesex County Council.—Visiting Dental Surg., 2 guincas
per session.
Northampton General Hosp.—H.S., at rate of £150.
North Middlesex and County Hosp., Edmonton.—Asst. M.O.,
a rate of £350. Also Jun. Res. Asst. M. O., at rate of
525
Norwich Infirmary.—Res. Asst. M.O., £350. ;
Norwich, Norfolk and Norwich Hosp. —Gen. H.S., H.S. to
Orthopredic Dept. Also Cas. O., cach £120.
Nottingham General Hosp.—Res. Cas. ’O. and H.S. to Ear, Nose,
and Throat Dept., each at rate of £150.
Oldham Municipal Hosp. —Res. Asst. M.O., at rate of £200.
Oldham Royal Infirmary.—Two H.S.’s. Also Cas. O. and H.S.
to Fracture Dept., each at rate of £175.
LE Prince of Wales's Hosp.—H.S. and H.P., at rate of
£120
Pontefract General Infirmary.—Jun. Res. y O., at rate of £150.
Port of Spain City Council. M.O.H., £800
Preston and County of Lancaster Royal I nfirmary. —Two H.S.’s,
each at rate of £150.
Princess Louise Kensington Hosp. for eare St. Quintin-
avenue, W.—H.S., at rate of £120-£15
Queen’s Hosp. for C hildren, Hackney- ee E.— Additional
Visiting Anesthetist, 1 guinea per attendance.
Queen Mary’s Hosp. for the East End, Stratford, E.—Cas. and
Out-Patient O., at rate of £150. ‘Also Anæsthetist.
Reading, Royal Berkshire Hosp.—H.S. Also Cas. O., each at
rate of £150.
a EU .—H.S. for Ophth. and Ear, Nose, and Throat
epts.
Royal National ‘Orthopadic Hosp.—Two H.S.’s for Country
Branch, each at rate of £150.
St. George’s Hosp., S.JV.—Asst. Physician.
St. Mary's Hosp., W.—Cas. H.P., i rate of £150.
Sheffield Children’s Hosp.— H.S., £10
Sheffield Royal Hosp.—Cas. O., ‘at rate of £150.
Shrewsbury, Royal Salop Infirmary. — Res. H.S., at rate of £160
Smethwick County Borough—sSen. Asst. M. Ò. H., &c., £750.
Also Asst. M.O.H.. &c., £350.
Southampton, Royal South’ Hants and Southampton Hosp.—
Cas O., and Res. Anesthetist and H.S. to Ear, Nose, and
Throat Dept., each at rate of £150.
South Eastern Hosp. for Children, Sydenham, S.E.—Two R.M.0O.’s
each at rate of £100.
Stoke-on-Trent, Burslem, Haywood, and Tunstall War Memorial
Hosp.—Res. H.S., at rate of £175.
Stoke-on-Trent, Longton Hosp.—H.S8., £160.
Sunderland Royal Infirmary. Res. Surg. O., £250. Also Cas. O.,
£150.
Swansea General and Eye Hosp —Ħ.S., at rate of £150.
a Wells, Kent and Sussex Hosp.—H.S. and Cas. O.,
£150.
Weir Hosp., Grove- road, Balham, S.W.— Jun. Res. M.O., €150.
West Ham Mental Hosp., Goodmayes.——Jun. Asst. M.O., £350.
ee ote aca County’ Hosp., Isleworth.—sSurgeon, Grade I,
Westminster Hosp., Broad Sanctuary, S.JV.—Dental Surgeon.
Whipps Cross Hosp., Leytonstone, E.—Asst. Res. M.O., £350.
Willesden General Hosp., Harlesden-road, N. IV.—Cas. O., at
rate of £100.
HOE Royal Hampshire County Jlosp.—HU.S., at rate of
9.
Wolverhampton Royal Hosp.—Hon. Asst. Surgeon and Hon.
Asst. Gyneccologist.
Worksop, Victoria Hosp.—Jun. Res., at rate of £150.
Yiewsley and West Drayton Urban District. M,O:H.,. £125.
Medical Diary
re te
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.
SATURDAY, June 26th.
Orthopedics : provincial meeting in Exeter 145 P.M.,
Demonstration of Cases at the Princess Elizabeth
Orthopedic Hospital.
MEDICO-LEGAL SOCIETY.
THURSDAY, June 24th.—8.15 P.M. (Manson House, 26,
Portland- -place, W.), annual general meeting. Miss
Alice Raven: Prejudicial Assumptions in Poison
e Cases.
BRITISH PSYCHOLOGICAL SOCIETY.
Medical Section.
WEDNESDAY, June 23rd.—8.30 P.M. (11, Chandos-street,
W.), Dr. J. L. Halliday: The Approach to Asthma.
LECTURES, ADDRESSES, DEMONSTRATIONS, &c.
NATIONAL COUNCIL FOR MENTAL HYGIENE.
TUESDAY, June 22nd.—3 P.M. (26, Portland-place, W.),
annual general meeting. 4.30 P.M., Dr. Henry Yellow-
lees: Mental Hygiene in the Home.
AA ODAL TEMPERANCE HOSPITAL, Hampstead-road,
THURSDAY, June 24th.—9 P.M., Sir Arthur MacNalty:
The Doctor in Politics and Diplomacy.
BEITIRA POSTGRADUATE MEDICAL SCHOOL, Ducane-
road, W.
TUESDAY, June 22nd.—4.30 P.M., Dr. D. Hunter :
tional Diseases.
WEDNESDAY.—12 noon, clinical and pathological con-
ference (medical). 2 P.M., Mr. E. J. King, Ph.D. : Carbo-
hydrate Metabolism and Diabetes. 3 P.M., clinical
and pathological conference (surgical).
THURSDAY.—?2.15 P.M., Dr. Duncan White: Radiological
Demonstration. 3 P.M., operative obstetrics.
FRIDAY.—3 P.M., clinical and pathological conference
(obstetrics and gyneecology).
Daily, 10 A.M. to 4 P.M., medical clinics, surgical clinics
and operations, obstetrical and gy necologica! clinics
and operations.
Occupa-
FELLOWSHIP OF MEDICINE AND POST-GRADUATE
MEDICAL ASSOCIATION, 1, Wimpole-street, W.
Monnay, June 21st, to SATURDAY, June 26th.— Wrst END
HOSPITAL FOR NERVOUS DISEASES, Welbeck-street. W.
Afternoon M.R.C.P. course in neurology CHELSEA
HOSPITAL FOR WOMEN, Arthur-street, SW. All-day
course in gyneecology.—LONDON CHEST Hos SPITAL,
Victoria Park. Wed. and Fri, 6 P.M., M.R.C.P.
course in heart and lung diseases BROMPTON Hos-
Twice weekly, 5 P.M., M.R.C.P. course
PITAL, S.W.
Open only to members of the
in chest diseases.
fellowship.
A FOR EPILEPSY AND PARALYSIS,
ale,
THURSDAY, June 24th.—3 P.M., Dr. Blake Pritchard:
Demonstration.
ST. MARY’S HOSPITAL, W.
TUESDAY, June 22nd.—5 P.M. (Institute of Pathology and
Research), Dr. W. E. Gye: Recent Work on Cancer.
a FOR SICK CHILDREN, Great Ormond-street,
Mr. Eric Lloyd : Spinal
Deformities in Children. 3 ’P. M., Dr. A. Signy : Inter-
pretation of Frecal Bacteriology.
Out-patient clinics daily at 10 A.M. and ward visits at 2 P.M.
SOUTH-WEST LONDON POST-GRADUATE ASSOCIATION.
WEDNESDAY, June 23rd.—12.30 P.M., Visit to Parke,
Davis and Co., Hounslow.
Maida
THURSDAY, June 24th. —2 P.M.,
THE LANCET] i
NOTES, COMMENTS,
KIPLING AND DOCTORS *
By Victor Bonney, M.S.
No writer has depicted the technical and spiritual
aspects of medicine so understandingly as Rudyard
Kipling, and therein medical men are in debt to him
for ever. Unlike the problems of other callings those
presented to the doctor, concerned as they are with
the shifting phenomena of life, are contained in no
fixed framework of laws whereby they may be
measured and solved, so that for an outsider to
conceive and don the mental response to them
requires not only great imagination but profound
observation and thought as well. Kipling’s under-
standing is assignable, firstly, to that insatiable
craving for inner knowledge which was so striking
a part of his nature and which compelled him to
observe minutely and study the details of every sort
of work; and secondly, to his power of vision which
perceived in all work a spiritual significance far greater
than the work itself. He himself has described to us
how in his earlier days he was by force of circum-
stances brought into intimate relation with men of
many varied callings :
“and in that Club and elsewhere I met none but picked
men at their definite work—Civilians, Army, Education,
Canals, Forestry, Engineering, Irrigation, Railways,
Doctors and Lawyers, and each talking his own shop.
It follows then that the show of technical knowledge for
which I was blamed later came to me from the horse’s
mouth—even to boredom.”’
But medicine had, I think, a special attraction for
Kipling, probably because its subtle problems
challenged his deeply inquiring mind. In “ Something
of Myself’? two doctors have specific mention,
Dr. Conland, ‘‘the best friend I made in New
England,” and the late Sir John Bland-Sutton with
whom, as readers of the biography will remember,
Kipling pursued an unwilling cock to verify the
workings of its gizzard. Bland-Sutton was a very
remarkable person, avid for the acquirement of
knowledge, especially if the knowledge concerned
matters odd and unthought-of, and he was moreover
gifted with the faculty of viewing things from an angle
quite different from that used by the ordinary man.
He possessed, in short, the very type of mind to
interest and attract a mind like Kipling’s, and an
old-standing and intimate friendship subsisted between
them. He is introduced as Sir James Belton into the
story “‘ The Tender Achilles.”
“ In the*few precisely articulated words one could see
Sir James himself—his likeness in face and carriage to the
hawk-headed Egyptian god, the mobile pursed lips and
- the stillness of the wonderful hands at his sides.”’
The portrait is quite unmistakable to those who
knew this famous surgeon. The “St. Peggotty’s ”
of the tale is the Middlesex Hospital, to which
Bland-Sutton gave a fully equipped pathological
institute. His bust stands in the museum which
forms a part of it, and underneath the bust is this
epitaph written by Kipling.
* Abridged fom a paper read before the Kipling Society on
June 15th, 1937
[JUNE 19, 1937 1501
AND ABSTRACTS
JOHN BLAND-SUTTON
A SEEKER AFTER KNOWLEDGE THAT SHOULD
AVERT OR MITIGATE PAIN
Labouring throughout life to this end,
he gave greatly of his substance that
the search should continue in this place.
His Knowledge of Medicine
Evidences of Kipling’s knowledge of the technical
side of medicine are numerous. For instance, from
“The Spies’ March,’ which deals with medical
men in relation to infectious disease, take the follow-
ing verse:
“ Go where his pickets hide—
Unmask the shape they take,
Whether a gnat by the waterside,
Or a stinging fly in the brake,
Or filth of the crowded street,
Or a sick rat limping by,
Or a smear of spittle dried in the heat,
That is the work of a spy! ”
In “A Deathbed ” the last two lines of the first
verse accurately describe the outward signs of
malignant disease of the throat or tongue: °
“ This is a gland at the back of the jaw,—
And an answering lump by the collar-bone.”
Witness his reference to bacteriology in “ A Trans-
lation.”
“ Some cultivate in broths impure
The clients of our body—these
Increasing without Venus, cure
or cause, disease.”
In ‘‘ Marklake Witches” one of the characters is
René Laennec, the French physician who by his
invention of the stethoscope laid the foundation
of our knowledge of diseases of the heart and lungs.
René in the story is a prisoner of war on parole and
Philadelphia tells Dan and Una how she watched
René demonstrating his “little wooden trumpet ”’
to Jerry, the local seller of charms and cures. Jerry
listening to René’s chest says:
“ But unless I’ve a buzzin’ in my ears Mosheur Lanark
you make much about the same kind of noises as old
Gaffer Macklin, but not quite so loud as young Copper—
It sounds like breakers on a reef, a long way off. Com-
prenny ?” “ Perfectly ” replies René, ‘I drive on the
breakers. But before I strike I shall save hundreds,
thousands, millions perhaps, by my little trumpets.”
The earliest stethoscopes were made of wood and
were shaped like a short trumpet. Jerry’s picturesque
simile exactly describes ‘‘ tubular preatuing,’ and how
fine is René’s reply !
But the fullest example of the accuracy of his
medical knowledge is to be found in “The Ballad
of Boh Da Thone’’—You remember:
“ Boh Da Thone was a warrior bold ;
His sword and his rifle were bossed with gold,
And the Peacock Banner his henchmen bore
Was stiff with bullion but stiffer with gore.
He shot at the strong and he slashed at the weak
From the Salween scrub to the Chindwin teak :
He crucified noble, he sacrificed mean,
He filled old ladies with kerosene ! ”’
He is pursued by Captain O'N eil of the Black
Tyrone :
“ And his was a company seventy strong,
Who hustled that dissolute chief along.”
1502 THE LANCET]
O’Neil and his men eventually overtake him:
“ And at last they came when the Daystar tired,
To a camp deserted—a village fired,
A black cross blistered the morning-gold,
But the body upon it was stark and cold.
The wind of the dawn went merrily past,
The high grass bowed her plumes to the blast.
And out of the grass on a sudden broke
A spirtle of fire, a whorl of smoke—
And Captain O’Neil of the Black Tyrone
Was blessed with a slug in the ulna bone—
The gift of his enemy Boh Da Thone.”
Now mark Kipling’s medical knowledge : '
“ Now a slug that is hammered from telegraph wire
Is a thorn in the flesh and a rankling fire.”
The wound suppurates as it would be sure to do.
“ The shot-wound festered—as shot-wounds may
In a steaming barrack at Mandalay.
The left arm throbbed and the Captain swore
‘Td like to be after the Boh once more!’ ”
Septic fever supervenes and he becomes delirious :
“ The fever held him—the Captain said
‘I'd give a hundred to look at his head!’ ”
Babu Harendra hears him and hankers for the
rupees but is too cowardly to attempt to earn them.
The Captain is invalided, goes to a hill-station and
takes him a wife:
“« And she was a damsel of delicate mould,
With hair of sunshine and heart of gold,
And little she knew the arms that embraced
Had cloven a man from the brow to the waist.
And little she knew that the loving lips
Had ordered a quivering life’s eclipse,
Or the eye that lit at her lightest breath
Had glared unawed in the Gates of Death.
For these be matters a man would hide,
-As a general rule from an innocent bride.”
Meantime Babu Harendra is wending his way in the
rearmost cart of the Government bullock train when
the Boh and his followers attack the convoy. There
is a fierce fight with the escort :
“ But Fate had ordained that the Boh should start
On a lone-hand raid on the rearmost cart,
And out of that cart, with a bellow of woe
The Babu fell—flat on top of the Boh!
For years had Harendra served the State,
To the growth of his purse and the girth of his pé
There were twenty stone, as the tally-man knows,
On the broad of the chest of this best of Bohs.
And twenty stone from a height discharged
Are bad for a Boh with a spleen enlarged..
Oh! short was the struggle,—severe was the shock—
He dropped like a bullock—he lay like a block ;
And the Babu above him, convulsed with fear,
Heard the labouring life-breath hissed out in his ear.”
Repeated attacks of malaria cause great enlarge-
ment of the spleen, and a large proportion of the
natives of malarial districts are so affected. This is
a perfect picture of extensive rupture of the spleen
with severe internal hzmorrhage causing rapid
death. Harendra then hacks off the head of the Boh,
- and sends it in a packing-case to O’Neil with the
finest example of a Babu’s letter ever rendered into
verse, asking for the rupees. The case arrives at
breakfast time :
“Their breakfast was stopped while the screwjack and
hammer
Tore wax cloth, split teak-wood, and chipped out the
dammer ;
Open eyed, open mouthed, on the napery’s snow,
With a crash and a thud rolled—the Head of the Boh! ”’
NOTES, COMMENTS, AND ‘ABSTRACTS
[JUNE ‘19, 1937
O’Neil’s wife who is with child four months (this
is very cleverly expressed) is terribly shocked and
faints. From time immemorial it has been believed
that impressions strongly stamped on the mind of a
pregnant woman may imprint a physical simulacrum
on the child, and at intervals cases are reported in the
medical journals lending colour to the belief, as for
instance, when a woman frightened by a one-armed
man brings forth a child with congenital absence
of an arm. In this instance the child is born with a
superficial birth-mark, or congenital nevus, on its
shoulder, resembling the contour of the Boh’s head.
‘ And this is a fiction ? No, go to Simoorie
And laok at their baby, a twelve-month old Houri,
A pert little Irish-eyed Kathleen Mavournin—
She’s always about on the Mall of a mornin’—
And you'll see, if her right shoulder-strap is displaced,
This : Gules upon Argent, a Boh’s head, erased! ”
As in heraldry “ gules ” means red and ‘“ argent”
white, the description of the red birth-mark against
the child’s white skin is very apt. The term ‘ erased ”
is also used in heraldry where an object, such as
a head, is separated from the body it belongs
to leaving a jagged edge, and the Boh’s head was
so separated. But Kipling also intended the word
to be interpreted in a second sense. At the time
the poem was written these birth-marks were usually
treated by obliterating or erasing them by electrolysis,
and because the position of this one would render it
specially unsightly electrolysis would have been
almost surely carried out. It is a good example of
Kipling’s genius for playing on the double meaning
of a word and blending the parlances special to two
apparently unrelated subjects.
_ His Conception of the Doctor’s Duty
The dominant force that lies behind medical work is
often ascribed to conscious benevolence, whereas it is
something quite different. Medicine disciplines its
followers—not by order or drill as a regiment discip-
lines its men, but by the power of its traditional
aims. The result, however, is the same—an automatic
habit of thought and action which continues to work
long after conscience and courage have gone by the
board; and the doctor who struggles out of his
sick-bed to see a patient far less ill than himself;
or from an island shieling to the boat bound for the
mainland, carries in his arms a case of typhus; or
allows a mosquito known to be infected with yellow
fever to bite him, in order that the disease may be
further studied, is embarrassed when his deed is
lauded on the score of humanity and courage. He
knows that its mainspring is a habit of duty, so long
engrained, that it has become subconscious. This
and the nature of the experiences through which
the doctor’s mentality is attained were well known
to Kipling, as the following unpublished verse shows :
“< Such as in Ships and brittle Barks
Into the Seas descend,’
They see the glories of the Lord
And wonders without end.
But such as heal the sick and maimed,
Do meet more manifold
Amazements, in one midnight watch,
Than all the oceans hold.”
You will observe that he quotes the first two lines
from a previous poem of his.
In 1908 he delivered an address to the students of the
Middlesex Hospital which in eloquence and under-
standing is by far the finest appreciation of the
medical profession ever written, and almost every
SETTER:
THE LANCET]
NOTES, COMMENTS, AND ABSTRACTS
[JUNE 19, 1937 1503
sentence of it might be used as a text on which to
found a dissertation. He described doctors as:
“Your permanently mobilized army which is always
in action, always under fire against Death.”
and whose business is:
“to make the best terms you can with Death on our
behalf ; to see how his attacks can best be delayed or
diverted, and when he insists on driving the attack home,
to take care that he does it according to the rules of
civilized warfare.”
The same conception of the doctor’s function recurs
in the following unpublished verse written, I believe,
many years afterwards:
‘‘ Man dies too soon, beside his work half planned.
His days are counted and reprieve is vain.
Who shall entreat with Death to stay his hand ;
Or cloke the shameful nakedness of pain?”
The last line is very wonderful. The speech went
on to recite the obligations of the profession :
“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,”
and then its privileges :
“If you fly a yellow flag over a centre of population
you can turn it into a desert. If you choose to fly a
Red Cross flag over a desert you can turn it into a centre
of population towards which, as I have seen, men will
crawl on hands and knees.”
You must remember that the South African War
was only six years distant. He ended thus:
“ I do not think I need stretch your patience by talking
to you about the high ideals and lofty ethics of a pro-
fession which exacts from its followers the largest responsi-
bility and the highest death rate—for its practitioners—
of any profession in the world. If you will let me, I will
wish you in your future what all men desire—enough
work to do, and strength enough to do the work.”
What finer wish could be uttered to an audience
of young men ?
Of all doctors, those who devote themselves to
research are, I think, the highest type, for not only
are the rewards small, but years of strenuous thought
and labour may be expended only to find that the
path followed to seek for knowledge leads nowhere or
comes to a blind end. Kipling has voiced this as only
he could voice it: these are the lines, unpublished
as yet:
“ Send here the bold, the seekers of the way—
The passionless, the unshakeable of soul,
Who serve the inmost mysteries of man’s clay,
And ask no more than leave to make them whole.”
The interest Kipling took in medicine covered not
only its present but its past and its future. In ‘ Our
Fathers of Old” he sings of the ancient physician-
astrologers :
“ Yet when the sickness was sore in the land,
And neither planets nor herbs assuaged,
They took their lives in their lancet-hand
And, oh, what a wonderful war they waged!....
None too learned, but nobly bold
Into the fight went our fathers of old.”
These held that the universe and all it contains is
one in ultimate essence and that happenings in the
whole are reflected in the individual man who forms
a part of it. In the address that he gave to the Royal
Society of Medicine in 1928 he dwelt on this doctrine
and, looking into the future, said: .
“ Is it then arguable that we may still mistake secondary
causes for primary ones, and attribute to instant and
visible agents of disease unconditioned activities, which
e
in truth, depend on some breath drawn from the motion
of the universe,—the entire universe, revolving as one body
(or dynamo if you choose) through infinite but occupied
space ? The idea is wildly absurd ? Quite true. But what
does that matter if any fraction of an idea helps towards
mastering even one combination in the great time-locks
of Life and Death.”
In the labyrinth of knowledge through which we
thread our way science has already unlocked many
doors, but a myriad remain through which we must
pass, and who shall assert where or where not we may
come to at last ?—-No doctor.
OVERFEEDING AND PROTEIN METABOLISM
A GROUP of workers at the institute of physiology
of Glasgow University have recently recorded the
results of experiments designed to throw light on two
important points—the effects of overfeeding on
metabolism and the relative values, to human adults
and ‘“‘ young people,” of the proteins of boiled and
raw milk.:
In 1904 Chittenden of Yale startled physiologists
with his ‘‘ Physiological Economy in Nutrition,”
in which he maintained that the 15-18 grammes
of nitrogen or 100 g. of protein considered by Voit
and other early workers to be a minimum daily
requirement was in fact very much more than was
needed for the repair of waste tissues, and that the
excess, although the non-nitrogenous part was
available for energy requirements, mainly passed
‘from organ to organ, or from tissue to tissue, on
the way to elimination, and we can fancy that liver
and kidneys must at times rebel at the excessive
labour they are called upon to perform.”’
The method of experiment adopted in Glasgow by
Dr. Cuthbertson and his six fellow subjects who
varied in age from 19 to 35 and in weight from 56 to
87 kg. (under 9 st. to 14 st.), was to reach a stable
output of urinary nitrogen on a self-selected basal
diet of white and brown bread, 100 g. of fresh butter,
cheese, 500 ml. raw milk, apple jelly, and raw apples.
The water intake was kept constant. Some subjects
received lettuce and tomato in addition. The daily
protein intake varied from 0°82 to 1°21 g. per kg. of
body-weight, and the calories supplied from 34 to 52
per kg. A stable condition having been reached, the
excess ration was superimposed; it consisted of
either 1000 ml. of raw or boiled milk, or in a further
series, beef, lactose, and butter, with water, this
being dissimilar from the milk supplement only
in the nature of the protein. An attempt to use a
soya preparation as source of extra protein was closed
after five days because of difficulty in consuming it.
All seven subjects showed a large retention of both
nitrogen and sulphur after taking the extra food.
The difference between raw and boiled milk was not
significant, either after a one-day surfeit or after a
surfeit prolonged for eight days (two subjects only).
Subject 5, in the longer experiment, showed decreas-
ing retention as the experiment progressed. As he
was 35 years of age he may be presumed to have
finished growing, but his younger companion, who
was only 19, seems to have made permanent use of
the extra protein. A substantial, but less, retention
of nitrogen was observed with beef and with the
soya-bean preparation. It is worth noting that the
calcium retention was, for raw or boiled milk, only
about 6 per cent. of the excess ingested, and the
authors point out that their experiments have no
reference to the general merits of raw and boiled milk,
but only to the relative retention of protein from
them.
Further experiments were directed to making clear
the relative protein-saving effect of fat and carbo-
hydrate. It is obvious that the thermostatic and
work-output requirements of the body can only be
eee Ne ee ee eee ke
1 Cuthbertson, D. P., McCutcheon, A.,and Munro, H.N.
ary Biochem. J. 31, 681; Cuthbertson and Munro, Ibid,
p. 694. i
1504 THE LANCET]
met by the provision of combustible material. Fats,
carbohydrates, and proteins will all burn, and there
is some ground for the view that intake of protein
might be reduced to that required for repair of wear
and tear in the body or that amounts above this
might be retained for future use, if either fat or
carbohydrates were supplied in greater amount than
is required to maintain body-weight. Apparently
the only work showing the relative effect of addition
of fat and carbohydrate to an apparently adequate
diet is that of Voit in 1869. The present authors
find that the effect of carbohydrate in sparing already
metabolised protein is about half as much again as
that of fat, but it seems that fat was more readily
acceptable.
These investigations carried out on and by human
subjects who chose and thrived on a basal diet on
which they reached equilibrium are of greater value
to the dietitian than similar experiments on the
lower animals which have to make the best of what
they can get and whose nervous systems are less
affected by fads or idiosyncrasies. The diets chosen
are hardly typical of the food of people—certainly
not of medical students—in these islands and the
subjects were few. The only exercise they took was
short and fairly uniform walks which may partly
account for the rather low diet which satisfied them.
Allowing these criticisms, the important fact is
established that the human system can, when circum-
stances permit of a rather fuller meal than usual,
store for future use some of the extra ‘‘ goodness ”
taken in. Further, if one cannot afford extra first-
class protein one may do well to take extra fat and
carbohydrates ; in fact, a lot can be done by eating
bread and butter. The stored nitrogen may be
distributed over the body, but Cuthbertson and his
collaborators incline to think that much of it is kept
in the liver.
AN ADJUSTABLE BED-CUSHION
THE Dunlop Rubber Co., Ltd. (Cambridge-street,
Manchester), now make an adjustable bed-cushion
from their Dunlopillo material. It is shaped like a
thick wedge but can be bent in the middle so that
LEG REST
the thicker end of the wedge is doubled in thickness.
The accompanying drawings show the cushions used
as a bolster (opened out flat) and as a head-rest
or leg-rest (one half folded laterally on the other).
Dunlopillo cushioning is firm but soft as a support
and is described as porous, self-ventilating, moth-proof,
and dustless. The bed-cushion is 3 feet wide (unfolded).
HOLIDAYS FOR WORKING WOMEN
THE following letter reaches us from the Women’s
Holiday Fund: ‘‘ May we once more appeal to those
now enjoying all the delights a holiday brings, on
behalf of the working women of London living in
crowded homes and noisy streets, among dingy
surroundings? A short respite from monotonous
drudgery and the struggle to carry on in the face of
almost overwhelming odds would bring fresh courage
and health to many a tired and harassed wife and
mother. But the so much needed holiday is beyond
her reach, even though at times the longing ‘to
get right away’ becomes unbearable. The narrow
margin of money for the necessities of life in thousands
of poor homes does not allow of such a luxury as a
fortnight’s holiday. Even by dint of saving a small
sum weekly the cost is beyond the means of most.
BIRTHS, MARRIAGES, AND DEATHS
[JUNE 19, 1937
Last year through the help of the Fund, which was
founded 42 years ago, 1400 women obtained seaside
holidays—over 700 took with them babies or small
children (under 5 years of age). The society has now
two homes of its own for mothers and babies, at
St. Leonard’s and Littlehampton, and in addition
makes use of other suitable seaside homes and
lodgings. . . . The society is making every effort
not only to maintain its existing work but to extend
it. An urgent appeal is therefore made for donations
- {however small), so that a still larger number of
weary women. may have the refreshment of a holiday
by the sea. Two pounds will pay for a mother and
baby for two weeks.”
The appeal is signed by the Bishop of London,
the Dowager Countess of Leven and Melville, Sir
George Blacker, The Rev. Father Devas, The Rev.
J. Scott Lidgett, and Mrs. Alfred Loder, chairman
of the executive committee. Donations should be
sent to Miss Cooper, Denison House, Vauxhall
Bridge-road, S.W.1.
A REVISED LIBRARY CLASSIFICATION
THOSE who regard the international decimal
classification as inadequate for medical libraries, and
yet hesitate to add to the numerous existing systems
by inventing one of their own, will doubtless welcome
the second edition of the classification used in the
Vanderbilt University Medical Library.' It was
originally intended for the documentation of a large
collection of reprints, a purpose which the inter-
national system might have served equally well. As
revised for use on the general medical library, how-
ever, this classification certainly has merits, though in
many ways C. C. Barnard’s scheme? seems preferable.
An important and new feature is the comprehensive
index with over 2000 entries, but the value of this
has been considerably reduced by the maze-like
collation of the indexed pages,
Births, Marriages, and Deaths
BIRTHS
FLEW.—On June 10th, at Heath-strect, Hampstead, N.W.,
the wife of Dr. J. D. S. Flew, of a daughter.
GAYvus.—On June 10th, at a nursing-home in London, to
. Dr. Irene Kenworthy Gayus—a son and daughter.
SOPER.—On June 7th, at High Wycombe, Bucks, the wife of
Flight-Lieut. R. L. Soper, R.A.F. Medical Service, of a
daughter.
SPICER.—On June 3rd, at Kampala, Uganda, the wife of Dr.
J. R. Spicer, of a son.
MARRIAGES
GAWNE—SVOBODOVA.—On June 12th, at St. Mary's, Cadogan-
gardens, Douglas W. C. Gawne, M.B., to Anna Maria
Svobodova, daughter of Ladislav Svoboda, of Popovic,
Czechoslovakia.
MORTON—WOODHEAD.—On June &th, at St. Ethelburga's,
Bishopsgate, Harold James Storrs Morton, M.D.. to N ancy
Sybilla Vincent Woodhead, of Aldbury, Herts.
NEwTON-DAvVIES—WHITTAKER.—On June 9th, at the Priory
Church of St. Bartholomew-the-Great, London, Lieut.-Col.
C. Newton-Davis, M.C., I.M.S., to Mrs. Kathleen Mary
Whittaker, widow of Squadron Leader J. T. Whittaker,
M.C., R.A.F., of Belfast.
WILLIAMS—CROCKER.—On_ June 10th, at Parkstone, Hugh
Morgan Williams, F.R.C.S., to Jean Esmé Crocker, of
Parkstone.
DEATHS
CoGan.—On June 9th, at Northampton, Lee Fyson Cogan,
J.P., M.R.C.S. Eng., L.R.C.P. Edin., in his 89th year
COLLINSON.—On June 9th, at Preston, Frederick Wiliam
Collinson, M.D., F.R.C.S. Edin., in his 34th year
DAvVIDSON.—On June 12th, at Guildford, George Edward
Davidson, M.B. Camb., of Shere, aged 59
RIDLEY.—On June 8th, at Leicester, Nicholas Charles Ridley,
R.N. (retd.), M.B. Lond., F.R.C.S. Eng.
WALDMEIER.—On June 2nd, in London, Jobn
Waldmeier, L.S.A. Lond., M.R.C.S. Eng.
N.B.—A fee of 1s. 6d. is charged for the insertion of Notices of
Births, Marriages, and Deaths.
Frederick
1 A Classification for Medical Literature. Second edition. By
Eileen R. Cunningham. Nashville, Tenn. : Cullom and Ghertner.
1937. Pp. 104. $2.00.
2 See Lancet, 1936, 1, 961.
THE LANCET]
[JUNE 26, 1937
ADDRESSES AND ORIGINAL ARTICLES
A STUDY OF CRETINISM IN LONDON
WITH ESPECIAL REFERENCE TO MENTAL DEVELOP-
MENT AND PROBLEMS OF GROWTH
By Ausrey Lewis, M.D. Adelaide, M.R.C.P. Lond.
CLINICAL DIRECTOR AND LECTURER IN PSYCHIATRY, MAUDSLEY
HOSPITAL, DENMARK HILL, S.E.
With the assistance of .
NANCY SAMUEL, B.A., Dip. Psych. Lond.
LATE PSYCHOLOGIST AT THE HOSPITAL; AND
JANET GALLOWAY, M.A. Edin.
LATE RESEARCH PSYCHIATRIC SOCIAL WORKER AT
THE HOSPITAL
THE following investigation was undertaken for
the purpose of studying the psychological effects of
thyroid deficiency in childhood, and what benefit
substitution therapy provided for the mental retarda-
tion. As the material accumulated other questions
presented themselves (chiefly concerned with growth),
and led to some alteration in the intended method of
presentation.
METHOD OF ASCERTAINMENT
For the first problem mentioned above, it was
desirable to examine patients who had definite
retardation: a search was therefore made in the
institutions for mental deficiency. The permission
of the medical superintendents* of Leavesden, Darenth,
The Manor, The Fountain, Caterham, and Tooting
Bec Hospitals made it possible to examine all the
patients diagnosed as “‘ cretins ” in these institutions
for defectives, conducted by the London County
Council. As they represented a population selected
for defect, it was impossible to use them for an
assessment of the beneficial results of treatment.
By the coöperation of a number of physicians,
attached to voluntary hospitals, a collection of cases
diagnosed as “cretin” or “juvenile myxcdema’”’
was obtained, which was not open to this objection.
The bulk of the cases from voluntary hospitals came
from two sources—the London Hospital and
St. Thomas’s Hospital. The latter were out-patients
—23 of them—whom Dr. H. Gardiner-Hill put at our
disposal for this investigation. The records of the
London Hospital, when searched through for the last
thirty-five years, yielded the names of 40 in-patients
in whom the diagnosis of juvenile myxcdema or
cretinism had been made. Besides the patients
from St. Thomas’s and the London, and those found
in the mental deficiency institutions of the L.C.C.,
others, less systematically collected, were got from
various out-patient departments (King’s College,
The Queen’s, Hackney-road, Paddington Green, and
the Maudsley MHospitals).* The Central Associa-
tion for Mental Welfare was also approached ; they
supplied a list of patients, some of whom were available
for examination, It was not possible to be sure that
one had, by the above means, obtained a good sample
of all those in London who have suffered from thyroid
deficiency during childhood, but it seemed possible
that the collection would include most varieties of
course and treatment, as well as of severity of illness.
In all, 145 cases were collected of whom 89 were
examined. The remainder were either dead (6 cases),
*We would like to record our warm thanks to the many
hysicians who so kindly made records and patients available
o us.
5939
or unavailable for physical and psychological examina-
tion; in some of these latter, where the diagnosis
had been beyond question, details of their family
history, personality, &c., were obtained. Ten of the
cases examined were rejected because the diagnosis
was doubtful or definitely. erroneous.
The ages of the cretins tested ranged from 3 to 58:
eleven were 12 years old or less, twenty-three were
more than 12 and less than 21 years old, fourteen
were in the next decade (21—30), seventeen between
31 and 40, twelve between 41 and 50, and two were
over 50.
INVESTIGATION
The patients were examined physically ; they were
inspected, the texture of the skin felt, and measure-
ments, chiefly of height and hand dimensions, made,
In 35 cases the impedance angle was measured by
Mrs. M. A. B. Brazier, Ph.D., at the Maudsley
Hospital. A psychological examination was made
in detail by one of us (N. S.}: the Binet-Simon test
was applied; where the degree of deficiency was
very great, the Merrill-Palmer and the Gesell methods
of assessing intellectual development were used
instead. The Goddard form board, the Woodworth-
Wells substitution test, and manikin, vocabulary, and
reading and writing tests were also employed. The
general demeanour of the subject and his attitude
towards the examination were recorded and particular
note taken of the speed of his performances—e.g.,
in tying a bow, and carrying out the Goddard form
board test. Fuller inquiries were also made by one of |
us (J. G.), who visited the homes of the patients,
and obtained from the relatives a detailed history
which, together with the hospital records, gave a
fairly complete picture of the patient’s personality
and development. The family history was also
investigated. The condition of the mother in preg-
nancy, the type of birth, weight at birth, history
of fits in infancy.and childhood, ages of sitting up,
walking, talking, teething, and the attainment of
clean habits and of sexual maturity were among the
data collected. Details of speech, as regards quality
of voice, mispronunciation, and extent of voluntary
usage of speech were also noted. Consideration of
many of these details must be excluded here for want
of space.
PHYSICAL FEATURES
The familiar signs of the condition were found to
be present in differing degrees and combinations.
Some of the cases were as typical as the illustrations
in text-books; others had a characteristic face,
skeleton, and gait, but their skin and hair were
normal, Those who presented difficulty in diagnosis
were either free from nearly all the recognised
physical features of the condition, or might have been
cases of mongoloid deficiency.. As regards the latter,
in only one instance was there still doubt after care-
ful examination; the balance of evidence favoured
mongolism, The former, physically negative, cases,
however, raised a difficult problem: were they to be
included on the history alone? Inasmuch as some
other cases, which had been previously diagnosed as
“ cretins,’’ were rejected after investigation—e.g., one
was found to be a hydrocephalic idiot—it seemed partial
to accept all these without present evidence of the
condition. On the other hand, to exclude them would
be to eliminate any case in which treatment had been
entirely effective in clearing up the symptoms. A
scrutiny of the hospital records written when the
patient was first seen, and a detailed history from
co
1506 THE. LANCET]
the parents, made it possible to include these cases—
except a case of adult myxedema. It: may be
reasonably concluded that ,all of the patients upon
whom the following report is based had at some time
in their childhood shown recognisable symptoms of
thyroid deficiency. | o
The hope of correlating amount of treatment with `
persistence of physical signs proved vain. Except
for skeletal changes, the physical features cannot
be measured, and are difficult even to rank in order
of severity. The amount and continuity of treat-
ment with thyroid can rarely be measured. Such
data are therefore unsuitable for statistical analysis.
There were other difficulties, which are discussed
below in connexion with the effect of treatment and
mental development. Such crude comparisons as
could be made between treatment and disappearance
of physical signs are given below, as well as the data
concerning stature (see Table). It was found easier
to compare physical measurements with mental
measurements than to compare either with amount
of treatment. l
MENTAL FEATURES
Text-books give meagre descriptions of the mental
changes due to thyroid deficiency in early childhood.
Slowness is the characteristic insisted on. Still
says: “‘Slowness of the mental processes is the most
distinguishing mental feature of the cretin. ... In
temper he is usually amiable and placid, not to say
stolid. He acquires clean habits, and is not
destructive.” There is moreover some disagreement
as to the effect of adequate treatment on mental
development. Fordyce says, for example, that if
careful treatment is commenced early and. con-
scientiously continued, the children at the best may
become indistinguishable, physically and mentally,
from normal children—a view held also by Cockayne
and by John Thomson—whereas Still, on this point,
says that “when the educational attainments of
even the best of them are inquired into, they are
obviously below the normal . . . some cases are
reported to have become perfectly normal, but I
think this must be very exceptional.” Many
authorities agree with Still—e.g., Petterson, and Kim-
ball and Marine. All writers hold that the mental
improvement is seldom as satisfactory as the physical ;
spasticity is regarded as an ominous sign (cf. Rolleston).
Some Austrian and Swiss investigators have gone
more fully into the mental characteristics of cretins.
The endemic form has been the more fully studied and
reported in systematic treatises, because of the large
material available. De Quervain gives a lively
account, tallying with those of other writers. He
stresses the slowness of the cretins, their conservatism
and need for security, their good memory for places,
their tendency to collect and hoard, to imitate
others, and to like praise. They dodge trouble,
love eating, and show little emotion, except when
they have rare and brief outbursts of rage or brood
discontentedly. As Maffei pointed out, they are by
no means incapable of learning and reasoning, or of
utilising general concepts. But such observations
cannot be taken as applying necessarily to the sporadi¢
cages of cretinism under consideration in this paper.
De Quervain, though he does not go as far as Zondek,
draws a distinction between the two forms, and even
describes mental differences between cretins who have
a goitre and those who have not; he also thinks that
many of the more engaging characteristics of the
cretins under his care are those of the Alpine peasants
in general, and are independent of the cretinism,
though somewhat coloured by the cretin’s optimism.
DR. A. LEWIS AND OTHERS: CRETINISM IN LONDON
[JUNE 26, 1937
In the admirably full description given by Gamper
this point is stressed ; the torpidity and other features
of the cretins may be seen in a mild form throughout
the local population. The writers emphasise, more-
over, that no specific features can be found in the
psychic structure and dynamics of cretins which would
make recognition of the thyroid deficiency possible
from the mental state alone; there is a torpor which
is myxcedematous, and a defect, not accessible to
thyroid therapy, which is attributable to arrest of
cerebral development and changes in cerebral structure,
This is also the view of Wagner-Jauregg.
In the literature of sporadic cretinism, very little
is to be found about the details of the mental changes,
Kornfeld, and Lazar and Nobel have made investiga-
tions, but it is doubtful whether the cretinism in
their cases may not have been of the endemic sort.
They found a great delay in the development of
motor functions, such as, grasping, sitting, and
crawling; to this they attributed much of the
apparent mental impairment, since the child had not
the usual early mastery of means of getting at grips
with the environment by his movements, nor, when
he did acquire it, had he the curiosity and other
stimuli to use it. Lazar and Nobel say they know
no case in which treatment has led to complete mental
normality. Kornfeld, who carried out intelligence
tests on a small number of cases, did not find
parallelism between somatic and psychic effects of
treatment, and he emphasised that the deficient
auditory attention, poverty of ideas and associations,
and few volitional acts of the cretin made special
pedagogic training necessary if the best intellectual
improvement was to be attained; by such training
he was able to get improvement in understanding,
reading, and talking. It seems probable, however,
that the benefit from special education here is the same
as that obtained in other forms of mental defect,
whether general or special; it would not be required
if hormone therapy had repaired the intellectual
defect as well as it does the physical: Bronstein
and Brown examined 20 children, and found the
intelligence quotient to be below 70 in all but 2.
Kimball and Marine considered that with adequate
treatment cretins might reach a mental age of eight
years.
In the investigation here reported, a description
of the personality was first arrived at from direct
observation of the patients during examination, and
from detailed discussion of their traits with their
parents, siblings, or others—e.g., nurses and doctors
who knew them well. Often information was obtained
from more than one such source.
The following description of one of the patients
is a typical account of the more striking features of the
personality of these people.
“ She is exceedingly stubborn. When she is not
humoured, or you cross her in any way, she will sit solidly
in a chair for hours sulking. She is very slow to under-
stand, or to do what she is told, however simple it is.
She has no initiative ; you have to tell her to do the same
thing day after day. She rarely speaks of her own accord,
but will sit mum sooner than ask for anything she wants.
She is very particular about being clean and likes to have
all her clothes tidy and fresh. She will do whatever you
want her to if you promise her a reward. She is very pig-
headed, and insists on having her own way in spite of all
reason.”
Slowness was the characteristic most often remarked
upon: it is recorded as a salient feature in three-
quarters of the cases—“‘ painfully slow; no idea of
time, you have to prod her all the time.” Nearly
a third of them were placid, though this depended
THE LANCET]
somewhat on their circumstances; for example,
some who at home had been spiteful and bad-tempered
were contented when they got into the routine of an
institution. It was noteworthy that only 4 of the 79
patients were reported to be of a depressive tempera-
ment: 2 were prone to attacks of excitement, with
transient hallucinations when overdosed with thyroid,
and many flared up if much provoked (‘“‘ when I jawed
at her she would fire up,” as was said by the mother
of one girl, who was mostly content “ to sit like a
block ”). Obstinacy was a frequent trait. Note-
worthy, and little remarked upon by any previous
writers, was the prominence of traits that are more
common in obsessional patients than any others—
excessive care about order and cleanliness, with a
proneness to repeat their behaviour. This was con-
Spicuous in at least a quarter of the cases and was in
contrast to their general indifference and slowness.
Thus one apathetic cretin was described as ‘“‘ most
painstaking and thorough and slow over everything
she does. She must polish the stairs, although she
has been told not to; she polishes an electric switch
in a dark cupboard, although it can’t be seen. She
is always washing herself and her clothes.” A few
others showed related attributes: they were thrifty,
or given to hoarding trifles.
Half of them were fairly sociable or friendly.
Hypochondriacal tendencies and suspiciousness also
occurred, but had little or no relationship to the
cretinism. Most of the patients showed the fore-
going attributes more when they stopped taking their
thyroid tablets. Inquiries about personality were made
in another 18 patients, who were not available for
examination, but whose medical history was that of
unequivocal thyroid deficiency in childhood : of these
no less than 15 were reported to be placid or apathetic,
and 10 showed “obsessional ” traits.
PSYCHOLOGICAL TESTS
The most important feature of the psychological
testing was the estimation of mental age by the
customary Binet method, confirmed. or replaced by
the Merrill-Palmer test in those too low in the scale
to be suitable for Binet testing: in 2 cases the
Gesell method of testing infants was employed. The
120
aos ooo =,
O2OoOOoO oO Oo
O
Intelligence Quotients
=
©
@
GW
O
Speed Ratio (66 Cases)
FIG. 2.—Relation of speed to intelligence in a group of cretins.
= _ Mental age in speed tests __
Speed ratio = mental age in intelligence tests x A100
DR. A. LEWIS AND OTHERS: CRETINISM IN LONDON
40 50 60 70 80 90 100 llO 120 130 140 150 (60
[JUNE 26;'1987 1507
notorious difficulties in ranking adults by a Binet
test would make it desirable to give the scores in
terms of “mental age” rather than intelligence
quotient, but as 10 of the subjects were less than
fourteen years old they could not be included in: such
Number Of Cases
©
AO
atte ge
mo LH Mm ©
“10 20 30 40 50 60 70 80 90 100 110 120
Intelligence Quotients
FIG. 1.—Distribution of intelligence, as measured by tests, in
79 cretins.
a series. It was, therefore, necessary to grade the
subjects according to intelligence quotient. Owing
to the unrepresentative method of selection, it would
‘not be justifiable to compare the frequency curve
of the intelligence quotients in these subjects with
that which is obtained when a true sample of the
average population is tested. It is, however, clear
from Fig. 1 that, although the number of mentally
defective people is high, no less than a fifth of the
subjects had intelligence quotients which fell within
the range of what is usually called “ normal ’’—i.e.,
above 80. Somewhat contrary to expectation there
was in the individual cases no more scattering of suc-
cesses over several years than is usually found when
these tests are given to an average population.
Certain special tests were, however, done better or
worse than they might be by non-cretinous subjects.
As slowness seemed so striking a feature in these
subjects, various tests were specially employed because
speed was a factor taken into account in
scoring them. Of these, the chief were the
Goddard or Seguin form board, the Wood-
worth-Wells substitution test, and the numerous
Merrill-Palmer tests in which time of per-
formance determines the score—e.g., manikin,
matching, cube-pyramid, pink tower, picture
puzzles. By scoring these in terms of mental
age it was possible to compare the speed of
performance with the general level of intelli-
gence. (Fig. 2.) In spite of the incompleteness of
such a method it gives valuable information, con-
firming the clinical impression and showing
that the slowness may be notable in those
whose intelligence quotient is not far below
normal or is actually normal; consequently
such people may, in. school and elsewhere, give
an impression of greater deficiency in intelli-
gence than is actually the case (cf. Ziehen). It
is also evident that slowness in the performance
of intellectual tasks may be greater than that
exhibited in ordinary motility. This is in con-
formity with Kassowitz’s observation that there
may be remarkable improvement in motility
after treatment, but it partly invalidates his
view that the improvement in motility
supplies a measure of the general psychological
improvement, l ;
| 1508 THE LANCET]
The apparent lessening or even reversal of the dis-
parity in some of the cases with low intelligence
quotient is partly attributable to the preponderance,
among intelligence tests at this level, of tests in which
speed is an important factor, and to the figures
employed in scoring and computing the ratio.
Vocabulary tests were also given to the subjects,
and a similar procedure—i.e., comparison between
mental age so estimated and mental age measured by
the customary Binet tests—indicated that there was
a slight superiority in respect of vocabulary over
what is customarily found in non-cretinous persons. |
This is in keeping with the observations of de Quervain.
Few of those with an intelligence quotient below 80
could articulate clearly: they slurred their con-
sonants and in many instances used F for Th, and
other childish mispronunciations. This was more
common in those with severe defect, who also had,
for the most part, husky, gruff voices, and little to say.
The results of the intelligence tests on this sample,
which is not necessarily representative, do not in
themselves indicate more than that some people
who have thyroid deficiency in childhood can become
intellectually quite normal, and that in this disease
every gradation can occur from normality to idiocy.
For fuller use of the findings, it is necessary to com-
pare them with the age of onset of the illness, its
severity, the adequacy of treatment (as to dosage,
continuity, and promptness of administration after
the onset of symptoms), and the other, i.e., physical,
evidences of the disorder now evident. On many of
these points certitude is unobtainable. Still less can
the innate endowment of the affected individuals be
assessed ; it is not unlikely, for example, that a few
of these people might have been of poor intelligence
even if they had not had any thyroid deficiency.
This last problem can best be met by considering the
general level of intelligence in their family, especially
among their siblings. The other points as to the
illness and its adequate treatment have been settled,
as far as was possible, by considering the details of
their illness obtainable from hospital records and their
parents’ recollection, and then grading the cases as
to adequacy of treatment on a five-point scale (see
Table).
FAMILY HISTORY
1. Familial intelligence.—In 14 families there were
one or, rarely, more members (parents or siblings)
who were described as dull or feeble-minded, apart
from cretinism. Of these, only six persons were
certified defectives or imbeciles: in 4 families one
parent was feeble-minded or dull, and in two cases a
collateral was recorded as defective. These data are
of course, not complete, and are given mainly to
indicate that the general level of intelligence may be
assumed to have been average in the majority of the
patients, had they not had thyroid deficiency.
2. Thyroid disorder.—Of the “familial” incidence
of thyroid disease it is not possible to say more
than that, apart from 4 families in which there were
two or more cretins, in five cases a sibling also had
“eretinoid ” features, and in one case a sibling
was hyperthyroid, in another a sister had a goitre ;
two had myxedema. In seven there were sub-
thyroid features in the mother, in four they were
present on the father’s side: in one the mother had
a goitre until the birth of the child, and in another
the mother was hyperthyroid and her mother had had
myxedema. Many of the families were of short
stature, so that there seems a possibility that a
cretinoid constitution may predispose to the illness ;
the data do not warrant a conclusion.
DR. A. LEWIS AND OTHERS: CRETINISM IN LONDON
[JUNE 26,* 1937
3. Familial cretiniem.—One of the 3 families in
which several cretin members were examined ‘is
of interest (see L. H., F. H., and A. H., in Table f).
In this family there were four cretins, the most
severely affected having died when 43 years of age.
Eleven other children had died in infancy of causes
unknown, and three were normal. The mether, an active
woman, was slight in build though not short, but her
features were cretinoid (her nose was flat, the eyes far
apart, and the skin somewhat flabby). None of the
other maternal collaterals nor members of the father's
family were cretinoid or short. In another family with
a brother and sister mildly affected neither the parents
nor any collaterals showed cretinoid features or short
stature. The female patient had been born during
the war, when the mother was very anxious, and
there was a history of fits in the mother’s family.
In the third family (where two brothers were cretins)
the mother had a goitre, which disappeared at the
birth of the elder cretin. There were seven other
healthy children surviving to adult age, all successful
in their work, and of good physique. One is a police-
man. The father was also in the Metropolitan Police,
and came of very healthy stock. One of the cretins’
healthy siblings has, however, a strong facial resem-
blance to the elder cretin.
4. Mental dtsorder.—In 11 families there was a
history of mental disorder (the diagnosis of which
cannot now be determined) ; in 3, one or more siblings
had fits ; in 2, the siblings were deaf or deaf and dumb.
5. External factors—An external factor could
seldom be discovered or held responsible for the
disease: there had been a difficult or prolonged labour
in 20 cases; one patient was syphilitic, another had
had meningitis, It is noteworthy that 12 were
reported as having had one or more fits, but only 2
of these were reported as having been born asphyxiated
or after a difficult labour.
In an additional 18 cases investigated as to familial
incidence of abnormality, there were 4 instances of
fraternal imbecility, 2 of fraternal goitre, 1 of paternal
cretinism,. Late menarche in the mother was found
occasionally here as in the larger group.
AGE OF ONSET
The age of onset can be determined satisfactorily
only by medical records made at the time. Unfor-
tunately, since most of these cases had been seen as
out-patients, their records are no longer available,
most hospitals destroying their out-patient notes after
fifteen years. For those who were in-patients, or
whose parents have photographs and other data
less deceptive than their memory, some estimate
can be made, It seems that definite signs of thyroid
deficiency had been noticed by the doctor or parent
before the end of the first year in twenty patients,
of whom the intelligence quotients were found to be
still low, varying between 70 and idiocy which
defied measurement. In ten more, signs had been
noticed before the end of their second year. The
latest recorded ages of onset among the remainder
were 8, 9, and 12, the corresponding intelligence
quotients being respectively 69, 80, and 102. It
looks as though, other things being equal, the earlier
the onset the worse the outlook; but the data are,
as already pointed out, unsatisfactory, and closer
inspection of the details of the early history as
recalled by the parents suggests that signs of thyroid
deficiency could probably have been noted very
much earlier than they had been in the majority
t The Table appears in the conclu art of the paper, to
be published next week. ding p pap
: THE LANCET]
of the cases. This is also indicated by a large number
of instances in which walking and talking were
acquired later than the third year (in just two-thirds
of the cases). Clean habits were remembered as
having been attained before the end of the third year
N > O ON
8838802
Intelligence Quotients
QO
3h 4 4)2 5⁄2
S
Height in Feet of Cretins aged I7yrs &over
FIG. 3.—Relation of intelligence to standing height in a group
of cretins,
in only a third of the cases; in 31 others there was
delay, in the rest it was not recorded.
INTERVAL BEFORE TREATMENT
In ascertaining the interval before treatment
began there are much the same difficulties as in
regard to the preceding question. In 26 cases treat-
ment had been instituted promptly—i.e., less than a
year after symptoms were first noticed. At the cost
of anticipating some other points as to adequacy of
treatment, it is worth recording here that in one case
where treatment had commenced when the patient
was only four months old, and had been continued
with scarcely any interruption since, the intelligence
quotient is now only 34, and that in another whose
symptoms appeared at the age of eighteen months
and were immediately treated, the intelligence
quotient is only 27, though thyroid administration
had gone on steadily ever since; moreover, as a
paradoxical instance of the opposite kind, a man who
showed some symptoms soon after birth had no
treatment until he was thirty-one, and yet has an
intelligence quotient of 63. There are cases in the
series where symptoms had been noticed before the
age of three, no treatment had been instituted for
ten years or more, but the intelligence quotient is
within normal range; the most striking instance
being a girl with an intelligence quotient of 101, and
typical cretin appearance, whose symptoms began
during the first six months of life, yet she had no
treatment until she was eleven, and then it was stopped
for good after a year. It would be a manifest error
to conclude from these cases that treatment is as
effective when tardy as when prompt: it is, however,
legitimate to suppose that in some cases conspicuous
physical evidence of cretinism may not be associated
with gross mental deficiency, irrespective of whether
treatment has been given at all, or been started late.
The relationship of physical to mental retardation of
development is discussed below, as is also the adequacy
of treatment.
RELATIONSHIP OF MENTAL TO PHYSICAL
DEVELOPMENT
Fig. 3 shows the relation of height to intelligence
quotient. The individual figures are given in the
Table. a . |
There was no reason to suppose that the physical
and the mental development would in these cases have
run parallel, or that standing height is the best criterion
DR. R. G. MALIPHANT: MENSTRUAL FISTULZ
[ZUNE 26, 1937 1509
of defects of physical development. If it be assumed
that thyroid deficiency leads to an arrest of develop-
ment, the comparable data would be those of children.
The correlation here is sometimes made between
intelligence quotient and actual height, sometimes
between. intelligence quotient and the comparable
- relative measure—i.e., the deviation from the average
height for each age-sex group. There is a slight
positive correlation, varying between 0:14 + 0-03
(Murdock and Sullivan), 0-45 + 0-026 for boys,
0-3 + 0-028 for girls (Dawson), and 0:22 + 0-036
for gifted boys, 0:21 + 0-38 for gifted girls (Terman).
There is, in short, a definite but slight correlation
between height and intelligence in children.
It is, however, unsafe to assume that the effect
of thyroid deficiency is to arrest development as a
whole; it may only retard development and its
effect may be selective on different organs and
functions. On these matters there is a large body
of evidence.
(To be concluded)
MENSTRUAL FISTULZ *
WITH A NOTE ON THE SIGNIFICANCE OF
TRANSTUBAL MENSTRUATION
By R. GLYN Mazrenant, M.D., M.R.C.P. Lond.,
F.R.C.S. Eng., M.C.O.G.
GYNÆCOLOGIST, CARDIFF ROYAL INFIRMARY; LECTURER
IN OBSTETRICS AND GYNÆCOLOGY, WELSH NATIONAL
SOHOOL OF MEDICINE
In 1928 Max Ballin suggested the term “ menstrual
fistula ” for a sinus in a laparotomy scar characterised
by the periodic discharge of blood more or less
coincident with menstruation. It may be assumed
that such a sinus communicates either with the
uterine mucosa or with aberrant endometrial tissue,
but it is only to the former that the term “‘ fistula ”
is strictly applicable. Endometriomata have a
symptomatology and pathology of their own, and in
this paper I propose to confine the title ‘‘ menstrual
fistula ” to cases in which connexion with the uterine
cavity is established.
Fistulous tracts leading from the uterus to the
abdominal wall are almost always sequel of an
operation, and their symptoms are pathognomonic.
After operation the wound fails to heal completely
and a small sinus remains which discharges dark blood
at the time of the menses, In some cases the skin
unites and the menstrual discharge collects as a
subcutaneous hematoma, to rupture externally
later.
CASE REPORT
Mrs. A., aged 39, with one child of 5 years, was
admitted to the Cardiff Royal Infirmary in March,
1936, with a discharging wound in the left groin.
The wound ordinarily drained pus, but at the men-
strual periods blood issued from it freely. Menstrua-
tion was regular, unaccompanied by pain, and of ten
days’ duration. During the last few years there had
been a slightly increased menstrual loss, but no
intermenstrual bleeding had occurred either from the
wound or vaginally. The woman had previously
been admitted to the surgical side of the hospital
on two occasions, and the, surgical note-sheets
furnished the following history :— |
In March, 1931, she was admitted as an emergency
with pain in the right iliac fossa. Appendicitis was
* Read before the Midland Obstetrical and Gynecological .
Society, May 28th, 1937. |
1510 THE LANCET]
DR. R. G. MALIPHANT: MENSTRUAL FISTULE
[JUNE 26, 1937
suspected and the abdomen was opened through a right
paramedian incision. The vermiform appendix was only
superficially congested, but the right appendages were
acutely inflamed, and thin yellow pus was found in the
pelvis. Right salpingectomy and appendicectomy were
performed. No comment was made on the state of the
adnexe on the left side. i
She remained well until October, 1932, when she was
readmitted with a tense painful fluctuating swelling in the
left groin, immediately above the inner two-thirds of
Poupart’s ligament. An incision 3 in., long was made
over the swelling in the line of the inguinal canal. The
tissues were dissected down to the external oblique muscle
which was divided along its fibres. This opened an abscess
full of foul-smelling pus, which communicated with an
intraperitoneal abscess by an opening too small to admit
one finger. Two drainage-tubes were inserted into the
abscess cavity and the wound was closed in layers. The
pus was sterile on culture and the drainage-tubes were
removed next day. The inguinal wound did not heal
and a sinus remained which had since regularly discharged
blood coincidentally with menstruation. The blood
appeared almost simultaneously with the onset of the
menstrual flow, and disappeared a few hours after the
menses ceased.
When she was transferred.to the gynzcological
department in March, 1936, her general condition
was fairly good. There were two scars in the anterior
abdominal wall, a well-healed paramedian scar, and
one in the left groin running a short distance above
and parallel with Poupart’s ligament. In the centre
of the latter there was a small opening from which
dark blood was exuding. The uterus was normal
in size, but somewhat fixed, and no gross lesion
could be detected in the appendages. The tissues about
the sinus were indurated but no definite tumour was
palpable. The sinus admitted a probe for a distance
of an inch, and on injecting methyl-violet into it the
fluid escaped from the cervix.
In view of the chronicity of the condition and
the annoyance caused by the constant discharge, it
was decided to operate. After closing the mouth
of the fistula, an elliptical incision was made around
it and the scar of the previous operation was excised.
On opening the peritoneal cavity, the pelvic organs
were found buried in adhesions. The free end of
the left fallopian tube was fixed to the posterior
aspect of the inguinal wound and the canal in the
parietes was continuous with the tubal lumen. The
uterus and ovaries were macroscopically normal.
The left fallopian tube and the canal in the abdominal
wall were removed in one piece, and the abdomen
was closed. The post-operative course was uneventful,
Menstruation occurred a few weeks after the operation
and the wound remained dry. When last seen the
patient was in good health, and the wound in the
groin was soundly healed.
The tract in the abdominal wall and the attached
fallopian tube measured 5 in. The tubal wall
was thickened and on microscopic examination
showed tuberculous endosalpingitis with numerous
giant-cell systems. The canal in the parietes was
lined throughout with granulation tissue, and the
examination of many sections failed to show any
tuberculous disease or glandular tissue in its wall.
DISCUSSION ON ZXTIOLOGY
Clinical reports of uteroparietal fistule are not
common, particularly in this country, but there are
70 cases referred to in the literature. These fall in
two groups which are anatomically and etiologically
distinct.
In the first group the communication between
the uterine cavity and abdominal wall is direct.
Fistule of this type may follow ventrofixation
(Bireher 1910) or myomectomy (Ballin 1928), but
in most of the cases reported they have been incidental
to a previous Cesarean section. In 1922 Loicg
found accounts of 28 cases of uterine fistula following
Ceesarean section, and added one of his own. Similar
ones have since been recorded by Puccioni (1926),
Price (1928), Brayne (1930), and Devraigne, Banzet,
and Mayer (1930), bringing the total to 37. Faulty
operative technique, infection, and subsequent adhe-
sion of the uterine and parietal wounds are the
principal causes of fistula-formation after Czesarean
section, but the use of non-absorbable suture material
in the uterus is probably a contributory factor.
Uteroparietal union is of major importance, and it may
be for this reason that fistula of the uterus is a sequel
which seems to be peculiar to the upper-segment
operation.
In the second. group the connexion between the
uterus and abdominal wall is indirect via one of the
fallopian tubes or tubal stumps. Indirect utero-
‘parietal fistula are rarities at the present time, but
half a century ago they were common complications
of gynecological operations. In the early days of
ovariotomy, when it was customary to fix the ovarian
pedicle in the abdominal wound, the tubal stump
often became the site of a menstrual fistula, but these
fistule, unlike the ‘type seen nowadays, usually
closed without delay. Spencer Wells (1882) refers
to this sequel of ovariotomy in the folowing words:
“ Then after the wound is closed, it is said to lead to a
re-opening each month, and an escape of some menstrual
fluid. And this is true in some—perhaps in nearly a third
of the cases. But if the patient be prepared for it, it is
not of the slightest consequence. The fallopian tube
almost always contracts completely after a few months,
and there is no further escape. I can recollect only two
cases where it has continued up to the date of the last
report from the patient, and then it caused but slight
inconvenience. . . . If menstrual fluid can escape through
the partially closed fallopian tube fixed in the cicatrized
wound, so it may escape if the tube be left within the
peritoneal cavity, and the result may be a fatal
heematocele.”’
Fixation of the fallopian tube or tubal stump to
the parietes is probably essential to the development
of a tubo-abdominal fistula, and under modern
surgical conditions such fixation is almost always the
result of infection. Thus pelvic sepsis imitates closely
the effect of the deliberate extraperitoneal fixation
of the tubal stump of the last century.
There are three instances on record of indirect
uterine fistulae of spontaneous origin. One followed
the rupture of a pelvic abscess in the region of the
umbilicus (Deverre 1920); another appeared in the
scar of a laparotomy performed 16 years previously
(Tortora and Sanvitale 1930); and in the third case,
an advanced extra-uterine gestation became attached
to and fistulous in the anterior abdominal wall
After discharging feetal parts, the fistula continued to
discharge blood at intervals, in addition to a small
amount of fecal matter (Bouzol 1884).
Occasionally the condition has followed salpingo-
odphorectomy performed by the usual ligature
method in a potentially clean field (Ballin 1928,
Drips 1929), but some element of infection seems
to have been operative in each instance. In Drips’s
case there was an additional mechanical factor—
namely, complete stenosis of the cervix following
amputation—and the fistula was the sole outlet
for the menstrual discharge.
These cases are however exceptional, and the great
majority of tubo-abdominal fistule follow operations
performed for gross pelvic imfection—such as the
` THE LANCET]
removal of infected appendages or the drainage of
an appendiceal or tubo-ovarian abscess (Masson
and Simon 1928, Busche and Curthe 1929, Brady
1930). In salpingectomy the use of non-absorbable
suture material in the presence of infection, and the
slipping of the ligature on the tubal stump are
probably important causal factors. Non-absorbable
suture material was removed at the second operation
in three cases of tubo-abdominal fistula seen at the
Mayo Clinic (Masson and Simon 1928).
The formation of an indirect menstrual fistula
depends upon three conditions—adhesion of the
fallopian tube or tubal stump to the abdominal wall,
patency of the tubal lumen, and reflux of menstrual
blood from the uterus. It is generally recognised that
transtubal menstruation may occur under certain
circumstances. It has already been noted that
Spencer Wells observed an escape of menstrual blood
from the tubal stump in nearly a third of his cases of
ovariotomy. Pelvic infection often leads to adhesion of
the adnexz to the parietes, but in such circumstances
the third factor—patency of the tubal lumen—is
unusual, and it is the incompatibility of these two
conditions that probably accounts for the rarity
of tubo-abdominal fistule. In pyococcal infection
the fimbrial extremity of the fallopian tube tends
to close early. In tuberculous salpingitis, on the
contrary, the tubal lumen is more often preserved
(Frank 1931), and a striking feature of this review of
indirect menstrual fistule is the relatively high
incidence of associated pelvic tuberculosis. In the
series of 16 menstrual fistulz collected by Masson and
Simon (1928) from the records of the Mayo Clinic,
5 were associated with adnexal tuberculosis. Iribarne
(1927), Ballin (1928), Mesa (1929), and Jeanneney
and Laporte (1932) have also described cases of
tuberculous salpingitis with menstrual abdominal
fistula, and another instance of this association is
published in this paper.
There are now records of approximately 30 cases of
indirect menstrual fistula, and 10 of these have
occurred in conjunction with peritoneal or adnexal
tuberculosis.
DIAGNOSIS
Granulation tissue may bleed about the time of the
menses, but the blood is usually bright red and the
relationship of the hemorrhage to menstruation
is not constant. The diagnosis of menstrual bleeding
rests on the regular occurrence of dark hemorrhage
limited to the catamenia, and the only condition which
can in this respect simulate a menstrual fistula is a
sinus in connexion with an area of ectopic endometrial
tissue. Extragenital endometriomata are not uncom-
mon, and there are numerous records of endometrial
tumours developing in laparotomy scars. Endo-
metrial grafts however rarely grow in wounds which
suppurate and fail to heal by first mtention, so
endometriomata which discharge on to the skin
surface are rare. One of the first examples was
recorded by Fletcher Shaw in 1925 of an “ Adeno-
myoma of the round ligament which menstruated
through an inguinal incision,’ and in this case the
tumour was incised under a mistaken diagnosis.
Menstrual sinuses in association with endometriomata
have since been described by Ballin (1928), Schauffler
(1929), and Martin, Michon, and Pigeaud (1933).
Clinically these cases closely resemble uterine
fistula, and as Martin suggests, have probably been
the cause of some confusion in the past. The endo-
metrioma is sometimes palpable beneath the sinus,
and it may undergo the painful premenstrual swelling
typical of such tumours. A uterine fistula, on the
DR. R. G. MALIPRANT:
contains an endometrial tumour in its
MENSTRUAL FISTULÆ [June 26, 1937 1511
contrary, is usually painless, and as a rule the amount
of discharge from it is much greater. In these respects
a menstrual fistula may differ from a menstrual
sinus, but the former diagnosis is only established when
communication with the uterine cavity is demonstrated
either radiographically, by the injection of coloured
fluids, or at operation.
Ballin (1928) reported one case in which the two
conditions were combined. When a uterine fistula
wall, the
hemorrhagic discharge may be derived from the
uterine cavity, from the wall of the fistula or from
both. Such a combination of lesions is probably
exceptional, but can only be ruled out after endo-
metriosis of the abdominal wall has been excluded
by microscopic examination of the entire fistulous
tract. The few histological records available suggest
that the canal in the abdominal wall is usually lined
with ordinary granulation tissue, but remains of
glandular crypts have occasionally been described
(Devraigne 1930, Jeanneney and Laporte 1932).
In the case recorded by Jeanneney and Laporte, the
wall of a tubo-abdominal fistula which followed the
removal of a tuberculous pyosalpinx, was lined
with tuberculous granulation tissue.
PROGNOSIS AND TREATMENT
Spontaneous healing of a uterine fistula is rare,
and it is for the annoyance and persistence of the
condition that operation is usually required. But a
direct uterine fistula carries in addition the risks of
uteroparietal fixation in relation to childbearing, and
in such a case it is advisable to operate not merely
for the inconvenience of the discharge but to avoid
the obstetrical consequences.
In an uncomplicated case the operative risk is
small, but interference should be postponed so long
as the fistula is acutely inflamed. An indirect
fistula may be excised with the corresponding fallopian
tube. If the fistula leads directly to the uterus, the
tract with the old scar may be completely excised,
and the wound in the uterus carefully closed, but
many of these cases require hysterectomy. Tortora
and Sanvitale (1930) succeeded in causing a direct
uterine fistula to heal by dilating the cervix widely,
curetting the sinus, and draining the uterus vaginally
for several days.
If the fistula communicates with bowel as well as
with the uterus, prognosis for operation is grave.
Menstrual-fecal fistule have been recorded by Bouzol
(1884), Puccioni (1925), Ballin (1928), and Mesa (1929).
Although fertility is probably reduced by the
coexisting infection, pregnancy may occur and
proceed normally. In the event of pregnancy, this
may be allowed to continue to term, and Cesarean
section performed through the posterior uterine wall
as recommended by Devraigne, Banzet, and Mayer
(1930). If an attempt be made to excise the fistula
in the course of the Cesarean operation, the risks
of peritonitis are considerable (Martin 1933).
RETROGRADE MENSTRUATION
Not the least interesting feature of a study of
tubo-abdominal] fistule is its bearing on transtubal
menstruation. Many authorities consider that this
plays an important part in pelvic pathology. It is a
link of outstanding importance in Sampson’s hypo-
thesis of ovarian endometriosis, and it also provides a
possible mode of dissemination for uterine cancer.
_In 1925 Sampson reported that blood may occasionally
be seen dripping from the fimbrial ends of the fallopian
tubes of women operated upon at the time of the
menses, and in Goodall’s opinion (1934) this observation
1512 THE LANCET]
has since been confirmed by so many surgeons
that its occurrence can no longer be a matter of doubt.
Nevertheless many gynecologists of wide experience
have never observed it. Novak (1926) operated upon
13 women during menstruation without seeing any
blood entering the peritoneal cavity, and argues
further that menstruation is normally unaccompanied
by any sign or symptom of peritoneal irritation
such as is found with a tubal abortion. Novak’s
experience corresponds to that of many surgeons, so
the conclusion must be that although transtubal
menstruation may occur, it does so very rarely ;
and even in those cases in which menstrual spill has
been observed it is hard to exclude some pathological
basis for the regurgitation.
Radiography has now shown that the mechanism
which prevents the free passage of fluid from the
uterine cavity into the fallopian tubes is the sphincteric
action of the uterotubal junction. When air or fluid
is injected into the uterus, the isthmic and intra-
mural portions of the tubes contract, thereby pre-
venting for a time any leakage through the tubal
ostia, and this spasm has occasionally led to the
incorrect assumption of tubal obstruction. But the
sphincter is not strong enough to offer lasting resist-
ance to injection, and is usually overcome by a
pressure of 90 or 100 mm. of mercury. Heuser (1924)
noted that when the uterine cornu is in contraction,
the uterotubal sphincter is closed, and it is no doubt
for this reason that in uterine hemorrhage the
blood does not more commonly enter the peritoneal
cavity. Whether the closure of the ostia depends
upon uterine or tubal action is still debated, but the
copious reflux which may take place through a tubo-
abdominal fistula suggests that contraction of the uterus
is not sufficient to prevent leakage, and that there is
a true sphincteric apparatus in the fallopian tube.
It is evident that in tubo-abdominal menstrual
fistule this sphincteric mechanism is defective.
It has been noted that fistule of this type have,
in the past, commonly followed ovariotomy, but
are nowadays almost without exception associated
with pelvic inflammation. It may be ‘presumed that
both sets of circumstances in some way disturb
tubal action—division of the infundibulopelvic liga-
ment in ovariotomy destroys an important section .
of the tubal nerve-supply, and its musculature is
damaged in pelvic infection—so the retrograde
menstruation may be regarded as a manifestation of
abnormal permeability of the uterotubal junction.
It is well recognised that the permeability of the
fallopian tubes varies considerably in different subjects.
Goodall (1934) has described 4 cases in which vaginal
douche fluid has gained access to the peritoneal
cavity, and in these it was subsequently shown that a
pressure of 40 mm. of mercury was sufficient to force
gas through the tubal ostia. He concludes that
in such women the oviducts are unusually patulous,
and points out that a developmental anomaly of
this nature may be an occasional cause of menstrual
spill. Predisposition to retrograde menstruation would
also result from deficiency and lack of control of the
uterotubal sphincter, and the associated pathology
of indirect menstrual fistula suggests that this may
be a sequel of tubal inflammation. The frequency
with which chronic salpingitis is found as a com-
plicating lesion of ovarian endometriosis lends some
support to this view.
SUMMARY
A case of uteroparietal fistula is described, which |
followed the drainage of a tuberculous pelvic abscess,
and other cases on record are reviewed.
MR. G. GARRY : DUODENITIS AND ITS SURGICAL TREATMENT
[JUNE 26, 1937
Uteroparietal fistules are of two types. In the first
there is direct connexion with the uterine cavity,
and the fistula is usually the sequel of Cesarean
section. The second type is seen in conjunction with
pelvic inflammation, and communication with the
uterine cavity is indirect via one of the fallopian
tubes or tubal stumps. In approximately one-
third of the recorded cases indirect uterine fistula
has been associated with peritoneal or adnexal
tuberculosis. —
. The free transtubal menstruation often con-
spicuous in cases of tubo-abdominal fistuls signifies
a breakdown of the sphincteric mechanism at the
uterotubal junction. Chronic inflammation, by
disturbing normal tubal physiology, may play an
important part in the causation of pelvic endo-
metriosis,
REFERENCES
Ballin, i M. ( (1928) Surg. Gynec. Obstet. 46, 525; quoted by Novak
Bircher (1910) Zbl. EAA ore 952.
Bouzol (1884) Lyon méd. 513; anotar by Ballin.
Brady, L. (1930) Bull. Sch. "Mod. Univ. Maryland, 15, 73.
Brayne, W. F. (1930) Brit. med. J. i 862.
Busche, A., and Carbe. W. (1929) Derm. Wschr. 88, 266.
Deverre, M. J. (1920) Rev. franç. Gynéc.
Devraigne, L., Banzet, b and Mayer, M. (1930) Bul. Soc.
Obstét. Gynéc., Paris 408.
Drips, Della G. (1929) ied. ‘Clin. N. Amer. 12, 1577.
Frank, aves te 931) Gynecological ana Obstetrical Pathology,
Ne
Goodall, J. R. Sy pat Obstet. se, Saag
Heuser, C. (1924) S
na méd., Yr e 3 1496.
Iribarne, J. (1927) Ibid, "i 1550.
Jeannency., G., and Laporte, F. (1982) J. Méd. Bordeauz,
, 415.
Hole K. 1922) l Ganee: et. Obstét. 6
a, ‘ Michon, M., and Bernd, H. (1933) Pr. méd.
Masson, J C., and Simon, H. E. pea Amer. J. Obstet. Gynec.
Mesa, O. (1929) See
Molfino, A. H., and Boero, R. er 938) loH 2 1152.
Novak, E. (981) ] Menstruation aad | its kader, New York.
2a) Amer. J. Obstet. Gynec. 12, 484.
Price, . W. (1928) Kentucky med. T 26, 475.
Puccioni, L. (1925) Riv. ital. Ginec. 3 , 107.
Sampson, J. A. (1925) Amer. J. Obstet. heres 10, 649.
Schauffler, G. C. ay Northw. Me 28, 399.
Schlink, H. (1923 , 67.
Shaw, W. Fletcher (1925) J. stel,
Tortora, M., and Sanvitale he 4930) EFAA tinec. 39, 163.
Wells, T. Spencer (1888) Ovarian and Uterine Tumours: Their
Diagnosis and Treatment, London.
DUODENITIS AND ITS SURGICAL
TREATMENT
g By GERSHON GARRY, M.D. Tufts, U.S.A.
SURGEON TO THE SHAARE ZEDEK HOSPITAL, JERUSALEM
BEFORE discussing the surgical treatment of
duodenitis a brief review of the clinical aspect of
the disease should be of interest. Till compara-
tively recent times duodenal ulcer was the most clearly
defined disease, but recently duodenal dysfunction
and duodenitis are becoming more and more realised
as important factors. There have now been
a series of reports on the subject of duoden-
itis 1 2 7 9 13-16 18-28 30 82 and it is generally admitted
that often its diagnosis is made only with considerable
difficulty.
SYMPTOMS AND SIGNS
First in importance is the differential diagnosis
from duodenal ulcers. Other pathological states,
however, such as gall-bladder disease, pancreatitis,
appendicitis, and colitis closely resemble and may
often accompany the disease, so that careful clinical
judgment is required to arrive at a correct conclusion.
While the symptomatology of duodenitis is not
characteristic and may leave us in doubt about the
ne aa a ae =
THE LANCET]
actual condition, the X ray examination is of
considerable help in establishing the diagnosis, 18 21
Kirklin (1934) in his valuable contribution on the
subject emphasises several findings which he considers
pathognomonic of duodenitis.
“ First in importance among the signs is an abnormally
increased irritability of the duodenum. In typicalinstances
the hyperirritability is manifested in an intense spasticity
and a hypermotility of the duodenum. The barium races
through so rapidly that there is a scant opportunity to
inspect the shadow. The bulb is frequently small and
grossly deformed, both on its mesial and lateral borders,
and the configuration of the deformity varies quickly from
moment to moment. Further, the bulbar shadow lacks
the density commonly seen in cases of frank ulcers ;
it is thin and indistinct and its margins are hazy. A second
characteristic is the mucosa pattern which is coarsely and
irregularly reticular, and is depicted as translucent islets
lying in a denser network. This appearance is perhaps
attributable to puckering of the mucosa by spastic
contractions of its muscularis. A third characteristic
of simple duodenitis is the absence of an ulcer crater.
Neither marginal niche nor central fleck can be seen.
Finally, uncomplicated duodenitis is marked almost
invariably by absence of gastric retention or other evidence
of obstruction, whereas such obstruction occurs in more
than 25 per cent. of cases of true ulcer. It is clear both
from the roentgenologic and pathologic studies that
duodenitis does not tend to produce organic stenosis.
Completing the typical syndrome of duodenitis is a small
hypertonic stomach with active, sometimes disordered,
peristalsis, Like roentgenologic signs the foregoing
marks of duodenitis vary in emphasis, and only a minority
of cases are so typical that the diagnosis is obvious.
Thus among the last thirty-two cases only eight were
diagnosed as duodenitis, four were deemed negative, and
a diagnosis of duodenal ulcer was made in twenty.” i
In a series of our own comprising 20 cases of simple
duodenitis, verified by operation and in part by the
microscopic examination of excised tissues, the
diagnosis was not made in any of the cases previous
to operation, either clinically or roentgenologically.
In 13 the diagnosis was duodenal ulcer, and in the
remainder gall-bladder disease, appendicitis, and
colitis. The examination of the gastric contents
was not characteristic. The fasting contents showed
an average total acidity of 30 units and free acid 14;
after Ewald’s test-meal the figures were 59 and 30
respectively. The stool examinations for occult
blood were positive in 60 per cent. The X ray
FIG. 2 (Case 2).—Above: section of pylorus; inflammatory
infiltration by eosinophils and neutrophils, especially in the
muscularis layer. (x 100.) Below: Cluster of inflammatory
cells. (x 500.)
MR. G. GARRY: DUODENITIS AND ITS SURGICAL TREATMENT [JUNE 26, 1937 1513
findings were positive for duodenal ulcer in 15 of
the series; 3 were diagnosed as gall-bladder disease
and 2 as appendico-colitis. The operative findings
FIG. 1 (Case 1).—Section of duodenum showing muscularis
with displaced pancreatic tissue composed of solid alveoli
and dilated excretory ducts. (x 50.)
helped in establishing the diagnosis and comprised
changes in the duodenal wall such as congestion of
the serous coat, thickening of the entire duodenal
wall, and adhesions to the neighbouring organs
in some of the cases. No signs of an ulcer were
detected in any of our series. In 5 cases where
gastroduodenal resection was performed we were
able to examine the interior of the duodenum both
grossly and microscopically ; it presented signs of
general inflammation without ulceration.
In discussing the surgical treatment it should
be emphasised that duodenitis is essentially a medical
condition and surgery is resorted to only in the most
obstinate cases where medical means are of no avail.
The surgical procedures at our disposal comprise
gastro-enterostomy, which affords a certain rest
to the diseased area, duodeno-jejunostomy, serving
a like purpose, and gastroduodenal resection, a more
radical procedure affording a complete and per-
manent rest to the diseased duodenum.
The experiences with gastro-enterostomy have
not been very favourable. In the majority of cases
the operation failed to procure the desired results.
We performed it in 13 of our series. The follow-up
records showed good results in 3 cases, bad results
in 6, and the rest of the cases could not be traced.
Some authors claim satisfactory results with duodeno-
jejunostomy and consider it the method of choice.
In recent years, however, gastroduodenal resection
was performed in certain cases of duodenitis. On
Konjetzny’s suggestion (1934) cases with threatening
hematemesis associated with erosive gastritis were
treated with gastroduodenal resection (also
Finsterer 1923). We extended this indication to a
broader field and used gastroduodenal resection in
cases when duodenitis without hematemesis was
clinically severe and resisted: all internal therapy.
While our limited material in no way justifies general
conclusions, it may nevertheless .act as a stimulus
for further studies. A brief review of our cases is
given. below.
REPORT OF FIVE CASES
CASE l
A man, aged 24, was admitted to the hospital on
June 12th, 1933, with the following history. Seven
co 2
1514 THE LANCET]
FIG. 3 (Case 3).—(A) Above: section of duodenum showing
inflammatory infiltration of muscularis. ( x 120.) (B) Below:
(x 600.) of mucosa with plasma cells partly degenerated.
x °
years ago he began to complain of attacks of pain in the
right hypochondrium, pains lasting several weeks and
recurring every few months. At the onset the pains were
in relation to the intake of food, but lately they were
continuous; nausea but no vomiting. Bowels acted
regularly. Radiograms on May 23rd, 1931, showed
considerable hypersecretion and a tender and deformed
duodenal bulb. The diagnosis of duodenal ulcer was made
and subsequently a gastro-enterostomy was performed
which relieved complaints only for a brief period. Physical
examination on admission revealed tenderness in epigas-
trium and right hypochondrium. Gastric analysis follow-
ing Ewald’s test-meal showed total acidity 79 and free
acid 36. The stool had no occult blood. Radiogram
taken on June 15th, 1933, showed a patent anastomosis .
functioning well and a deformed duodenal bulb.
Operation on June 20th. The duodenum showed
congestion of its serous coat and general thickening of
its wall. No ulcer was detected. Gastroduodenal resection
‘was performed and previous anastomosis left intact.
Pathological report-—Duodeno-pylorus segment 65cm.
long. On opening lumen no ulcer was found and a small
diverticulum is seen on the duodenal side which extends
only into the mucosa. Microscopically the mucosa shows
eosinophils sparingly distributed around the crypts and
adjacent to the lymph follicles. The muscularis, below
the above-mentioned diverticulum, shows displaced pan-
creatic tissue composed of solid alveoli and a large number
of dilated excretory ducts (Fig. 1). Pericanalicular
infiltrations of neutrophilic leucocytes, an occasional
eosinophilic leucocyte, histiocytes, and some lymphocytes
are seen near the dilated ducts. The solid gland tissue
shows no inflammatory infiltration. Further away the
muscularis shows few eosinophils and an occasional
neutrophil, more so near the lymphatic layer. Diagnosis :
duodenum containing displaced pancreatic tissue with
dilated excretory ducts; duodenitis,
Subsequent course.—Convalescence uneventful;
operation he has been free from symptoms.
since
CASE 2
A man, aged 34, was admitted to the hospital on
August 27th, 1933, with a history of epigastric pain of one
year’s duration. The attacks occurred an hour or two
after meals and lasted for several hours, During the
period of his illness he had a number of attacks which
lasted two to three weeks at a stretch and left him in an
exhausted state. Dieting gave no relief. Alkaline as
well as other internal therapy was of no avail. Physical
examination showed tenderness in the epigastrium and
MR. G. GARRY: DUODENITIS AND ITS SURGICAL TREATMENT
‘long. On opening lumen mucosa found intact.
[JUNE 26, 1937
right hypochondrium. Gastric analysis following Ewald’s
test-meal showed total acidity 79 and free acid 58. Stool
was positive for occult blood. Urine negative. Leucocytes
5800. Radiogram showed considerable hypersecretion
and hyperperistalsis, bulbus duodeni tender and with a
“ clover-leaf’? shadow. Diagnosis: ulcus duodeni.
Operation on August 30th. The duodenum showed
congestion of serous coat and general thickening of its
wall. No ulcer detected. Gastroduodenal resection per-
formed in accordance with Billroth 2.
Pathological report.—Duodeno-pylorus segment 5:5 cm.
long. On opening lumen mucosa found intact. Micro-
scopically section of pylorus shows no changes in the
mucosa except for the presence of a moderate number of
plasma cells and an occasional eosinophil. The sub-
mucosa is cdematous and shows no inflammatory signs.
The muscularis shows cell clusters composed of eosinophils
and neutrophils infiltrating the tissue in all directions,
chiefly near the smaller vessels. Smaller foci as well
as single cells are seen also in other parts of the muscularis,
The infiltration is more abundant towards the periphery
in marked contrast to the inner muscular layer where
it is scantier. Section of the duodenum presents a similar
picture ; in the mucosa the leucocytes are more abundant ;
the submucosa is cedematous but otherwise shows no
inflammatory changes. The infiltration of the muscularis
is less abundant and foci of lesser extent. Diagnosis:
gastritis and duodenitis (Fig. 2).
Subsequent course.-—Convalescence uneventful ;
operation he has been free from symptoms.
since
CASE 3
A man, aged 29, was admitted to the hospital on
Sept. 10th, 1932, with a history of attacks of epigastric
pains of twelve years’ duration. The attacks lasted
several weeks and recurred every two to three months.
The pains were relieved immediately following intake of
food but returned two hours subsequently and with greater
intensity ; nausea but no vomiting. Bowels constipated.
Physical. examination showed considerable tenderness
in the epigastrium. Gastric analysis following Ewald’s
test-meal gave a total acidity of 75 and free acid 32.
Stool was positive for occult blood. Urine negative.
Leucocytes 7100. Radiogram a showed a deformed
bulbus with elongation of lateral process. The stomach
emptied itself completely four hours after the barium-
meal. Diagnosis: duodenal ulcer.
Operation on Sept. 15th. The duodenum showed con-
gestion of its serosa and thickening of entire wall.
No ulcer found. Gastroduodenal resection in accordance
with Billroth 2.
Pathological report.—Duodeno-pylorus segment 5 cm.
Micro-
FIG. 4 (Case 4).—Section of duodenum showing inflammatory
infiltration (perivascular) of muscularis. (x 500.)
scopically section of the duodenum shows mucosa with
an abundance of lymph follicles and large germinal
centres. The stroma of the mucosa is also rich in plasma
cells and lymphocytes (Fig. 34). Many cells are encountered
with broken-up nuclei and chromatin, which is subdivided
THE LANCET]
into two or three circular segments, peripherally placed ;
these are plasma cells with degenerated nuclei. The
muscularis mucoss# show an occasional eosinophil or
neutrophil. The muscularis shows in its outer layers
infiltrations of eosinophils and neutrophils distributed
throughout its extent; part of the infiltrations are peri-
vascular (Fig. 3B). Several leucocytes are also seen in the
adjacent fatty tissue. Diagnosis: duodenitis.
Subsequent course.—Convalescence uneventful ;
operation free from symptoms.
since
CASE 4
A man, aged 42, was admitted to the hospital on
Oct. 7th, 1934, with the following history. Three years
previously he was operated upon for duodenal ulcer and a
gastro-enterostomy was performed. This relieved him
for a year. Subsequently previous symptoms, returned
and with greater intensity, characterised by epigastric
attacks coming immediately after meals and lasting for
hours. At the onset of the illness the attacks recurred
evpry two to three weeks but recently they come on daily ;
nausea but no vomiting. Bowels act once in three days.
Abdominal distension often accompanies the constipation.
Physical examination showed tenderness in the epigas-
trium. The stools were negative for occult blood. Urine
negative. Leucocytes 9800. Radiogram showed a
patent anastomosis functioning well. Bulbus duodeni
tender and does not fill well. The stomach emptied
completely 20 mins. after administration of barium meal.
Operation on Oct. 16th. Anastomosis found faultless.
Duodenum showed thickening of entire wall. No ulcer
detected. Gastroduodenal resection performed and
anastomosis left intact.
Pathological report.—Gastroduodenal se gment 35 cm.
long. On opening lumen mucosa found intact. Micro-
scopically section of the duodenum shows mucosa rich
in lymph follicles. In the stroma around the crypts many
plasma cells and occasionally an eosinophilic leucocyte
are encountered. The muscularis shows small peri-
vascular infiltrations composed of neutrophils and eosino-
phils. Leucocytes, mostly eosinophils, are also seen
intravascular. Section of pylorus shows plasma cells
in the mucosa. The submucosa is cedematous and
contains large dilated veins. The muscularis mucosæ is
cedematous and many lymphocytes are found. Diagnosis :
gastroduodenitis (Fig. 4).
Subsequent course.—Convalescence uneventful ;
operation free from symptoms.
since
CASE 5 |
A youth, aged 17, was admitted to the hospital on
August 6th, 1931, with a history of epigastric attacks of
three years’ duration. At the outset the attacks occurred
daily and lasted half an hour. Recently the pains became
continuous. There was no relationship between the pains
and the intake of food. Had nausea but never vomited.
Bowels were constipated. Physical examination showed
tenderness in the epigastrium and right hypochrondrium.
Gastric analysis following Ewald’s test-meal showed a
total acidity of 75 and free acid 32. The stool was positive
for occult blood. Urine negative. Leucocytes 9000.
Radiogram showed much hypersecretion and hyper-
peristalsis and thickened folds of gastric mucosa. The
duodenal bulb emptied rapidly and was very deformed.
Three hours following barium meal the stomach was two-
thirds full of residue. Diagnosis: duodenal ulcer.
Operation on August 12th. The duodenum showed con-
gestion of serosa and thickening of entire wall. No ulcer
detected. Fibrous adhesions found between the duodenum
and gall-bladder; the latter showed no pathological
changes. Gastroduodenal resection (Billroth 2).
Pathological report.—Gastroduodenal segment 4 cm.
long. On opening lumen mucosa found intact. Micro-
scopically section of duodenum shows many plasma cells
in the mucosa. The submucosa is cedematous but shows
otherwise no inflammatory changes. The muscularis
shows small infiltrations of neutrophils and eosinophils,
especially near small vessels. Diagnosis: duodenitis.
Subsequent course.—Convalescence uneventful; since
operation free from symptoms.
MR. G. GARRY: DUODENITIS AND ITS SURGICAL TREATMENT
[JUNE 26, 1937 1515
DISCUSSION
In reviewing the microscopic findings in our cases
of duodenitis we are impressed by the close
resemblance between this clinical entity and that.
of appendicitis. In both conditions the mucosa is
only lightly affected while the intensity of the process
is confined largely to the muscular coats. In
appendicitis the portal of entrance is through a
minute break in the mucosa (the Primfr-affekt of
Aschoff). Except for Case 3 of our series, where
there was considerable infiltration of the mucosa with
plasma cells partly degenerated, the mucosa had
minimal pathological changes. Yet it is plausible
to assume that in duodenitis the entrance of the
infection is also through the mucosa and the inflamma-
tion extends from within outwards. The intensity
of the inflammation varies from a moderate degree
as shown by Cases 1, 4, and 5 to the very intense,
almost phlegmonous inflammation of the duodenal
muscularis as shown by Cases 2 and 3. It is readily
conceivable why the clinical manifestations of
duodenitis are most intense as the inflammatory
infiltration of the duodenum interferes with the
physiological peristalsis of the duodenum. In Case 1
we are likewise to assume that the pericanalicular
inflammation and not the displaced pancreatic tissue
accounted for the clinical manifestations, as one at
times encounters displaced pancreatic tissue in other
parts of the intestines without giving rise to symptoms.
Clinically these cases emphasise the problem of
the diagnosis and treatment of duodenitis. As a
rule there is great disproportion between the symptoms
and, the anatomical changes. The severest clinical
manifestations often stand out in contrast to the
insignificant operative findings. Under the circum-
stances the surgeon finds himself in a predicament
about the correct diagnosis and proper procedure
to be followed. As is often the case a mere explora-
tory operation is. performed without benefiting the
patient. It is therefore incumbent upon us to
establish as far as possible the diagnosis before
resorting to surgery. This should be based upon a
painstaking X ray examination of the gastro-
intestinal tract and by eliminating affections of the
adjacent organs. Once the diagnosis of duodenitis
is established, the only recourse left for obstinate
cases refuting all internal therapy is opera-
tion. Considering the unfavourable results with
previous surgical procedures, it appears that gastro-
duodenal resection should be the method of choice.
I wish to thank Prof. S. Getzowa, of the Patho-
logical Institute, Hadassah, Jerusalem, for the micro-
scopical slides, for the pathological reports, and for her
helpful advice, and Dr. A. Druckman for the radio-
graphic examinations.
BIBLIOGRAPHY
. de Abreu, M. (1933) Fortschr. Réntgenstr. 48, 547.
. Andersen, T. & 934) Bibl. Laeger, 136, 447.
. Aschner, "Pp, W., and Grossman, S. (1933) Surg. Gynec.
Obstet. 57, 398.
. Balfour, D. Cc. (1927) J. Amer. med. Ass. 89, 1650.
: Bolton, C., and Salmond, W. A. AED St , 1230.
; oralni oy C and Walsh, E. L. (1931) Surg Gynec. Obstet.
53, 753.
. Cunha, F. ere: Amer. J. Surg. 70.
: Finsterer, H (1923) Wien. Klin. Week. 38, 913.
; Friedenwaid, T , and Feldman, M. (1934) J. ” Amer. med. Ass.
= 20
10. Hauser, G. (1927) Med. Klinik, a2, 120.
11. Ivanoff, L.M. (1930) Klin. Med. peel
12. Ivantschenko, A (1930) ia. D. 50
13. Judd, S. (1921) a. Lancet, p. 215 (quoted by Kirklin 1929,
1934b b
14. — ee Ibid, 381 (quoted by Kirklin 1929, 1934b).
(1927) Ann. Surg. 85, 380
$ and Ao E.W. (1926) 19th Ann. Session of South.
urg.
(Continued al foot of next page)
Coon Gop whe
15. —
16. —
1516 THE LANCET]
MR. DEITCH AND DR. ROGAN : GLUTEAL ANEURYSM
[JUNE 26, 1937
GLUTEAL ANEURYSM
By H. I. Drircu, M.S. Lond., F.R.C.S. Eng.
LATE RESIDENT SURGICAL OFFICER AT THE ROYAL
INFIRMARY, BRADFORD ; AND
JOHN McGuig RoGan, M.B. Edin.
LATE HOUSE PHYSICIAN AT THE INFIRMARY
Gluteal aneurysm is rare, but its importance
is more than academic since its prompt recognition
may save a patient’s life, either by securing correct
treatment or by preventing a disastrous incision.
Russell Howard has said that all swellings of the
buttock shoni be regarded as gluteal aneurysms
until a satisfactory contrary diagnosis has been made,
and the following case report shows the wisdom of
his statement.
CASE REPORT
A man aged 49, by occupation a motor mate, had been
treated for 15 years for various gastric disorders and
had undergone several operations 10 years previously,
since when he had suffered intermittently from melena.
On his admission to hospital in July, 1935, a diagnosis
was made of ‘‘achlorhydric microcytic anemia following
gastro-enterostomy.’”’ In February, 1936, he was
readmitted under the care of Dr. W. Messer. He said he
had enjoyed good health until two months previously
when he began to have severe and rapidly progressive
pain in the left buttock, which forced him to take to bed
within a few days. Three weeks before admission he
noticed a swelling in that buttock and it appeared to be
increasing. On admission he was pale and emaciated.
His blood count showed a hemoglobin of 61 per cent.,
with a colour-index of 0°63, and the typical picture of
a secondary anemia. The spleen was enlarged, The
greater part of the left buttock was involved in a swelling
which was fluctuant and the left thigh was wasted.
Clinically, his condition was graver than his blood picture
suggests. Melena was absent, and no abnormality could
be discovered on radiography of the alimentary tract.
Some new bone formation was, however, apparent in
the region of the left ilium; Dr. H. Franklyn reported
upon it thus: ‘“? Myositis ossificans or new bone
formation due to inflammatory process.’
Aspiration was attempted, but failed. As the most
likely diagnosis appeared to be neoplasm, the then house
physician performed a biopsy, noting at the time that the
specimen appeared to be blood-clot. Dr. C. J. Young
issued a pathological report to the effect that the specimen
consisted of degenerated muscle-fibres replaced by fibrous
tissue, with no evidence of neoplasm. Soon after J. M. R.
became house physician the biopsy wound began to ooze,
and the patient’s condition deteriorated, and when seen
by H. I. D. he was looking desperately ill. The diagnosis
of gluteal aneurysm was tentatively made, but operative
treatment was considered out of the question because the
patient was so ill, and the wound was therefore packed.
Three days later there was a severe secondary hxmor-
rhage which could not be stopped by pressure and it
(Continued from previous page)
17. mee 36s.” and Kellog, W. A. (1933) Amer. J. Surg.
18. Kirklin, R. (1929) Radiology, 12, 377.
19. — 1983) Proc. Mayo Clin. 8, 629.
20. — (1934a) Amer. J. Digest. Dis. 1, 260.
(1934b) Amer. J. Roentgenol. 31,
21. — 581
and Puhl, H. (1925) Verh. dtsch. path. Ges.
22. Konjetzny, G. E.,
36
23 — (1931) Beitr. klin. Chir. 152. 552
24 — (1932a) Zbl. inn. Med. ii 225.
25. — (1932b) Chirurg. 4, 402
26. — (1934) Arch. Klin. Chir. Pec 139.
27. — (1936) Med. Klinik, 32,
28. Rivet aa B., and Wilbur, D. H “ (1931) Ann. intern. Med.
29. Seifert, E. (1926) Arch. klin. Chir. 141, 663.
30. Senserich, R. L. paar Stale Med. Soc. J. 25, 117.
31. Smith, J.S. K., a Ton (1933) Brit. med. J. i 362.
32. Tscheboks Sarow, 1939) Wien. klin. Wschr. 42, 971.
became essential to explore the wound. This was done
under local anæsthesia while an intravenous gum -saline
infusion was given pending the arrival of a blood donor.
On enlarging the wound it became apparent that the
gluteal swelling was a mass of tightly packed laminated
blood-clot and round the mass blood oozed rapidly up
into the wound. A laparotomy was impossible (the pulse
was almost imperceptible) so an attempt was made to
pack the vessel against the great sciatic notch by turning
down a flap of all the tissues at the back of the ileum, but
the patient died while this was being done.
At autopsy an aneurysm of the left superior gluteal
artery which had ruptured, just outside the pelvis, was
demonstrated; from the condition of the clot and the
remnants of the vessel it seemed probable that the
rupture had occurred some weeks previously. The clot
had separated the muscles from the dorsum of the ilium
and measured about two pints.
COMMENT
The cause of gluteal aneurysm varies. The
majority are. traumatic in origin, but a few are
spontaneous. The case described above must be
included among the latter since no history of trauma
could be elicited. Of about 80 cases recorded (Matas,
Rupp) 49 were traumatic and 23 spontaneous, the
cause of the remainder being undetermined. Of
those due to trauma half followed stab-wounds and
half falls on, or blows on, the buttocks. Rupp states
that the condition is commoner on the left side, but
may be bilateral.
Signs and symptoms.—Pain in the buttock is usually
the first symptom, but there may also be pressure
symptoms from involvement of the nerves. Then
as a rule comes a gluteal swelling, small if the
aneurysm is intact, large if it has ruptured. (Although,
as in a case reported by Haggard, an unruptured
aneurysm may be “‘enormous.’’) Till the blood has
clotted the swelling will give an expansile impulse
with perhaps a thrill and a bruit.
Diagnosis.—A careful history and examination will
be of great value and further information may be
obtained by aspiration of the swelling and by radio-
graphy. It may be difficult to distinguish a ruptured
aneurysm from an abscess, from osteosarcoma (which
may be pulsatile), and from rarer conditions such as
lymphosarcoma.
Prognosis.—Matas says that gluteal aneurysms
“tend to rupture spontaneously and sometimes
choke up the thigh with massive extravasations of
blood which cause death from hemorrhage very
rapidly.”
Treatment consists in ligating the internal iliac
artery and obliterating the sac to prevent recurrence
(Haggard, Frost, Adams, Maguire). Where the
aneurysm is small, a proximal and distal ligation with
extirpation of the sac may be satisfactory. Adams
describes in detail the treatment of an aneurysm
developing after a gunshot wound thus :—
First operation: ligation of the internal iliac artery
with subsequent disappearance of the swelling which,
however, recurred in a week’s time. Second operation :
ligation of the gluteal and obturator arteries in the pelvis.
This was ineffective. Third operation: the sac was
incised and the vessels entering the sac ligated (Antyllus’s
operation). This was successful.
We wish to thank Dr. F. W. Eurich and Dr. Messer
for allowing us to publish this case.
REFERENCES
ooms A W. (1923) ee. 1, 697.
Frost, H a oa Ibid, 2 42.
Haggard, W. D. (1922) Ann. Surg. 76, 520.
Maguire, D. L. (1926) Ann. Surg. 84, 760.
Matas, quoted by Hacrard.
Rupp, ues by Hagg
Williams, L . H. (19297 Military Surg. 65, 206.
\
THE LANCET]
AN EXPERIMENTAL ASSESSMENT OF
THE THERAPEUTIC EFFICACY OF
AMINO COMPOUNDS
WITH SPECIAL REFERENCE TO p-BENZYLAMINO-
BENZENESULPHONAMIDE
By LIONEL E. H. WuHitsBy, C.V.O., M.D. Camb.,
F.R.C.P. Lond.
ASSISTANT PATHOLOGIST, BLAND-SUTTON INSTITUTE OF
PATHOLOGY, THE MIDDLESEX HOSPITAL, LONDON
THE effectiveness of p-aminobenzenesulphonamide
(sulphanilamide) in streptococcal infections, experi-
mental and spontaneous, is now conclusively proved.
The same compound has also been shown to have
some effect in experimental infections with meningo-
coccus (Proom 1937), B. typhosus, B. paratyphosus B,
ang a negligible action on other bacteria (Buttle,
Parish, McLeod, and Stephenson 1937). The dis-
persion of this knowledge has led to a wide use of
p-aminobenzenesulphonamide, not only in coccal
infections but also in many quite unrelated conditions.
But the persuasive influence of advertisement or
traveller tends to emphasise only the successes of
experimental or clinical trials and to suppress the
failures and disasters. There must be now in this
country a vast quantity of information available for
assessment, if only those who have used these sulphon-
amide compounds could be persuaded to send a
letter to THE LANCET tabulating their experiences
in terms of case, dose, compound, and complication
(if any). Such information, when collated, might
prove very useful. Toxic effects with Prontosil and
p-aminobenzenesulphonamide appear to be fairly
frequent, though the number of fatalities has been
small. But since these compounds are toxic they are
neither of them ideal and there has naturally been
a search for substances which have an effective
dose well within the limits of toxicity. The following
report of some nine months of experimental work is
an attempt to assess the advantages and disadvantages
of the various compounds which can readily be
obtained and contains also a note as to the effective-
ness and toxicity of some hitherto undescribed
synthetic compounds.
TABLE I
No. of mice dying T
No. on day— Pe
— Dose. | of Te
mice jo
1/2|/314/5|6|7/8/9|10 =
Lethal titration. | 50,000) 12 |9/3)].. A 0
3 ú 500| 12 19/211 ee 0
a ý 5| 12 10/71/010 0/110) 3
p-aminobenzene- | 50,000; 12 |0 ,0)1/)1 1/02] 7
sulphonamide |
25 mg. (oral).
p-benzylamino- | 50,000; 12 ;0/1/0/0/0/1/0/0/0;2] 8
benzenesulphon-
amide 50 mg. (oral).
Prontosil soluble | 50,000
(subcut.) 7:5 mg. |
EXPERIMENTAL INFECTIONS WITH STREPTOCOCCI
Groups of 20-gramme mice, usually 6 but sometimes
12, were inoculated with 10,000 lethal doses of the
Richards strain of streptococci. Mice receiving the
drug were given the optimum dose (as found by
previous experiments) at the time of inoculation,
DR. LIONEL WHITBY: AMINO COMPOUNDS
[JUNE 26, 1937 1517
7 hours later, and once a day on the Ist, 2nd, 3rd, 4th,
6th, and 9th days. The culture used was a 6-hour
growth in O’Meara’s broth of which a 10-5 ailution,
using an inoculum of 0:3 c.cm., fulfilled the lethal
requirements, and contained approximately 50,000
streptococci. Repeated passage of the strain main
tained the virulence over a long period. Table I
is a typical protocol in a group of 12 mice.
TABLE II
Average
No. of Total No. of
= Dose mice days days
survived survived
Lethal titration. 50,000 12 3 0°25
” » 500 12 4 0°3
” 3 5 12 50 4
p-aminobenzene- 50,000 12 100 8'3
sulphonamide 25 mg.
p-benzylaminobenzene- | 50,000 12 104 8'6
sulphonamide 50 mg.
Prontosil soluble 50,000 12 60 5°0
7°5 mg.
In order to compare the effect of a drug in causing
delay in death, the protocol may be assessed in a
manner which is more informative than a mere
record of the ten-day survivors. For each drug
there can be calculated a figure which expresses the
average number of days survived during a definite
period of observation. The procedure is as follows :—
Multiply the number of mice by the number of days
which they survive, sum the products, and divide by the
number of mice used. Thus, considering p-aminobenzene-
sulphonamide: 7 mice survived the observation period
of 10 days=70; 2 mice survived 9 days=18; 1 mouse
survived 7 days=7; 1 for 3 days=3; 1 for 2 days=2.
The total=70+18+7+38+2=100 days. The number of
TABLE III
Experimental Streptococcal Infections in Mice
(Survivals with 50,000 streptococci (Richards) with drug
administered as previously stated)
No. of Total | Average
Compound and dose. mice days days
survived.'survived.
p-aminobenzenesulphonamide 12 50 4°1
50 mg. (oral).
p-aminobenzenesulphonamide 66 505 TT
25 mg. (oral).
p-aminobenzenesulphonamide 12 84 7:0
0 mg. (oral).
p-benzylaminobenzene- 54 430 7'9
sulphonamide 50 mg. (oral).
Prontosil soluble 7'5 mg. 114 776 6'8
(subcutaneous).
Disodium-p (y-phenyl-propyl- 30 199 6'6
amino) benzenesulphonamide-
a-y-disulphonate 30 mg.
(subcutaneous).
Control: 50,000 streptococci 168 52 0°3
(Richards).
(1) p-aminobenzenesulphonamide. Deaths arising from
50-gramme doses were due to toxic effects on the central nervous
system. Suspensions for injection made after powdering the
compound in a mortar.
(2) p-benzylaminosulphonamide. 50 mg. found by experi-
ment to be the optimum dose for mice. Completely non-toxic
to mice. R. L. Mayer (personal communication) has informed
me that the optimum dose for mice can be greatly reduced if
the substance is reduced to such fineness that it will pass through
a sieve with a mesh to 300 to the inch. More consistent
experimental results are also said to be obtained under these
conditions.
(3) Disodium-p (y-phenyl-propyl-amino) benzenesulphonamide-
a-y-disulphonate. 30 mg. subcutaneously the optimum dose.
Slightly toxic to 20-g. mice at 200 mg.
1518 THE LANCET]
DR. LIONEL WHITBY: AMINO COMPOUNDS
[JUNE 26, 1937
mice used was 12, so that the average number of days
survived was 100/12=8-3.
The above protocol can, therefore, be reduced to the
figures shown in Table II which are available for
comparison with other experiments provided the
lethal dose of the infecting organism remains constant
in size and virulence.
Table III summarises multiple experiments using
various compounds. The figures in the last column
provide a reasonable assessment of comparative
efficiency. Pipa
In addition to the compounds shown in. Table III
some 28 other synthetic sulphonamide derivatives
have been tested. Of these, two show considerable
promise.
(1) 4:4’diaminobenzenesulphonanilide tartrate (oral)
had an average day survival figure of 7:5 with a dose of
10 mg. in experiments involving 46 mice.
(2) 4:3’diaminobenzenesulphonanilide (oral) had an
average day survival figure of 7:1 with a dose of 20 mg.
in experiments involving 54 mice.
Conclusions. Experimentally the following oral
compounds are effective in the treatment of strepto-
coccal infections in mice: /p-aminobenzenesulphon-
amide, p-benzylaminobenzenesulphonamide, 4:4’
diaminobenzenesulphonanilide tartrate and 4:3’
diaminobenzenesulphonanilide. Of the soluble com-
pounds, Prontosil (soluble) and disodium-p (-phenyl-
propyl-amino) benzenesulphonamide-«-y-disulphonate
are less efficient than either of the above oral
preparations, but are. themselves equally effective.
HUMAN STREPTOCOCCAL INFECTIONS
Prontosil (soluble) has been shown to be effective in
pyerperal infections (Colebrook and Kenny 1936 a, b), ,
in erysipelas (Becker 1937), and in a number of other
lesions which are reported singly or reviewed in
annotations in The Lancet or British Medical Journal
of 1936 and the current year. Foulis and Barr
(1937) report favourably on p-aminobenzenesulphon-
amide in puerperal infections.
TABLE IV
Toxic
Disease. Cases. Success. | Failure. compli-
° cations:
Streptococcal
septicemia 5 4 1 Nil
Erysipelas 2 2 0 »
Tonsillitis 9 7 2 ”
Cellulitis.. 1 1 0 E
p-benzylaminobenzenesulphonamide has been less
widely reported on but was found to be effective in
erysipelas by Bloch-Michel, Conte, and Duvel (1936)
and by Peters and Havard (1937); the latter also
report success in other types of streptococcal infection.
My own experience with a limited number of cases
proved the effectiveness of the substance in erysipelas,
streptococcal septicemia, streptococcal tonsillitis,
and streptococcal cellulitis. This experience is set
out in Table IV. All the patients received 2 tablets
(0-5 gramme) of p-benzylaminobenzenesulphonamide
three times a day. :
EXPERIMENTAL INFECTIONS IN MICE WITH
MENINGOCOCCUS
Experiments were carried out using a technique
similar to that described by Proom (1937). To Dr.
R. A. O’Brien I am indebted both for the culture used
by Proom and for a supply of mucin. The assessment
of experimental infections is very difficult owing to
the relatively low virulence of the organism for mice.
Huge doses of culture have to be used and mucin
must be added to make the inoculation effective ;
a method for exalting mouse virulence has not yet
been satisfactorily devised. |
Table V is a typical protocol.
TABLE V
à l Deaths on Dad SES
Calog given day— |E a>
Sales Received. E pj S E b
Z% za ARAA A in i das
A 1'2|3/4|5|6|7
108| 6 Nil. TiS TATA . 0 0'8
108| 6 a 1/3/10/0|\010/0] 2 2°8
104! 6 5 0/2;0\|0;0/1/0! 3 4'6
108| 6 p-aminobenzene- 1;/0/0/0/0/0/0} 5 5'8
106! 6 sulphonamide 1/0;0/0/0)1/0| 4 5°5
6 25 meg. (three 0;0/0!/0/0)/0!0)} 6 -T'O
104
doses only).
As the result of a series of experiments for the
testing of various compounds the following average
day survivals were obtained over an observation
period of 7 days, using 108 dose of culture : Control 108
(42 mice): 0:75 days ; p-aminobenzenesulphonamide,
25 mg. (24 mice): 4:1 days; p-benzylaminobenzene-
sulphonamide, 50 mg. (18 mice): 06 days;
disodium-p (y-phenyl-propyl-amino) benzenesulphon-
amide-q-y-disulphonate, 30 mg. (12 mice): 0-8 days ;
4: 4'diaminobenzenesulphonanilide tartrate, 10 mg.
(12 mice): 42 days; 4:3’diaminobenzenesulphon-
anilide, 20 mg. (12 mice): 1-2 days.
Conclusion.—p-amino benzenesulphonamide is effec-
tive against meningococcus as previously found by
Proom (1937); this is borne out by preliminary
clinical reports (Schwentker, Gelman, and Long 1937).
4: 4’diaminobenzenesulphonanilide tartrate is equally
effective.
TABLE VI
Showing Toxicity of Various Compounds and Comparative
Efficiency in Experimental Infections in 20-gramme Mice
age
aye) A O
none SEBo.
ose |.2 ene =| Toxicity to
Compound. Infection. | (mg.). | 5 5 i ae 20-g. mice.
SEERE
4 80 mg. (subcut.)
Prontosil
. : is tolerated
(soluble) Streptoc. 7'5 16'8 (10 ee
(subcutancous). ed (Medizin und
Chemie 1936).
Streptoc. 25 |777
Meningoc. 25 f'l
Pneumoc. 25 |1°2
Markedly toxic
at 50 ing. Fatal
at 150 mg.
p-aminobenzene-
sulphonamide.
Type I.
‘ Streptoc. 50 17:9
p-benzylamino- Meni .
ningoc. 50 0'6
benzene- f Pneumoc.| 50 l0'5
sulphonamide. Mayer 1937).
|
|
Type I.
Disodium- ; ;
p (y-phenyl- || Streptoc. | 10 '6-6 (10) {| Slightly toxic
propyl amino) Meningoc. 10 a8 (7) (Halpern aoe
enzenesulphon- neumoc. i
amide-a-y- Type I. Mayer 1937).
disulphonate. |
4:4’diamino- Streptoc. 10 |7'5 (10) Non-toxic
benzene- Meningoc. 10 |4°2 (7) in doses of
sulphonanilide Pneumoc. 10 |3 (7)? 0 mg.
tartrate. Type I.
SAREN Streptoc. 20 |7°1 (10) Non-toxic
i eee Meningoc. | A h 2 (7 i a doses of
ae ae neumoc. — mg.
sulphonanilide. Type I. |
Streptoc., meningoc., pneumoc. = streptococcus, meningococcus,
pneumococcus.
mg.
(Halpern and
- THE LANCET]
PNEUMOCOCCUS
A small number of experiments have been per-
formed with pneumococcus Type I. No evidence
has been found that either p-aminobenzenesulphon-
amide or p-benzylaminobenzenesulphonamide or
the disodium sulphonamide sulphonate compound
has any action in preventing death in experimental
infections. On the other hand both 4: 4’diamino-
benzenesulphonanilide tartrate and 4: 3’diamino-
benzenesulphonanilide have a definite protective
action. An indication of this is given in Table VI.
TOXICITY IN THE HUMAN SUBJECT
Prontosil (soluble) and p-aminobenzenesulphon-
amide have an irritant action on the urinary tract
_in a large proportion of cases (Colebrook and Kenny
1936a, Foulis and Barr 1937); sulphemoglobinzemia
is also common (Colebrook and Kenny 1936a, Foulis
and Barr 1937, Paton and Eaton 1937). In the
human subject no cases of nervous-system complica-
tions, such as occur in mice, have been reported, but
one such has come to my knowledge.
No cases of sulphzemoglobinemia occurred during
the treatment of 215 cases of streptococcal infection
with p-benzylaminobenzenesulphonamide by Peters
and Havard (1937), nor have any been observed in
my own experience of some 20 cases. Nausea and
vomiting are seen occasionally with all three
preparations.
DISCUSSION
The aim of any therapeutic procedure is to combine
efficiency with safety.
compounds available for the treatment of streptococcal
infections is summarised in Table VI where the known
toxic doses for mice are also stated. The most common
complications with p-aminobenzenesulphonamide are
sulphemoglobinemia and methemoglobinemia and
though there appears to have been very little mortality
from these complications they cannot be regarded as
a desirable burden for even a convalescent patient
to bear. p-benzylaminobenzenesulphonamide would
appear less likely to produce these complications
both from experimental evidence and from clinical
report; the substance is equally active and is there-
fore worthy of clinical trial. >
As to the soluble compounds there is again a bigger
margin of safety with disodium-p (y-phenyl-propyl-
amino) benzenesulphonamide-&-y-disulphonate than
with prontosil (soluble) as judged from animal experi-
ment. And, in my own experience, I have given
20 c.cm. of the first-named compound daily for five
days by the intravenous route without the slightest
toxic symptom; experimentally there is nothing to
choose between the efficiency of the two compounds.
It should be noted that p-benzylaminobenzene-
sulphonamide and the soluble disodium sulphonamide
sulphonate compound are both inactive in meningo-
coccal infections, whilst p-aminobenzenesulphonamide
is active. All three compounds are quite inactive in
pneumococcal infections.
SUMMARY
(1) The oral preparations, p-benzylaminobenzene-
sulphonamide and p-aminobenzenesulphonamide, are
equally effective in experimental streptococcal infec-
tions. The former is very much less toxic than the
latter. à
(2) Of preparations for injection, prontosil (soluble)
and disodium-p (y-phenyl-propyl-amino) benzene-
sulphonamide a-y-disulphonate are equally effective
in experimental streptococcal infections; the latter
is less toxic than the former.
DR. J. G. G. BORST: AGRANULOCYTOSIS AND PRONTOSIL FLAVUM
The efficiency of the various .
[JUNE 26, 1937 1519
(3) p-aminobenzenesulphonamide is effective in
experimental meningococcal infections. p-benzyl-
amino benzenesulphonamide and disodium-p (y-phenyl-
propyl-amino) benzenesulphonamide-«- 7 disulphonate
are inactive.
(4) Two diaminobenzenesulphonanilide compounds
have been found to have a considerable polyvalent
action; they are well tolerated and one protects
against streptococcus, pneumococcus, and meningo-
coccus, the other against streptococcus and pneumo-
coccus.
* I am greatly indebted to Messrs. May and Baker
Limited for supplies of p-benzylaminobenzenesulphon-
amide (Proseptasine), of disodium-p (y-phenyl-propyl-
amino) benzenesulphonamide-a-y-disulphonate (Solusep-
tasine), and of the other experimental products referred
to in this paper.
REFERENCES
Becker, W. (1937) Derm. Wschr. 104, 221.
Pici err H., Conte, M., and Durel, P. (1936) Pr. méd.
Buttle, G. A. H., Parish, H. J., McLeod, M., and Stephenson, D.
(1937) Lancet, 1, 681.
Colebrook, L., and Kenny, M. (1936a) Ibid, 1, 1279.
(1936b) Ibid, 2, 1319.
Foulis, M. A., and Barr, J. B. (1937) Brit. med. J. 1, 445.
Halpern, B. N., and Mayer, R. L. (1937) Pr. méd. 45, 747.
Medizin und Chemie (1936) 3, 24 (Bayer).
Paton, J. P. J., and Eaton, J. C. (1937) Lancet, 1, 1159.
Peters, B. A., and Havard, R. V. (1937) Ibid, 1, 1273. |
Proom, H. (1937) Ibid, 1, 16.
Schwentker, F. F., Gelman, S.,
and Long, P. H. (1937) J. Amer.
med. Ass. 108, 1407.
I
DEATH FROM AGRANULOCYTOSIS
AFTER TREATMENT WITH
PRONTOSIL FLAVUM
By J. G. G. Borst, M.D.
SENIOR ASSISTANT IN THE INTERNAL HOSPITAL DEPARTMENT
OF MEDICINE, UNIVERSITY OF AMSTERDAM
ALTHOUGH the benzenesulphonamide compounds
were introduced only a few years ago they are already
widely used. Originally they were given only in
streptococcal infections, but lately they have also
been recommended for meningococcal infections}
and pyelocystitis.2, It soon became clear, however,
that they were liable to have serious toxic effects,
and cases of sulphemoglobinsemia,? methzemoglobin- ©
æmia, and nitritoid crisis > have been reported.
Between September and December, 1936, I treated
13 cases of B. coli pyelocystitis with Prontosil Flavum,
and 5 of these developed toxic symptoms. One
patient became dyspnwic and developed Cheyne-
Stokes respiration ; she was seriously ill for one day,
but not cyanotic. As in September I had not yet
read Colebrook’s article I did not test the blood
for sulphemoglobin and methzmoglobin ; the number
of leucocytes and the differential leucocyte count
were normal, Three patients complained of pares-
thesis in the face and of the hands: two of them at
the same time had sensory disturbances; while
doing their hair they could not actually feel it. None
of these patients received more than six tablets of
300 mg. prontosil flavum daily, and after discon-
tinuing administration of the drug the eyimpionme
disappeared in a few days.
The fifth patient developed agranulocytosis.
She was a woman of 61, and was taken into the wards
on Nov. 21st, 1936, for pyelocystitis. In 1925 and 1926
she had been treated in the gynecological wards for
hemorrhagic discharge and gum-bleeding, while blue
v
1520 THE LANCET]
patches were showing on her arms also. The treatment
then given included curettage, irradiation of the spleen
with X rays, injection of horse-serum of the patient’s
own blood, and of gelatin. A diagnosis of thrombopenic
purpura was made. (A complete history of the case is
unfortunately not available.) In 1929 she was examined
in the out-patient department of Prof. Ruitinga, because
she had a few petechiz on her legs. A blood count showed :
red cells, 4,420,000 per c.mm.; hæmoglobin, 83 per cent. ;
platelets, slightly increased (estimated roughly); white
cells, 10,500 per c.mm. (eosinophils 2 per cent., basophils
14 per cent., stab cells 7 per cent., polymorphonuclears
45} per cent., lymphocytes 37 per cent., monocytes
7 per cent.). No important symptoms of disease developed
~ . 7 BET eTA
AVA vy PULSE
PRONTOSIL
FLAVUM
Temperature and pulse chart showing dosage of ioe flavum administered
"8g. and 2°4g. daily
after 1929, and the patient suffered from nothing except
frequency of micturition.
A fortnight before admission pains in the loins and
strangury developed, the urine becoming cloudy and foul.
On admission on Nov. 2lst her temperature was 39°C.
(102° F.). Nothing abnormal was found in lungs, heart,
or abdomen. The urine contained } per mille albumin,
and was full of pus and coli bacilli. A blood count on
Nov. 23rd showed 8000 white cells per c.mm. (eosinophils
2 per cent., metamyelocytes (juveniles) 1 per cent., stab
cells 12 per cent., polymorphonuclears 51 per cent., lympho-
cytes 11 per cent., plasma cells 7 per cent., and monocytes
16 per cent. The Wassermann and Sachs-Georgi test
were negative, the sedimentation-rate of the blood was
83 mm. in the first hour. From Nov. 21st till Dec. 3rd
the patient received daily six tablets of 300 mg. prontosil
flavum. At first the temperature dropped, but after a
few days it rose again to 39°C. (see Chart), though the
urine contained neither leucocytes nor bacteria, and a
culture remained sterile. The patient had no complaint.
The prontosil treatment was discontinued, the tempera-
ture dropped, but leucocytes and coli bacilli reappeared
in the urine; and after a few days the temperature went
up again.
On Dec. llth prontosil treatment was resumed; but
half an hour after taking the first two tablets the patient
had cold shivers, the temperature rising to 40° C. (104° F.).
The blood showed the full picture of infection with 14,000
white cells (polymorphonuclears 62 per cent., stab cells
28 per cent., metamyelocytes (juveniles) 2 per cent.»
lymphocytes 1 per cent., and monocytes 13 per cent.)-
The number of platelets, roughly estimated, was normal-
Hemoglobin 78 per cent. The patient complained of pain
in the left side, and there was much tenderness on
pressure in the region of the left kidney.
From Dec. llth to 2lst the patient again received six
tablets of prontosil flavum daily; and again the leuco-
cytes and bacteria disappeared from the urine within a
few days, while the temperature dropped. But this time
also the temperature did not become quite normal, as
it varied between 37:2 and 37:8°C. As I suspected that,
although the urine was sterile, the infection of the kidney
itself had not yet been cured, I increased the dose of
prontosil to eight tablets daily on Dec. 22nd.
On Dec. 28th the patient complained of general dis-
comfort, the temperature in the evening being 38:1°C.
(100-5° F.). No special attention was paid to this because
there was an outbreak of influenza among the other patients,
four of nine women in the ward having temperatures
above 38°C. On Dec. 29th the patient showed tympanic
DR. J. G. G. BORST: AGRANULOCYTOSIS AND PRONTOSIL FLAVUM
[JUNE 26, 1937
percussion of the left lower lobe accompanied by bronchial
breath sounds, the temperature rising to 39° C. (102-2° F.).
Prontosil treatment was discontinued. A blood count on
Dec. 30th showed: hemoglobin, 70 per cent.: red cells,
3,330,000 (slight anisocytosis); reticulocytes, 0-8 per
platelets (of normal appearance under the micro-
cent. ;
scope), 270,000 per c.mm.; white cells, 1225 (eosinophils 0,
basophils 24 per cent., polymorphonuclears, 2} per cent.,
lymphocytes 83% per cent., monocytes 11} per cent.),
That same evening the patient had difficulty in swallowing.
the throat being slightly red. On the morning of Dec. 31st
the number of leucocytes had dropped to 960 per c.mm.,
the differential count being polymorphonuclears | per cent.,
lymphocytes 87 per cent., monocytes 12 per cent.
the afternoon the patient died. Post-
mortem atelectasis of the left lower
lobe was found; no signs of pneu-
monia were apparent either naked-eye
or on microscopical examination. Also
the angina was not demonstrable any
more ; it certainly had not been severe
during life. There were no more signs
of inflammation of the bladder and
left and right pelvis; sections of the
kidneys showed a few small round-cell
infiltrations in the medulla; otherwise
kidneys were normal. No abnormali-
ties to account for the high tempera-
ture and death were found. As the
autopsy took place 28 hours after
death, the films taken from the bone-
marrow were (as was expected) unsuitable for drawing
any conclusions,
During her stay in the wards this patient had no
remedies except prontosil flavum, some dilute
hydrochloric acid to facilitate its absorption, and
(on Dec. 10th) 15 grammes of castor oil. There can
I think be no doubt about the close connexion
between the use of prontosil flavum and the occur-
rence of agranulocytosis in this case, but the patient’s
unusual previous history may indicate some pre-
disposing disease of the bone-marrow.
It is not clear why so many of the 13 patients in
this series showed toxic symptoms during prontosil
treatment. With 2 exceptions, none of the patients
were seriously ill before they were treated; during
the whole course of their illness 9 had had no fever.
Prontosil flavum is generally given to patients suffer-
ing from streptococcal sepsis, and where the illness
is already severe slight symptoms of intoxication are
not easily recognised, so that even a serious com-
plication like agranulocytosis may not alter the
clinical picture radically enough to attract attention.
In the case recorded here the first diagnosis was one
of influenzal pneumonia.
As a result of our unfavourable experience pron-
tosil flavum treatment was stopped,: but in 11 more
cases p-aminobenzenesulphonamide (Prontosil Album)
was given, This drug also caused toxic effects, but
these were fairly harmless. In all patients feeling
ill or having fever, the blood was repeatedly examined,
but no qualitative or quantitative abnormalities of
the leucocytes were found. :
REFERENCES
1. Buttle, G. A. Bi oror W. H., and T parnom, D. (1936)
6 .
Lancet, 1, Proom, H. (1937) Ibid, 1, 16;
Schwentker, F. F, G elman, S., Long, P. H. (1937)
J. Amer. med. ASS. "108, 1407.
2. Imbatiser, K. (1935) Med. Klin. 31, 282; Huber, H. G.
(1936) Münch. med. Wschr. 3, 2014; Unshelm, E.
(1936) Arch. Kinderheilk. 109, 66.
3. Cplcbrookid L., and Senny, I (1936) Lancet, 1,1279; Frost,
(1937) Ibid, , 519; Discombe, G. (1937) Ibid,
4. Poron oa J., and Eaton, A. I. C. (1937) Ibid, 1, 1159
an
5. Sézary, A., and Friedmann, E. (1936) Bull. Soc. méd. Hôp.
Paris, 52, 636.
THE LANCET]
[sone 26, 1937 1521
CLINICAL AND LABORATORY NOTES
A CASE OF PARATYPHOID A
By HENRY COHEN, M.D. Liverp., F.R.C.P. Lond.
PROFESSOR OF MEDICINE, UNIVERSITY OF LIVERPOOL ;
HONORARY PHYSICIAN, ROYAL INFIRMARY,
LIVERPOOL
A. G. C. FFOLLIOTT, M.B. Dubl.
AND ;
HEDLEY D. Wricuat, M.D., D.Sc., M.R.C.P. Edin.
PROFESSOR OF BACTERIOLOGY, UNIVERSITY OF
LIVERPOOL
BEFORE the Great War paratyphoid fever due to
Bact. paratyphosum A was almost unknown in
England. Lehmann (1916) could find no cases
recorded from Great Britain up to 1912, and although
Windsor (1910), in a study of the bacteriology
of the bile, isolated the organism in two cases;
neither of these patients gave a history of enteric
infection. During the war the incidence of the
disease increased, but, as Bruce White (1929) has
pointed out, the organism for some unknown reason
failed to establish itself in western Europe after the
war although epidemics due to Bact. paratyphosum B
have not been infrequent. l
We have been able to find records of only two
cases in England since 1918. One is reported by
Dive (1922) in a patient recently returned from
Mesopotamia, and the other by Gray and Gardiner
(1934) which appears to have been of local origin
: (Bristol). Both these cases were diagnosed sero-
logically, and the reactions in the second were some-
what anomalous. The literature, however, probably
does not represent the actual frequency at all accu-
TEMPERATURE DEGREES FAHRENHEIT.
PULSE RATE
Q
R
R ud
v 6
ME IO Te ee ne ee ee Tee ae ae am ae a og Ac EMEMEMEMEMEME MEMEMEMEME
67 8 1125345 7 8
9 10 1 12 13141516 17 18
ISS6OCTOBER
19 2021 22 23 24 25 26 27 28 29 303
Temperature and pulse chart.
rately. Dr. W. M. Scott (of the Pathological Labora-
tory, Ministry of Health, London) informs us that
the number of official notifications of Bact. para-
typhosum A for England since the war is three in
‘1924, one in 1926, one in 1927, and three in 1928.
It is not certain but appears probable that all these
diagnoses were based on agglutination tests.
previous illnesses.
Hae
NOVEMBER
CASE RECORD |
Our patient was a healthy man aged 26 with no relevant
He first experienced slight malaise on
Oct. Ist, 1936, but remained at work until the afternoon
of the 2nd, when he had to return home early because of
abdominal discomfort which gradually intensified and
was later associated with vomiting. He was first seen by
A. G. C. ff. on the morning of Oct. 3rd with generalised
abdominal tenderness and a .temperature of 100°F.
There were no local signs, and next day, although the
abdominal pain had subsided, his temperature was 101° F.
and he complained of constipation. On Oct. 5th his tempera-
ture rose to 102° F. and he had severe headache, though
his general condition was unchanged.
The accompanying Chart records the course of the
temperature from the evening of Oct. 6th onwards. On
the 7th an enteric infection was suspected, but agglutina-
tions were negative and fecal culture showed no typhoid
or paratyphoid bacilli. A blood culture on Oct. 8th was
sterile. On the 10th two rose spots appeared on the
abdomen, but the spleen was not palpable. On the 12th
agglutinations were again carried out with negative
results. Next day he was seen by H. C., still complaining
of headache, generalised abdominal discomfort, profound
weakness, and constipation. He had the characterigtic
appearance of an enteric patient with a few rose spots
on the abdomen, but the spleen was still not palpable.
There was a slight bronchitis but no other chest trouble.
The clinical diagnosis of an enteric infection was made
and further blood tests advised. On Oct. 16th—i.e.,
fifteen days after the first clinical evidence of infection—
& positive agglutination reaction to Bact. paratyphosum A
was found in a dilution of 1 in 160. On the 17th he had
a severe intestinal hemorrhage with profound collapse,
aggravation of his abdominal pain, and his pulse-rate rose
to 120; next day he passed a large quantity of blood —
per rectum, and his previous apathy gave place to irrita-
bility. On Oct. 18th the agglutination to Bact. para-
typhosum A rose to 1 in 320, and on the 22nd the organism
was recovered from the feces though
the urine remained sterile. Gradu-
ally his clinical condition improved
and his temperature remained normal
after Nov. 3rd. On Nov. 27th his
urine and fæces were both free of
organisms of the enteric group.
Throughout the illness the spleen
was not palpable ; the patient had no
natural movement of the bowel
except on the day following the
hemorrhage; there was never abdo-
mina] distension despite the fact that
feeding was chiefly per rectum as the
patient refused to take food by the
mouth.
DISCUSSION
In attempting to find a possible
source of infection, we ascertained
that the patient had travelled to
Hamburg on August 22nd return-
ing on the 29th. If it be assumed
w v that the infection occurred out-
side this country, the incubation
period would be at least thirty-
three days. The man who shared
the cabin with our patient was
tested for agglutinins, and his
urine and fæces were cultured with
negative results. Although the incubation period
seems lengthy if the infection occurred outside this
country, it is within known limits. Vincent and
Muratet (1917) described a case of laboratory infec-
tion in typhoid fever where symptoms appeared first
on the fortieth day. = |
It should be noted that the serum was in all cases
cc3
1522
THE LANCET]
tested against Bact. typhosum (H and O), Bact. para-
typhosum B (H type, H group and O), and Brucella
abortus as well as Bact. paratyphosum A. In all
cases reactions with these organisms, other than with
Bact. paratyphosum A, were completely negative
(i.e, no reaction occurred in a dilution of serum of `
1 in 20). The relatively late appearance of a positive
Widal reaction in cases of Bact. paratyphosum A
has been noted by MacAdam (1918). In one mild
case he noted its first appearance on the twenty-first
day ; in one severe case after the fourth week; and
in another in the fifth week.
The media used for the isolation of the organism
from the fæces were brilliant-green eosin-agar plates
and sodium tetrathionate broth (Jones 1936). The
interesting point was that the culture was obtained
by directly plating the feces on the brilliant-green
eosin-agar but no growth was obtained when the
feeces were inoculated into tetrathionate broth and
this was plated on the solid medium after 24 hours’
incubation. This enrichment method has proved
very satisfactory with Bact. typhosum and Bact.
paratyphosum B. <A few experiments indicate that
it is not suitable for Bact. paratyphosum A, but it
requires to be tested on more strains. Krumwiede
(1917) found Bact. paratyphosum A in the faces
most frequently in the first week.
SUMMARY
A case of paratyphoid A is recorded in which the
infection occurred probably outside this country.
The agglutination reaction was negative on the
twelfth day but positive on the sixteenth. The
organism was recovered from the fæces on the twenty-
second day. sy
REFERENCES
Dive, G. H. (1922) Jour. R. Army Med. Cops. 38, 306.
Gray, J. D. A., and Gardiner, A. D. (1934) Lancet, 2, 21.
Jones, E. R. (1936) J. Path. Bact. 42, 455.
Krumwiede, C. (1917) J. infect. Dis. 21, 141.
Lehmann, E. (1916) Zbl. Bakt. (Orig.) 78, 49
MacAdam,, W. (1918) Jour. R. Army Cops. 31, 208.
Vincent, H., and Muratet, L. (1917) Typhoid and Paratyphoid
Fevers, English Translation, edited by J. D. Rolleston.
London, 1917.
White, P. Bruce (1929) A System of Bacteriology, Med. Res.
Coun., London, vol. iv., p. 124.
Windsor, J. F. (1910-11) Quart. J. Med. 4, 113.
AN UNUSUAL CASE OF GALL-STONES
By Joun Mackay, M.D. Glasg., D.P.M.
ASSISTANT MEDICAL OFFICER, COUNTY MENTAL HOSPITAL,
WHITTINGHAM, PRESTON
A MAN, aged 44, was admitted to the County
Mental Hospital, Whittingham, Preston, on April 3rd,
1901. He had delusions of persecution; he was
noisy and excited at times, and he suffered from
auditory hallucinations. During 36 years’ stay in
hospital he remained deluded and was often querulous
and irritable. He was convinced that there was a
conspiracy against him, and that electricity was
being passed through him. He maintained fair
health, however, until the early part of 1933, when
he showed signs of cardiac insufficiency, and he
slowly deteriorated physically up to the time of his
death at 80 years of age on March 13th, 1937.
Post-mortem examination revealed advanced arterio-
sclerosis and myocardial degeneration. The mitral
and tricuspid valves were thickened. But the most
striking finding was a greatly enlarged gall-bladder,
CLINICAL AND LABORATORY NOTES
[JUNE 26, 1937
44 in. in length (see Figure). It contained three
large stones and numerous small ones. The measure-
ments of the three large stones were 1-251 in.,
1-2x0°6 in., 1:75x2 in. The wall of the gall-bladder
was tightly stretched over the stones, and there was
no bile present.
This case is unusual for several reasons. Firstly,
although the patient was of the querulous type, he
never once made complaint of abdominal pain.
Secondly, routine physical examination conducted by
vA WIT E GN ee ~
a! a by ae ~ j
Ae dl i
pogi aen OE Sa a
The gall-bladder containing its stones.
several medical officers failed to determine any
abdominal tenderness. Thirdly, his delusional locus
was the head and not the abdomen, as he imagined
that electrical influences were destroying the hair of
his head and were making him deaf.
I have to thank Dr. A. R. Grant, medical superinten-
dent, and Mr. J. Gates, chief laboratory assistant, for
their help and interest in this case,
DUODENAL DIVERTICULA
WRITING in the Riforma Medica (1937, 53, 599)
M. Donati describes a case of diverticulum of the
third part of the duodenum.
The patient was a married woman aged 43. At the
age of 20 she began to suffer from attacks of diarrhea,
lasting a few days and recurring at intervals of about
a month. These went on for about five years, after which
she was much troubled by constipation. For a year
she suffered from a sense of weight in the epigastrium,
increased by lying down and relieved by standing, and
accompanied by distaste for food. As medical treatment
failed to cure her, an X ray examination was made,
and revealed a large diverticulum in connexion with
the inferior limb of the duodenum. Soon afterwards
the patient had an attack of acute epigastric pain and
nausea, lasting 12 hours. This attack was repeated a
month later and after a second (confirmatory) X ray
examination, operation was decided upon. The divertie
culum, which consisted only of mucosa and submucosa,
was dissected out after incising the peritoneum over it,
and removed. The resulting aperture in the duodenum
was sutured transversely so as to avoid narrowing the
lumen. Convalescence was uneventful, and the symptoms
were completely relieved.
Discussing the origin of these diverticula and
the indications for operation, Donati emphasises the
importance of a confirmatory radiography since the
appearances may be deceptive and may lead to the
performance of an unnecessary laparotomy. The
operative procedure to be adopted can only be
decided after the abdomen has been opened; the
ideal is removal of the diverticulum and suture of
the bowel, but it may not be possible to carry this
out, and in complicated or very difficult cases the
surgeon may have to fall back upon a palliative
operation such as gastro-jejunostomy.
THE LANCET]
[Jone 26, 1937 1523
t
MEDICAL SOCIETIES
ASSOCIATION OF CLINICAL
PATHOLOGISTS
THE summer meeting of this association was held
on June 12th in the pathological department of the
Royal East Sussex Hospital, Hastings. Dr. P.
LAZARUS-BaRLow, pathologist to the hospital, occu-
pied the chair, and the meeting was devoted to
various aspects of the problems of
Blood Transfusion
Dr. H. F. BREWER, medical officer to the London
Blood Transfusion Service, spoke on the organisation
and medical administration of a voluntary blood
transfusion service. He commended the aim of the
British Red Cross Society to coördinate all such
services in a national scheme. The routine running
of a transfusion service was best carried out by a
body independent of the hospitals making use of the
donors, and its medical administration was preferably
centralised in the hands of a clinical pathologist.
Dr. Brewer advised a full re-examination of donors
after ten (and multiples of ten) donations. He con-
sidered the safe minimum time interval between
. bleedings to be three months for men and four months
for women, but there was no need to limit the number
of donations given. The needle method of extraction
of blood was alone permissible. Certain desiderata were
emphasised—the withdrawal of blood from a donor
only in the supine position, the avoidance of direct
arm-to-arm technique, the use of a local anæsthetic
at the site of needle puncture, the exclusion of iodine
in the dressing, and the elimination of overbleeding.
He. paid a tribute to Mr. P. L. Oliver, the founder
and honorary secretary of the London service.
The Presipent (Dr. S. C. Dyke) described the
blood transfusion service organised for the Royal
Hospital, Wolverhampton. (His paper appears on
p. 1538.)
STORED BLOOD
Dr. NORAH SCHUSTER (London) described some
of the experimental work on the keeping properties of
blood. She said that the red cells in ordinary citrated
blood remained intact for about 21 days, after which
hæmolysis begins. They could be preserved longer
by adding glucose to the blood, and in certain physio-
logical fluids they had been kept intact for 190 days.
Red cells would remain physiologically active in
the circulation of a recipient animal after having
been kept for 14 days. Red cells could be kept for
four weeks and retain their power of absorbing
oxygen. She described the Russian method of
storing blood taken from a cadaver a few hours
after sudden death, which had the advantage that
more could be collected from the donor, and that
there was no need for the addition of citrate on
account of fibrinolysis. She also described methods
used in France, Spain, and South America for storage
of blood from living donors. The medical service
of the Government forces in Spain in the course of
the present rebellion were using blood stored in
ampoules under a positive pressure of two atmo-
spheres for emergency use on the field. The blood
was usually of Group A or O. It was administered
straight into the vein from the ampoule, usually by
medically unqualified orderlies or nurses. The usual
period of keeping was three to four weeks. Dr.
Schuster showed photographs of the service supplied
through the courtesy of Mr. Oliver of the London
Blood Transfusion Service. Experience showed tha
there was no likelihood of damage from infection or
the development of toxins in blood stored for one
month. She discussed the possible toxic effects of
hemolysis, and referred to experimental work by
Bayliss, from which he concluded that hemolysis, as
such, was not harmful. Dr. Schuster suggested that
it might often be more convenient to collect blood
and store it for emergencies rather than arrange for
donors at short notice.
Dr. R. V. Facey (Bournemouth) stated that he
had on a number of occasions given blood which had
been stored in the ice-chest for various periods.
Nothing untoward had ever happened after six days’
storage. On one occasion after two weeks’ storage
the recipient had shown jaundice and hemoglo-
binuria, but there had been no serious constitutional
symptoms.
Dr. A. F. S. SLADDEN (Swansea) asked whether
the fact that the blood in the Spanish Government
Service was stored under increased atmospheric
pressure might not be the explanation of its keeping
qualities.
Dr. J. OLIVER (London) said he was in the habit
of storing blood in the ice-chest for periods up to
two weeks. During the period of storage, oxygen
was slowly bubbled through the blood. Such blood
for transfusion purposes appeared to have all the
qualities of fresh blood.
Dr. BREWER reported that he had twice seen
severe allergic reactions after the use of stored blood.
He thought that more work was required before the
practice could become a matter of routine.
REACTIONS AFTER TRANSFUSION
Dr. J. A. Boycott (London) described three cases
of anomalous blood-grouping reactions. (1) A blood
of Group AB appeared to be of Group A; the B
agglutinogen being very weak was only demonstrated
later. (2) A patient apparently of Group O was trans-
fused with blood from a donor of that group, but
developed the symptoms of intravascular agglutina-
tion and died; post-mortem examination showed
the usual blockage of the urinary tubules with dis-
organised blood pigment. The recipient’s serum was
subsequently found to agglutinate with the donor’s
red cells in vitro. Both the red cells of donor and
recipient were checked and were found to be inagglu-
tinable by the grouping serum used. It was possible
that the recipient was actually of Group A, or AB,
and that his serum contained anti-O agglutinins.
(3) The serum of a patient apparently of Group AB
was found to agglutinate the red cells of a known
AB subject. Later it was found to agglutinate his
own red cells. On putting up the red cells of this
subject against known anti-A and B serum at incu-
bator temperature no agglutination occurred. Actu-
ally he belonged to Group O and the phenomenon
was that of “cold” agglutination, in this instance
occurring up to: a temperature of 25°C. All these
cases illustrated the danger of placing too much
reliance on grouping alone and the necessity
of careful matching of bloods for transfusion
purposes.
Dr. R. J. V. PULVERTAFT (London) in describing
certain abnormal reactions first referred to some of
the effects of infusion of simple saline. In a number
of cases coming to autopsy after saline infusions he
had found oedema of the lungs and of other viscera,
particularly the heart. He suggested that physio-
1524 THE LANCET]
logical solutions such as that of Hartmann were
preferable to normal saline. Certain reactions after
transfusion of blood were in his opinion allergic ;
he described one case in which a transfusion was
followed by severe urticaria. Four cases of trans-
fusion with incompatible blood were described ; in
no case was the amount infused over 300 c.cm., and
all the patients recovered. Incompatible blood had
been administered owing to wrong grouping, this
being due to loss of potency of the grouping serum
through addition of phenol as a preservative. Dr.
Pulvertaft stated that he had injected doses of
5-20 c.cm. of incompatible blood at weekly intervals
into patients over long periods ; no untoward symp-
toms had developed, and he considered sensitisation
to blood previously given from the same donor an
unlikely cause of reactions. He described four cases
of hemoglobinuria after transfusion in hemolytic
anemia. The infused red cells being normal ought
theoretically not to be susceptible of lysis; perhaps
in these diseases the organism attained a certain
red cell level and on infusion it was the subject’s
own red cells, and not those of the donor, that were
destroyed. After splenectomy. lysis after infusion
. of blood did not occur.
Dr. N. HAMILTON FAIRLEY (London) pointed out
that American figures showed that infusion into an
adult of up to 350 c.cm. of incompatible blood had
never caused death while infusion of 540 c.cm. or
over had always done so. This suggested a critical
level for the disposal of the products of hæmolysis.
_ Dr. SCHUSTER asked why transfusions of blood are
given. Two indications covered all possibilities.
They might be given to replace blood in hæmorrhage
or in certain of the “idiopathic” anæmias with a
view to stimulating in some unknown and unspecified
way the blood-forming organs. One of the com-
monest reasons for which blood was given was
“shock.” In shock without severe blood loss, trans-
fusion of. blood was not required. Far too many
transfusions were being performed.—Many members
expressed their concurrence with this view.
- Dr. JANET VAUGHAN (London) was of the opinion
that transfusions were given far too casually ; many
of the untoward incidents following transfusions
were due to chilling of the infused blood; this was
liable to give rise to in-vivo cold hemolysis.
The PRESIDENT believed that reactions after
transfusion, apart from those dependent on incom-
patibility, were due to inattention to essential details.
The most important of these were temperature of
the blood, the use (in making up solutions) of freshly
glass-distilled water only, and strict cleanliness of
all apparatus. The simpler the apparatus the more
, easily it could be kept clean. On that: account he
used a small glass reservoir from which the blood
was run in by gravity. The rubber tubing employed
was kept in short lengths which were taken apart
for cleaning and united by metal joints for use.
The maintenance of all apparatus and solutions in
readiness for immediate use demanded the super-
vision of one person. Since the appointment of a
single responsible blood transfusion officer reactions
after transfusion had become rare at the Royal
Hospital, Wolverhampton.
TECHNIQUE OF TRANSFUSION
Dr. H. L. Marriott and Dr. A. KEKwick (London)
described the uses of the transfusion of blood in large
quantities by the continuous drip method. The
purpose of the method was to bring the red cells of
the blood up to a suitable level as quickly as possible.
When large quantities of blood were infused slowly
ASSOCIATION OF CLINICAL PATHOLOGISTS
[JUNE 26, 1937.
the red cells remained in the circulation but the
fluid elements were excreted. The principal indica-
tion for continuous transfusion was persistent
bleeding. |
Dr. Lazarus-BARLOow said that i in his opinion the
direct method of blood transfusion was the method
of choice. The blood transfused was less interfered
with in this method than in any other. It did not
entail the exposing of the veins of either patient or
donor. In nearly 400 transfusions, the great majority
of which were carried out by the direct method, no
donor’s vein had been exposed. A Louis Joubé
syringe of 5 c.cm. capacity was used, No. 17 gauge
Record needles being connected to the syringe by
two pieces of thin pressure tubing each about six
inches long. The essential point was to keep the
piston constantly on the move, once the transfusion
had started, in order to prevent clotting. It might
be argued that this entailed giving the blood too
fast, but no ill effects from this cause had been
observed. Dr. Lazarus-Barlow said that, apart
from the impossibility of getting two beds alongside
one another, the only contra-indications were when
a constant drip transfusion was required and when
a comparatively large transfusion was needed in the
case of a patient whose veins were too small to admit
a No. 17 gauge needle.
Dr. R. OFFICER (London) described a method for
post-operative blood and saline transfusion. Patients
recovering from long and severe operations required
large amounts of water and salt ; gevidences of salt
deficiencies could be got from the urine which in
such cases was free from or low in chlorides. Both
blood and saline were administered by the “drip ”
method, and were kept in separate containers; Dr.
Officer had devised a special apparatus by which a
change-over from blood to saline could be effected
without undue admixture of the saline and citrated
blood. This was important as the addition to citrated
blood of saline often led to clotting. As a routine
500 to 700 c.cm. of blood was given immediately on
the return of the patient from the theatre; this was
followed by saline at the rate of 344 pints in each
twenty-four hours for forty-eight hours. In a series
of 27 cases of combined excision of the rectum in
which this technique had been employed there had
been only 1 death.
APLASTIC AN ZMIA
Dr. F. A. Knorr (London), represented in absence
by Dr. Cuthbert Dukes, reported on 4 cases of aplastic
anemia treated by repeated transfusions. Dr. Knott’
pointed out that the blood picture could by this
means be restored to normal, but there was no means
at present of judging whether or not the haemopoietic
system would be capable of maintaining it there.
By a careful study of his cases Dr. Knott arrived
at the conclusion that a continued reticulocytosis.
was a bad prognostic sign, indicating a state of strain
on the part of the hemopoietic system. In three
of the four cases such a reticulocytosis had persisted,
and all had ended fatally: in the fourth case, after
repeated transfusions the reticulocytosis had dis-
appeared and the patient was now doing well.
INTRAVASCULAR HEMOLYSIS
Dr. FAIRLEY gave a report of his observations on-
formation of pseudo-methiemoglobin in intravenous
hemolysis. He pointed out that disintegration
within reticulo-endothelial cells was the normal
physiological fate of the erythrocyte. Lysis in the
blood stream was a pathological event. The clinical
syndrome was characterised by sudden rigor, fever,
THE LANCET]
loin pain, anæmia, hemolytic jaundice, oliguria, and
perhaps. anuria.
of hzmosiderosis, blockage of the renal tubules,
toxic changes in their lining epithelium and, perhaps,
degeneration of hepatic cells. As to the mechanism
involved—extracorpuscular hemoglobin was treated
as a foreign substance. Some 10 per cent. was
excreted through the glomerulus and appeared in
the urine ;
the tubules, methemoglobin and possibly acid hematin
was formed (Dodds). In these circumstances silting-
up effects followed, which led to oliguria, anuria,
nitrogen-retention with high blood-urea and renal
acidosis characterised by a low plasma bicarbonate,
low serum calcium, and high blood phosphorus.
The remaining 90 per cent. appeared to be disposed
of by the reticulo-endothelial cell system and liver,
the oxyhzmoglobin producing hematin which gave
rise to hzmosiderin and hemobilirubin. Excess
of bilirubin led to pleocholia, bilious stools, and
urobilinuria.
Recent work on blackwater fever by Fairley and
Bromfield had shown the presence of another pigment
in the plasma allied to methemoglobin, but having
‘its « band somewhat nearer the blue end of the
spectrum (6240 A°). Unlike methemoglobin this
band was not dispersed with Stokes’s reagent, ammo-
nium sulphide (10 per cent.), ammonia or hydrogen
peroxide (10 vols.). The new pigment was formed
both in vivo and in vitro by the action of plasma
on hemoglobin and was probably an intermediary
product in the formation of hematin. It was not
excreted by the kidneys and from this viewpoint
its formation was a conservative process protective
to the organism.
cases of, blackwater fever and is probably ultimately
formed in all instances of intravascular hemolysis.
MEDICAL SOCIETY OF INDIVIDUAL
PSYCHOLOGY
ArT a meeting of this society on June 10th a paper
entitled
The Psychological Approach
was read by Dr. T. A. Ross. Such an approach, he
said, had two aspects—first the understanding by
the physician of his patient’s illness, and secondly
the understanding by the patient of the origins and
causes of his illness, in so far as these are psychogenic.
As regards the doctor’s understanding of the patient’s
illness, two views may be contrasted. According
to one view there is no psychological approach ;
no suffering can be accepted as genuine unless there
are physical signs, and those who complain of
such suffering should be handed over to the policeman
or the priest—if only these functionaries would do
their duty. According to the second view—as
expressed, for example, by Groddeck—psychogeny
embraces the whole of medicine and is the key to
the understanding of every patient. Whether an
illness be traumatic or microbic, the patient comes
by his catastrophe because he wishes it; the catas-
trophe being preferable to something which it averts.
For Groddeck intention is the key to everything.
But this view is unprovable ; anxiety can be found
in any case with a good history if we look for it
industriously enough, and there are many who
“wish ’ for an illness who do not get it. Indeed,
many obviously refuse the advantage which their
physica] illness might confer on them, and go about
MEDICAL SOCIETY OF INDIVIDUAL PSYCHOLOGY
The pathological lesions consisted .
if a pH of less than 6-4 was reached in =
‘interested in the subject.
It was constantly found in severe .
[JUNg 26, 1987 1525
courageously when they might. well be, and could
be, at rest.
Illness, even if it has not originated psychogenically,
must soon be complicated by events.. The average
man does not want to be ill; he wants to do a lot
of things which illness will stop—to play or watch
football, or play golf, or go to the cinema. Illness
brings fear, anxiety, loss of confidence in his doctor,
resentment against his employers, hope of unearned
increment, and other factors inimical to recovery.
Thus truth, said Dr. Ross, lies intermediately between
the doctrine of physical causation and that of pure
psychogenic causation. It seems obvious that every
patient presents both a mental and a physical prob-
lem. For this reason among others, medical psycho-
logists of all people have much need to look more
at their patients and less at their books. Medical
psychology has suffered of late from having one.
clinical observer of outstanding genius with no one
quite competent to criticise him effectually, and who
is surrounded by a cohort of pretorians ready to
slay any outside critic who arises.
Dr. Ross related that when he began to study the
effect of mind on bodily symptoms he was living and
working in the Isle of Wight, in isolation from others
There were disadvantages
in this; there were also considerable advantages.
There are advantages in having a director super-
vising one’s earlier cases, certainly for the early
patients ; but the pupil tends to become subservient
to the teacher, to lose his critical faculties, to depend
less on the picture provided ,by the patient and more
and more on the master’s ideas. When we come to
the regulation that every would-be therapist must
himself be analysed before he starts treating, we
have come to the end of originality. No one ever
quite recovers from an analysis. The patient may
lose his illness ; but every successful analysis, whether
of patient or of pupil, must result in the more or
less permanent adoption of the analyst’s views.
One may hope to geta number of people well without
making them subjects of transference neurosis ;
which may sometimes be an incurable neurosis,
meaning that the doctor shares the illness with the
patient instead of some member of the latter’s own
family doing so.
All sick persons, said Dr. Ross, demand some form
of psychological approach. Even a sick horse must
be so approached. There are two possible strategic
methods for the psychological approach: one is
analysis and the other persuasion. Whenever we
take a history we probably make an interpretation—
some more skilfully than others—and there is little
difference between this and analysis. Whenever we
give a good, or a guarded, or a bad prognosis we are
using persuasion. Persuasion may be divided into
encouragement and discouragement: each has its
place. There is one pitfall and one only about
encouragement: it may be the last thing the patient
seeks or desires; in that case it may make him
worse. The good doctor must believe in his treat-
ment. No one can give encouragement, unless he is
a rogue, about something in which he has no faith.
The analytic approach is of value in the psycho-
neuroses and in every kind of chronic illness ; who-
ever takes a history is fairly sure to begin to analyse.
In acute illness like pneumonia or measles there is
almost.no analytic approach. The analytic approach
does not necessarily mean a deep analysis; and. a
great number of psychoneurotics can be got to remain
well for years without any knowledge of their infancy,
or young childhood. Deep analysis has its uses ; but
every abdominal pain does not call for a laparotomy.
1526 THE LANCET]
ROYAL SOCIETY OF MEDICINE
SECTIONS OF LARYNGOLOGY AND
OTOLOGY
THE summer meetings of these sections took place
at the Norfolk and Norwich Hospital, Norwich, on
June 18th and 19th. .
At the section of laryngology, with Mr. LIONEL
COLLEDGE, the president, in the chair, a discussion
was held on
Orbital Cellulitis due to Sinus Infection
Mr. E. D. D. Davis, in opening, defined orbital
cellulitis as an acute inflammation of all or part of
the contents of the orbit, characterised by considerable
cdema of the eyelids and conjunctiva. With the
progress of inflammation and suppuration the edema
rapidly increased, the eyeball became immobile and
displaced forwards, and the conjunctiva was so
edematous that it protruded between the eyelids.
On account of the rigidity of the orbital walls the
compression and tension were severe, and were contri-
butory factors in the thrombosis of vessels and
injury to the orbital contents. The condition was
always serious and dangerous, and might terminate
in cavernous sinus thrombosis, meningitis, brain
abscess, septicemia, or optic atrophy. Inflammation
could extend to the orbit by three paths: by direct
spread from the nose through the bone, or along the
ethmoidal vessels; by the blood stream when the
orbital cellulitis was part of a septicemia or pyæmia ;
and by lymphatic spread, but he doubted whether
this occurred. In 54 cases of swelling of orbital
contents sent him by ophthalmic surgeons for exami-
nation of the nose, 24 had suppuration of the frontal
sinus and 15 of the ethmoid, 4 were due to injury,
5 had orbital tumour, 2 optic nerve tumour, and
there was one each of foreign body with abscess,
suppurating cyst, panophthalmitis, and syphilis.
The commonest cause in adults was suppuration of
the frontal sinus, and in children ethmoidal sup-
puration. Pus burst through the thin bony floor of
the frontal sinus, just to the inner side of the supra-
orbital notch, and an orbital abscess was formed
between the bone and the orbital periosteum. In a
similar way, pus from the ethmoidal cells tracked
through the thin os planum or inner wall of the
orbit. In some cases the pus was near the foramen
of the anterior ethmoidal artery ; there was also a
second collection in the affected nasal sinus, and both
collections must be drained. Injury to the orbital
periosteum must be avoided, as it was an effective
barrier between the abscess and the delicate orbital
contents.
Frontal sinus suppuration involving the orbit
produced a downward and outward displacement of
the eyeball, and most of the swelling was over the
floor of the frontal sinus and at the inner third of
the supra-orbital ridge. Ethmoidal suppuration dis-
placed the eyeball outwards. In the majority of
cases there were signs of sinus suppuration, and
pressure on the external swelling might cause pus to
exude into the nose. But a mucocele, which was a
closed distension of a nasal sinus, resembled a tumour
and might not show signs of inflammation, and in
such a case the nose might be normal. A positive
skiagram was a valuable confirmation of the diag-
nosis of sinusitis. When orbital cdema was severe
there was reason to fear cavernous sinus thrombosis.
In this condition the patient was severely ill, with
frequent rigors ; the edema was soft and bluish, and
extended to the other eye and to the face. Diplopia
ROYAL SOCIETY OF MEDICINE:
LARYNGOLOGY: AND OTOLOGY [JUNE 26, 1937
on account of paresis of an ocular muscle was an
early sign. The pupil was dilated, inactive, and
blindness rapidly supervened. It was important to
note whether a primary source of infection, such as
a boil of the face or middle-ear suppuration, was
present. Three of the four cases of injury were due
to direct blows, and in one of the cases the roof of
the orbit was fractured.
Indications of an orbital abscess arising from the nose
were an increasing and brawny œdema of eyelids
and conjunctiva, a fixed and displaced eyeball,
and excessive pain. Its treatment was always urgent ;
there should be no hesitation in operating to bring
about satisfactory drainage. The cornea must be
protected from abrasions, and during the induction
of anesthesia castor oil was dropped into the eye ;
the eye was closed by means of a stitch passed through
the loose skin of the eyelids. A deliberate incision
was made along the inner two-thirds of the supra-
orbital ridge in the line of the eyebrow, and this was
carried down below the inner canthus.- With the
complete arrest of hemorrhage, gentle retraction
and a little dissection enabled the origin of the
abscess to be inspected. When a good exposure had |
been obtained the fistula of the affected sinus was freely
enlarged, and the operation was not complete until
the suppurating sinus had been attacked from the
nose and had been well drained into the latter. He
always removed the middle turbinal, and had never
had cause to regret this. Of the 37 operated cases
34 had made a rapid recovery and were highly satis-
factory. One patient, who had had a previous inci-
sion through the upper eyelid, already had menin-
gitis when admitted and died; another died of
longitudinal sinus thrombosis. In his series the
complications were few. ‘
Dr. S. H. Myainp (Copenhagen) spoke of his
experiences in connexion with 86 cases of acute
swelling of the orbit; the mortality was 16 per cent.
The cause was a sinusitis in 70 cases. The external
operation was carried out in 46 cases and 7 died ;
there were no fatalities, however, in the 24 cases in
which the endonasal operation was done. In 46 cases
in which sinusitis was verified by operation, the
ethmoid alone was involved in 13 and one died ;
in 5 the frontal alone was affected, with no mor-
tality; in one the maxillary sinus was concerned,
in another the sphenoid sinus, and both patients
died. In 26 cases two or more sinuses were affected.
Often it was difficult, he said, to decide whether a
swelling of the orbit was caused by a sinusitis or not,
and there was often no history of nasal discharge ;
aspiration and syringing of the nose might not reveal
pus because of a closed empyema. For this reason
he had operated even on cases of subperiorbital
abscess which had only slight swelling of the mucous
membrane, or in which he found pus only in a single
ethmoidal cell. Abscess might occur at any age,
and there was not necessarily accompanying fever,
even in fatal cases. None of the well-known signs
could be regarded as pathognomonic, and he had
come to rely on an examination of the condition of
the patient as a whole. Prof. Renne had pointed
out that in cases of scarlet fever, in which orbital
swelling was sometimes very alarming, conservative
treatment could nearly always be safely carried out.
In the presence of alarming symptoms it was best to
operate forthwith, as the great danger was eventual
intracranial complications. The frontal lobe of the
brain being a silent area, indications of these com-
plications might be shown too late. On the slightest
suspicious sign, lumbar puncture should be carried
out. In children under 5 the frontal sinus was not
THE LANCET]
usually developed; in others he preferred to open.
not only the ethmoid, but also the frontal sinus. ©
Mr. G. H. HOWELLS said that the commonest site
of the primary infection was the anterior ethmoid.
At first there was a pure edema, which had no line
of demarcation ; hence it was unwise at this stage to
embark on any drainage operation, as this carried
the risk of infecting fresh tissue.
be as conservative as possible, an attempt being
made to drain the sinus by the natural route—namely,
into the nose, and inhalations, sprays, &c., were
useful. Conservative treatment, if begun early, gave
considerable prospect of success. It must be
realised that surgical complications might arise even
after the orbital symptoms had subsided. In cases
secondary to osteoma—which might be in the frontal
sinus or ethmoid—free drainage through the orbit
should first be established, then the offending tumour
removed after the subsidence of the acute stage.
He had not found it necessary to close the eyelid
by means of a stitch; he had placed a pad of gauze
over the eye when operating, and instilled Argyrol
during convalescence, and this, he found, kept the
eye clear. A drainage-tube he had always found
useful; he brought it down through the nose, and
kept it in position for four days. The antrum on the
affected side was punctured and washed out on
alternate days until the washing was clear.
Mr. F. C. W. Carrs said he did not consider a case
to have orbital cellulitis unless proptosis was present,
indicating an abscess. This ruled out cases of edema
of the upper eyelid and supra-orbital region asso-
ciated with acute sinusitis without true involvement
of intra-orbital tissues. While agreeing that sup-
puration was a definite indication for external opera-
tion, he could not always feel sure that this had
occurred. When in doubt he incised the orbit,
preferring in. these cases the route favoured by
ophthalmic surgeons in draining orbital cellulitis,
leaving the periosteum alone.
The PRESIDENT said that sometimes a small
puncture was made in these cases without finding
pus, but operation revealed that the frontal sinus and
ethmoid were full of pus. He spoke of the great
change for the better in the outlook of these cases
after the use_of Prontosil.
Early Bronchiectasis in Children
Dr. J. H. Esss (Birmingham) read a paper on the
relation of early bronchiectasis to ear, nose, and
throat diseases in children. His material had been
gathered from 200 cases; 42:5 per cent. of these
had gross infection of one or more accessory sinuses,
and 66:3 per cent. had evidence of purulent infection
of the middle ear. Whooping-cough and measles
accounted for a large proportion of the cases of
bronchiectasis in children, but ulcerative bronchitis
and severe broncho-pneumonia were the direct causes.
The danger period was the first two years of life ; in
360 cases of pneumonia 80 per cent. were under two,
a third were without symptoms, a third had pul-
monary catarrh. The younger the child, the more
severe was its lung condition ; respiratory affections
caused more damage in infancy than at any other
period. The most important factor in all these cases
was infection of the bronchi, and here there was a
constant reinfection. But not all cases of bronchitis
and pneumonia proceeded to bronchiectasis. The
pathology of bronchiectasis pointed to a hope of
relief of symptoms, probably to cure, if adequate
treatment was begun at an early stage. In the
chronic stage the only hope lay in removing or
destroying the diseased area. Most cases occurred
Treatment should:
ROYAL SOCIETY OF MEDICINE: LARYNGOLOGY AND OTOLOGY [JUNE 26; 198} 1527: °
among children of the poorer classes:.who: had bad -
homes; there was a great need of more convalescent.
homes in the country to which these children could.
be sent. In Switzerland very good ‘results. followed.
short residential treatment, and the recognition of
the causal connexion of sinus infection. with the
upper respiratory tract conditions gave real. hope for
a tangible lowering of the incidence of these diseases
in young children. )
The Ear, Nose, and Throat in Children’s
Diseases
Dr. BranrorpD Morean (Norwich) said that,
apart from syphilis and tubercle, the common infec-
tions arose from the upper respiratory and urinary
tracts and the skin, the first-named vastly pre-
ponderating. A simple rhinopharyngitis might suffice
to cause refusal of feeds, with vomiting and diar-
rhea. Authorities had insisted on the almost con-
stant infection of the ears which resulted from naso-
pharyngitis in the infant, in whom the short and
wide Eustachian tube provided an easy path for
organisms from throat to ear. He paid particular
attention to the relationship between gastro-enteritis
and ear infections, especially to the question whether
the ear infection was due to vomitus spreading up
the Eustachian tube. Referring to the modern
tendency to refrain from treating acute mastoiditis
as a surgical emergency, he asked whether by post-
poning the operation the liability to meningeal or
intracerebral infections was increased. - He had
recently seen cases in which meningitis had rapidly
followed an aural infection, and in which, on opening
the mastoid, comparatively slight disease was found.
A number of children brought to hospital because
they were constantly catching cold had allergic
rhinitis, and some had a latent infection of the
sinuses ; their temperature was raised, with head-
ache and a feeling of stuffiness. These symptoms
abated when free drainage was instituted.
Tuberculous Ulcerations of Mouth-and Pharynx
Mr. F. C. ORMEROD said that when the tonsil
and fauces were affected with tuberculosis the out-
look was always grave, and a fatal termination could
be expected in two or three months. Tuberculous
disease of the tongue, however, was a more curable
disease, and the life of the patient with this was
considerably longer than with faucial tubercle. When
the floor of the mouth, the gums, and lips were
involved the outlook was definitely more serious.
Of 17,000 cases of ulceration referred to the throat
department at Brompton Hospital, 12,000 were
tuberculous, and in the same time there were 3120
cases of tuberculosis of the larynx, 20 of the tonsil,
32 of the pharynx, 20 of the tongue, 4 of the post-
nasal space, 2 of the lips. The age of attack in
mouth and pharynx cases was slightly younger than
in tubercle of the larynx—namely, 20-30 as against
30-40. Tuberculous disease in pharynx and mouth
was, nearly always, a complication of very severe
disease in the lung; it could often be taken as a
sign that the patient’s resistance to tubercle was
breaking down. The chief symptom in the pharyn-
geal cases was the extreme pain, the difficulty in
swallowing, and the distressing quantity of saliva
formed, which the patient was constantly feeling the
impulse to swallow, though it was such a painful
process. An exceedingly serious type of lesion was
ulceration of the posterior pharyngeal wall. In some
cases this extended upwards into the postnasal
space, and laterally on to the posterior pillar of the
fauces, so that whatever the patient ate or drank
1528 THE LANCET]
it was impossible to steer the food clear of an ulcerated
area, and unless some remedial measure was carried
out death from starvation might take place. In most
of these cases the prognosis was very bad. It was
useless to attempt to treat these cases as out-patients ;
they required thoracoplasty, or paralysis of nerve,
or artificial pneumothorax, or at least sanatorium
treatment. The best local measure was diathermy,
carried out under cocaine, anesthesia; in many
cases this enabled comfortable swallowing to be
carried out for a time.
- At the meeting of the section of otology, presided
over by Dr. DOUGLAS GUTHRIE, a paper on some
Problems of Aural Medicine
by Dr. Myaeinp and Dr. D1pA DEDERDING was read
by the former. | The treatment of the non-surgical
diseases of the ear, he said, had not got far beyond
the catheterisation of the Eustachian tube of 200
years ago. This. was possibly due to the dramatic
evolution of aural surgery, but perhaps in part, too,
to an erroneous conception of the localisation and
nature of a series of non-suppurative ear diseases.
The usual interpretation of the findings from acoustic
tests needed revision. Perception deafness was
characterised by a lowering of the upper limit, but
only if there was a lowering by bone conduction as
well as by air. . Hearing of the high-pitched whispered
voice was more severely impaired than the hearing
of the low-pitched conversational voice. On the
other hand, sound-conducting deafness was charac-
terised, in the first place, by an elevation of the lower
limit, the upper limit in the less severe cases being
preserved.. The double testing of upper limit of
hearing by air and by bone became the best method
of distinguishing between a sound-conducting and
a sound-perceiving affection. In 721 cases 89 per
cent. had a sound-conducting affection, 3 per cent.
were defective in sound perception, and in 8 per cent.
there was a combination of the two. His colleague’s
and his own investigations had shown no sharp line
of separation between affections of middle ear and
those of the labyrinth. On examining cases of so-
called neuro-labyrinthitis the cochlear nerve was
found to be intact; the labyrinth was affected, as
shown by vestibular signs and frequent tinnitus, but
the lesion was localised peripherally to the perceiving
organ itself; the middle ear was also involved.
Many cases of apparently ordinary tubal stenosis
or middle-ear catarrh were accompanied by laby-
rinthine symptoms, not only tinnitus, but also ver-
tigo and nystagmus. He was convinced that both
NEW INVENTIONS
[JUNE 26, 1937
in Méniére’s disease and many other sound-conducting
affections one was dealing with a disturbance of the
vascular function, especially in the capillaries. As
a result there was a hydropic swelling of the inade-:
quately nourished cells. If such a patient were
dehydrated, either by excessive perspiration, or by
diuretics, his hearing would be found to improve.
The ear was often found to be the site of a morning
edema, which wore off during the day’s activities.
The object of the paper was to present an explanation
based on clinical, anatomical, and physiological
phenomena for conditions found not only in the ear
but in all parts of the body, the prime causal agent
being vascular. The object to aim at in treatment
was to train by stimulation the capillaries of skin,
muscles, and lungs to a higher capacity.
Dr. PHYLLIS KERRIDGE read a paper and gave
gramophone demonstrations on
Hearing and Speech in Deaf Children -
She had been instrumental in testing the hearing
of 500 children in schools for the deaf in London by
means of the pure-tone audiometer, and in some
cases by other means also, so that methods could be
compared. This capacity or incapacity was corre-
lated with the intelligence, the age; and other factors.
As a result it was estimated that three-fourths of
the children in schools for the deaf would benefit
from the use of suitable sound-magnification instru-
ments. The hearing power of the children by air
and by bone conduction was tested at eight pitches,
and the results correlated with the medical history
and the degree of speech proficiency.
Mr. HAMBLEN THOMAS, in a paper on the
Physical Aspects of Tinnitus
defined tinnitus as the response of the auditory part
of the 8th nerve to abnormal stimuli. The causes
‘of this were many, and little accurate information
was available as to what they were. Causes could
be classed as either extrinsic (arising outside the
ear) or intrinsic. The former included muscle move-
ments outside, and sounds coming through the
Eustachian tube. Intrinsic causes included vascular
conditions and hyperesthesia of the 8th nerve, and
perhaps the abnormal action of currents. Whatever
.might be discovered in respect of physical causes of
tinnitus was likely to be of help in these distressing
cases, which were sometimes so severe that the
patients committed or attempted suicide.
During Friday afternoon some twenty cases were
inspected and discussed, and in the evening members
dined together.
NEW INVENTIONS
AN IMPROVED AND INEXPENSIVE
CULTURE BOTTLE
FOR THE PREPARATION OF VACCINES
Roux bottles have almost completely replaced
other forms of culture bottles when a solid medium
is used, particularly in the preparation of vaccines.
The ordinary type have, however, a number of
. disadvantages :—
Firstly, they are expensive, varying in price from 27s.
to 35s. per dozen. The cheaper varieties rely entirely on
the thinness of the glass for their heat-resistant properties,
and in consequence are extremely fragile; they have to
be handled with the greatest of care and there is the
attendant risk. It has therefore been safer and more
economical to use the stouter but more expensive varieties.
4
Secondly, the mouth requires to be plugged, and when
vaccines are being made on a large scale this occupies much
time.
Thirdly, the agar is inclined to slip in the bottles, so it
has become customary to incubate them lying flat with the
agar lined side downwards and the growing surface of the
agar pointing upwards. This is not good practice, for water
condenses on the upper and inner wall.of the bottle in
large drops which eventually fall on the surface of the
agar below. The constant drip damages the surface of the
agar and results in some agar being retained in the sus-
pension when the growth is eventually washed off. This
can be avoided to some extent by giving the bottles a slope
while they are being incubated, but even so slipping of the
agar is likely to occur. The retention of even small
quantities of agar in the finished vaccine is in my opinion
one of the most potent causes of those severe reactions to
. T.A.B.C. vaccine that are occasionally experienced.
THE LANCET]
It was considered, therefore, that some sort of
screw cap bottle might be used with advantage.
To have such a bottle made was out of the question
as the cost would have been prohibi-
tive. Accordingly experiments were
made with various types of bottles
available commercially. Of those
tried a bottle made by the United Glass
Bottle Manufacturing Co., London,
and catalogued by them as ‘“‘ bow
panel” 32 oz. was found to be very
satisfactory, and the cost is only
44s. per gross.
This bottle measures 84 in. from
bottom to shoulder, is 4 in. wide and
1} in. deep. The bottom is flat externally
and has a low convex surface internally.
One side of the bottle is flat and the
other low concavo-convex from within
outwards. On the flat side externally
there is an oblong depressed area which
corresponds to a raised area on its
internal surface. This peculiarly indented
panel, together with the convex internal
surface of the bottom, holds the agar
firmly after it has set. The neck of the bottle is
14 in. long and the mouth has an internal diameter of
3 in. which is covered with an aluminium screw cap. As
supplied by the manufacturers this cap is fitted with a cork
and grease paper washer.
The whole bottle is constructed stoutly of clear
glass through which any medium inside the bottle
and the characteristics of any growth on such can
be easily seen. The Figure shows the internal and
external characteristics.
METHOD OF USE
The cork and grease paper washer must be removed from
the aluminium cap and replaced by one of rubber. The
bottle is thoroughly washed with soft soap solution,
rinsed with tap water, then with distilled water, and
sterilised in the autoclave at 120°C. for 1 hour. While
being sterilised the screw cap is in position but not screwed
REVIEWS AND NOTICES OF BOOKS
[JUNE 26, 1937 1529
tight. After sterilisation 130 c.cm. of sterile agar is poured
into the bottle and autoclaved at 115° C. for 20 minutes.
The bottle is then laid on the bench flat side downwards
on an incline of about 3°, so as to give the agar a slight
slope from the bottom towards the neck, and the cap is
screwed down tight. The screw cap with its rubber washer
prevents any evaporation of the water of condensation, &c.,
and media can be stored ready for use in these bottles for
short periods without fear of deterioration from this cause.
After the agar has set each bottle is incubated for 24 hours
at 37° C. as a test for sterility. While being incubated they
are placed in the incubator so that the flat agar-lined side
is uppermost. The surface of the agar available for growth
in these bottles is equivalent to four-fifths of that obtained
in a Roux bottle of 1000 c.cm. capacity. By using a
two-way metal screw cap fitting similar to that employed
by McCartney,' by means of which air can be with-
drawn and replaced by CO, or any other gas that may be
desired, these bottles can be adapted for the seuieure of
micro- aerophilic organisms, &c.
These bottles have certain darmos They
are heavy and they cannot be sterilised in the hot-air
oven. It might be thought that the airtight fitting
screw cap would lead to such a deficiency of oxygen
in the bottle in the presence of rapidly growing
aerobic organisms that a poorer growth of these
organisms would result. It was found that in actual
practice, where only 24-hour cultures are used for
vaccines, this was not the case and indeed heavier
suspensions were obtained per square cm. of growing
surface than from the Roux bottle. These bottles
have been put through an extensive trial at the
Medical School, Royal Naval College, Greenwich,
and have been employed in the preparation of
70,000 c.cm. of T.A.B.C. vaccine. During this period
420 of these bottles were used and in no instance
was trouble experienced with slipped agar. These
bottles can be obtained fitted with aluminium caps
and rubber washers ready for use from A. Gallenkamp
and Co., Ltd., London.
S. G. Ratsrorp, M.D. Dubl.,
Surgeon Commander, R.N.
1 McCartney, J. E. (1935) Lancet, 2, 1476.
REVIEWS AND NOTICES OF BOOKS
A Manual of Radiological Diagnosis
By Ivan C. C. TCHAPEROFF, M.A., M.D., D.M.R.E.
Camb., Assistant Radiologist and-Radium Registrar,
St. Thomas’s Hospital, London. Cambridge :
W. Heffer and Sons. 1937. Pp. 256. 21s.
In this book Dr. Tchaperoff has attempted with
considerable success to set out clearly the typical
radiological appearance of any disease, so that
rapid reference can be made to it. The work will
thus be useful not only to the student preparing for
examination but to the busy radiologist wishing to
refresh his knowledge of a particular lesion. In the
scope afforded by 250 pages the reader will not
expect to find full. descriptions of the rarer
abnormalities, but he must be prepared for certain
omissions of more consequence. Fractures are
only very briefly considered; there are only two
lipiodol pictures of the chest and no arteriograms.
It is disappointing, also, to find no pictures of ulcer
deformities of the duodenum and in the last chapter
(3 pages) on tumours of the spinal cord and ventriculo-
graphy, only one abnormal ventriculogram.
The work is well planned. In the introductory
chapters the author refers to several technical points
which will help the inexperienced reader to interpret
films. In each section of the book a description
of the normal appearances precedes discussion of
the various pathological appearances recognisable
by X ray examination. The differential diagnosis
is outlined with the description of the lesion. Each
section is freely illustrated and the abnormalities
in the radiograms are clearly demonstrated by
numbers. The book is a practical addition to
radiological literature.
The Morphine
Treatment
Second edition. By G. Laucuton Scorr, M.R.C.S.,
B.A. Oxon., late Senior Physician, London Neuro-
logical Clinic ; late Chief Assistant, Guy’s Hospital
Neurological Department. London: H. K. Lewis
and Co. 1937. Pp. 106. 5s.
Dr. Laughton Scott’s method of treatment of
morphine addiction consists of covering the gradual
withdrawal of the drug by means of increasing doses
of belladonna. In this second edition of his book he
has introduced a brief discussion of the physiology
of this method of treatment. He points out that the
effect of morphine upon the addict is to stimulate
the vagus, while its narcotic action tends to dis-
appear. Consequently a shortage of supplies of the
drug means the diminution of vagal control and
sympathetic over-action. The physiological object
of treatment, therefore, is to redress the disturbance
Habit and its Painless
1530 THE LANCET]
of autonomic balance by increasing doses of bella-
donna,' a drug which, given in this way, exercises a
stimulating, instead of its usual depressing, effect
upon the vagus. Dr. Scott describes his technique
in detail, particularly emphasising the importance
of careful management during convalescence, which
is essential to prevent relapse. He contrasts the
absence of shock associated with this method, which
has given excellent results in his hands, with the
effect of older and more drastic methods. He does
not, however, describe treatment with insulin, which
is employed with a similar effect upon autonomic
balance, nor the use of the drug ‘“‘ rossium ” for which
good results have been clainied, especially in the
United States. This book will undoubtedly be
useful to those faced with the difficult task of treating
morphine addiction.
When Temperaments Clash
By MURDO MACKENZIE, M.D., M.R.C.P., Physician
for Psychological Medicine, St. John’s Hospital,
Lewisham, and the Wilson Hospital, Mitcham.
London: Thos. Murby and Co. 1937. Pp. 227.
. Ts, 6d. s A |
Tis small book deals in a non-technical. manner
with the subject of *“ nerves ” and seeks to describe
the symptoms and to explain the causes of this modern
curse. The early chapters contain an account
of neuronic instability and the resulting “ anxiety-
apathy cycle,” with examples drawn from everyday
experience. Later Dr. Mackenzie discusses in detail
the fundamental components of temperament, pace,
and sense of value, and holds that everyone is by
natural bias a craftsman, an advertiser, a dealer,
or an administrator according to whether his pace
is deliberate or immediate and his sense of value one
of simplification or of amplification. Neuronic
instability results when the individual's natural bias,
through ignorance or compulsion, is prevented from
acting freely and is used in defence instead of for
progress, and when, instead of codperating with the
opposite temperaments with which he comes in
contact, he clashes with them. To make the most
of his natural bias, the individual must consciously
or unconsciously know what it is and must be able
to release it to the full.
The book is presumably intended mainly for the
layman and probably for this reason Dr. Mackenzie
is inclined to repeat his arguments and to multiply
his instances to what may seem an unnecessary extent,
perhaps thereby showing that his natural bias is
towards amplification rather than towards simplifica-
tion, but apart from this defect, the medical reader
will find much of interest and value in its explanation
of common problems.
Latent Syphilis
And the Autonomic Nervous System. Second
edition. By Grirritu Evans, D.M. Oxon., F.R.C.S8.,
D.O.M.S., formerly Hon. Surgeon, Caernarvonshire
and Anglesey Infirmary. Bristol: John Wright
and Sons. 1937. Pp. 158. 7s. 6d.
Mr. Griffith Evans’s work is based upon the belief
that the diagnosis of syphilis ought not to be restricted
to those cases which satisfy one of the three customary
criteria—namely: (1) the Wassermann test; (2)
demonstration of spirochetes; (3) gross pathog-
nomonic lesions. It is not altogether clear what
are his further diagnostic criteria, but his views on the
importance of syphilis in the etiology of many dis-
orders are indicated in a table which shows that
REVIEWS AND NOTICES OF BOOKS
[JUNE 26, 1937
syphilis is responsible for 27 per cent. of cases of
“ blanching of the extremities,” over 30 per cent. `
of cases of diseases of the thyroid and of asthma,
63 per cent. of cases of ‘‘ congestion of the extremities,”
and 100 per cent. of (six) cases of purpura. Syphilis
appears also, in his view, to be an important cause of
“ the chronic abdomen” and of cancer. Osler once
said that if you know syphilis, you know clinical
medicine: Mr. Evans seems to regard the two as
identical.
Canning Practice and Control
By Osman JONES, F.I.C., Chief Chemist, C. and T.
Harris (Calne) Ltd.; and T. W. Jones, B.Sc.,
Editor the Industrial Chemist and Food. London:
© Chapman and Hall. 1937. Pp. 254. 25s.
CANNING in this book is limited to foodstutis
put up in metal containers. In their preface the
authors describe it as a bench book and their aim is to
make it of practical value to the canner, In this object
they have succeeded ; but a large part of the book
is a technical treatise which will appeal also to the
works chemist. About 87 pages deal with factory
and mechanical questions while more purely laboratory
matters occupy about 131 pages.
On the practical factory side the authors deal very
comprehensively with their subject. The chapter on
the cannery and its equipment is a good illustration
of its quality. This chapter deals, amongst other
things, with single versus multi-storeys, the position
of the factory, and the mechanical equipment.
The location in country or town depends a good deal
upon the nature of the food to be canned. The
requirements of each type of food canned are con-
sidered separately. Such important matters as the
type and size of can, the nature of the tinplate,
and the use of lacquer are discussed. The
important question of lacquer might have received
more comprehensive treatment with advantage.
Rather more space might have been devoted to
the life of canned foods. On the other hand an
excellent account is given of “ hydrogen swell.”
Cannery waste and cannery hygiene are treated in
separate chapters. ‘The effect of canning upon
nutritive values is discussed in rather a tentative
way; as the authors point out our knowledge on
this aspect of the subject is still far from complete.
~ The chemical, bacteriological, and microbiological
aspects are dealt with in considerable detail. Indeed
some questions, such as the ordinary chemical
examination methods for water, might have been
omitted with advantage as they are so fully described
in the ordinary text-books on the subject. The
more technical matters which specially apply to
canned foods, such as testing for leaks, tinplate
examination, metallic contamination, and the detailed
examination of the raw food products, are all
adequately considered. On the bacteriological side
the authors do not seem quite decided as to the
significance of aerobic spore contamination and in
holding that these are causes of spoilage hold views
not in accord with those of most bacteriologists.
The treatment of B. botultnus in relation to canned
foods omits much of value and in view of its great
importance should have received much ampler
treatment.
On the whole the volume is likely to be of great
practical utility and should help to make canning a
less empirical and a more scientific procedure. It
should be of material service both to the food canner
and to the technical experts associated with the
manufacturer.
THE LANCET]
THE LANCET
LONDON: SATURDAY, JUNE 26, 1937
THE GENERAL REGISTER OFFICE, 1837-1937
In the publicity attending the centenary of
the General Register Office much has been heard of
marriage registers, something of census taking and
a little, a very little, of medical statistics. In this
office our thoughts turn naturally to the romance
of medical statistics rather than to that of the
Fleet and Mint registers of marriages (now, we
understand, in the custody of the General Register
Office) because, had it not been for the founder
of THE LANCET, we might not now be celebrating
a medical-statistical centenary. On June 29th,
1839, we published a leading article on the first
report of the Registrar-General. Its writer said:
“ Magendie has starved rabbits, poisoned dogs,
cut their nerves, drained their veins, and investi-
gated the effects of reagents upon their blood :—
thousands of frogs and cats, sparrows, chickens
and mice, geese, pigeons and turtles have been
sacrificed, not cruelly—not to gratify carnivorous
propensities—not to seek superstitiousindications,—
but in the -hope of surprising the mysteries and
laws of vitality. The Lecturer of the College of
France, in the plenitude of his zeal would, however,
never think of rendering men the subjects of his
experimental crucifixions.”” ‘“‘ But,’ continues the
writer, “in the present state of society are not the
experiments from which the physiologist would
shrink—and which he would not dare to name,
or which he would not think of proposing,
performed upon a large scale? . . . . What variety
of occupation and exercise can the experimentalist
require that is not practised upon the hills and
the plains, in the factories and the potteries,
under the earth and on the seas? .... And
must it be that because we can only observe these
phenomena, and cannot experiment, that they
‘are to be neglected ?”’ One sees to what this is
tending and how it must have rejoiced the heart
of young Mr. Farr. Indeed as there are two
Latin quotations, a reference to augurs and to
-men of such widely different celebrity as MAGENDIE
and UDE, one might even ‘conjecture that—but
we need not do so. Anyhow the founder of THE
LANCET believed in Farr and said in the very
next issue: “The pages of this Journal have
frequently been enriched by statistical contri-
butions of Mr. Farr, and we feel much pleasure
in recording our approbation of the article now
‘before us, which cannot fail to lay a lasting founda-
tion of honour for its learned author.”
Indeed we may fairly look upon Farr’s career
with some parental pride. In our columns he
commenced author, we rejoiced in his later achieve-
ments, over the way in which he really did drive
home to the sanitarian the lessons to be learned
from experiments in the factories and the potteries,
THE GENERAL REGISTER OFFICE, 1837-1937
[s0nn 26, 1937 1531
the results of which were recorded in the registers.
Perhaps we might even claim that Farr’s associa-
tion with journalism served him well. Nicely
educated young men of this age who eschew super-
latives, true-blue civil servants whose principles
forbid, them to come nearer the crudity of “I
think ”?” than is expressed by “it may, perhaps,
-be thought,” find Farr a trifle flamboyant. But
nobody could find him dull. The belief that
medical statistics are dull reading will not, we hope,
survive Dr. Braprorp Hinw’s book. Anybody
needing further reassurance should turn over
Annual Reports of the Registrar-General in Farr’s
time. One of the last of his “ Letters to the
Registrar-General on the Causes of Death,” that
for 1876, contains an essay on that topical subject
maternal mortality. From the statistical and
historical point of view it is profitable reading.
In collecting materials for his statistical study
Farr had perused the details of individual cases.
There was one, of a death from flooding due, it
would seem, to the practitioner’s negligence.
Farr obtained, and printed, a moving letter from
the dead woman’s husband. A prudent official
would have left it without comment or, at most,
have added ‘it is, perhaps, to be regretted that.”
But the old journalist’s blood was stirred and he
wrote : “ In recollecting her pale lips and blanched
cheeks as she lay, the tears rushed to her ANER S
eyes.
In questa forma
Passa la bella donna e par che dorma.,
Such fearful cases should be judged by the Medical
Council.”
Farr’s genius. „ide medical statistics a science.
His training helped him to make others share in
. human sorrows, the events of which were merged
into averages. Carefully avoiding a Latin quota-
tion which he would surely have made, we will
say that Farr was never in any danger of forgetting
in statistical analysis the real object of collecting
statistics. The work he began has grown so great
that, whether we like it or not, idiosyncracies of
expression, however charming, must be eliminated
from official documents.. Now it is for the readers,
not for the compilers, of official medical statistics
to realise what is behind these serried ranks of
numbers. i
BLOOD TRANSFUSION
It is now about twenty years since transfusion
was established on a sound basis and became an
accepted part of medical and surgical routine.
No figures are available for the number of trans-
fusions yearly performed in this country but it
must run into many thousands and is rapidly
increasing. In 1921—the year of its inception—
the London Blood Transfusion Service arranged
a donor for 1 transfusion; by 1931 the number
had risen to 2078, and this year it will probably
prove to be more than three times greater. For
the country as a whole the increase is probably
very similar. But whereas the needs of London
have been admirably met by the comprehensive
service directed by Mr. P. L. OLIVER, the provision
of donors in other districts has usually had to be
1532 THE LANCET] BLOOD
organised by individual hospitals. The work is
apt to devolve upon the hospital’s pathologist,
and any who have to start or control such a service
will find valuable ideas in Dr. S. C. DyKz’s account
of the one established at the Royal Hospital,
Wolverhampton, which appears on p. 1538. This
service was organised for the hospital, and is
maintained free of charge to it, by the Wolver-
hampton Rotary and Round Table Clubs which
thus put into effect their motto “service for all.”
The example has already been followed by other
rotary and round table clubs both in this
country and abroad and deserves further emulation.
It is a pleasant fact that donors are seldom
lacking when urgently required; but even with
the most perfect organisation the delivery of
blood by donors in their own person entails diffi-
culties and inconvenience, and it would obviously
be a great advantage if suitable blood could be
stored for use as required. At the Hastings meet-
ing of the Association of Clinical Pathologists,
reported on p. 1523, various speakers recorded
experience pointing to the conclusion that untoward
reactions are to be expected after the use for
infusion of blood stored under ordinary ice-box
conditions for. more than a week; but far more
information on the subject should soon be available
from Russia and from Spain, where stored blood
is widely used. Much of the blood used in Spain,
apparently with success, is stored under a positive
pressure of two atmospheres.’ Dr. J. O. OLIVER,
of St. Thomas’s Hospital, reported that by bubbling
oxygen through stored blood he had been able
to keep it in a state suitable for infusion for at
least a fortnight, and the question arises whether
the oxygen tension may not be the determining
factor in the preservation of the blood for infusion.
Of more immediate interest to most of us, how-
ever, is the continuing possibility of “ reactions ”’
after transfusion of fresh blood, leaving aside
those due to gross incompatibility. In the past
there has been too great a tendency to regard these
as necessary evils. In Russia, where transfusion
is largely practised, reactions appear to be both
frequent and severe. BoOGOMOLETZ? attributes
them to a mysterious process of “‘ colloidoclasia ”’
in the infused serum, and thinks them more or
less inevitable. His paper is largely a statement
of this view, which appears to be orthodox in
Russia, and a polemic against HEssE and Fimarov,
both recent immigrants into the Soviet Union,
by whom the reactions are attributed to errors
in technique such as chilling of the infused blood,
improper preparation of solutions used, and lack
of cleanliness in .the apparatus. This view is
hotly contested by BoGOMOLETZ, but most workers
in this country will agree with HEssE and Fmatov.
As Dr. JANET VAUGHAN pointed out in the course
of the discussion at the Hastings meeting, many
transfusions are performed very casually. To
secure such attention to detail as is required to
ensure a perfect technique, Dr. Dyker believes
that the whole transfusion service of a hospital
1 See Lancet, June 5th, 1937, p. 1359.
2 Bogomolctz, A., Journal médical (Acad. des Sciences de la
R.S.S. d'Ukraine: Inst. de Physiol. clin.) 1937,
TRANSFUSION
[JUNE 26, 1937
should be the responsibility of one person, pre-
ferably a senior resident officer; and he reports
that since this has been done at the Royal Hospital,
Wolverhampton, reactions after transfusion have
almost disappeared. It is worth pointing out that.
the importance of avoiding the chilling of infused
blood is now so well recognised that in skirting
Scylla some have been dragged into Charybdis.
Only a week or two ago Prof. S. L. BAKER recorded
in our own columns * a death following infusion of
overheated blood.
The number of transfusions given increases by
leaps and bounds, but are they all really required ?
The general opinion at the Hastings meeting was
that they are not, and there can be little doubt
that many patients are given blood that would
have been far more useful to others. The primary
indication for infusion of blood is to replace blood
lost by hæmorrhage. Sudden loss of blood, to an
extent that will not cause dangerous exsanguina-
tion, is often followed by a degree of ` shock,”
and many transfusions are performed for such
shock where the actual loss of blood is not serious.
It is increasingly clear that such patients, though
they need fluid, do well—perhaps better—without
transfusion. It is also questionable how far it is
useful to transfuse blood in the so-called idiopathic
anemias with a view to stimulating the hemo-
poietic system, but here at least there is little
likelihood of doing harm. Transfusion is likewise
often employed in acute and even chronic septic
states, and here again its value is doubtful. Finally,
it is used by no means seldom because things are
desperate and transfusion seems a good sort of
thing to do. Clearly there is room for much better
definition of its appropriate application.
NEUTRALISING ANTIBODY IN
POLIOMYELITIS
THERE is ample evidence that virus infections,.
whether natural or experimental, call forth specific
antibodies just as bacterial diseases do. The
relation of these antibodies to immunity has
been closely studied and it is generally agreed that
in many virus infections, at any rate, they play
an important part; the practical application of
this is seen in the passive prophylaxis of a disease
like measles. It was thought at one time that
infection with the virus of poliomyelitis gave rise
to the production of specific viricidal antibody
which was necessary for combating the infection
and preventing reinfection ; indeed it was on this
assumption that convalescent serum was used
in the hope of arresting the infection at an early
(preparalytic) stage. The fact that the serum of
many adults who have never suffered from polio-
myelitis contains antibody has been attributed to
subclinical infection; just as the majority of
adults, especially in our urban populations, acquire
diphtheria antitoxin without having ever had
manifest diphtheria, so also they might acquire
poliomyelitis antibodies through mild unrecognised.
attacks of the disease.
3 Baker, S. L., Lancet, June 12th, 1937, p. 1390.
THE LANCET]
‘During the past few years, however, evidence
has been accumulating which suggests that the
happenings in poliomyelitis are not in accord with
this orthodox belief. The therapeutic use of
convalescent serum, despite earlier favourable
reports, is now looked on with scepticism by the
majority. This change of front has been due to
the negative clinical results obtained in America
by PARK and his colleagues,’ and also to a better
understanding of the route by which the virus
of poliomyelitis reaches the susceptible cells in the
central nervous system. The apparent failure of
convalescent serum to affect the course of the
disease is not surprising if it is accepted that the
virus infects via the olfactory nerves—which,
it reaches either by way of the olfactory hairs or
the olfactory cells—and that its spread thence to
the susceptible cells in the central nervous system
is axonal; for from the very earliest stage of
infection the virus is intracellular and therefore
protected against specific antibody. The idea that
antibody is unimportant in resistance to infection
with poliomyelitis virus finds further support in
the experimental work of SCHULTZ and GEBHARDT °
who have shown that the monkey passively
immunised and possessing adequate circulating
antibody is little less suceptible to infection by the
nasal route than the normal animal. Fresh
information is now provided in a paper by BRODIE,
FISCHER, and STILLERMAN® recording
observations on the incidence of neutralising
antibody in poliomyelitis. They tested for anti-
body by intracerebral inoculation in monkeys
of serum-virus mixtures, two strains of virus being
employed, a monkey passage strain and a recently
isolated human strain. Their investigations failed
to show any relationship between the presence of
antibody in the blood and resistance to or recovery
from infection. Antibody was found in the acute
stage of the disease in 32 out of 114 cases—in 2
Trans. Ass. Amer. Phys. 1932, 47, 123.
5 Schultz, E. W., and Gebhardt, L. P., J. Pediat.1935, 7,
8 Brodie, M,. FEE A. E., and Stillerman, M., J. clin.
Invest. May, 1937, p.
1 Park, W. H.,
PSEUDO-METHÆMOGLOBIN
their
[JUNE 26, 1937 1533
of these the serum was obtained in the pre-
paralytic stage of the disease—and out of 39
patients with residual paralysis who had had no |
protective substances in their blood in the acute
stage of the disease, only 2 developed antibody
during 12-16 months’ observation.
Observations like these reported by BRODIE
and his colleagues have been made before by others,
and it appears that neutralising antibody may be
present early in the disease, probably before its
onset, and that infection often fails either to
influence the titre of pre-existing antibody or to
evoke its production in those in whom it is initially
absent. From what has already been said about
the route of infection followed by this virus it is
understandable that the presence of neutralising
antibody should be without much influence either
on the incidence or the course of infection. Whatis
rather disturbing is the complete lack of correlation
between infection and the development of anti-
body. As we have said, this is not the first time
that the discrepancy has been noted and it has
led some workers to doubt the specific nature of
the neutralising antibody and to suggest that its
development is the outcome of physiological
activities.4 The problem is of course not confined
to: poliomyelitis, for we are faced with a similar
difficulty in the interpretation of the origin and
significance of the so-called normal antibodies.
Are these the result of infection or is some other
mechanism responsible for them? The evidence
available does not allow of a definite answer,
but for the time being it would perhaps be a
mistake too readily to abandon the orthodox
view. As far as poliomyelitis is concerned,
might not antibody be merely a by-product of
infection, the response to that variable amount of
virus which gains access to tissues other than
those of the central nervous system? This might
account for the irregularity of its development.
Meanwhile, however, we remain in ignorance of
the mechanism of immunity to poliomyelitis.
4 Jungeblut, C. W., and Engle, E. T., J. Amer. med. Ass.
1932, 99, 2091.
ANNOTATIONS
PSEUDO-METHAEMOGLOBIN
ELSEWHERE in this issue, in a report on p. 1523,
brief mention is made of a paper read by Dr. Hamilton
Fairley to the Association of Clinical Pathologists,
describing the occurrence of pseudo-methemoglobin in
blackwater fever. Dr. Fairley and Dr. J. J. Brom-
field made a further communication on the same
subject to the Royal Society of Tropical Medicine
and Hygiene on June 17th. Quite apart from their
bearing on blackwater fever the observations now
reported appear fundamental to the understanding
of hemoglobin metabolism. Like all real advances
in science they raise many new and exciting problems.
In 1934 Fairley and Bromfield first noted in the
plasma of a patient suffering from blackwater fever
& previously unrecognised pigment closely related
to methemoglobin but differing from it. This pig-
ment produced a chocolate-coloured blood, with a
brown plasma ; it was absent from washed corpuscles
and did not appear in the urine. Prof. David Keilin,
to whom the pigment was sent, regarded it as a modi-
fication of methemoglobin in which the globin portion
of the molecule had been altered, undergoing some
irreversible change. Its spectrum has the general
appearance of methzemoglobin, but the bands are
shifted about 60 Angstrém units towards the short-
wave end of the spectrum, and it has none of the
properties of methemoglobin when tested with
Stokes’s reagent or ammonium sulphide. Recently
Fairley and Bromfield have continued their investi-
gations on a large group of cases of blackwater fever
in Macedonia, a country which might from their
accounts be described as the hematologist’s paradise.
They found this new pigment, which they have
named pseudo-methemoglobin, constantly present in
the plasma in all severe cases of blackwater fever.
In the past it has been mistaken for methemoglobin.
It is never found in corpuscles and is apparently
formed from oxyhemoglobin only after its liberation
1534 THE LANCET]
from the red blood-cells. The investigators were
able to produce it in vitro by incubating solutions of
oxyhemoglobin, methemoglobin, or sulphemoglobin
at 40°C. for 24 hours or longer in the presence of
sterile plasma. They believe that it is in no way
peculiar to blackwater fever, but will probably be
found in the serum in any condition in which there
is sudden severe hemolysis, such as cold hemo-
globinuria, possibly: acute hemolytic anzmias,
and in incompatible blood transfusions. It does not
appear in the urine. Methzemoglobinuria is common
in blackwater fever, but the methzmoglobin is derived
from oxyhemoglobin after it has traversed the
glomeruli and does not result from methzemoglo-
binemia. It is known that the presence of large
amounts of oxyhemoglobin in the plasma leads to
serious renal damage with injury. of the renal
tubules due to precipitated pigment and consequent
anuria and often death. Fairley and Bromfield
suggest therefore that the conversion of free oxyhamo-
globin into pseudo-methemoglobin is to be regarded
as a conservative action on the part of the body,
since pseudo-methemoglobin does not itself pass
through the kidneys and in its formation reduces
the amount of oxyhemoglobin available to damage
these organs. This reaction, they suggest, is the
first stage in a hitherto unrecognised mechanism by
which the body disposes of circulating extracorpuscular
blood pigment. Why the cells in blackwater fever
are hemolysed is still not known. What property
or factor in the plasma induces the formation of
pseudo-methemoglobin remains to be discovered.
Why in some patients oxyhzemoglobin is not con-
verted into the less dangerous pseudo-methzemoglobin
in sufficient quantity or with sufficient speed to
prevent renal damage is also not known. As Fairley
himself suggested, the recognition of this mechanism
opens up the possibility that a drug may be found
that will convert oxyhemoglobin into the more
harmless pigment when the body’s own processes
fail.
Many must have felt as they listened to Dr. Fairley .
that he and Dr. Bromfield with a company of hema-
tologists should pack their bags at once for Macedonia
to try to answer some of the questions their work has
raised. |
COMPATIBLES IN THE MENU
FEw doctors in this country can have escaped being
asked at some time or another. what they think of the
Hay diet. The questioner is more often an acquaint-
ance than a patient, and the question casual rather
than serious; for the person who intends to follow
directions given in his newspaper does not want to
hear his regular medical adviser say that these are
unreasonable. Dr. W. H. Hay and his business
associates have shown, if nothing else, that there are
a great many people who can readily be persuaded
to follow such directions; with suitable assistance
one simple idea can be made to go a very long way.
Dr. Hay’s idea—or, as some call it, bugaboo—is that
carbohydrates and proteins should not be eaten at
the same meal, because protein (he says) increases
the gastric secretion of acid and so hinders the
digestion of starch by the saliva. The delayed
digestion of carbohydrate is supposed to allow
fermentation to take place and the acids (of secretion
and fermentation) are absorbed into the circulation,
causing almost every known ailment and eventually
death. This month Dr. Eugene Toldes ? of New York
has demonstrated how completely experience and
1 Hygeia, August, 1936, p. 683. _
2 Rev. Gastroenterol. June, 1937, p. 125.
COMPATIBLES IN THE MENU
[JUNE 26, 1937
experiment contradict this theory. The amount of
hydrochloric acid secreted after taking carbohydrates
is not very different from the amount secreted after
taking proteins. Even if there were a significant
difference an increased amount of hydrochloric acid
in the stomach would not wholly interrupt starch
digestion ; and even if it did so, fermentation in the
stomach would not follow. If there were any
fermentation it would be in the intestines rather than
the stomach, and it would not lead to the production
of significant quantities of acid; nor is there any
reason to believe that the body would be unable
to cope with such acids even if they formed in larger
quantities. So far then there is no evidence to
substantiate the theory. Against it are the intimate
mixture of protein and carbohydrate in many natural
. foods, the fact that contents of the stomach ferment
only where there is achlorhydria, and the comparative
harmlessness of ‘“‘ acids ” in a ketogenic diet except
in one or two well-defined conditions like diabetic
coma. The chief danger run by followers of the
Hay diet is that they may reduce the protein in their
daily ration unsuitably. = |
THE BLOOD AT HIGH ALTITUDES
Krupski and Almasy! have been studying the
influence of high altitude on the physiology of the
blood. The material of their research consisted of
two men aged 45 and 33, two women both aged 25,
a bull-calf aged 4 months, and a goat aged 6 years.
These spent 83 days at Zurich, 19 days on the
Jungfraujoch (11,200 feet), and 27 days again at
Zurich. Like other workers, Krupski and Almasy
found that the rise in altitude brought an increase
in the red blood-cells, not exceeding 15 per cent.
The maximum increase for the four volunteers and
the goat was in the second and third week; for the
calf it was in the first week. The human beings
also showed individual differences. On going down
into the valley the red cell counts returned to normal.
The. reticulocyte count increased during the first
week’s residence at high altitude and diminished
during the second week. An important fact was
that the maximum amount of hemoglobin in all
four persons was reached during the second week
they remained at a height—that is, at a time when
the reticulocyte count had already decreased, In the
calf and the goat no reticulocytes were observed in
any of the three periods, but this is not interpreted
as meaning that there was no increase in bone-marrow
activity. The nunfber of leucocytes was hardly changed
at a high altitude, but a decrease of lymphocytes was
noteworthy and all investigators are agreed on an
increase of neutrophils, such as Hartmann discovered
at over 10,000 feet in the Himalayas. The Jung-
fraujoch counts showed neutrophil-lymphocyte ratios
different from those described by Hartmann at the
same altitude. At the high altitude the calf and the
goat had no diminution of lymphocytes, but a relative
increase of neutrophils. (A high lymphocyte count is
normal in goats and cattle.) A slight increase of
monocytes was noticed in three of the human beings
and the two animals. During the residence on the
Jungfraujoch hardly any deviation from the normal
was apparent in eosinophils and basophils. This
corresponds with Hartmann’s observations. Serum
of both the animals showed a negative bilirubin
reaction (Ehrlich-Proscher) not only in the valley
but also at a height and even after considerable
reduction of the erythrocyte count in the third period
1 Krupski, A., and Almasy, F., Helv. med. Acta, February,
1937, p. 94.
THE LANCET]
at Zurich. Determination of the dry substance of the
plasma showed that the changes in the red blood-cell
count are seldom due to loss of water from the plasma,
The comparison of oxygen capacity with carbon
monoxide capacity of normal blood, used for the
determination of hæmoglobin, showed agreement.
The oxygen capacity is normally proportionate to
the red blood-cell count, any deviation from this
being expressed in the average oxygen capacity
per erythrocyte (SK E—Sauerstoffkapazitaét pro Ery-
throzyt). In the valley when the red ‘ivod-cell
count was raised SKE diminished and vice versa ;
on the Jungfraujoch when the red cells rose SKE
rose too. The influence of intensive walking exercise
at medium and at high altitudes was investigated
on three occasions in one individual. The number of
leucocytes was much increased on two of the expe-
ditions and on the third remained unaltered. It is
‘to be noted that there was a decrease of lymphocytes
and an increase of neutrophils. On the third
expedition, after 14 days at high altitude and five
hours’ strenuous exercise, there was no definite
increase of reticulocytes.
. Authorities do not agree about the effects of the
altitude on the oxyhxemoglobin absorption bands seen
in spectroscopy of the blood, but during residence on
the Jungfraujoch the oxyhxemoglobin absorption
bands almost always showed an increase, both in
humans and in animals.
MEDICAL PROTECTION
THERE should be no need to harp upon the advisa-
bility of joining a professional defence society. Mem-
bership has become particularly important since the
passing of the Law Reform (Miscellaneous Provisions)
Act of 1934, whereby the estate of a deceased person
may now be made liable to claims based on some act
or fault during his life-time. Whether or not the
sponsors of this so-called law reform intended merely
to give a remedy to the victims of fatal accidents in
‘* running down ” actions, the recent case of Rubra v.
Connolly has shown that the widow of a doctor may
be adjudged liable to pay heavy damages out of his
estate for some alleged default by her dead husband
in the course of his practice. The medical defence
societies have consequently been extending their
benefits so as to give the personal representatives
of a deceased member all such privileges as would
have been available if the member were still alive.
The report of the London and Counties Medical
Protection Society, presented at the annual meeting
on June 16th, rightly draws attention to this
new risk of practice. In addition it repeats much
salutary advice of a general kind.
their own interests should refer matters imme-
diately to the society before dealing with them in
any other way. Not for the first time the practitioner
is urged to secure X ray examination in all cases of
injury which may have caused fracture or dislocation
or to provide proof that X ray examination was
advised but refused. He should also, tiresome as it
may be, keep accurate records of all work done for
individual patients at the time when treatment is
carried out. This advice applies even to dental
practitioners who see a casual patient of whom they
have no knowledge. <A defence society can be seriously
embarrassed in the task of defending a dental member
through want of accurate entries in his dental charts.
Many a panel doctor would have been saved anxiety
if he had made systematic entries on ‘his record
cards, especially entries of visits to patients. It is
not mental anxiety alone that the incalculable risks.
of litigation inflict. Financial loss is also involved.
MEDICAL PROTECTION.—ALLERGY AND NEPSRITIS
Members in
[JUNE 26, 1937 1535
Reports of a defence society’s operations, describing
legal action taken to check or defeat some claim
against a professional man, frequently have occasion
to record that the claimant was a person without
means and that it was useless to attempt to recover
the costs. When a society takes up a case, it pays
all the costs of its member, whether he be plaintiff
or defendant, and whether he succeeds or not. If
the society recovers damages for a member, he
receives them without deduction. Societies can offer
these advantages because members’ subscriptions
make them possible. The bigger the membership,
the greater its resources for mutual protection.
ALLERGY AND NEPHRITIS
REFERENCE was made in these columns a year ago !
to the experimental production of a .glomerulo-
nephritis, histologically similar to Bright’s disease
in man, by the injection of heteronephrotoxins.
This work, originally brought into prominence by
Matsugi, was confirmed in Edinburgh by Arnott,
Kellar, and Matthew using rabbits. The method
they adopted, in brief, was to subject rabbits to a
series of intravenous injections of duck’s serum, the
ducks having previously received. numerous intra-
peritoneal injections of a suspension of rabbits’
kidneys. The rabbits so treated showed a glomerulo-
nephritis closely comparable to human Bright’s
disease. The experimental facts may now be taken
as established, but the mechanism of causation
remains doubtful. Most observers seem to agree
that the nephritis is an allergic manifestation, but
this statement leaves us in some doubt as to what
actually takes place in the body. Amongst points
awaiting clarification are the following. First, we
need to know whether the “ nephrotoxin ” is specific
for the kidney or whether comparable effects can
be produced by sera prepared from other organs.
Klinge and Knepper consider that it is only one of
several factors required to induce sensitisation and
is not specific. Next, it has been suggested that
the effect on the kidney is due to a hemolysin evoked
by blood included during the preparation of the
serum. But Arnott, Kellar, and Matthew perfused
the kidneys of their rabbits with saline to remove
blood ; it therefore appears that a hemolysin can
be excluded in their experimental nephritis. Other
workers, however, state that when perfused organs
are used a tubular degeneration only is induced by
the prepared serum. Lastly, it is claimed by Knepper
that the so-called localisation of allergic response
can be observed after the use of mechanical, thermal,
pharmacological, and hormonal factors.
A theory deserving close attention is that advanced |
by C. E. Kellett,? who suggests that the mechanism
involved in this experimental nephritis is that of
“reversed anaphylaxis.” By this, as he has explained
in an earlier paper,’ it is understood that the ana-
phylactic reaction ensues when circulating antibody
unites with antigen which is fixed to the cell—in
contrast to the usual type of reaction in which the
antibody is fixed to the cell and the antigen is in
the circulation. Kellett thinks that the procedure
involved in the experimental nephritis under con-
sideration closely mimics the mechanism of reversed
anaphylaxis. Glomerulonephritis in man, he sug-
gests, may result from a reaction between antibodies
elaborated by the body in response to an infection
and the toxins resulting from that infection which
have become fixed to the tissues, more particularly
1 Lancet, 1936, 1, 1078.
2 Ibid, 1936, 2, 1262.
3 J. Path. Bact. 1935, 41, 479.
1536 THE LANCET]
the kidney which is concerned in their elimination.
While this hypothesis is as yet unsubstantiated it
is of interest that Kellett finds ? a sharp fall in the
complement in a small series of cases of acute Bright’s
disease, suggesting that an extensive antigen-antibody
reaction has taken place. No comparable fall was
found in a contro! series, including cases of chronic
nephritis. The -whole subject of experimental neph-
ritis and so-called ‘‘ nephropathy ” has recently been
ably reviewed by H. Horn.‘ His comment upon the
production of nephritis by parenteral injections of
proteins and nephrotoxins is as follows :—
“ Repeated parenteral injections of protein have beei
shown to produce marked glomerular and tubular changes
and occasionally to result in the reactivation of the mesen-
chymal elements of the interstitial tissue. The results
with isonephrotoxins and autonephrotoxins have been
inconclusive. With heteronephrotoxins, on the other hand,
marked abnormalities of the renal structural units have
been obtained, their distribution and intensity varying
with the dose:of the injected material. The significance,
however, of the hemolytic factor which seems to be com-
mon to all serums employed in these experiments has not
been definitely shown. . . . In spite of this, the pictures
described indicate that the presence of a state of hyper-
sensitivity is largely responsible for the appearance of
the more widespread changes and seems to substantiate
further the contention that tissue allergy is essential for
the production of a diffuse non-suppurative renal lesion.”
CHEMOTHERAPY OF STREPTOCOCCAL
INFECTIONS
EVERY week now sees fresh developments in the
chemotherapy of streptococcal and other bacterial
infections, and the situation is becoming increasingly
complex in two distinct ways. In the first place, the
supremacy of sulphanilamide, which is the active
derivative of the original Prontosil and has superseded
it in therapeutics, is now being challenged by other
related compounds, and on present information it
seems scarcely possible to assess their relative merits
even in streptococcal infections alone, while their
wider potentialities, at least in the clinical field, are
almost completely unknown. Dr. G. A. H. Buttle
and his colleagues reported in our issue of June 5th
some preliminary observations on two new com-
pounds, diaminosulphone and dinitrosulphone, the
efficacy of which in relation to their toxicity is greater
than that of sulphanilamide, at least in experimental
infections in mice. Another compound, p-benzyl-
aminobenzenesulphonamide, marketed in this
country under the name of Proseptasine, entered the
therapeutic field some time ago with less experimental
backing than that which has accumulated in con-
nexion with sulphanilamide, and the results reported
by Dr. L. E. H. Whitby (p. 1517) in this issue are
accordingly welcome as confirmation of its experi-
mentally demonstrable efficacy. The chief advantage
of this compound is that it is decidedly less toxic
than sulphanilamide, at least as measured by deter-
mining the maximum tolerated dose in animals.
Favourable clinical reports on it have appeared in
France: Bloch-Michel, Conte, and Durel,5 for
instance, treated 180 cases of erysipelas with excellent
results. Let it not be supposed, however, that these
are the only compounds related to sulphanilamide
with which experimental and clinical research will
have shortly to deal: for other reports are already
appearing in which freshly synthesised compounds of
this nature are mentioned as yielding promising
initial results.
4 Arch. Path. 1937, 23, 121, 241.
5 Ann. Méd. January, 1937, p. 62.
CHEMOTHERAPY OF STREPTOCOCCAL INFECTIONS
.Lancefield’s serologic group A.”
[JUNE 26, 1937
A greater variety of infections are also being
treated. While the hemolytic streptococcus is still
the outstanding organism of proven susceptibility,
experimental evidence justifies the adoption of this
treatment in meningococcal meningitis, although
clinical reports on its effect are still scanty, and in
mouse infections there has been experimental success
with bacteria of the enteric group and with the
pneumococcus. According to Branham and Rosen-
thal € the combined use of sulphanilamide and serum
is more effective than either alone in pneumococcal
and meningococcal infections in mice. We also
noted last week a paper by Dees and Colston of
Baltimore, describing a degree of success in the
treatment of gonorrhea with sulphanilamide that
has evidently impressed and perhaps surprised these
authors themselves. There are thus three genera of
bacteria—streptococcus, bacterium, and neisseria—.
which include one or more species susceptible to the
action of these drugs, and it is not unlikely that
others will be included shortly.
The Council on Pharmacy and Chemistry of the
American Medical Association has now published a
report ? briefly setting forth the steps by which the
present position has been reached and approving
sulphanilamide ‘‘for inclusion in New and None
official Remedies as a therapeutic agent for the treat-
ment of infections by hemolytic streptococci of
This report also
adopts ‘‘ sulfanilamide ” as the non-proprietary name
for p-aminobenzenesulphonamide, and deplores the
coining of a variety of proprietary names for it. The
Council finally announces its intention to “ proceed
with determining the acceptability of the various
brands that have been submitted.” This is likely to be
no small task, and if the scope of the inquiry comes
to embrace other related compounds it will strain
the resources of the greatest medical organisation of
the world to their utmost. That there is no official
organisation in this country capable of conducting
such an inquiry on the scale which may shortly be
necessary makes us dependent on the work of indi-
vidual observers; but they can at all events claim
a very large measure of success in advancing this
research within the past year.
A COMFORTABLE CURE OF THE OPIUM HABIT
WHATEVER adjectives their exponents may have
applied to the various methods of treating opium
addiction, it is doubtful whether any but the lecithin-
diet method has been described as comfortable.
Wen-Chao Ma and his colleagues, who treated a
number of Chinese opium-smokers in this way and
applied to it this epithet, found that, even when the
patients remained at home without restrictions, the
majority lost their desire for the drug in the course
of a few days. The method, being both simple and
inexpensive, was clearly worthy of further trial, and
such has now been accorded it at the Carmichael
Hospital for Tropical Diseases at Calcutta by R. N.
and G. S. Chopra.® They treated in all 200 patients
varying in age from twenty to seventy years, 80 in
hospital and 120 in the out-patient department,
2 being opium-smokers, 1 a morphine addict, and
the remainder taking opium by the mouth. Before
starting on the special diet a careful history was
taken and each patient had a thorough physical
¢ Branham, S. E.,.and Rosenthal, S. M., Publ. Huh Rep.,
Wash. May 28th, 1937.
ee ‘Amer. med. Ass. May 29th 1937, p: 1887.
8 Ma, W.-C., Ni, Y.Y., and Kao, H. C., Far-East. Ass.
Trop. Med. Trans. (Ninth Congress) Sere val. ii, P 381.
® Chopra, R. N., and Chopra, G. S., Gaz. May,
1937, p. 265.
-
THE LANCET]
examination, any septic or toxic foci found being
dealt with during the period of observation following
treatment. In order to reduce withdrawal symptoms
- to a minimum it was found best to give lecithin and
glucose on the day before the opium was to be com-
pletely withdrawn. One pill containing 10 grains of
lecithin (Ovo Lecithin, Merck) was given three times
a day, usually for the first five days, and 25 c.cm.
of 25 per cent. glucose was given intravenously each
morning for the first three or four days, glucose then
being continued by the mouth. The diet otherwise
consisted of fluids only for the first two or three days,
light solids rich in protein and lecithin being added
later when these could be taken. Usually no treat-
ment was required after a week, but in-patients were
kept under observation in hospital for 10-20 days
and later they were seen as out-patients for 1-3
months or longer, while they were accustoming
themselves to a drug-free existence. During the
withdrawal period, especially on the first day, most
of the addicts suffered more or less from pains in the
body and limbs, nausea and vomiting, constipation
or diarrhoea, cardiovascular and vasomotor dis-
turbances, “ spermatorrhea,” insomnia, or anorexia
which required symptomatic treatment, the severity
of these symptoms depending largely on the mental
condition. The younger addicts and those who had
not acquired a high tolerance showed, as might be
expected; the best results, and of the entire series
70 per cent. were completely cured and a further
10 per cent. were able to reduce their dosage by
four-fifths. In only 2-5 per cent. was there complete
failure, and only 2:5 per cent. relapsed within six
months of discharge. It was concluded that the
lecithin and glucose considerably reduced the risk,
intensity, and duration of the withdrawal symptoms,
and the method appears suitable for ‘‘ mass treat-
ment” and one which can be tried in the addict’s
house if his faithful coöperation is ensured.
MAGNESIUM AND VASCULAR SPASM
EVIDENCE that spasm of the terminal arterioles
is concerned in a number of human diseases—notably
in nephritis—has been accumulating steadily. If
only the physician had at his disposal means of
checking such spasm it is evident that considerable
therapeutic advances might become possible. In
this connexion some experiments by Rubin and
Rapoport ! deserve attention. It is well known that
ergotamine tartrate, by causing intense vasocon-
striction, can produce gangrene of the rat’s tail.
Rubin and Rapoport found that this gangrene is
preceded and accompanied by a rise in systolic blood
pressure. This is almost certainly a manifestation
of generalised vasoconstriction, and the rat treated
with ergotamine is therefore a useful test animal
for studying the effect of various factors on vascular
spasm. The investigators, having previously shown
that the magnesium ion is capable of preventing the
contraction of plain muscle both in vivo and in vitro,
decided to study its effect on ergotamine hyper-
tension. A group of rats were accordingly fed on a
diet containing 2 per cent. of magnesium carbonate,
a proportion too small to cause diarrhea. After
three weeks the blood pressures were measured and
subcutaneous injections of ergotamine tartrate were
given. The blood pressure remained within normal
limits, although control rats, which received similar
treatment but no magnesium, developed gross hyper-
tension. Magnesium did not, however, protect the
1 Rubin, M. I., and Rapoport, M., Arch, intern. Med. April,
1937, p. 714.
MAGNESIUM AND VASCULAR SPASM
[JUNE 26, 1937 1537
animal from gangrene of the tail. In further experi-
ments it was found that animals protected by mag-
nesium developed hypertension when the latter was
withdrawn, and, conversely, that established hyper-
tension in control rats could be corrected by adding
magnesium to the diet. It seems fairly certain that
magnesium exerts its effect by relaxing the peri-
pheral vessels, and the question arises whether the
spasm of human disease is likely to respond to such
simple measures. Magnesium salts have of course
been used by physicians for centuries, and it seems
incredible that dramatic reductions of blood pressure
of the order of those observed by Rubin and Rapoport
could have been overlooked. On the other hand the
human alimentary tract does not absorb magnesium
very easily and it is possible that parenteral adminis-
tration might be more useful.
MR. J. G. KETCHEN
THE Hospital for Sick Children, Great Ormond-
street, has lost a good friend by the death on May 15th
of John Gavin Ketchen in his eightieth year. In
early life-he was representative in London of several
important provincial newspapers and knew many
of the great Victorian statesmen and men of letters.
He was fond of travel and became a fellow of the
Royal Geographical Society. But in later years it
was in the philanthropic world that he was best
known; for his sympathetic personality and his
courtesy made him a formidable ‘“‘ beggar ” for good
causes, and he was responsible for collecting the large
sum of £500,000 for the Earl Roberts Memorial with
which he was associated. In 1923 he became financial
secretary at Great Ormond-street, and shortly after
his appointment he was able to obtain the support
of the Prudential Assurance Company for a research
department lately instituted there. He also interested
the late Mr. Bernhard Baron and the late Sir Basil
Zaharoff in the work of the hospital, and it benefited
much thereby. In his appeal work he was greatly
helped for many years by his daughter; but he was
well aware of the importance of a personal approach,
and he would often work until midnight writing
letters with his own hand which rarely failed to
persuade his correspondents that it is more blessed
to give than to receive. Late in life he became a
Freemason and achieved the rare—perhaps unique—
distinction of becoming Master of his mother lodge ©
at the advanced age of 78.
On Thursday, July 8th, at 3 P.M., Queen Mary will
open the new medical block of St. Bartholomew’s
Hospital. It is to be called the King George V
building.
THE third annual exhibition of the Medical Art
Society will be held at the Royal Society of Medicine
during the first fortnight in July. It will be open at
noon each day (except Saturday) from Thursday,
July lst, to Wednesday, July 14th. Admission is
free without ticket.
THE out-patient arrangements committee of King
Edwards Hospital Fund for London have this week
ssued a memorandum on Time-saving Methods in
connexion with Arrival and: Registration of Out-
patients. The committee, over whom Dr. H. Morley
Fletcher presides, say that much has been done to
shorten the interval between the patient’s arrival
and his interview with the doctor, but they have
many suggestions to offer for further improvement.
The report may be had from Geo. Barber and Son,
Ltd., Furnival-street, E.C.4, at 14d. post free.
1538 THE LANCET] `
[JUNE 26, 1937
SPECIAL ARTICLES
THE ORGANISATION OF A
VOLUNTARY HOSPITAL BLOOD
TRANSFUSION SERVICE *
By 8. C. Dyke, D.M., F.R.C.P.
PATHOLOGIST AND DIRECTOR OF THE BLOOD TRANSFUSION
SERVICE, THE ROYAL HOSPITAL, WOLVERHAMPTON
A READILY available supply of blood for the
purposes of transfusion is a necessity for every
hospital of any size. Beyond the technical difficulties
of withdrawing and storing it in a sterile state there
appears to be nothing against the establishment of
depots of bottled or canned blood; but to solve
these difficulties will involve considerable labour and
expense and until they are solved hospitals must
depend upon blood brought to them by donors on
the hoof. This demands a corps of readily available
donors and the means of getting them when required
to the hospital in the shortest possible time.
In London the requirements of the hospitals are
met by the London Blood Transfusion Service. In
some large towns the British Red Cross has taken on
the organisation of blood transfusion services. In
most places the establishment and maintenance of
the hospital blood transfusion service will fall upon
that officer of the hospital who feels it incumbent
upon himself to undertake it.
Experience in the organisation of the transfusion
service of the Royal Hospital, Wolverhampton, may
prove useful to those who are struggling with the
same problem elsewhere and is therefore here recorded.
The service was first organised some ten years ago ;
a plea was made through the press for donors and
met with a good response. As a result a roster of
about 50 was established. All donors not only gave
their services free but also arranged for their own
transport to and from the hospital. Most of them
were working men, and often the giving of their
services entailed to them pecuniary loss not only in
the cost of transport but also in time lost from work.
For the most part these donors responded readily
when called upon, and on no occasion was any com-
plaint of time and money lost or any demand for
remuneration received. The hospital is deeply
indebted to them.
The service was run from the pathological depart-
ment of the hospital and as transfusions increased
in frequency became an ever-increasing addition to
the work of an already fully occupied department.
Difficulties involving the expenditure of much time
and energy were perpetually arising in getting hold
of donors, and, particularly at night, in arranging
transport. It became evident that the organisation
and maintenance of the service could no longer
depend entirely upon the staff of the pathological
department.
On the suggestion of the house governor, Mr. W. H.
Harper, the needs and difficulties of the hospital in
this respect were laid before the then president of
the Rotary Club, Mr. J. Whitehead. To him the
state of affairs immediately presented itself as an
opportunity for putting into effect the club motto
“ Service for All.” He called a meeting of the
Rotary Club at which the director of the service
was given an opportunity of explaining what was
* Contribution to discussion at the summer mecting of the
Association of Clinical Pathologists, Hastings, June 12tb, 1937.
required ; the appeal met with a gratifying enthusi-
astic reception. A similar address was given to the
affiliated Round Table Club and as a result the two
clubs undertook to organise not only a donor but
also a transport service.
The organisation of the combined service was
delegated to Rotarian E. G. Matthewman and Tabler
L. R. Guy, both of Wolverhampton. The result of
their efforts has been:to place at the disposal of the
Royal Hospital a blood transfusion service, with
associated transport service, which have since worked
and continue to work with the utmost efficiency and
—so far as its hospital end is concerned—with
amazingly little effort.
TRANSFUSION OFFICER
In order to secure so far as possible the efficient
working of the service on the hospital side and in
particular with a view to ensuring that withdrawals
Form 1
ENROLMENT FORM-—BLOOD DONOR
I freely offer myself for Blood Transfusion, and undertake to be ready to proceed to
The Royal Hospital when called upon.
DATE oe Go SiICNED ht i a eet
Mr.
Mrs.
Furr NAME MISS. ec eececescecteeee ene, ACE.
ADDRESS ooo anaes acca oneone anneme aaa
If a member of any Social Service Organisation. Please give particulars „...n....nnnoonannnn nmm
meme cree COSC C RTC LC CoN NERS OTST ENERO tS escanos s emee ORO BOD ES enoa STRESSES SOT CREDOSE RESO RE RER SCORSESE ee teetara ness mmes eanet 1 oemet at earr oaenes tonta namana aea o aare maa
Days and times when it is convenient for me to have Group Test taken at The Royal Hospital
‘as set out below :— l
HOSPITAL PURPOSES ONLY.
Date and Time appointment suggested ...........
eat eee e en we tae anena- Boren cenen te met Sent OES etr LOR ONE te otera mmIeT Sem. een eee
Fiume Carp COMPLETED sy...
of blood were made by someone thoroughly experi-
enced in the procedure, the hospital established the
post of blood transfusion officer; this is combined
with that of resident assistant pathologist. The
duties of this officer are defined as follows :—
1. The transfusion officer shall work under the super-
vision of the director of the transfusion service.
2. He/she shall have charge of the files of donors and of
transport and of all other documents in connexion with
the service.
3. He/she shall deal with the enrolment of new donors
and shall see that on enrolment their blood groups are
ascertained, the Wassermann reaction examined, and the
results properly and punctually recorded.
4. He/she shall see that all solutions necessary for the
performance of transfusions and all the apparatus required
for the withdrawal of blood and in the performance of
transfusions is available in the laboratory and in a condition
for immediate use.
5. Unless either a member of the honorary staff or the
resident assistant surgeon expresses his intention of doing
so, it shall be the duty of the officer to withdraw the
blood from the donor.
THE LANCET]
DR. S. C. DYKE: VOLUNTARY HOSPITAL BLOOD TRANSFUSION SERVICE [JUNE 26, 1937 l 1539
6. If called upon to do so, the transfusion officer shall
either him/herself perform the transfusion or shall assist a
member of the honorary staff or the resident assistant
surgeon in its performance.
ORGANISATION
The smooth working of tlie organisation has largely
depended upon the series of enrolment and record
forms designed by its secretaries. The methods of
business organisation are strange to most medical
men and it may be worth describing these forms in
case they may prove useful to others.
_ Form 1 is filled in in duplicate on enrolment by the
donor and handed over to one of the secretaries. It
gives times convenient to himself at which the.
- volunteer can attend at the pathological department
for examination of his blood. The original is for-
‘warded to the house governor of the hospital, who
after consultation with the blood transfusion officer,
fills in Form 2 and sends it to the volunteer in
question.
Form 3 is filled in when the volunteer arrives at
the pathological department. The upper portion of
this form gives details of the availability of the
volunteer; the lower portion is devoted to medical
details of his blood group and general suitability.
On completion this form is forwarded to one of the
Form 3
prv BLOOD DONOR
NAME IN FULL
Form 2
BLOOD TRANSFUSION SERVICE
Där e nne E
The Board of Management of the Royal Hospital tender to
you their grateful thanks for your kind offer to become a member
of the Blood Transfusion Service.
In order that the usual teft may be. taken will you kindly
attend here 09 wn nm .the__. :
Btu eeeeeenee Please ask for... liek sists ate Be ten te ENS
who. will take the tes.
Yours very truly,
HOUSE GOVERNOR & SECRETARY
To
secretaries by whom Form 3a is filled in. This is the
final record and is a filing card. It is kept in four
colours, each of which indicates one of the four
- blood groups. The appro-
priately coloured and
designated card is filled
in according to the data
supplied on Form 3.
Besides reproducing the
information given on
Form 3 it includes par-
POET ORE ET ORO MEST, ERATI TIEI ERTA A Depta... ticulars of services ren-
E a a aa aa EE E A E T ANE T . dered, as follows: date;
ene A ET LEN ee RT LUNTR RM nT Deen ee Sane ney TC tee TC ar a ener ine z - amount withdrawn; by
Telephone Exchange............-.-.--en-o-oomoooo---oooccocnnsoseeeme NOsaoncooneeoo00eeeeae A Telephone Exchange a... eesceencccseneecesseeeee | (a whom ; for Case No. ;
S nn E T T remarks on withdrawal ;
Any well known Landmark for guidance of Drivers ..........--..--------—----- ] Any well known Landmark for guidance of Drivers ............—........ P date when service certifi-
PEAASI EEO EER NIOEN REAA IO TE A ELIEL EI ORS EERE ROIT AEE N | PES IIE PERE POLPRA ORRE E ENEI ESEA EE A ooansseedsnens dees = cate was forwarded.
= USUAL BUSINESS HOURS.
FA I PE cE cde te,
Times or special occasions when NOT available
(exclude Business Hours)
PEE EAE
AEE E EEE A E E
a ern A a a Muara ated wee
VEE EARE EAI ESEA aaa E E IEA
PESEE tee EEEIEE EEN te E E EA
E REESE E EERIE AA A E EE EN AATE,
Records completed By _..............cccecccccccrneee Daten cece
1: Am Veiis i cts eet ecm eaa a iaaa i E dante i i
2: Physique tisha ei a be aol A A eei ATi
3 WR os si et rides rca E A ach i Ea
A, Tests taken by... ccccceccecceecceeseteceeceecnseenere GROUP ee cccesstceeeeeceeneetes
a e a on SP sa ce Maio eh Ce ey ceed eas cece I
Le Se NAi sascha ceed T a oA AS pt a Rete oat Aare alts tatty
i) PR ow 02 0 NOR OROC El as pree tean UTORRENT OS CTU TE ETE ONE esae eeann OTE E orearen EES OR OCETRRT EN HOE OUES CLIO CEODEOCOT OE TOO ONDE stena OD OORT ERC HE CEH EONEE ESOS tara
This Form when completed to be forwarded with Enrolment Form and duplicate of House Governor's letter to one
of the undermentioned Joint Honorary Secretaries to enable the records to be completed.
1. ROTARIAN E. C. MATTHEWMAN, Barclays Bank, Ltd., Snow Hill, Wolverhampton. Telephone 22907.
2. TABLER L. R. GUY, B. Billingham, Ltd., Snow Hill, Wolverbampton. Telephone 20232.
For Medical Details and Services Rendered Records see other side.
ott iret tere ott toto titi rr ie terror
kad
Prererrerrrtrerrrre rere rie titer irritate
For the purposes of the
service the area included
in it has been divided into
districts, each indicated
by a capital letter. This
identifying letter is filled
in to the square at the top
of the card marked ‘“‘ dis-
trict”; it is similarly
filled in on the transport
volunteer cards. When a
donor is required who
cannot himself provide
transport it is an easy
matter to obtain a trans-
port volunteer residing in
own district at no
great distance from him.
Through the kindness of
Mr. E. Tilley, chief of the
Wolverhampton police,
instructions have been
issued to the police to
facilitate in every ‘pos-
sible way the passage of
cars engaged in the trans-
port of donors. In order
that such cars may be
readily identified by con-
stables on duty, members
of the transport service
1540 THE LANCET] DR. S.C. DYKE: VOLUNTARY HOSPITAL BLOOD TRANSFUSION ‘SERVICE
[JUNE 26, 1937
are provided with special labels fixable to the
windscreen of the car; these bear in large letters
the words ‘“‘ EMERGENCY CAR” and in smaller
“The Royal Hospital Blood Transfusion Service.”
Each label issued also carries a registration-number
by which the identity of the person to whom
it was issued may be known. Cars showing this
label are given precedence over all other trafec.
The routine for the enrolment of the transport
volunteers involves no medical work and is under-
taken entirely by the secretaries. Final entry of the
details is made on Form 8 which is again a filing card.
When completed, the filing cards—Form 3a for
donors and Form 8 for transport volunteers—are
returned to the pathological department where they
are kept in a file under the charge of the director of |
the service. :
When a donor is required, several cards of suitable
donors are selected and handed into the telephone
office of the hospital from which the call is sent out.
If transport is required calls are similarly sent out to a
transport volunteer living in the same district. A donor
having beensecured, the cards are returned to the trans-
fusion officer by whom the requisite entries are made.
Form 5 is sent to the donor as a recognition of his
services ; it is the only recognition he gets.
SERVICE REGULATIONS
The following regulations govern the working of
the service within the hospital :—
1. Whenever time allows an attempt shall always be
made to secure the services of friends or relatives of the
patient as donors, before a call is made upon donors
enrolled in the blood transfusion service of the hospital.
2. Whenever a donor under the service is called upon,
arrangements shall be made for his reception immediately
on arrival at the hospital, and for the withdrawal of
blood and his release at the earliest possible moment.
Form 8
Form 5
$
THE ROYAL HOSPITAL, WOLVERHAMPTON
Blond Transfusion Service
Bie IS HEREBY RECORDED THAT
Dao m ens ne e a mm mia pa a ame m a st a G con D DOAS cess 8008 abt eee eee aS FORD amt e CERES 280 P otaa DEERE o es oe nes. - -= ms
voluntarily gave Blood for Transfusion at the Hospital on
PA E a bpp pnia qpe DE E BD p Occ e E E E DAD E E D E G a Gema a eS D a etana ea Da BDG A a paee ai arara a o o —
to aid an unknown sufferer.
iene nena ED House Governor S& Secretary
3. Except in cases of extreme urgency, adirect matching
of the red cells of the proposed donor against the serum
of the proposed recipient shall always be made in the
pathological Yepartment under the supervision of the
director of the transfusion service, or his deputy before a
donor is actually selected for use.
4. Blood shall only be withdrawn with the donor in a
recumbent position.
5. The withdrawal of blood shall be made either by a
member of the honorary staff, the resident assistant
surgeon, or the transfusion officer. Resident officers other
than those named shall not withdraw blood from donors
under the service.
6. Withdrawal of blood from donors under the service
shall be made by means of venipuncture only ; under no
circumstances shall the vein be exposed. A local anzs-
thetic shall always be used before needling the vein.
7. Donors shall remain recumbent for at least ten
minutes after the withdrawal of blood. Thereafter they
may be allowed to leave the hospital. Donors during
their attendance at hos-
pital must be treated with
every possible courtesy
C] BLOOD TRANSFUSION TO and attention.
District (Private Address)
TRANSPORT District [| cosine Aten een
ioe errs Sed RST Car Label No. Since its inception two
| h
Telephone Exchange. NOn] Telephone Exchange ie years ago the system has
Times or special occasions when NOT available
Business Hours.
SEE EF ELEG AE ODE OOS 8420S OUD HOSE OEP E MM aira OO FERS CEES: DAnGowoEVLET D E a O E F EES DEEA O ET
excluding
ee Oa Afuranca | Evening (fs
rere [Kise A CES (eae
a ee ce cc Mc ian eat DY wells ot se ee ed
‘Wednesday
Coe BOTH HES G EEDS PORTH PTET SOPOT SEE BOO D A DEO UE Sa ono,
pats Ss as
| Thursday
seeeveneneccces secovescccwscaseseonnes sechtebemnenEnees see cae merete eet pes comro prer Dancerenguncecarrromuescasscccetes oe emere ee
worked with the maxi-
mum of efficiency and
the minimum of trouble ;
the shortest time to
. elapse between the send-
ing out of a call for a
donor and his appear-
ance at the hospital has
been two minutes and
ETOT OET 62 CSSD ONE E E a a a ee ee
pete » <.essoeasseoseao . . Oooo Oooo el
BUSINESS NAME AND ADDRESS,
OENE EA ar
even at night the time
has never exceeded two
hours. Al lay workers
—secretaries and donor
and transport volunteers
alike—give their services
without remuneration.
Even the printing and
stationery has through
the kindness of a mem-
ber of the Rotary Club
been provided free of
charge. The service is
designed and maintained
entirely for the benefit
of the patients in the
Royal Hospital. Neither
donor nor recipient is
THE LANCET]
MEDICINE AND THE LAW
1
\
[JUNE 26, 1937 1541
ever made aware of the identity of the other. The
question of making the services of the volunteers
available for patients outside the hospital has been
freely canvassed ; it was feared that this might lead
to exploitation and it has not, therefore, been put
into effect.
On behalf of my colleagues on the staff of the Royal
Hospital I should like to take this opportunity of
thanking publicly the organisers, the secretaries, and
all volunteers.
MEDICINE AND THE LAW
Doctors and Panel Dentistry
WHEN in 1921 the Dentists Act conferred a
monopoly of dental practice upon registered dentists,
there was a saving clause to protect the practice of
dentistry by a registered medical practitioner. This
' did not mean that the registered doctor, when prac-
tising dentistry, became for all purposes the equivalent
of a registered dentist. The Dental Benefit Regula-
tions, for instance, do not contemplate that a panel
patient shall receive dental treatment from a doctor.
The regulations declare that the patient may have
dental treatment from any dentist who is prepared
to provide such treatment at scale fees. The word
‘“ dentist ” in this context means a registered dentist ;
the medica] practitioner, unless his name appears
also on the Dentists Register, is excluded.
The point was made clear last week in Bynoe v.
General Federation of Trade Unions Approved
Society. A man named Evans, being a member of
the defendant society, received dental treatment
from Dr. Bynoe, who sent the society an account for
£1 12s. 6d. on the prescribed form known as a dental
letter. The approved society told Mr. Evans that it
could not pay the account, Dr. Bynoe’s name not
being on the Dentists Register. The society sug-
gested that Mr. Evans should get an estimate from
somebody who was registered as a dentist. Dr.
Bynoe then applied to the High Court for an injunc-
tion to prevent the defendant society from saying or
writing that he was a person not entitled to give
dental service or to receive payment for such service
under the National Health Insurance Act. Clearly
the society was in the right inasmuch as the wording
of the regulations excluded dental service by anyone
but a registered dentist. Dr. Bynoe, as Mr. Justice
Simonds observed, was not a person with whom
arrangements had been made to give dental treat-
ment in accordance with the Dental Benefit Regula-
tions.
could impeach the regulations as ultra vires and void.
The regulation-making powers given by the National
Health Insurance Act are wide ; they not only cover
many purposes where such powers are expressly
conferred but they also extend to the elastically
stated purpose of carrying the Act into effect generally.
The court decided that there was no substance in the
suggestion that the Dental Benefit Regulations, or
any of them, were ultra vires. “There may,” said
the judge, “ be persons not on the Dentists Register
who are quite competent to give dental treatment ;
but I can quite understand the Minister of Health
confining the right to give dental treatment under
the Act to those persons who are on the Dentists
Register.” |
Synthetic Vinegar
The Food and Drugs (Adulteration) Act penalises
the sale of substances not of the nature, substance,
and quality demanded by the purchaser, but does not
He could therefore not succeed unless he |
attempt to prescribe specific standards for all con-
ceivable foods and drugs. The magistrates, if there
is no prescribed standard, must listen to the evidence
and adopt their own standard. They must decide,
for instance, whether, if a purchaser asks to be
supplied with vinegar, a synthetic substance can be
served. The Westminster city council recently
brought a test case on this point. A fish frier was
fined £5 with 25 guineas costs for selling vinegar
which, on analysis, was found to consist of acetic
acid and water coloured with burnt sugar. The
council contended that vinegar means brewed
vinegar, and that brewed vinegar has a distinct
and pleasant aroma which synthetic vinegar does not
possess. If a purchaser asks for vinegar and is given
synthetic vinegar, he should be told what he is
getting. On appeal to the London sessions the con-
viction was confirmed. There was evidence that
“table vinegar” is the trade name for synthetic
vinegar, that the manufacturers have had no com-
plaints, and that 80 to 90 per cent. of the vinegar
trade is in the non-fermented or synthetic type. The
appeal tribunal, dismissing the appeal with 75 guineas
costs, expressed itself as satisfied that, if sold without
qualification, the substance offered as vinegar or
table vinegar was the product of fermentation. The
court thus falls into line with the decision in Preston
v. Jackson (1929) or perhaps carries the decision a
little further. Synthetic vinegar plainly cannot be
sold as “malt vinegar”; the recent case suggests
that it cannot be sold as “table vinegar” either.
There seems no reason why trade interests should
find a way round the Food and Drugs (Adultera-
tion) Act by inventing a commercial name which does
not tell the purchaser what he may want to know.
These decisions grow more important as the com-
mercial application of chemistry is developed. In
Bowker v. Woodroffe (1928) a bottle bore the label
“extract of meat and malt wine.” The prosecution
argued that the word “wine” implied the presence
of the fermented juice of the grape. The analyst’s
certificate, said Mr. Justice Avory, stated that the
article was not a meat and malt wine ; the magistrate
therefore, unless any evidence qualified or contra-
dicted that statement, ought to hold that the article
was sold to the prejudice of the purchaser. There
are probably considerable opportunities for enforcing
the law in respect of synthetic lime-juices, lemon |
squash, and fruit-juice products. It would be
interesting to see what evidence is given of the
inferiority of the synthetic article in respect of taste,
flavour, or dietetic value.
NEw BUILDING FOR THE GENERAL NURSING COUNCIL,
The new home of the council, which is to be opened
to-day, Friday, by the Princess Royal, occupies the site
of two houses built between 1776 and 1778 from the designs
of Robert and James Adam. Although the paintings
(attributed to Cipriani) on the ceilings were done on paper
which was stuck to the plaster ceilings in the old houses,
they were all successfully taken down undamaged and
incorporated in the designs for the new ceilings, after the
necessary cleaning and repair. Some mahogany doors
and fireplaces, as well as the iron balustrading on the
main stair landings and a beautiful fanlight over the front
door were taken from the council’s former offices at
No. 20 Portland-place. The outside of the building is
faced with Portland stone, and the stairs up to the second
floor have margins of marble, while the hall and staircase
are panelled with marble. The council room is panelled
with sycamore, and other woods used for rooms on the
first floor are cherry, Indian laurel, English walnut, and
Honduras cedar. The new address of the council is
23, Portland-place, W, .
THE LANCET]
1542
[JUNE 26, 1937
GRAINS AND SCRUPLES
Under this heading appear week by week the unfettered thoughts of doctors in
various occupations.
Each contributor is responsible for the section for a month ;
his name can be seen later in the half-yearly index.
FROM TWELFTH MAN
IV
. Ir is difficult, and perhaps impossible, to eliminate
entirely one’s personal bias from a discussion of public
questions. If I were asked my opinion of the National
Campaign for Physical Fitness I should say that I
saw no reason to believe that physical fitness and
good health were synonymous terms; that brains
and character were more important than physical
fitness ; that it was stupid to be more physically fit
than was necessary for the daily performance of one’s
job and the enjoyment of one’s recreation ; that an
inquiry into the mental health of the community
and a campaign for mental fitness were of vastly
more importance; that if our leaders were thinking
of the next war, it would be wise to pay more atten-
tion to our intelligence quotients and less to our chest
measurements; that if the hearties who directed
this National Campaign were looking for a slogan I
should suggest, “ The Lord taketh no delight in the
legs of a man.’
This is not a complete view of this question, but
I should be prepared to defend it as more rational
than the views of the ardent physical campaigners.
It is not, however, free from personal bias. It owes
something to the fact that in the gymnasium I was
wont to reach the top of the ropes—perspiringly
last ; that in the days when I considered it my duty
to take a morning run [ arrived back for breakfast
feeling slightly sick and spent the rest of the day in
a mental twilight; and that a mediocrity at ball
games was early accepted as part of my inadequate
endowment.
If it is of such childish reminiscences, with a nice
admixture of acquired prejudice, that the rational
opinions of our maturity, are composed it is not
surprising that Freud has issued a modern version
of Cromwell’s injunction: ‘‘ Gentlemen, I beg you to
remember, in the name of the Censor, that you must
be mistaken.” It is a comforting reflection that
Freud does not escape his own net.
* x *
We are invited, as doctors, to believe that we have
some specific contribution to make to the question
of war and peace. The Medical Peace Campaign
(which is not, as might be imagined, an organisation
devoted to the propagation of peace amongst doctors)
suggests ‘‘ that the profession as a whole should be
urged constantly to debate the problems associated
with war and its causation much as it debates the
etiology and prevention of disease.” My reply
would be that this last subject is our business, but
with the former we have, as a profession, no concern.
Indeed the intrusion of amateurs like ourselves into
this expert field may even make war more likely,
and cannot engender peace.
Moreover, doctors have no common opinion on
such matters. Why should they ? Are the members
of the Medical Peace Campaign to be expected to
agree with the opinion of Sir Arthur Keith ‘ that
the world, we are afraid, must sleep forever with a
loaded gun by its side”? ? I detest and deplore this
attitude of Keith’s, but his opinion and my dislike
of it find no support in our professional knowledge.
- Is democracy worth fighting for? Is the British
Empire worth fighting for? Is the maintenance of
a democratic state in Czechoslovakia worth fighting
for? Was the independence of Abyssinia worth
fighting for? We all, I hope, have our minds made
up on these problems ; as men, these questions touch
us nearly, but as doctors not at all We are urged by
the Medical Peace Campaign to join the peace councils
and the branches of the League of Nations Union.
Why? And which? For all these different organi-
sations have different opinions on this question of
peace, and all of them give different answers to the
four questions posed above.
But I shall be told that it is not suggested that
medical opinion can have anything to do with imme-
diate problems. It is the more remote and the more
profound causes of war that are to be debated, con-
sidered, assessed, and eradicated; that the more
important causes of war are psychological, and it is
therefore the psychologist’s business to explain and
eradicate these causes not only in ourselves but in
the Japanese, the Argentines, and the Greeks.
Well it may be so. And if it is so, it is a job not
for the average doctor, not for the Medical Peace
Campaign, but for the expert psychologist—and,
saving their reverences, are any of them expert in
this field? Trotter, who is genius enough to be
expert in two worlds, wrote a magnificent book
many years ago on “The Herd Instinct.” His is
still a lonely distinction. I have just read a pamphlet
by Dr. Burnett Rae, recommended by THE LANCET,
entitled ‘‘ Psychology and the Problem of War.”
It is sound and sensible but it contains no new ideas,
and it could equally well have been written by an
intelligent layman who was interested in the subject.
I came with more hope to Graham Howe’s new book
entitled “ War Dance,’ and was the more disap-
pointed. His book is full of good ideas but it is
always difficult and often irritating. He has developed
a highly stylised method of writing—Gertrude Stein
married to James Joyce. Almost any page will
show sentences of this sort, “The way of peace
cannot be more sure than that of war accepted,
peace about war, difference agreéd upon, tolerant
relations amidst the moving stress of opposing poles
rhythm and harmony.” Or this, ‘‘ The unseen other
aspect of this untimely error of masturbation is the
Holy Spirit, source of communion, deepest ecstasy,
but opposite pole. To interfere with one is to upset
the other, to which the lower needs to be lovingly
lifted.” Ideas drowned in a sea of words. Such a
book cannot be a practical contribution to the
understanding of the causes of war.
x * *
Nothing makes me more warlike than the pro-
nouncements of some psychologists on peace. I
should have hesitated to make this admission if a
distinguished psychologist had not told me that he
was affected in the same way. It has become almost
customary for a group of psychologists to issue
“ round robins ” to the press at times of international
crisis. It has seemed to me that these contributions
exacerbate controversies without elucidating issues.
To say that Germany since the Treaty of Versailles
is suffering from an ‘‘ inferiority feeling ” is to say
THE LANCET]
what everybody knows: diagnosis is easy; therapy
more difficult. To say that fear is the underlying
cause of trouble in Europe, that Czechoslovakia is
in an anxiety state, is to announce a platitude. To
declare in Rome that Mussolini’s desire for empire
springs from unpleasant psychological causes would
be an heroic last gesture; to say it in London is
merely to cock an irritating snook.
To the rules ‘I gave last week for the conduct
of experts let me add one more for psychologists
dogmatising about international affairs: Psycho-
therapeutic technique, which has not as yet been
uniformly successful in individual disorders, should
be used sparingly in international affairs—and when
used it should be limited in its application to the
psychotherapist’s own countrymen.
* * *
It is commonly held that science is an intellectual
force that works for peace. If this is true at all, it
is true in the same or greater degree of art, of litera-
ture, of education, of religion, of trade, of easy trans-
port. Nationalist temper runs so high to-day that
it is difficult even for men of goodwill to emulate the
serene detachment of Sir Thomas Browne when he
wrote some hundred years ago in “ Religio Medici ” :
‘I feel not in myself these common antipathies that
I can discover in others: those natural repugnances
do not touch me, nor do J behold with prejudice the
French, Italian, Spaniard, or Dutch: but where I
find their actions in balance with my countrymen’s,
I honour, love and embrace them in the same degree.”’
* * *
If the propaganda in favour of euthanasia does
nothing else it should develop a more civilised attitude
towards the problem of suicide. It is difficult to
understand the attitude of the Law and the Church ;
it almost certainly does not represent the mind of
lawyers and churchmen. Most family doctors have
witnessed a drama where suicide seemed the sane and
obvious solution. The coroner occasionally receives
a letter in which the writer states in restrained and
dignified language that he has not wished to prolong
an intolerable existence. A merciful but illogical
jury brings in a verdict of “ suicide while of unsound
mind ” because it is in England not only a disgrace but
a crime that a sane man should die by his own hand.
The Romans viewed the question differently.
ecky in his “ History of European Morals ” quotes
‘this noble passage from Seneca, “ I will not relinquish
old age, if it leaves my better part intact. But if it
begins to shake my mind, if it destroys my faculties
one by one, if it leaves me not life but breath, I will
depart from the putrid or tottering edifice. I will
not escape by death from disease, so long as it may
be healed, and leaves my mind unimpaired. I will
not raise my hand against myself on account of pain,
for so to die is to be conquered. But if I know that
I must suffer without hope of relief, I will depart,
not through fear of pain itself but because it prevents
all for which I would live.”
* * *
Raymond Asquith was in a company where this
problem was being debated and he was maintaining
that suicide was often justifiable but it should be
encompassed in as tidy and as dignified a manner as
possible and that all the great historical characters
who had died by their own hands had thus improved
the occasion. ‘“ What about Judas Iscariot ?”’
asked someone irrelevantly. ‘‘ Oh, that’s the worst
_ of these nouveaux riches,” said Raymond Asquith.
GRAINS AND SCRUPLES
[JUNE 26, 1937 1543
Sir William Willcox and his friends may be said to
have won the Battle of the Barbiturates. The family
physician views this victory without enthusiasm,
and even with distaste. The result for him is a few
more regulations to be observed. Ina town of 150,000
people, in which I write, some hundreds of thousands
of barbiturate tablets are consumed by the inhabitants
every year. There has never been a case of barbiturate
poisoning here and it was a safe bet that there would
never be one. The family doctor knows that the
barbiturates are not drugs of addiction and he sees
himself condemned to observe tiresome regulations
because a handful of neurotics in London chose to
imitate one another in this method of committing,
or attempting to commit, suicide. Before the issue
of the new regulations this fashion was already
abating. In the provinces the rope, the knife, the
river, and the gas oven are the methods of election.
And these remain uncontrolled. The socially
important reason for a Dangerous Drugs Act is not
that such drugs, when taken in excess, kill, but
simply that they create a craving and produce an
appalling mental and moral disintegration. Nothing
of the sort can be urged against the barbiturates.
* aK *
As the years pass it becomes increasingly unlikely
that any attempt will be made to control the patent
medicine indus The enormous advertising
= revenues which the trade brings to newspapers make
it a hot subject for any Government to handle, Is it
too much to hope, however, that we may get some-
thing done about the proprietary preparations of
reputable manufacturing druggists? Many of the
manufacturing houses have put advancing medicine.
heavily in their debt. Progress and profit have gone
hand in hand. A few of them have been, from a
scientific point of view, almost without blemish.
But even the best of them are sometimes guilty of
the higher charlatanry and their besetting sin is
still, as it was thirty or forty years ago, polypharmacy.
A very distinguished American firm is at the moment
pushing a preparation containing liver-stomach
concentrate, iron, and vitamin B. This is blunder-
buss prescribing of the worst sort. These are
substances which have in modern therapeutics a
well-defined and limited value. To say this is not
to ignore the facts that there is a small minority of
patients with pernicious anemia who benefit by iron
therapy, and that a handful of patients with micro-
cytic anæmia improve more rapidly with liver extract
added to iron. To suggest that this product should
be used in all anzemias where the facilities for making
a definite diagnosis are temporarily not available is
to invite the doctor to share in a make-believe. To
suggest further that this product may be of value
in clinical conditions’ without anzemia characterised
by loss of appetite, weakness, fatigability, or under-
nutrition is to descend to the level of the advertisers
of patent medicines.
I have before me a list of the proprietary prepara-
tions issued by one of the most renowned manu-
facturing chemists in the world. The list contains
more than 200 products, some of the highest value ; |
but at least 10 per cent. of them could not be sup-
ported by any scientific justification. Two brands
of liver extract have recently been advertised. One
was described as the purest available and the other as
“ from twice to forty times as pure as any other liver
extract.” Lord Baldwin likes to refer to the “ many-
sidedness of truth.” The truth must not only be
(Oontinued at foot of next page)
1544 THE LANCET]
[JUNE 26. 1937
CORRESPONDENCE
THE REVISED MEDICAL CURRICULUM
To the Editor of THE LANCET
Smr,—The recent session of the General Medical
Council was largely occupied with consideration of
the revised medical curriculum which the Council
proposes should come into operation in November,
1938. Its resolutions show a general agreement with
the recommendations for the reform of the medical
curriculum contained in the report (April, 1935) of a
conference of those licensing bodies whose qualifica-
tions are taken by students in the London medical
schools. Upon this conference were representatives
from the University of London, the Universities of
Oxford and Cambridge, from the Conjoint Board of
the Royal College of Physicians and the Royal
College of Surgeons, and the Society of Apothecaries,
but no representative of the General Medical Council.
The recommendations of the conference concern only
the London medical schools, but the resolutions of the
General Medical Council as the statutory authority
on medical education are operative throughout the
United Kingdom and the Irish Free State.
Reform of the medical curriculum has been pressed
from various sources for many years, and notably
from the student body, of which the medical society
of St. Mary’s Hospital was the first in the field in
May, 1932, with a resolution ‘‘That the present
system of medical education does not produce an
efficient practitioner.” In June, 1933, the students’
union of Edinburgh University carried the campaign
farther. At a discussion opened by the senior
physician of Edinburgh Infirmary the following
resolution was passed, with only seven dissentients
in a large assembly :—
That this House places'on record its opinion that the
present system of medical education in this country is
unsatisfactory. In its opinion important changes in the
curriculum are essential, whereby more facilities for
instruction in practical medicine are available, and more
assistance given in the principles and practices of pre-
ventive medicine. The time required for this additional
teaching can, in its opinion, be obtained by a judicious
modification of the teaching in the earlier scientific sub-
jects, with some revision of the time and attention devoted
to the teaching in the “‘ specials ’’ department of medicine
and surgery.
This resolution expressed a very general opinion held
by teachers, examiners, and the great bulk of the
(Continued from previous page)
many-sided but double-faced if it embraces such
statements as these.
They do these things better in America. The
American Association has had, for many years, a
Council on Pharmacy and Chemistry which examines
carefully and reports on ‘“‘ New and Unofficial Reme-
dies’ and the claims made for them. If the remedies
are rejected reasons are given and many manu-
facturers find it worth while to make alterations in
their products in the light of the council’s criticism.
If the remedy is rejected advertising space in
the Journal of the American Medical Association is
automatically refused to it.
Doctors are urgently in need of protection from
this ever-increasing spate of new preparations. Could
not the journals, the reputable manufacturing houses,
and a central pharmaceutical council coéperate after
the American example ?
How long, O Lord, how long ?
members of the medical profession, as well as by the
students who recorded it, and who are the persons
most directly concerned. How far does the new
Official curriculum now propounded by the Genera}
Medical Council meet the need thus revealed ?
It is clear from examination of the resolutions that
the duration of study is to be materially prolonged.
At present the regulations of the University of London
and of the licensing corporations in London allow of
completion of the professional education of the
student 54 years after taking the matriculation
examination in the case of London University,
5 years after taking that examination or its equiva-
lent in the case of the licensing corporations. The
‘matriculation examination or its equivalent can be
taken at the age of 16. But the new regulations
envisage 18 as the earliest age at which the medical
student can begin his professional education, thus
adding two years to the pre-registration period. This
provision is necessary to meet the new requirement
that the student shall complete his education in the
preliminary scientific subjects—chemistry. physics,
and biology—before coming to the medical school.
The period of professional study—that is, between
the date of passing this entrance examination and the
date of the final qualifying examination—is made up
of two phases; two academic years (nine months
each) are to be spent in the study of human anatomy
and human ‘physiology, and for the first time the
elements of normal psychology are to be added to
this course, as well as instruction in the elementary
methods of clinical examination, including physical
signs, the use of the stethoscope, ophthalmoscope,
&c. [sic], and some initiation into the principles of
general pathology, bacteriology, and pharmacology.
Eighteen months is likely to be insufficient to cover
this greatly enlarged and highly heterogeneous
programme.
The second phase, the period of clinical studies, is
to occupy three calendar years (12 months each),
during which “clinical instruction should be con-
tinuous.” The effect of this unobtrusive transforma-
tion of academic into calendar years is to add nine
months to the curriculum and contradicts the assertion
contained in the earlier part of the official statement
that the period of professional study may be com-
pleted in five academic years (the italics are mine).
The provision of the extra nine months is rendered.
eminently necessary by the further expansion of the
requirements in the clinical period, which now entail,
in addition to several new subjects cited below in
which instruction is required, residence for four
months during the clinical period in a hospital in
order to follow more closely the practice of the
hospital in medicine, surgery, and midwifery; to
meet a very vocal public demand for better midwifery
instruction, two of these four months are to be spent
in a maternity hospital or the maternity ward of a
general hospital, and ‘‘ these two months should be
devoted exclusively to instruction in midwifery and
in the hygiene of infants.” f
The call for training in preventive medicine is met
by the following direction: ‘‘ Throughout the whole
period of study the attention of the student should be
directed by his teachers (a) to the importance of the
measures by which normal health may be assessed
and maintained, and (b) to the principles and practice
for the prevention of disease.” This resolution bears
an unhappy resemblance to the resolution adopted
by the Council in 1922 which runs as follows.
THE LANCET]
<‘ Throughout the whole period of study the attention
of the student should be directed by his teachers to
the importance of the preventive aspects of medicine,”
and it is safe to predict that the new, resolution,
equally nebulous, will be ignored as completely as
was its predecessor.
Preventive medicine thus does not get any precise
niche in the new temple of learning but the following
items are specifically added to the special subjects of
the old curriculum: dietetics, therapeutics and
prescribing, physiotherapy, principles of nursing, child
welfare, psychology, radiology as applied to medicine
and to surgery, disease in infancy and in childhood,
dental diseases, and ‘instruction on the statutory
obligations of registered medical practitioners.”
The revision of the medical curriculum has been
conducted by bodies in which the general practitioner
has either not been represented at all, as in the case
of the conference, or by a small minority, as in the
case of the General Medical Council. The passing of
the National Health Insurance Act established the
general practitioner once and for all as the most
important unit in the medical service of this country,
inasmuch as the,service given by the Act was
expressly defined as a “ general practitioner service.”
By the operation of the same Act, as Sir Kaye Le
Fleming pertinently points out, “a standard is
afforded of the range of a general practitioner’s
duties”; that standard does not envisage any
specialist experience. The production of an efficient
general practitioner should therefore be the principal
aim of medical education. There is abundant and
accumulating evidence that the curriculum has been
overloaded in the past and a further addition to it is
surely disastrous. An admirable presentation of the
ideal curriculum was given by Prof. T. G. Moorhead,
when president of the Royal Academy: of Medicine in
Ireland :
“During the first two years the preliminary sciences
should be taught. He felt strongly that a sound know-
ledge of those preliminary sciences, including biology,
was absolutely essential. In teaching the principles of
those sciences facts bearing on the future life-work of
the student should be used as much as possible in illus-
tration. In the second or clinical part of the course he
felt that there was only time to give a man a thorough
knowledge of the principles of medicine, surgery, and
midwifery. Once those principles were acquired, and once
a student was placed in a responsible position himself,
he could acquire additional facts with extraordinary
rapidity. If, however, as a student he was swamped in’
detail and failed to acquire a scientific outlook, he could
never hope in after life to be a really sound practitioner.
As far as possible he should be made familiar with the
everyday emergencies included in the so-called specialities,
but a systematic course should be reserved for post-
graduate teaching.”
Can the present position be viewed with anything
but anxiety by those who are convinced that the
minimal curriculum for qualification should be
designed first of all to meet the needs of the general
practitioner and that the effort to produce a “ general
specialist,” which in itself is a contradiction in terms,
should be finally abandoned ?
The expense of medical education, both to the
individual and to the State, is creating a very difficult
position. The medical profession is becoming prac-
tically closed except to those who have abundant
financial means. The expenditure by the State in
subsidising medical education is a growing burden
upon the community and those responsible for its
distribution are ever more insistently asking the
question whether that expenditure i is justified. Could
there be a less opportune occasion for producing a
THE OVER-TREATMENT OF GONORRHCEA
1
[JUNE 26, 1937 1545
curriculum which must inevitably exact an increased
expenditure both of time and of money ?
I am, Sir, yours faithfully,
E. GRAHAM-LITTLE,
House of Commons, June 17th.
THE OVER-TREATMENT OF GONORRHŒA
To the Editor of THE LANCET
Sır, —This correspondence began with a piffling
complaint about the ‘“over-treatment ” of a case of
gonorrhea in a V.D. clinic—piffling because a clinic
medical officer, in his “dark and uncritical world,”
is rightly concerned rather about the under- treatment
of gonorrhca—and was continued by the report of
another ‘‘over-treated’’ patient who harboured
prostatic calculi. Before the calculi were so credit-
ably discovered in other hands, the clinic had
apparently, in this case too, cured the gonorrhea.
Interesting and again piffing. And now Mr. Johnston
Abraham hots it up with the story of a V.D. clinic’s
failure to recognise early a cancer of the bladder.
From his account the clinic’s treatment of the stricture
made easy that cystoscopy in other hands which
disclosed the cancer. Gratitude is hard to find!
Moreover, he, forgetting, as do the other two Superior
Complainants, that most of us live and practise long
enough to have the painful pleasure of correcting,
and. being corrected by, each other, lets loose against
his brethren (I dare not write “ colleagues ”’) of the
V.D. clinics, ‘‘our so-called venereal experts,” his
distinguished and discourteous diatribe. Distinction
was to be expected \of him, discourtesy not.
(‘‘ Venereal experts”? reminds me of the happy
occasion at our hospital when an eminent physician
whose friendship I have long valued and enjoyed
presented me to a noted and now startled lady
visitor as ‘“‘ our venereal doctor.’’)
Mr. Abraham’s misfounded ungilded charges against
us of ignorant incompetence, unenlivened even
by the hope of one day sitting down with
Olympians, need not be met. But you may take
it, Sir, that the V.D. clinics are well lighted enough
to uncover (but of course rarely) the blunders of
others, even of those in the illumined Socratian world
(so Mr. Abraham would have it) of Genito-Urinary
Surgery.
May I not also report ?
years.
A surgeon to the G.U. dept. of a hospital sent his patient,
who confessed to a gonorrhea one year previously, for
treatment to the V.D. clinic; and found time to write
the short report—‘“‘ hematuria, staphs, ? g.c.” The man,
engine-room greaser, chose the clinic nearest his home—
mine. I found staphs. allright; but no hematuria and
no g.c.; until a week later, after the patient had gone
motor-cycling, both of us (he first) found hematuria all
right, and I staphs. and no g.c.. And so, soon to the stone
in his kidney. I claim no credit; that should go to the
motor-bike. i
A senior retired ship’s officer asked me, in the V.D.
clinic, if he were fit to marry. He handed me medical
reports from which could be learnt that in the G.U. dept.
of a hospital, four years previously, he had had a testis
removed for sarcoma. Later a pathologist reported
gumma. Later, blood-serum Wassermann positive.
Later, maimed but untreated, transferred to care of a
physician (in whom it would be reasonable to look for
that “ widest possible knowledge of internal medicine ”),
who prescribed a mixture to be taken for three conse-
cutive months in every year; and this the patient had
done. The mixture was pot. iod. and hydrarg. perchlor. `
All made very easy for me. As for him, there was now
added unto him Argyll-Robertson pupils and Wassermann-
positive cerebro-spinal fluid.
I select from the last few
`
1546 THE LANCET] >-
RECENT ADVANCES IN OBSTETRICS
[JUNE 26, 1937
And now I should humble me.
A steward. was sent by his ship’s surgeon to my clinic
for “ pus in urine ? g.c.” I could detect no g.c., but did
try to treat the painless bloodless “cystitis.” After five
weeks of it he vanished. Six months later, back from a
voyage, he called at hospital to see me. Another steward
had advised him, from first-hand experience, to try a
“ better clinic with younger doctors.” So he did, and a
young gentleman had “popped it into him good and
quick,” and he, the patient, heard the chink as ‘‘it’’ hit
the stone. Operation had removed stone from bladder
and symptoms with it. Nevertheless, he gave me to
understand I had been the honourable trier: that young
ere seemed to chance it like.” Justice is indeed hard
O !
In conclusion, Sir, may I remind Mr. Johnston
Abraham that from what he thinks of and despises
as too stony a ground—“‘ the mental outlook of the
old dead and gone regimental medical officer °—was
raised up besides John Hunter, a Helmholtz, a
Laveran, a Bruce, Ross, and Leishman; and one
who should surely be a father for this Abraham, a
Peter Freyer. Doubtless he shares with me the
privilege of having once known and sat under the
last four: and he has forgotten them. These ghosts
will not trouble him even though grace is, for the
moment, hard to find in him. ‘
And I have the idea that some surgeons had for
long a clear field and few rivals with gonorrhcea in
the male—and left it to us “ unsurgical ” newcomers
in the new V.D. clinics.
I am, Sir, yours faithfully, .
H. M. HANSCHELL,
Hon. Med. Supt. and M.O. i/c V.D. Clinic,
Royal Albert Dock Hospital, E.
To the Editor of THE LANCET
Sir,—Mr. Johnston Abraham’s attainments and
experience in the fields of urology and of the venereal
diseases are so well known that his pronouncements
must receive the greatest respect and attention. For
this very reason I ask leave to join issue with him on
the subject of his recent damaging statements as to
the trainmg and standard of work of the venereal
specialist.
Few will deny that there are disadvantages in the
present system, and I believe that most medical
June 20th.
officers of venereal diseases clinics would admit that
the treatment of some patients with gonorrhea is
continued beyond the stage in which the benefit of
treatment is apparent. The reason is to be found,
not in the ignorance and carelessness of the medical
officer, as Mr. Abraham suggests, but in the realisa-
tion that, in the light of modern improved patho-
logical tests, such patients cannot be regarded as non-
infectious. The medical officer is between the Scylla
of releasing the infectious patient, and the Charybdis
of prolonging treatment unduly. Since he is unwilling
to admit, even to himself, that in such patients the
disease is ineradicable, he chooses the second
alternative.
Mr. Abraham truly says that venereal disease has
always been the Cinderella of medicine, but I cannot
agree that the remedy lies in restoring syphilis to
general medicine and gonorrhea to urology. It is
to the past neglect and indifference of the physician
and the urologist that the present ‘‘ lowly position ”
of the venereal diseases is due. I believe that most
of the shortcomings of venereal diseases clinics arise
from an attitude of mind which Mr. Abraham’s letter
well exemplies, The student gains the impression
from his medical and surgical instructors that the
subject of the venereal diseases is an unworthy and
slightly unsavoury study which no competent man
in his right mind would adopt as his sole life’s
work. In consequence there is small incentive for a
man with the necessary medical and surgical back-
ground to regard the venereal diseases department as
other than a possible convenience—a stepping-stone
to higher things. The appallingly high incidence of
these diseases among the general population has com-
pelled the public health authorities to intervene and
endeavour, by public organisation and subsidy, to
provide a remedy for a situation for which the medical
profession as a whole is woefully to blame. The
present inadequacy of the treatment of gonorrhwa
must be regarded as a direct legacy from the past
neglect of the urologist. ,
Mr. Abraham deplores with Mr. Nicholls the
“ unhappy and incompatible ” marriage of two such
widely dissimilar diseases as gonorrhæa and syphilis,
yet he himself has shown by his able writings on the
subjects of the treatment of both these diseases that
the gulf of dissimilarity can be bridged. To the
venereal diseases medical officer this incompatibility
is less obvious, since his daily problems in psychology,
arising from the patients’ shame and the necessity for
concealment, and his difficult task of handling family
situations, are almost identical in relation to the two
diseases. There is also the practical consideration
that it is common to find patients who are suffering
from both gonorrhea and syphilis. There are manifest.
‘advantages in treating both infections in the same
department.
A sound knowledge of the fundamental principles
of medicine and surgery is essential in venereal diseases
practice as in all other branches of medical science ;
but the occasional dabbler in surgery, the surgical
tinker, is always a menace. I do not agree that it is
either necessary or desirable for the venereal diseases
officer to be able to perform the surgical operations
which Mr, Abraham enumerates. The necessity is a
close liaison between venereal disease departments
and the departments of gynecology and urology. By
this means a competent surgical opinion is always
available, and the venereal diseases cease to ‘“‘ live
apart in a dark and uncritical world of their own.”
Mr. Abraham describes one case in which the
blunder of a venereal diseases officer resulted tragically
for his patient. It would be possible to give other
instances where ignorance of: the fundamentals of the
diagnosis and treatment of venereal diseases on the
part of the urologist and physician have resulted
most tragically for patients and their families. But
such recriminations are valueless and even harmful.
From the wealth of Mr. Abraham’s experience one
might have hoped for some more helpful and con-
structive suggestions in dealing with the undeniable
difficulties of the present situation.
I am, Sir, yours faithfully,
Harley-street, W., June 21st. AMBROSE J. KING.
RECENT ADVANCES IN OBSTETRICS
To the Editor of THE LANCET
Sm,—In the report of Miss Keren Parkes’s paper
at the London Association of the Medical Women’s
Federation, published on p. 1465 of your last issue,
there are two mis-statements which I feel should be
corrected.
(1) Discussing the Aschheim-Zondek and Friedman
tests Miss Parkes is quoted as stating that these
tests are of use in the diagnosis of intra-uterine death
of a fetus. I published a small series of cases in
which the date of intra-uterine death was known
(Lancet, 1935, 2, 364). In two the Friedman test
was still positive 6 weeks after the foetus died. In
THE LANCET]
the reports of cases collectéd from the literature at
that time there were four in which a positive result
was obtained at even longer intervals, the longest
being 91 days. A positive result therefore does not
definitely establish the fact that the footus is alive.
Nor does a negative result definitely establish the
fact that the fœtus is dead. I have obtained negative
Friedman reactions in three cases of threatened abor-
tion. In one of these, tests performed before and
after the time at which the patient was threatening
to abort were positive, though a negative result
was obtained at the time of threatening. Prof.
James Young (Brit. med. J. 1937, 1, 954) obtained
negative pregnancy tests at times when the fetus
was alive in over half the cases on which such tests
were performed in his habitual abortion series. It
is, I feel, important that this point should be empha-
sised, for one is frequently asked to perform a “ preg-
nancy ” test to settle the question as to whether the
ovum is alive or dead. The curve of cstrin excretion
in the urine drops more rapidly than does the prolan
curve, and an cestrin test is therefore of more value,
but still highly unreliable.
(2) fn discussing the treatment of habitual abortion
Miss Parkes is reported as advocating the use of
“ large doses of a substance stimulating luteal activity
which was found in the urine of pregnant women,
marketed as Antuitrin S or Progynon.” Progynon
is not a gonadotropic extract but the standardised
preparation of cestrin marketed by Schering Ltd.
It should not be used in the treatment of habitual
abortion. Miss Parkes’s reason for advocating
gonadotropic extracts rather than extracts of corpus
luteum is that the latter are ‘“‘ unfortunately still
very expensive.” The price of 50 ampoules of pro-
gestin, each containing 1 mg. (1 rabbit unit), as sup-
plied by a certain firm is 142s. The price of 50
ampoules of the luteinising gonadotropic extract
prepared by the same firm is 90s. if the strength of
each ampoule is 100 rat units, or 180s. if of 500 rat-
unit strength, which is the strength presumably
referred to when Miss Parkes mentions “large
doses.” I am, Sir, yours faithfully,
P. M. F. Bisyop.
, Endocrine Clinic, Guy’s Hospital, S.E., June 19th.
THE SEVENTH ENGLISH-SPEAKING
CONFERENCE ON MATERNITY AND CHILD
WELFARE
To the Editor of TuE LANCET
Sır, —The report of this conference in THE LANCET
of June 12th states that ‘reprints of a brief history
of the child welfare movement,” written by me, were
distributed to the delegates, and that this “ history ”
did not mention ‘the roots of the movement.” May
I say that my paper, which was entitled the Present
Position of Maternity and Child Welfare in the
English-speaking Countries, was not a “history”
but a brief summary of a large number of documents
received by the Conference Committee from the
United States, the Dominions, and the British
Colonies, Protectorates, and Dependencies describing
what is now being done for the welfare of mothers
and young children in those countries respectively.
The paper began by explaining that the conference
was the latest of a long series beginning with the
national conference of 1906, which had its origin
in a meeting of the British delegates to an inter-
national congress in Paris in the preceding year, but
except for those introductory remarks the paper
was given up not to the past but to the present.
What your correspondent specifies as among “the
REGIONAL ILEITIS
[JUNE 26, 1937 1547
t
- roots of the movement ” are of course well known to
students of the movement, and arè discussed in my
book, “The Early History of the Tatang Welfare
Movement, ” published in 1933.
I am, Sir, yours faithfully,
G. F. MCCLEARY.
Brockham Green, Betchworth, Surrey, June 19th.
ANTIBODIES AGAINST HORMONES
To the Editor of THE LANCET
_ Srr,—In the leading article on p. 1471 of your last
issue there is a statement suggesting that Collip and.
Anderson introduced the study of antihormones.
Over thirty years ago I remember the late Sir Edward
Sharpey-Schafer stating’ that Swale Vincent, also
recently deceased, had discovered a type of immunity
to internal secretions. Writing on the injection of
suprarenal extracts, Schafer said, concerning Vincent's
experiments, that ‘‘ Doses insufficient to cause a fatal
result produce immunity to larger doses which would
otherwise be fatal, and this effect may last a few
weeks ” (E. A. Schafer, Text Book of Physiology, Edin-
burgh and London, 1898, vol. i, p. 951). As both of.
these authorities have joined the great majority,
I feel that justice should be done to them as pioneers.
Vincent’s paper is, I believe, in the Journal of
Physiology (1897, 22, 111).
I am, Sir, yours faithfully, |
J. ARGYLL CAMPBELL,
National Institute for Medical Research,
Hampstead, N.W., June 18th.
REGIONAL ILEITIS
To the Editor of THE LANCET /
Sir,—Gastro-enterologists and clinicians generally
will be interested to know that Charles Combe and
William Saunders, a fellow of the Royal College of
Physicians of London, reported a case of terminal
or regional ileitis (Crohn-Braun type) before the
College, on July 4th, 1806, 131 years ago! The title
of the report was “ A singular case of Stricture and
Thickening of the Ileum.”
The patient was William Payne Georges, Esq., of a
very nervous and delicate habit . . . at necropsy
(Monday, Feb. 10th, 1806) ... it was found that the
stomach, duodenum, the jejunum, and the upper part
of the ileum, liver, pancreas, spleen, and kidneys were
in a natural and sound state. The lower part of the ileum
as far as the colon, was contracted, for the space of three
feet, to the size of a turkey’s quill..... (Medical
Transactions, published by the College of Physicians in
London, iv. 16-21, 1813, London.)
John Abercrombie (1780-1844) discusses pathologic
states of the ileum and reports cases of terminal
ileitis (Combe-Saunders-Crohn-Braun type). On
p. 263 of John Abercrombie’s book, “ Pathological
and Practical Researches on Diseases of the Stomach,
the Intestinal Canal, the Liver and other Viscera
of the Abdomen” (Edinburgh edition, pp. 238-263,
Waugh and Innes, 1828, report V., Case CIT), he tells
of “a girl, aged 13, about a year before her death,
began to be affected with pain of the abdomen and.
frequent vomiting. ...” The lower end of the ileum,
to the extent of about eighteen inches, was ‘distended,’
thickened in its coats, externally of a reddish colour,
and internally covered by numerous well-defined
ulcers, varying in size from the diameter of a split
pea to that of a sixpence.” The lungs and all other
viscera were healthy. | =
I am, Sir, yours faithfully,
Hyman I. GOLDSTEIN.
Camden, New Jersey, U.S.A., May 27th.
1548 THE LANCET]
INFECTION THROUGH OLFACTORY MUCOSA
[JUNE 26, 1937
INDIVIDUAL PSYCHOLOGY
To the Editor of THE LANCET
Sir,—In consequence of the sudden death of Prof.
Adler at Aberdeen on May 28th it has become necessary
to remodel the programme of lectures and vacation
courses in individual psychology arranged for this
‘summer, Dr. Alexandra Adler, Prof. Adler’s daughter
and herself a brilliant exponent of individual psycho-
logy, has very courageously undertaken to carry out,
as far as possible, the programme arranged for her
father. Certain adjustments and cancellations have,
however, been necessary and the programme now is
as follows :—
Lecture course, non-resident, in the
B.M.A. Hall, Edinburgh.
Vacation course at University Hall, .. July 7th-12th
Liverpool.
Vacation course at Bishop Otter
College, Chichester, Sussex.
We, the undersigned, being convinced of the great
value of individual psychology in throwing light on
the fundamental problems of human life in an age of
great perplexity, would appeal to the medical and
teaching professions, and the Church and parents
especially, for as large a measure of support as possible
for these courses. This would be the finest tribute
that could be paid to the memory of a great benefactor
of the human race, who devoted his life to freeing
men and women from the burden of misconception
and misunderstanding which lies so heavily upon the
human family.
We wish to take this opportunity of thanking the
University and City of Aberdeen for having done
everything in their power to honour the memory of
Prof. Adler by arranging an official funeral service in
the chapel of King’s College on June 2nd.
We are, Sir, yours faithfully,
Nina HAMILTON AND BRANDON,
ALBERT LIVERPOOL,
ISABEL MARGESSON,
ALFRED BEIT,
PHYLLIS BOTTOME,
Tan L. FLEMING,
ELIZABETH HOARE,
June 2Ist. - (Chairman, Adler Vacation Courses).
METHODS OF DESTROYING BED-BUGS
To the Editor of THE LANCET
Sir,—Fumigation against bed-bugs needs experts
to do it. There are millions of bug-infested houses
which are unlikely to be fumigated for years, and it
would be an advantage if we could suggest ways in
which the inhabitants could at least keep down the
bug population in the meantime. The only methods
they can use are contact insecticides, and, as I sug-
gested in my letter of June 5th, dilute methylated
spirit may be useful in this way. While fully appre-
ciating the improvements which Ashmore and
McKenny Hughes have described in their article and
recent letter, I see no reason why the victims should
have to wait until all local authorities have been
persuaded to use “‘ heavy naphtha.”
I cannot understand why Ashmore and McKenny
Hughes should say (The Lancet, June 12th) that
“contact insecticides . .. are helpful in dealing
with a light infestation, but in our opinion a heavy
infestation can only be dealt with successfully by a
fumigation process.” Surely any inefficient process—
even soap and hot water—will do much damage in
a really heavy infestation and so produce a light one.
It is the light infestations (perhaps the remains of
heavy ones!) which are difficult to eradicate, and
.. June 2)st—July 2nd
.. July 17th—26th
efficient fumigation which penetrates every crevice
is the best method. Fortunately a light infestation
causes less suffering in the house.
Contact insecticides can be used unknown to the
neighbours, who always realise when fumigation is
being carried out. The odour of heavy naphtha may
be “not unpleasant,” but. the neighbours may be!
There is still a stigma attached to having a bug-
infested house, even when it is a case of the “ pot and
the kettle.” I am, Sir, yours faithfully,
KENNETH MELLANBY.
Sorby Research Laboratory, Sheffield
University, June 17th.
INFECTION THROUGH OLFACTORY MUCOSA .
To the Editor of THE LANCET
Sır, —In reply to Dr. Rake’s request for further
information (The Lancet, June 12th) all his difficulties
‘are due to a slight acidity of the solutions he employs,
Prussian blue is not formed when iron ammonium
citrate and potassium ferrocyanide are mixed in
faintly alkaline solutions. We still have some such
solution made up July 4th, 1933, continuously
exposed to light, which is crystal clear and with only
slight deposit. It stil contains practically all the
ingredients in true solution, as shown by the amount
of deposit on acidification.
Although Dr. Rake’s mixture contained granules
it also contained some true solution, and the latter
would naturally permeate easily, as demonstrated by
Le Gros Clark. I am still unconvinced with regard
to the passage of pneumococci from the nose to the
subarachnoidal space within two minutes, and I hope
Dr. Rake will continue his researches in order to
substantiate this very important statement.
I am, Sir, yours faithfully,
F. A. PICKWORTH,
Director, City and University of Birmingham Joint
June 21st. Board of Research for Mental Disease.
PRESENTATION TO SIR FREDERICK HOBDAY
To the Editor of THE LANCET
SIR —An appeal has been launched for funds for
the purpose of making a presentation to Sir Frederick
Hobday on his retirement from the position of
principal and dean of the Royal Veterinary College,
as a mark of appreciation of his services to veterinary
science in general and the Royal Veterinary College
in particular.
Sir Frederick has intimated his wish to devote the
sum raised to the furtherance of the collaboration
between the medical and veterinary branches of
medicine in their mutual crusade against the diseases
of animals which are common to, or communicable
between, animals and man. Since the preliminary
letters were issued the method of carrying this out
has been considered by Sir Frederick and he desires
to found a research scholarship fund in order to
encourage research by veterinary and medical men
in connexion with the diseases of animals and man,
It is hoped that this will further the liaison between
the two professions and be of great benefit to the
science of medicine in its widest sense. The fund is
to be called the Hobday Research Endowment Fund.
The committee feel that these details, and
particularly the idea itself, will be of the greatest
interest to members of the veterinary and medical
professions. It is hoped that amongst his numerous
friends and well-wishers a substantial sum will be
raised which will be sufficient to enable this scheme
to be carried out adequately.
I am, Sir, yours faithfully,
Ep. T. Cox, Hon. Secretary.
St. Ermins, Westminster, S.W., June 19th.
THE LANCET]
BRITISH ASSOCIATION OF RADIOLOGISTS:
SKINNER LECTURE
To the Editor of THE LANCET
S1ir,—In the report of this lecture which appeared
in your last issue, the necessary compression has
resulted in ambiguity with regard to some of the
Opinions expressed. I should be grateful if you
would allow me a little of your space to clarify
matters.
(1) The report states that I advocated the use of
X rays after radical surgery, and that I also consider
surgical ablation valuable because of its psycho-
logical effect on patients. What I said was as follows:
“For practical purposes in this country we must
assume that the primary growth will be got rid of by
operation or by radium implantation. The latter saves
the patient from what is rather untactfully referred to
as ‘mutilation,’ and in the case of some women it is psycho-
logically very desirable to avoid ablation of the breast. Others,
of a different mentality, prefer, as they say, ‘to get it
over and done with’; actual removal gives them a
greater sense of security. I prefer surgical removal
if it is not too drastic. An ‘axilla in which the glands are
not palpable is best left alone. If there is microscopic
invasion, it can be dealt with by radiation.”
(2) The report states that I do not consider Todd’s
treatment suitable for hospital cases, but that I
recommend it where there is metastasis in bone. I
said that I did not consider Todd’s method suitable
PANEL AND CONTRACT PRACTICE
[JUNE 26, 1937 1549
for use as a routine procedure in general hospitals,
but reserved it for otherwise desperate cases of
generalised metastasis in bone where concentrated
X ray dosage was obviously impossible. For the
single, or at any rate non-multiple, metastasis deep
X ray treatment in the usually understood sense is
certainly indicated—‘‘ spontaneous fractures may
be caused to unite, and the patient restored to active
life for months, or even years.’
I am, Sir, yours faithfully,
. HERNAMAN- JOHNSON.
Brook-street, W., June 22nd.
THE FUTURE OF OBSTETRIC PRACTICE.—Dr. ELWIN
Nasu writes: “I notice that your report of my
paper (published on p. 1285 of your issue of May 29th)
states that in my district the average number of
deliveries attended by doctors was six a year. This,
I was very careful to record, was the result of a ques-
tionnaire sent out a few years ago to a large number
of towns, and represents the average number of
confinements attended by medical practitioners
outside an institution. It must be realised that
there are still a number of cases attended by general
practitioners in nursing-homes of varying grades.
Had I been present at the meeting this might not
have got into print in this particular form. Unfortu-
nately I was at the time a patient in hospital as the
result of a difference of opinion over the right of way
with a motor-car.”
PANEL AND CONTRACT PRACTICE
The Essex Public Medical Service
THE provision of medical treatment on a prepay-
ment basis is becoming increasingly popular, as is
shown by the rapid growth of hospital contributory
schemes, and the steady progress made in the estab-
lishment of public medical services for the treatment
of persons who, though not covered by the national
health insurance system, are in much the same
economic class as the insured. At the second annual
conference of public medical services last November
it was stated that the number of services now working
was 53, with approximately 404,000 subscribers, and
the organisation of such services has become a definite
part of the activities of the British Medical Asso-
ciation. The thirteenth annual report of the Essex
Public Medical Service, recently published, gives some
particulars of the working of this method of providing
medical care on a voluntary insurance basis. In 1936
the number of subscribers was 31,085 (adults 16,600,
children 14,485) and the number of practitioners 274,
of whom 30 joined during the year. The sub-
scriptions amounted to £21,481 and the payments to
doctors to £17,128, the largest amount collected for
any one practice being £1283. The sum of £3457
was expended on collectors’ commission and expenses,
and other administrative charges cost £1465. We
note that among the subscribers the proportion of
children to adults is becoming smaller. At one time
it was nearly two to one, but it has been diminishing
year by year until in 1936 the adults outnumbered
the children by 2115. This is attributed to the
declining birth-rate, which, as the Minister of Health
pointed out in the House of Commons last week, will
probably reduce the number of children attending
public elementary schools by about a million within
the next 15 years.
Understudying the Dentist: the Sequel
Readers will recall! the appeal of a practitioner
who was disallowed his fee of 10s. for attendance,
late at night, on a bleeding tooth-socket following
extraction. The Minister allowed the appeal, not
on any ground put forward by the practitioner,
but on the technical ground that the insurance com-
mittee had not obtained a formal expression of
opinion from the local medical committee that the
service rendered was within the scope of medical
benefit. That has now been done and the proper
tribunal has stated that the service was within the
scope. The Minister being informed of this remarked
in effect that it was now too late. The matter
having been dealt with by the insurance committee
and adjudicated upon by him on appeal was
‘now res judicata, and he was therefore precluded
from taking any cognisance of the report now
submitted under Regulation 46 (4). The’ medical
benefit subcommittee, not unnaturally, are dis-
pleased about it. They have caused the Minister
to be informed of their opinion that in a case of lapse
in procedure not of substance it is desirable that an
opportunity of rectifying the procedure should be
afforded rather than that the appeal should be
allowed on the ground of that lapse alone. Accepting
the position as now irremediable, the insurance
committee decided to return the 10s. to the insured `
person from their general purposes fund, subject of
course to the Minister’s consent. Dr. X is therefore
not out of pocket for his successful effort to focus
attention on the relation of dental work to the medical
practitioner’s capitation fee,
1 Lancet, Feb. 6th, p. 345.
CORONATION GIFTS FOR HOSPITALS.—The trustees
of the Albert Levy Benevolent Fund are allocating
£10,000 to be divided among twenty selected hospitals
as Coronation gifts. Among the institutions which will
receive them are St. George’s Hospital, the Royal
Free Hospital, Westminster Hospital, and the Chelsea
Hospital for Women.
[JUNE 26, 1937
1550 THE LANCET]
OBITUARY
SIR SQUIRE SPRIGGE
1860-1937
EDITOR OF ‘‘ THE LANCET ”
Sir Squire Sprigge died at noon on Thursday,
June 17th. He was at the office as usual up to
Coronation Day, and his death—from pulmonary
embolism following an operation—came unexpectedly.
“For the convenience of The Lancet sexton,”
as he put it, he had left among his papers an outline
of his life; but it was a bare outline.
BOYHOOD AND PURSUITS
Samuel Squire Sprigge was born on June 22nd,
1860, at Watton, Norfolk, where his father, Squire
Sprigge, was a doctor and small landowner. His
father, after taking distinction in surgery, had
settled in Norfolk and became widely beloved as a
general practitioner who was interested not only
in the maladies but in the lives of his patients. The
family was indigenous in East Anglia for the elder
Squire was the eleventh child and youngest son of
the Rev. James Sprigge, D.C.L., rector of Brockley,
Suffolk, a family living, and his wife was the daughter
of John Jackson, solicitor, of Duton Hill, Braintree,
and Bury St. Edmunds. His eldest son, Samuel
Squire, had his early schooling with the Rev. J. R.
Pilling at East Dereham before going to Uppingham
and Caius College, Cambridge, where many of his
mother’s family had been before him. At Uppingham
he came under the influence of Thring as head master, |
and in. the Lower VI he met G. Herbert Thring with
whom his friendship was lifelong. ‘ Neither of us,”
his friend admits, ‘‘ was a hard worker, but Sprigge
always showed a very quick power of grasping and
learning.” He could not be kept there long enough to
get into the highest form or into the cricket eleven or
Rugby XV, but he was a sound player at both, alert
in his movements and “terribly fast on his legs for
so small a man ”—a quality that later brought him
success as a fencer. On his father’s death in 1877 his
mother moved to Bury St. Edmunds where Squire
played regularly for the city cricket club and was
well known in the football field; he played for
Suffolk on many occasions, and later for Norfolk
and Middlesex. - Among his papers is a newspaper
account of a lively association match at West Ham
Park between Middlesex and the Norfolk County
Club in which it is recorded that ‘‘ Sprigge at centre
forward was enabled to place the first goal of the
game to Norfolk.”
From Cambridge he entered St. George’s Hospital
or “ The Corner,” as it was affectionately termed, and
was popular as a shrewd student who could sum up
a situation in six witty words. He was always
immaculately dressed and his charm of manner
endeared him to everybody, although he kept com-
pany mostly with the Cambridge men. For, two or
three years he lodged with Thring, and their rooms
were the centre for St. George’s men to collect.
There was a good hand of whist and a mild gamble
at loo. The party often included Hewitt, Bolton,
Sisley, Joseph Fayrer, John Hunter, and Weldon,
and after tea they might go on and dine at Victoria
Station. Sprigge clerked for Timothy Holmes, and
their sparring was a source of delight at Thursday
consultations. His memory was more than adequate
to give him a profound theoretical knowledge of
medicine, and it was by virtue of this rather than of
clinical acumen that he faced examiners who, it is
believed, were sometimes a little overawed by his
knowledge.
It was at this time Sprigge began to write stories
and cultivate the arts. His taste in books became
wide, but he liked a good plot and “ took great joy
in the perfection of a gem-like short story.” He
knew Dickens almost by heart, and enjoyed Wilkie
Collins, Gaboriau, Sterne, Balzac, Henry James,
de Maupassant, and in due course Edgar Wallace
(at his best), Likewise he cared for good food, having
high standards of simplicity, and knew well the
points of wine, especially claret and burgundy,
These tastes went with an expert's interest in moths
and butterflies—to the end of his life “he used to
point like a dog at the sight of an interesting-looking
one”’—and later a love of gardens. His town
garden was made as much like a country garden as
possible: he was especially proud of his herbaceous
border. Appreciation of colour and form led to his
becoming, in the last twenty years, a keen amateur
of water-colour painting, and he was at all times an
informed critic of architecture. In early days at the
Savile Club his chief associates were Edmund Gosse
and William Hunt the historian; and Rudyard
Kipling, Rider Haggard, Anthony Hope Hawkins,
Max Beerbohm, and William Rothenstein were to
become his friends.
INTRODUCTION TO JOURNALISM
After graduating in medicine at Cambridge in 1887
he made no bid for a resident post at St. George’s,
of which there were then only four in all, but went
on to the West London Hospital and Brompton
where he worked under Percy Kidd, also an old
Uppingham boy, for whom he had a great admira-
tion. He did some medical reviewing and medical
writing, mostly in lay papers and anonymously. He
also wrote a good many short stories in popular
publications, but had formed no plans for the future
when two very different openings presented them-
selves, and it happened that he could avail himself
of both. One was the post of secretary to Sir Russell
Reynolds, afterwards president of the Royal College
of Physicians of London, whom he assisted in the
preparation of literary work which was unfortunately
never completed. His experience at this time behind
the scenes in a famous consulting-room gave him,
however, the insight into the attitude of mind of the
practitioner as he goes about his work, which later
found expression in a remarkable chapter in “ Physic
and Fiction ” (1922) entitled ‘‘ the pathologist in the ©
street.”
The other opening came from an introduction to
Sir Walter Besant, the acquaintance soon developing
into a warm friendship, and he became secretary to
the Society of Authors, working there in the after-
noons and with Sir Russell Reynolds in the mornings.
Together Besant and Sprigge produced two pamphlets,
now out of print, on the cost of production and the
methods of publishing, and these formed the basis
of the society's programme. Sprigge’s force and
ability combined with Besant’s burning zeal gave
the society a start which it has never lost. The
novelist and his junior represented the society at
the Chicago Exhibition in 1893 and were both freely
caricatured in the American papers. It was in
Chicago that Sprigge received the telegram which
determined the course of his life. Mr. T. H. Wakley
who had noticed his writings offered him a responsible
aw
Tu J
E LANcET, June 26, 1937
Digitized by Google
THE LANCET]
post in the editorial room of The Lancet, and he returned
at once to London to begin work which he never laid
down. But having resigned the secretaryship he long
remained a leading spirit in the counsels of the
authors’ society, and in 1911 when the Copyright Bill
was being promoted he was elected chairman in succes-
sion to Maurice Hewlett. In December of that year he
presided at a dinner at the Criterion to celebrate the
passing of a Bill described by Mr. Comyns Carr as
the largest instalment of justice which Parliament
had ever given to English literature. The presence
at this dinner of Sir Frederick Macmillan was evidence,
said the chairman, that the Society of Authors could
no longer be described as a ring to fight the pub-
lishers. It was an earlier stage of this Bill which led
to Sprigge being interviewed by the Pall Mall, an
event which evidently gave him pleasure for he
wrote “my first interview ” on a cutting from that
journal,
EARLY DAYS AT THE OFFICE
After a short probationary period Sprigge became
assistant editor of The Lancet, which was then under
the joint control of Mr. T. H. Wakley, F.R.C.S., and his
son, Dr. Thomas Wakley, Jun., son and grandson
respectively of the founder of the paper. They were
advised by Surgeon-General Jeffrey Marston, Dr.
Sydney Coupland, and Dr. James Grey Glover, and
Sprigge has publicly recognised the excellence of
the early training he got from these advisers and
from the younger Wakley, his immediate chief. In
1907 the senior editor died, the junior surviving him
by only two years, and in 1909, at the age of 48,
Sprigge was promoted to sole editorship, and was free’
to develop his special interests. One of these was
medical education. From the moment he entered
the office he began to attend the sessions of the
General Medical Council, and made a daily study of
the regulations of universities and colleges in regard
to the training of students. Foremost in his mind
was always the training of the student on broad
cultural lines and the reform of the curriculum so as
to avoid overburdening him with detail. He began,
as was his wont, to expound his ideas to a trusted
secretary, waiting for an occasional comment, to which
he would reply with further long expositions. This was
always the way in which he worked out his ideas, and
then he would sit down and write rapidly and unceas-
ingly page after page, often racing up and down the
tortuous stairs of the old office when a fresh idea came
into his mind which must be set down without delay.
Some of these early thoughts were crystallised in the
address he gave at the opening session of St. George’s
Hospital medical school in 1910, in which he dis-
coursed on the award of prizes and scholarships.
These had their place as an incentive and no more.
The modern conception of medicine was that all men,
in whatever walk of life they were practising, should
see their life as one long education. He protested
against the multiplicity of examinations and their
intricacy, and pleaded for the wider endowment of
teaching. Only short-sightedness and a false economy
encouraged students freely with exhibitions and
scholarships while making scanty provision for those
who taught them. What was needed, he said, voicing
an opinion now, but not then, generally held, was pro-
fessorial chairs for the teachers, and he appealed to
wealthy and generous persons to found these chairs.
“What right,” he asked, ‘“ have we to expect that
the highly endowed student will receive adequate
instruction if we fail to endow his masters?” A
paper which he read in Paris at the First Inter-
national Congress of the Medical Press in 1900 set out
OBITUARY
[JUNE 26, 1987 1551
what became the policy of The Lancet towards medical
education ; this took more precise form in a modest
volume entitled “‘Some Considerations of Medical
Education,” which appeared in 1915. The main
theme of this book is that while the education of
the medical student in this country will bear favour-
able comparison with that in any other country, it
is an anomalous state of affairs that the diploma
giving permission to practise is in no sense an accurate -
measure of the soundness of his training. Another
series of anonymous articles on the relations of
medicine to the public was also republished in book
form. These articles were reconstructed as a thesis
for a belated M.D. degree at Cambridge.
Sprigge had as his first assistant at The Lancet Dr.
H. P. Cholmeley, historian and scholar; their colla-
boration, though congenial, lasted only two years in
that form. In 1911 Dr. N. Gerald Horner, now editor
of the British Medical Journal, joined the staff; but
here again the association was short, for on the out-
break of war in 1914 Dr. Horner went on active service,
and the editor brought out the journal single-handed
until Dr. Egbert Morland came to the office in 1915.
The war reduced The Lancet to small proportions,
but care was taken to use its pages to the best advan-
tage, and Sprigge was in constant and intimate con-
tact with the Army medical authorities. He found
time also to make a useful contribution of his own to
the care of those in distress, for the Belgian Doctors’
and Pharmacists’ Relief Fund, started in 1914, was
run from The Lancet office, with Dr. Harold Des Voeux
as treasurer and administrator, and the editor as
secretary. Over £25,000 was collected—much of it
through the help of Sir Dawson Williams and the
British Medical Association—and large quantities of
clothing were distributed, while hospitality of all
sorts was secured and professional openings were
found for refugee doctors unable to serve with
the Forces.
Some of his later outside activities should receive
mention here. Having with expert collaborators
done much in “ The Conduct of Medical Practice ”
(1927) to instruct medical men and women how to
protect themselves from unjust attack and how to
avoid giving occasion for attack he was invited
to become a vice-president of the London and
Counties Medical Protection Society ; later he became
a trustee of the society’s reserve fund, placing at
the disposal of its advisers his exceptional knowledge
of affairs. His interest in education naturally extended
to the public school which attracts so many sons of
medical men, and for twelve years he was a member
of the council of Epsom College, doing much, both
personally and through the medium of The Lancet,
to promote the interests of its Royal Medical Founda-
tion, and the improvement of its school curriculum.
When the Coal Smoke Abatement Society initiated
its first serious inquiry into atmospheric pollution
Sprigge put The Lancet laboratories at its disposal
and published its reports when no scientific journal
was willing to take them. He was a vice-president
of the London and National Society for Women’s
Service and took a special part in the development
of its junior council, often attending their meetings
and always standing their friend.
In 1921 Sprigge was elected F.R.C.S. Eng. and in
the same year received a knighthood. In 1928 he
went to the United States to deliver the annual
Hunterian lecture of the American College of Surgeons,
and while there was made a fellow of the College.
The Lancet had already profited much from his many
visits to the Continent, and at the instance of the
1552 THE LANCET]
proprietors he visited a group of the best known
American and Canadian universities, investigating
their medical curricula with the object of making
it easier for medicine to codperate across the Atlantic.
A report of these visits was published as a special
supplement of The Lancet and the report and lecture
are the only contributions which have ever appeared
in the paper under his own name. It was only in
the index that his authorship of the notes ‘‘ From a
Chronicler” (December, 1936) was revealed.
In 1927 he was elected F.R.C.P. Lond..
TWO CENTENARIES
Soon after Sprigge joined the office he was com-
missioned by the Wakleys to write a history of the
founder of The Lancet and of the early work of the
paper. In Sprigge’s hands this developed into a
connected story of The Life and Times of Thomas
Wakley, who was born just a hundred years before
this memoir of him. The biography in its serial
form occupied his week-ends for many months,
each chapter being revised and completed in the
train to and from Aldeburgh. The second centenary
of which Sprigge was the chronicler was that of the
foundation of the journal itself; nearly 30 years later
he retold the story of medical progress in Wakley’s
time and brought the centenary issue of The Lancet
up to date in what might be truly described as the
life and times of Squire Sprigge. At the centenary
dinner, held in November, 1923, addressing a gathering
which included most of the leaders of the medical
profession, he assured them that “the past out-
rageous energies can never be repeated by us... the
- violence of past days is gone, but the desire for the
right and the zeal to achieve it remain as forcible
as they were a hundred years ago.” And he went
on to describe The Lancet as a friend-made paper,
relying on the good offices of its supporters who read
each other’s wisdom and clarify or correct each
other’s views. ‘‘I also,’ he added, “am a friend-
made man. Through school, college, and hospital
associations I have exacted levies from friends and,
as time went on, enlarging environment gave me
enlarging opportunities for such exactions. It is
to others I owe what you have accorded to me.
Any measure of success which has been obtained has
been in return for labours of love. It is they who
have to discharge a dull routine and face distasteful
duties whose devotion is really admirable. I have
enjoyed myself. Medicine may be only one section
of the world’s activities but it is an ever-developing
and all-permeating’one. It has been my delightful
duty to record the phases and ramifications of
medicine as they are produced and as they are justified
by the workers themselves.” This second centenary
came after the ownership of the journal had passed
to Messrs. Hodder and Stoughton, but the con-
tinuity of policy was evident when Sir Ernest
Hodder-Williams, then the chairman, recalled at the
dinner a pledge made by the new proprietors to
maintain the honoured name of the paper ‘ even
though it should mean—as in the case of Wakley—
having our houses burned down and gutted, even if it
means we have to fight half a dozen libel actions in
as many years... .”’
DEPARTMENTAL CONTACTS
The successful conduct of any journal depends on
the harmonious working of the several parts—the
ofhice, the printing house, the advertisement depart-
ment. It was Sprigge’s good fortune, for which he
was himeelf largely responsible, to be associated over
long years with departmental chiefs on terms of
OBITUARY
[JUNE 26, 1937
intimacy. ‘Until the move from the old house in
Bedford-street across the Strand to the Adelphi the
composing-room, three floors above the editorial
room, was ruled throughout his time by two men,
father and son. The latter, who is still “ the printer,”
writes: ‘‘At the period when the typesetting of
The Lancet was done in our own offices Sir Squire
was exceedingly popular with the readers and com-
positors, who to a man would work with great
enthusiasm when a big article arrived barely in time
to be inserted in the current issue (at this time the
type was hand-set). Sir Squire deeply appreciated
this help ; and in return took a personal interest in
the staff and remembered the varied characteristics
of the men, whose future careers he took great
pleasure in discussing for years afterwards. Should
further advice be needed in cases of illness he would
gladly make the necessary arrangements. Also at
Christmas he would devote a sum of money to pur-
chase a present for each man, consisting of a pipe,
tobacco or cigarettes. The juniors, whose job it
was to carry copy and proofs to and from the editor
and the printing department, found that he was
never too busy to enjoy a joke. For instance, on a
certain Boat Race day the messenger wore a large
Oxford favour in his coat when he carried proofs
down to the editor. ‘I can’t be bothered with you
to-day,’ said he, with twinkling eye, ‘ you must hand
them to Dr. Cholmeley (an Oxford graduate).’ In
the early part of the war he had to work without the
aid of a sub-editor, but the printer’s readers came
to the rescue and helped him to put the copy in
, proper order. Altogether his was a great and lovable
personality, and he found no difficulty in arousing
the interest and enthusiasm of those fortunate enough
to work with him.”
Here are a few impressions from a member of the
office staff who “had the pleasure of knowing Sir
Squire during 45 years at The Lancet office. From
his early start he endeared himself to all, being
ever willing to help and advise. In fact he never
tired of doing good. Anecdotes about his resource
are many, but one must suffice. On one occasion a
man who called to subpoena him to give evidence,
being told he had not arrived, announced a deter-
mination to wait outside for him. Sir Squire, wishing
to get away, sent the office boy to buy a cap, put it
on, turned his coat collar up, and walked out past the
waiting man, leaving a truthful message that he had
gone to an inebriate’s home (of which a friend was
superintendent).—Sir Squire Sprigge was both good
and generous, We all loved him and we shall sorely
miss him.”
“ He was kindness personified,” writes the Manager.
“It will always be a cherished thought that I was
privileged to have been associated with him for
seventeen years. During the whole of this period,
and particularly the last eight years, there was
never a difficulty, either of a business or domestic
nature, in which I did not know I could ask his
counsel and readily receive the guidance needed to
surmount the obstacle. In my absence from the
office on holidays his help was constantly available
in business matters. His great human kindness
and foresight were always available for the solution
of problems, large or small. The charm of his
personality affected senior and junior alike, and
especially those who had suffered loss or misfortune.
were helped by his presence and by his manner.”
THE EDITOR
An editor is necessarily a journalist, but the two
roles are not the same. Sprigge was less modern
THE LANCET]
in technique than in policy. His prose was leisurely
and unemphatic ; at its best it was rich and charm-
ing, but he did not strive to put his meaning into
words of one syllable, and he sometimes deliberately
weakened his argument by a qualifying phrase that
sounded like an after-thought. He was content, in
fact, to develop his ideas in dignified English, with
reservations in parentheses ; whereas the journalist
of to-day, conscious that the world is full of distrac-
tions, seeks first to engage and keep his reader’s
attention. Characteristically, Sprigge despised the
tricks of his trade—the attempts to catch eye or
ear. He did not much care whether a page looked
formidable or readable. He seldom baited his
articles with ingenious headings, but liked them to
have plain descriptive titles. In a word, he was not at
heart a propagandist. Equally fundamental was his
disinclination to alter argument or narrative for the
sake of a good phrase or a witticism ; which meant
that his professional essays were less entertaining
in type than they were in draft. Similarly, as an editor
he never attacked for the pleasure of ‘attacking.
When a junior suggested gloomily that the function
of a leading article was surely to lead, he replied,
accurately enough; that the word “leader” merely
indicates an article in which the lines are leaded or
spaced.
It has been said that he was “a typical English
gentleman in his shyness of showing personal emotion
or of touching in conversation upon serious prob-
lems... . The emotion was there, however care-
fully concealed, and his truly tender concern for the
interests of others sometimes broke through his self-
control.” The same applies to his behaviour as an
editor. Though he took pride in the influence that
The Lancet might exert on medical affairs and was
anxious’ to exert it sanely and wisely, he felt no
temptation to go out to look for windmills on which
he could demonstrate his skill and thus enliven his
pages. But his feelings on medical and public affairs
were none the less real because he sought to sup-
press them, and the indignations or sympathies of his
liberal mind occasionally found forcible expression.
In selecting material for publication he preferred
the contributions of men who worked in an environ-
ment of criticism, at hospital or elsewhere. But his
personal contacts were not confined to the conven-
tionally successful and he knew well that good sense
could be spoken in strange tongues. He wrote once
to an assistant: “you are too forthright; bounders
do not always bound, boasters do not always lie,
the third-rate person sometimes produces second-
rate stufi.” He showed perspicacity in seeing
what people were fit for and in not attempting
to make them do more. He once said: ‘‘ Never
take away a man’s vanity. If you do that, he’s
done for.”
He disliked arm-chair medicine; but his general
outlook did not conform with the definition of an
editor as ‘‘a man who keeps things out of a news-
paper.” Where a member of the profession had
earned a right to be heard, he would often take
great pains that he should be heard effectively. If
it was folly to insist on speaking to “the editor
himself ” over the telephone—which instrument he
never learnt to control—it was very wise to call and
secure recognition as a person rather than a signature.
As an editor he had catholic tastes. If he did not
interpret free speech as meaning that the columns
of The Lancet were open at all times to letters on
controversial subjects, it was because he knew how
hard it may be to deny the claims of interested
parties to replies that lead nowhere. Ultimately the
OBITUARY
[JUNE 26, 1937 1553
editor must decide what he wants to put in his
paper and as an editor Sprigge’s highest qualification
was that he knew his own world—and also much of
the world outside it. He was a familiar and a much
beloved figure at the United University Club as well as
at the Athenzum, and was often consulted about new
developments while they were being planned.
It is useful that an editor should have private
knowledge of events; but here, in later years, he
resembled C. P. Scott of the Manchester Guardian,
who occasionally omitted to mention his special
knowledge until it was too late for his staff to make
use of.it. What he did provide all the time, however,
was an eye for errors, large or small, and a judgment
based on knowledge of men; and it was a mature
and sagacious judgment. Like Scott again, he had
a low opinion of his readers’ capacity for appreciating
irony ; but in other respects he felt himself repre-
sentative of the plain medical man faced with advanc-
ing science. ‘If I can understand this,” he said,
“so can any of our readers.” He strongly objected
to any suggestion that special fare should be pro-
vided for general practitioners as a class apart: his
journal was for the medical profession, all of whom
had the same basic training. At the same time
he tried to prevent its becoming what he called
“too pathological.” His highest praise, when his
advance copy of The Lancet arrived on Thursdays,
and he exchanged cigarettes with the printer—an
invariable custom—at his morning. visit, was that
its contents were “all over the place.” If this
favourable verdict was sometimes associated with
regret at the inclusion of material that he personally
found unreadable, the regret remained unspoken.
For his modesty led him to drive his team with the
lightest of reins, and those who worked with him
will remember that he gave them all the freedom
they wanted, criticising rarely and holding himself
responsible only when things went wrong. In recent
years the inside medical staff of The Lancet has
consisted of the editor and four assistants, who
shared one large room. Though their ages ranged
from 26 to 76, sectional division of the work was
avoided; each was encouraged to tackle any
aspect of it and submit to robust comment on the
results, being in turn expected to use his know-
ledge in criticism of the efforts of his colleagues.
The fact that the chief did not pursue consis-
tency in detail made it easier for him to delegate
tasks to others. The tradition he established was that
all were working for The Lancet, not for the editor.
But these apparently simple solutions came from
a complex mind. He liked to follow custom but did
not readily remember rules, even when he had made
them himself. He was no enthusiast for policies ;
he was true to national type in his opportunist out-
look and ability to compromise. The opportunism,
however, was that of a philosopher and the com-
promises those of a diplomat. He often followed the
classical advice to give a decision without the reasons
for it. Nevertheless, his office was a school of the
diplomacy of which he was a master. His anger was
not always righteous, but his associates learned to
know that irritability was sometimes assumed so
as to put an artificial end to discussion that tended
to be too protracted. Moreover he usually managed
to make it appear impersonal, directing it at objects
and subjects rather than at persons. His mood
could change as quickly as April weather. But |
fidgety or cheerful, blunt or bland, he had an
uncommon air of breeding; and no one seeing his
fine and fearless face could doubt either his wisdom
or his power to manage others.
1554 THE LANCET]
OBITUARY
[June 26, 1937
THE TRUSTEE
In 1894 Sprigge succeeded to a small family property
in Buckinghamshire, and in the following year he
married Beatrice, daughter of the late Sir Charles
Moss, chief justice of Ontario. There are two
children of this marriage, Mr. Cecil Sprigge (financial
editor of the Manchester Guardian) and Mrs. Mark
Napier (Elizabeth Sprigge the novelist), and five
grandchildren. In 1905 he married Ethel, daughter
of the late Major Charles Jones, and she survives him.
His second daughter, Annabel, is a sculptor.
He was thus the centre of a large family circle,
going down to the third generation, but he was also
trustee for many outside it, and trusteeship of one
kind and another made up a large part of his life.
He held in trust the assets (not only material) of
many who had no claim on him save that of a common
profession, college, or school; for the impulse to
confide in him was widely felt. So sure was his
touch, so wise his discretion, that no awkward-
ness or embarrassment came to mar future relations.
He did not ask sympathy in return ; indeed he would
mostly have resented it. He was taciturn about his
own troubles and worries. But his hand was always
ready to be outstretched, and his purse to be
opened, to friends or even acquaintances in difficulties.
Chivalrous is the word used of him by some German
friends in whose house he often spent his summer
holidays. All his ingenuity was often taxed to
find means by which he could avoid being thanked.
To the casual observer he may not have appeared
a patient man; but in fact one of his outstanding
qualities was his patience—patience with the follies
of a large number of men and women who came to
him for help and advice, but particularly patience
with the vagaries of the young. Responsibility had
been early thrust upon him, for he was only at the
end of his school days when his father died and he
was left as eldest son of a young family. The sense
of family obligations was, and remained, imperious
in him. He viewed the small estate he later inherited
as a trust vested in the head of the family, carrying
with it the privilege and duty of active interest in
the well-being of a considerable number of people,
young and old. No man, however, could have been
freer from the reproach of laying down duties for
others, and though he might often have imposed his
will upon the young he preferred to offer his help
in whatever course they should choose, even (or
more particularly) if it were not the course which he
would have had them pursue. Indeed he respected
personal independence to the point of appearing
sometimes to abdicate authority. But he had
usually chosen his ground well, and by allowing
free play to others secured all the more surely their
affection, and, at the really critical point, their
cooperation.
Whatever he undertook to do, whether it was a task
in the public service, a matter of necessary private
business, or a study for delight or ornament, he
performed with precision and energy yet with no
inhuman airs of self-dedication. As a well-balanced
human being with a fine taste in intellectual principles
and in conduct he was a reverent inquirer into mean-
ings rather than a confident assertor of opinions about
first and last things. He had been born and brought
up a country lad, and yet his lot was to work for half
a century in the centre of a great town and to become
a loyal and even a passionate Londoner. Always in
the back of his mind he had the broad fields and
the trees and a village church like that where he was
laid to rest last Saturday. A single wreath sent
anonymously bore the words: “In long memory
of Sir Squire Sprigge: To know him was to gain
strength.”
IMPRESSIONS '
Some idea of the effect of Squire Sprigge on his
contemporaries and juniors may be gained from the
selection of personal tributes which follows.
Sir Charles Sherrington.—To contribute a few
sentences in appreciation of Squire Sprigge, my
friend and old fellow-collegian, to your columns,
which were so long his, comes, although it has its
sadness, as in some sort a satisfaction. It may seem
odd but my memory’s picture of him at Cambridge
mostly recalls a figure, characteristically well dressed,
bound for the football field or the tennis courts, and,
even in flannels, something of a Beau Brummel—
but in the field or court a formidable hard-bitten
player. He was a general favourite with us all, witty
and companionable, one who never seemed to have
any particular work to do.
Meeting him later in London after he had joined his
hospital I found a talk with him always an intriguing
change from what I met elsewhere. I fancy he already
moved in circles where the literary work of the day
with its artistic and its business vicissitudes was
constantly uppermost. At that time he would seem
to me so detached from the interests of a medical
school that I supposed he would drift off altogether.
Later still I met him at a friend’s house in Toronto,
and Toronto seemed to him almost a second home.
I cannot trust my memory as to how long it is that
he had been identified with the editorial work on
The Lancet, but almost from the very earliest of my
own personal contacts with the editorial office it was
with Sprigge that my contacts had to do, always to
find myself impressed, and indeed charmed by his
ability, his geniality, and his helpfulness. In more
recent years a scene which remains vividly to me is
the commemoration banquet organised by him in
celebration of The Lancet’s centenary. All the world
was represented. The speeches went on well beyond
midnight. Everybody felt it a great success, and
the presiding spirit throughout was personified in
Sprigge.
Others will pay tribute to other sides of his versatile
personality than those it was my privilege to know.
To me his memory remains as that of a life-long
friend, whose gifts and character were such as often
to raise in me the wish that good fortune might yet
more than it did throw me in the way of his society
and fellowship.
Dr. Alfred Cox.—lIt needs a great effort to imagine
The Lancet without Sprigge, for, as must be the case
with all great editors, he impressed his personality on
every page of it. The sense of loss that our profession
will feel on hearing of his death will be specially felt
by those of us who knew him in his younger days
when he was such a prominent personage in literary
as well as in medical circles.
I had my first contact with him in the late ’nineties,
when as an ardent medical politician I was much
concerned with the abuses of medical contract prac-
tice. The Lancet had commissioned Mr. Adolphe
Smith to visit various parts of the country and write
a series of articles on ‘‘ The Battle of the Clubs,”
in which the sordid horrors of that branch of practice
were exposed in a masterly fashion worthy of the best
Lancet traditions. Sprigge wrote to me and asked me
to help Smith in his investigations on Tyneside, which
I willingly did. The effect of those articles was
THE LANCET]
profound, not only on the outlook of many active
doctors of my generation but on the subsequent
policy of the British Medical Association. Occasional
correspondence with Sprigge followed but it was not
until 1900 that I first met him, on a memorable
occasion. At that time there was much dissatis-
faction with the inertia of the B.M.A. with regard to
the interests of the general practitioner. A body of us
got together and a small deputation, of which I was
one, was sent to ask Sprigge if The Lancet would put
itself at the head of a new body and become its
official organ. The interview was specially memorable
to me because Sprigge, after listening to us very
sympathetically, took the line I had persistently
advocated. He said it would be a great mistake to
do anything to weaken the one great organisation the
profession had, and told us we could come back if we
liked, but we must then be in a position to convince
ourselves and him that it was impossible to get the
B.M.A. to do what we wanted. Theresult is well known.
His attitude then, as I found later, was charac-
teristic of the man. Proud as he was of his journal
and always anxious to extend its influence, he always
tried to take the long view of what was best for the
profession as a whole. Many times in my official
career I sought his advice and help and never in vain.
He was sometimes critical of the policy we were
pursuing and said so quite plainly, in private at any
rate. But he was ready to back us up with all his
power when he knew we were right, and he occasion-
ally took considerable risks in doing so. Many a
time he used his great personal influence, behind the
scenes, with prominent public men, in order to further
our objects ; this was notably so during the Insurance
Act fight and in connexion with the recruiting of
doctors during the war.
His action in joining the Editor of the British
Medical Journal to found the Medical Insurance
Agency should not be forgotten. That useful and
prosperous institution owed much in its earlier days
to the support given by The Lancet.
It was with surprise, but great pleasure, that I
found on joining the staff at the B.M.A. that Sprigge
and the Editor of the B.M.J. were on cordial terms.
They were both strong men and liked and respected
each other. It is easy to imagine how much less
unity and good feeling there might be in our profession
had the situation been otherwise. I remember
Dawson Williams telling me, when after the war
both he and Sprigge were knighted, that his pleasure
in the distinction was greatly increased by the fact
, that Sprigge’s good work had also been recognised.
There. can be few such examples of loyal and cordial
coöperation, alongside honourable rivalry, in the
history of journalism.
Sprigge was a delightful companion, genial, witty,
and humorous. I have heard him make one or two
of the best after-dinner speeches in my recollection.
Few men can have been more utterly devoted to their
life’s work or prouder of it than Sprigge was, and
I am glad that when the end came it found him still
in harness, He carried on and improved the great
Wakley tradition, and in saying this I fancy there
could be few things Sprigge would more gladly have
heard. I am grateful to have this opportunity of
paying a tribute to the Editor I respected and to
the man it was a privilege to call a friend.
Sir Humphry Rolleston.—Squire Sprigge and I
first met in 1883 in the final of the Hospital Rugby
tie, played on the Half Moon ground, Putney, long
ago built over, when he was playing for St. George’s
Hospital which on that occasion lost to St. Bartholo-
OBITUARY
[JUNE 26, 1937 1555
mew’s Hospital.1 Sprigge had just come up from
Caius College, Cambridge, and was slight and light,
but quick as a forward, especially in the Rugby
football of those far-off days. Essentially a cultivated
littérateur, probably few of those who knew him in
his later life only would have guessed his earlier
athletic activity, or perhaps have read his two books,
long out of print, in a vein much lighter than some
which followed about medical education. These
were ‘“‘ Odd Issues” (1898) and ‘‘ The Industrious
Chevalier ” (1902), collections of stories charmingly
told, and drawing some of their local colour and
incident from his life at Cambridge and St. George’s
Hospital. His Life of Thomas Wakley, his pre-
decessor in the editorial chair of The Lancet, and his
work on the autobiography of Sir Walter Besant,
with whom he was closely associated, were fine
pieces of biography. With an exceptionally wide
acquaintance with medical London he was a shrewd
judge of men and manners, and could have written
an extraordinarily interesting account of the last
half-century ; possibly he has yielded to the sug-
gestion of friends that he should record his observa-
tions. His great work was at The Lancet and, with
Sir Dawson Willfams of the British Medical Journal,
who died in 1928, he exerted a memorable, though
unobtrusive, influence on medical journalism in this
country. Like Delane of the Times, he was a man
of the world with many friends, an interesting and
arresting talker, and leaves a gap it will be indeed
hard to fill, But he had trained a number of his
assistants on his own lines who will thus be able to
carry on the fine tradition of this doyen of British
medical journalism,
Sir Farquhar Buzzard.—tThe death of Sir Squire
Sprigge means, at any rate to a large number of his
contemporaries, something more than the loss of a
friend whose personal gifts and qualities were
peculiarly distinctive and attractive. The experience
of many years, a real test of general opinion, has
given us an almost blind confidence in the manage-
ment of the journal for which he has been responsible
and which, largely owing to his able direction, has
become an essential and outstanding feature of our
professional life. The news that The Lancet has lost
its editor cannot fail to make us realise, suddenly and
perhaps for the first time, how satisfied we have long
been with the knowledge that the control of its policy
and of its contents lay in his safe and masterly hands,
One cannot doubt, too, that Sprigge’s immutable
loyalty to the highest traditions of the profession
and to the interests of the public was always a great
contributing factor to the mutual consideration which
has distinguished the friendly rivalry of The Lancet
and the British Medical Journal. There could
be no better example of two parallel enterprises
conducted with signal success and without resort to
the unworthy expedients of journalistic competition.
The respect in which Sprigge was held by the two
professions he adorned was based on his intellectual
ability and integrity; the personal affection with
which he was regarded by his many friends had its
origin in his modesty, his generosity, and his kindly
but keen sense of humour. His services to the art
and science and literature of medicine were performed
silently behind the scenes and therefore difficult to
record or assess, but their great value was indis-
putable and worthy of our homage, our gratitude,
and our memory. |
1 A contemporary tells us that Sprigge’s comment on Rol-
leston’s election to the staff of St. George’s was: “I remember
him well as a vicious Bart.’s forward.”
1556 THE LANCET]
Sir D’Arcy Power.—He was a great editor and
many of us have watched with interest the numerous
changes he made so unobtrusively whilst he occupied
the editorial chair—changes always for the good—
until he brought The Lancet to its present position.
It is a journal which appeals alike to the profes-
sional and the non-professional reader.
His death carries my mind back to a far distant
period. As long as I can recollect my father—Mr,
Henry Power—paid a weekly visit to The Lancet office,
then in the Strand at the corner of Bedford-street,
and brought back two or three books for review.
They were, I was told, laid out on a table and each
took what he fancied. The books were not returned
and my shelves still hold a complete set of Darwin’s
works with ‘“‘review copy” stamped inside them.
What was paid in cash I never knew, but every
Christmas a barrel of oysters arrived with Mr. Wakley’s
compliments and good wishes. The oysters in later
years were replaced by a huge home-grown turkey
bringing the compliments of the season from Tom
Wakley. Once on a day never to be forgotten we
found ourselves with our noses flattened against the
first-floor window of The Lancet office with a magnifi-
cent lunch in the room behind us; m front a glorious
cavalcade, for Albert Edward, Prince of Wales, was
on his way to St. Paul’s Cathedral to return thanks
for his recovery from an attack of typhoid fever.
The day, therefore, was Feb. 27th and the year 1872.
Alas ! all have passed away. The medical members
of the Wakley family; Dr. Buzzard, Dr. Sydney
Coupland, Dr. Glover, my friend Dr. H. P. Cholmeley,
quiet, capable, and scholarly, and now Sir Squire
Sprigge. It is the penalty of age and Virgil was
right when he spoke of tristis senectus. .
Dr. R. A. Young.—Sir Squire Sprigge was a man
of outstanding personality, with a wide range of
knowledge and a clear perspective. He was quick to
appreciate ability, intolerant of shams and of inepti-
tude, but with a deep sympathy for his fellow man in
distress or difficulty. He had a very quickly acting
mind, with an almost intuitive grasp of the crux of
any problem submitted to him. He was a good,
attentive listener, where his interest or his sympathy
was aroused, and would often at once suggest a
solution of a difficult problem or point out the fallacies
in its presentation. His position as editor enabled
him to watch and to assess the progress of medical
science and practice, and he often showed a remark-
able perception of the importance of new discoveries.
He had a more profound knowledge of the persons
and personalities in medicine than almost any man of
his time. Such qualities and such experience com-
bined to make a great medical editor, interested not
only in medicine as a science and in the art of
practice, but always keeping in mind the relations of
medicine and medical men to the State and to the
common weal.
He wrote easily and in a happy, clear, literary
style. His comments were often as keen and as
incisive as his editorial mind. He had the rare gift
of constructive criticism, and he could quickly rewrite
or reshape an article with good material ill presented,
which most editors would have discarded. He was a
kind and generous host, and with his wide general
culture and great artistic gifts he was always inter-
esting and illuminating. Jle had a keen and some-
times caustic wit, but it was never unkindly. The
high standard of medical journalism in Great Britain
owes much to his constant watch on the contributions
to The Lancet, to his avoidance of the sensational, and
to the sanity of his policy. The best tribute to him.
OBITUARY
[JUNE 26, 1937
is the esteem in which English medical journals are
held not only in the profession but by the general
public, and that not only in this country.
Sir George Newman.—tThe death of Squire Sprigge
comes as an unexpected blow to me. One always
thought of him as young, alert, and virile. He was,
with his great contemporary, Dawson Williams, one
of the lights of modern English medicine. It is
difficult for the younger generation of medicine to
realise what these two men did for the profession and
for the public. The British Medical Journal and
The Lancet owe much to their respective proprietors
and publishers, but they would be the first to recog-
nise that their two famous editors made the papers
what they became. Both papers have rendered a
unique service to medical science and to the profession.
Squire Sprigge brought to The Lancet his own peculiar
„intellectual gifts.
more a free lance, than his colleague, the editor of
the B.M.J., who naturally and properly stood for
the Association. He had the foresight and faculty of
the literary critic and thinker. More than thirty
years ago he published a compilation of papers,
entitled ‘‘ Medicine and the Public,” which reveals
the wide sweep of his comprehensive understanding
of the new age, and embodies the views he had
formulated in The Lancet before he became its editor
in 1907, Though not widely read, it was an epoch-
making book and its remarkable prevision has been
justified in the generation which followed. Sprigge
understood, as few men, the principles of governance,
what would be best yet what is only practicable,
what would be good yet what could be got. He
remained steadfast for the dignity of the profession
and was jealous of its credit and repute. He did not
suffer fools gladly and could be righteously angry.
He was very keen on modern research from 1911
onwards, but was impatient when it appeared to go
astray ; no wild courses for him and no advertising.
Wise and urbane man, happy and hopeful traveller,
great editor, faithful friend—hail and farewell !
Sir William Collins.—As the biographer of the
founder of The Lancet Sir Squire Sprigge seemed
predestined to succeed the representative of the third
generation of the Wakley family in the editorial
chair of that journal. He brought to the office a
scholarly mind and refined taste, qualities which
imparted to The Lancet a distinction and inde-
pendence which secured and retained the confidence
and esteem of the profession. Among Sprigge’s
literary friends and co-workers was Dr. Sydney
Coupland, whose wise and modest advice in medical
Journalism he gratefully acknowledged. Sprigge’s
own writings were characterised by width of view
and liberality of sentiment. In his ‘“ Physic and
Fiction ” he asserts that ‘‘ medicine is not yet an
exact science,” while repudiating the indictment of
“a medical priestcraft.””’ He foresaw the need for
unification of the public health and poor-law services
under a Ministry of Health and the supersession of
the latter by the Local Government Board. If his
advocacy of reforms and the redress of abuses was
less dramatic and trenchant than that of the redoubt-
able Dr. Tom Wakley, M.P., the first editor of The
Lancet, it was none the less effective by reason of
its erudition and cogency.
Miss R. E. Darbyshire.—The nursing profession
owe to Sir Squire Sprigge a lasting debt for his help
and wise counsel. During the sittings of The Lancet
Commission on Nursing Sir Squire gave much time
He was also more independent, `
THE LANCET]
and thought to our problems and took so great a
part in the work of the Commission that his name
will be gratefully remembered by nurses. His work
for the welfare of our profession will prove of increasing
value to us all.
Sir William Rothenstein.—I scarcely realised,
when I first knew Squire Sprigge, that he was a
medical, a scientific man. To me he was of the clan of
writers and painters who met at Robbie Ross’s rooms,
at the Café Royal, at the Savile Club, to discuss books,
and poets, and the sins of the bourgeois. Sprigge
seemed to know all about painters, pre-Raphaelites,
and impressionists, and joined in our worship of Jimmie
Whistler. To him also Meredith and Swinburne
were god-like heroes ; those were days when we were
hero-worshippers as well as revolutionaries and
scoffers. Sprigge had the painter’s eye, and the large
humanity of the writer, a combination which gave an
added grace to a naturally gracious mind. No one
was quicker to detect talent in his contemporaries
and to hearten the hopes of those who pursued
wisdom and beauty in one way or another. And to
our rougher, more impatient natures he held up a
standard of courtesy and quiet wisdom which he
retained during the course of his own life.
Mr. Harold Barwell.—On meeting Sir Squire
Sprigge one recognised at once an uncommon per-
sonality. A small slight figure, his well-marked
features, evidence of his great strength of character,
were relieved by a humorous expression, and his smile
was charming. He was a modest man, whose
unaffected manner put everyone quickly at his ease ;
a good conversationalist, with a fund of anecdote,
he was also a good listener and was therefore the most
pleasant of companions. I must speak, too, of his
devotion to duty, his loyalty to his old school at
St. George’s Hospital, and his many kindnesses, as
well as of his outstanding ability. He was, indeed,
exemplary in conduct, courteous in manners, easy of
address, and steady and firm in principle, as became
a master of his craft and a great man. We can ill
spare him.
Prof. M. Greenwood.—A few months ago Sir
Squire and I were dining together and in our talk the
name of an eminent man, prone to an oratory we
did not relish, cropped up. ‘The truth is, you
know,” said Sprigge, with a characteristic tightening
-of the lips, ‘“ X.Y.Z. is getting ga-ga.’ I assented
cordially and lost myself for a moment in trying to
calculate whether X.Y.Z. was twenty or only fifteen
years younger than Sprigge. Indeed it was very
difficult to believe that he was not one’s own age or
younger and some newspapers will be unjustly sus-
pected of publishing portraits of him taken at least
a quarter of a century ago. Yet with this perennial
youthfulness he combined a flavour of a past age.
He was never the old gentleman shaking his head at
modern follies; he often seemed a reincarnation of
the spirit of the eighteenth century, or rather of what
we idealise as its spirit. Witty, neither under-
valuing nor over-valuing the little good things of life,
with an unerring eye for humbug and an intellectual
epicure’s pleasure in a neat, clear argument, one felt
he would have been on terms of happy equality with
Charles Fox, William Windham, and Dr. George
Fordyce.
Those who had the privilege of close association
with him can speak with fuller knowledge; to me he
seemed an ideal mentor for young men with literary
ambitions. I grieve over the loss of a kind friend,
OBITUARY
[JUNE 26, 1937 1557
but rejoice that to him was vouchsafed a petition we
all should make:
Let me not live
After my flame lacks oil, to be the scoff
Of meaner spirits.
His flame never lacked oil.
Mr. Cecil Binney.—To me Sir Squire Sprigge
stands out as my first grown-up friend. As I had
been some years at a public school when I first met
him, I had previously seen and talked to numerous
grown-up people; but those who were not school-
masters were older relations or friends of my family,
who, kind as they might be, always treated me as a
schoolboy. Dr. Sprigge was entirely different. It
was not only that he treated me as a grown person;
he was himself at the same time so extraordinarily
young. He entertained me and discussed current
affairs with me as though I were a contemporary.
I went with him to the South Kensington museums.
I had often been to them before but in his company
they took on a different aspect. From being gloomy
places where children were sent on Sunday after-
noons, they became galleries where educated people
wandered around and discussed the exhibits without
any pretence of taking them too seriously. It was
like going with one of one’s own friends who hap-
pened to be extremely well-informed and entertaining.
Yet there was no affected boyishness about him. His
attitude to life was one of kindly tolerant cynicism,
as though he could understand and pardon every-
thing. Before I met him, I had heard a great deal
about him, and thought of him as a unique parent
who did not mind his children or their friends wearing
strange clothes or adopting strange creeds, and had
amused but kindly comments to make on any such
developments. It had come therefore as a surprise
to me to find that he lived like other people in a
normal Kensington house with furniture. But that
was my ignorance: I had not enough experience of
the world to know that with his breadth of mind, his
comprehension, and complete sincerity, he could
have no use for any eccentricity.
Mr. John Paul Ross.—To the younger generation
the company of “ Squire ’’ was a great treat and joy,
and a visit to him was always happily anticipated
and even more happily realised. His was a wit that
made that of other reputed raconteurs seem
laboured, and the versatility of his mind was sur-
prising. He seemed to have an inexhaustible fund
of knowledge, and he would contribute to almost
any subject of conversation in a way that was all
the more authoritative ‘because of its modesty and
lack of dogmatism. His sympathy and kindness to
all was a by-word, but none had in him a greater
partisan than young people. He had no use for those
who constantly lament the effeteness of the present
generation, and we have lost a true champion. All
will miss Squire Sprigge: the clubs whose smoking-
rooms he delighted ; the medical profession which he
served ; and the countryside which he loved to paint ;
but none will miss him more than we youngsters.
Mr. F. C. Goodall.—As a beginner in a branch
of journalism on the fringe of medicine I called at
The Lancet office some thirty years ago to leave
some copy in the hope that it might be used, and I
was told that the editor would see me, Having
hitherto in my short acquaintance with man received
more kicks than halfpence I was prepared for another
kick, and resigned to the thought of it. But nothing
like that happened. Going into the presence, humble
and perhaps scared, I was at once put at my ease
1558 THE LANCET]
and for the first time in my newly started career
was made to feel a person of some use in the world.
He gave me friendly advice and commissioned me
to write an article on a subject he suggested, and
when the interview was over he did not dismiss me
with the nod to which I was accustomed ; he walked
down stairs with me and shook my hand at the street
door. I went away with a new hope and a new heart
and vowed that if ever it was my lot to become a
leader of any concern J would show the same courtesy
to young aspirants.
Dr. C. P. Blacker.—The intense masculinity of
“his personality and the enormous range of his culture
were capable, at first, of inspiring many people with
feelings of respect amounting to awe: but these
were quickly thawed by his friendliness, his humour,
and his directness. Very soon one found oneself
talking to him as to a man of one’s own age. The
wide range of his friendships and of his experience
of affairs frequently led to attempts being made by
younger men to draw him out, to their asking his
opinion about controversial matters or outstanding
personalities. His power of giving humorous, pene-
trating yet always kindly appreciation of people
and events was memorable. Good qualities never
went unrecognised by him; but weaknesses rarely
passed undetected. Nearly everyone, as described
by him, was likeable, understandable, and human ;
and the world as seen by him was a better place,
peopled by pleasanter people, than as seen by most.
His personal modesty was one of the most obvious
of his traits; but it did not take long to recognise,
in the background of his personality, as an implica-
tion and corollary of all that he said and did, an
integrity of mind and a fineness of personal quality
which made it understandable that he was held in
both affection and esteem by his juniors no less than
by his contemporaries.
Mr. Anthony Bevir.—First as a boy, and after-
wards as I grew up, he always seemed to stand for
courtesy and kindliness in the world of affairs. I am
quite sure (memory may be fallible but in this it should
not be) that he gave me, each at its appropriate stage,
ices, the unexpected half-sovereign, then the early cigar,
or glass of port at his club; then a suitable range of
introduction there ; and finally (amongst other things)
the suave covering of ignorance on library committees
and so forth. I daresay he enjoyed watching the
grub turning into a moth: but the appreciation was
not only on his side. And always there was an appro-
priate flow of worldly wisdom, touched and lightened
by a delightful half mordant, half sympathetic wit.
The truth is, I think, that he liked young people
and was naturally more at ease with them than with
their elders in the world, though he moved easily
enough among them, Adult humanity was not
infrequently suspected of humbug, and if there was
one thing he detested it was humbug, though he
would be the first to appreciate its nicer uses. I think
he might have said that it was probably less developed
in the young.
It is not for me to write of his professional side
either as physician or journalist, though I have had
reason to be grateful for advice from his experience
or knowledge of both spheres—I only write as a young
friend, always engaged by his conversation, delighted
in his books (‘‘ An Industrious Chevalier ” read and
re-read always with fresh pleasure), and grateful for
his unvarying generosity and kindliness, As I write
this I inevitably think of his own judgment on what
I have written. That young man, he might have
OBITUARY
[JUNE 26, 1937
said, with a slight deprecation, might just as well
have made it a sovereign while he was about it.
Those who knew him will know what I mean.
AT THE MEMORIAL SERVICE
Lord Dawson said: At this service of remembrance
I will try and give expression to our admiration and
thankfulness for the life of Squire Sprigge.
The son of a Norfolk doctor, he belonged to the
countryside, and there his spirit lived during life,
and his body now rests. His life was long, rich and
varied in achievement, clear and staunch in its
purpose. Coming from Uppingham, Caius College,
and St. George’s Hospital, his career was from the
first that of author and journalist in varied fields, to
which he brought scholarship, competency, and a
lively sense of the problems of his day and generation,
The Lancet—this was the chief sphere of his work
and influence. His association with that great
journal began when he was aged thirty-four, and he
was editor, by succession from the distinguished
Wakley family, for the last thirty years of his life.
And picture those years—the rising tide of new
knowledge, the growing concern for the health and
weal of the people, the uprise of medical insurance
and communal services—these and other changes
surged round us in the hurry of the times. From
Sprigge in his weekly chronicle came the still small
voice of reason, which went far to save our profession.
from the mere clamour of the passing life. Let me
bear witness to the service rendered not only to
medical science but to national well-being by those
friendly rivals, the Lancet and the British Medical
Journal, who both regard power.as a trust for the
public good. Together they embody the expression
of the compass, the expanding sphere, and the
dignity of English medicine of which the last two
generations have been the witness.
With the passing of the years Sprigge’s influence
radiated far and wide. His culture and urbanity,
his liberal outlook and quick appreciation, his enter-
prise of thought and youthfulness of spirit, and his
apt choice of word and phrase made welcome his
counsel and companionship. That his life was many-
sided is shown by his devotion to sport in his youth,
and in later life his enthusiasm as a painter in water
colour and his love of gardens. For him beauty was
truth and truth beauty.
He was a leader by the force of example, the
power to persuade and encourage others and to
make his workers feel themselves to be friends
engaged in a common enterprise; and his kindness
had a sureness of touch which brought all men to
him. And yet he was a shy man who sought the
shadows, forgetful of self though never forgetful
of others. Without sense of mission, his message was
part of himself, “ for a man’s soul is sometime wont
to bring him tidings, more than seven watchmen
that sit on high on a watch tower.” All through he
made truth and the counsel of his heart to stand.
Ilis work done—we say farewell and hold fast to
a memory—proud, grateful, and long-abiding.
The following SPECIAL PRAYER was Offered :—
O THOU who knowest the secrets of men’s suffer-
ings and strivings, we heartily thank Thee for the
long life of him whom we mourn to-day, and for his
courage and steadfastness in the tasks that were
committed to him. And we pray that all we who
have known him and loved him, or have worked with
him and for him, may likewise find out the way through
all perplexities to serve Thine eterna] purposes,
Ta ii oR Sar ea
THE LANCET]
SCOTLAND.— BUCHAREST
[UNE 26, 1937 1559
SCOTLAND
(FROM OUR OWN CORRESPONDENT)
DISORDERS OF CONDUCT
Dr. R. G. Gordon of Bath delivered the Morison
lectures before the Royal College of Physicians of
Edinburgh last week.: His subject was the neuro-
psychological basis of conduct disorder, the latter
being defined as any behaviour not in accordance
with the accepted code of the community in which
the individual lives. To understand the neurological
correlates of conduct one must study the neuro-
logical basis of emotional life, and Dr. Gordon
emphasised the importance of the thalamic and
hypothalamic regions in the control of emotions.
These lower centres are under cortical control. The
main afferent systems converge on the posterior part
of the cerebral hemispheres, where ‘are situated also
the mechanisms for visual and auditory imagery. In
front of the central sulcus the brain tissue is largely
effector in function, and disease of the frontal region
may lead to behaviour disturbance. In a series of
200 cases of conduct disorder in children there was
no discoverable organic factor in 76 per cent. Even
when there is an organic factor Dr. Gordon holds that
it merely loosens the control of an uncodrdinated
emotional activity. The study of cases of encephalitis
and of chorea is of special interest, for in these diseases .
there is evidence of destruction of cortical cells and
consequent interference with control over the
emotions.
The study of epilepsy also throws light on conduct
disorders. The personality of the epileptic is peculiar.
He is solitary, selfish, and. incapable of normal
affects ; he shows egotism, morbid sensitiveness, and
poverty of ideas; he adapts himself badly to social
conditions. In some respects he is not dissimilar to
persons who have been deprived. of their prefrontal
cortical areas. Such a person may have high intel-
lectual capacities and yet a defective power of social
adjustment. The extreme example of this was
Napoleon, The lecturer suggested that the symptom
of epilepsy depends on three factors: (1) a state of
undue sensitivity or irritability ; (2) the excessive
number of cells receiving stimuli from the afferent
division of the nervous system; and (3) an imperfect
inhibition or control by higher levels in the nervous
system. Conduct disorders, if they occur in epilepsy,
are sudden, violent, and unexpected. Tbe conduct of
mental defectives may be regarded as a too direct
response of primitive behaviour patterns not far
removed from instincts and there are, as a conse-
‘quence, poorly developed powers of inhibition. Dr.
Gordon maintained that the great majority of those
who commit a social act of conduct disorder are
neither psychotic nor even psychoneurotic. The key
of the situation is usually some obvious condition in
the complex unity built up by the individual’s rela-
tions with his environment. It is desirable, therefore,
that in young children stimuli that are likely to
evoke undesirable responses should be avoided. As
the child grows older a system of ideals and internal
inhibitions is built up which serve as a means of
regulating conduct. If the instincts are unduly
inhibited or unduly realised it is not easy to build up
a smooth social integration.
EXPERIMENTAL CEREBRAL DEGENERATION
At a meeting of the Edinburgh Pathological Club
last week Dr. David Orr gave the results of some
experiments he had made on pregnant rabbits. He
found that by repeated injections of Atoxyl into the
general circulation of the rabbit he was able to cause
necrotic lesions in the fornix and cornu ammonis of
the brain of the embryo. After similar experiments
with acridine, hydrocephalus was commonly produced
and was associated with perivascular hypertrophy of
neuroglia in the subventricular region,
BUCHAREST
(FROM OUR OWN CORRESPONDENT)
CONGO-RED FOR PULMONARY HEMORRHAGE
Dr. J. Popoviciu, senior physician at the Geoagiu
Sanatorium, has been giving the Bucharest Medical
Society an account of his experiences in treating
pulmonary hemorrhage with Congo-red. He pointed
out that all the methods in general use have some
defect or other. Collapse therapy acts quickly,
but it is not always applicable and the means are
often not available; while the doubtful value of
various drugs, opiates, vasoconstrictors, and coagu-
lating and hypotensive substances is shown by the
great number recommended. Of drugs put forward of
late years Congo-red has proved the most effective
in his hands. It was introduced by Becker in 1930,
and Morlock and Pinchin recorded a long series of
cases in which it failed only twice. In Rumania,
Copaceanu and Letu described 11 cases of pulmonary
hemorrhage, with loss of at least 50 c.cm. of blood,
in all of which Congo-red gave very good results.
Usually one injection sufficed to stop even large
hemorrhages.
The hezmostatic action of Congo-red has been
used for other purposes besides relief of hemoptysis ;
thus it has been tried for the intestinal hemorrhages
of typhoid and for hemophilia. Its exact action
is unknown, but experimentally it changes the
clotting-time, increases the number of monocytes,
induces thrombocytosis, and augments the quantity
of fibrin. According to recent observations it also
stimulates erythropoiesis, which explains the favour-
able results achieved by Massa and Zolez in pernicious
anemia,
The method is very simple. The dose is 10 c.cm.
of a 1 per cent. solution, and it must be given intra-
venously. Sometimes the injection causes shivering.
for a short time, caused by a cardio-depressive shock,
and in order to avoid this the dose has been decreased
to 5 c.cm.; but the reduction also diminishes the
hzemostatic action. Doses larger than 10 c.cm. are
not advisable, though they are powerfully hemostatic,
for they may cause a collapse that may even threaten
life. If hemoptysis recurs after the first injection,
the dose should be repeated after 4-6 hours. Dr.
Popoviciu administered Congo-red in the Geoagiu
Sanatorium to 20 cases, and in 12 of them good results
were achieved. The patients did not complain of
any discomfort after the injections, and Popoviciu
thinks that intravenous Congo-red injections should
be regarded as an important antidote for pulmonary
hemorrhage.
TUBERCULOSIS MORTALITY IN RUMANIA
The tuberculosis death-rate in Rumania is one of
the highest in Europe. It is higher in towns and
cities than in the villages, and though it decreased
in cities during 1932-35 it began to rise again in 1936.
In general, more men die than women, and the age-
groups most affected are those between 15 and 50.
Mortality is highest in the early spring. In the
mountainous districts of the Carpathians it is lower
1560 THE LANCET]
than in the plains of the provinces of Transylvania
and Bessarabia, excepting the mountains inhabited
by the Moczs, where the disease is encouraged by
poverty and by bad housing and food.
PROF. MARINESCU’S RETIREMENT
Prof. George Marinescu, who holds the chair of
neurology and psychiatry at the University of
Bucharest, some years ago reached the age at which
professors are legally bound to retire. But at the
request of the medical profession his retirement has
been twice postponed. Now at 70 he remains full
of vigour and it would be hard to replace him. The
council of the University have therefore asked the
Minister of Education to take steps, if necessary
by Act of Parliament, to postpone Dr. Marinescu’s
retirement yet a third time.
VIENNA
(FROM OUR OWN CORRESPONDENT)
MEDICAL CELEBRATIONS
THkE last weeks of May gave a welcome oppor-
tunity to the medical profession to celebrate the
centenary of our famous Gesellschaft der Aerzte
in Wien (Medical Society of Vienna). All the progress
achieved in the past century in medical knowledge
in Vienna—indeed in Austria—has been reported
to this learned body. Founded by Franz v. Wirer,
it soon attained such prominence in scientific
circles that the imperial court delegated two arch-
dukes to act as its patrons, while among its presidents
we find the leading men of the profession. In 1893
the society opened its own house and it boasts of
possessing the largest and best equipped medical
library in Europe. In the 100 years of its existence
over 4000 meetings have taken place. There have
been over 15,000 demonstrations of patients and
specimens and over 3000 papers have been read.
We may mention among others Billroth’s papers
on the first total removal of thé larynx and of the
stomach, Koller’s report on the use of cocaine in
ophthalmology, and Freund’s first demonstrations
of the therapeutic use of X rays. The celebrations
took the form of official receptions by the Govern-
ment, by the city of Vienna and by the society,
and a series of scientific meetings, in which representa-
tives of foreign learned societies took part. There
were also many informal social functions including
some fine concerts.
Honorary degrees were conferred by the University on
three veteran Viennese professors: Prof. J. v. Wagner-
Jauregg, Prof. A. v. Eiselsberg, and Prof. H. Horst
Meyer. In ‘the issue of the Wiener Klinische
Wochenschrift for May 22nd which is dedicated to
the society the speeches at the graduation ceremony
are reproduced. Over 600 medical men took part
in the celebrations and there were also many oflicial
delegates from foreign societies.
It is of course impossible to mention all the lectures
given at the scientific meetings and a short survey
must suffice. Prof. Paul Clairmont of Zurich
(a former assistant in the Vienna clinic for surgery)
gave an account of actinomycosis of the lungs;
Prof. August Mayer (Tübingen) spoke on the constitu-
tion in relation to gynecology and obstetrics; Prof,
de Langen (Utrecht) discussed modern views on the
circulation; Prof. Walter Stoekel (Berlin) showed
films of vaginal hysterectomy; Prof. Erich Lexer
(Munich) lectured on infection of wounds; Dr.
VIENNA
[JUNE 26, 1937 _
Verbelg (Budapest) read a paper on tumours, and
Prof. G. A. Wagner (Berlin) one on ovarian dysfunction
and its treatment; Prof. R. Leriche (Strasbourg)
lectured on modern surgery to an enthusiastic
audience; Prof. Karl Wessely (Munich) spoke on
myopia, Prof. O. Kahler (Freiburg) on the tonsils,
and Prof. J. H. Rille (Leipzig) on extragenital
syphilis. Special meetings of the various medical
societies were also held at which leading Viennese
consultants, including Prof. K. F. Wenckebach and
Prof. Hans Eppinger, gave addresses.
TOO MANY DOCTORS IN VIENNA
In a communication to the Economic Society of
Vienna Prof. Eiselsberg reviewed the figures published
by the dean of the medical faculty of the University
and gave the following details :—
No. of students.
Year. ee EE. SE
M. Fr.
1912-13 ae oe 2553 Aare 152
1913-14 ee eis 2634 Pree 184
1919-20 6 oe 3005 cous 578
1936-37 ks oe 2457 kgs 682
He also stated that last year in the present Austria
of 64 million inhabitants 58 more medical students
graduated than in 1914 when the Austrian Empire
comprised 36 million inhabitants. Fifty years ago
Vienna had 774,000 inhabitants, with 1200 medical
men, To-day a population of 1,800,000 has 5300
doctors looking after its health. The proportion of
one doctor for 645 of the population has gone down
to one doctor for 340. Furthermore, the economic
condition of the Viennese has deteriorated to such a
degree that half the practising doctors can barely
make both ends meet from their professional income ;
only one-tenth have a paying practice, while the others
do not earn enough to meet their daily expenditure.
A substantial increase in the number of women
practitioners (and specialists) also makes for over-
crowding with its- harmful effects on the financial
position of the profession, for competition is much
keener and as a result fees are lower. Prof. Eiselsberg
thought an attempt should be made to restrict
the number of students admitted to the medical
faculty. He suggested that the preliminary examina-
tions should be made stricter’; and that the public
should be informed of the large sums of money
required to put a student through his medical course
and set him up in practice. He referred to Sweden
where only as many students are admitted to the
medical register as are required to fill gaps in the
profession caused by death or by the creation of new
appointments. The system works there satisfactorily,
but if it were adopted in Austria all graduation
would have to cease for several years.
NEw HEALTH CENTRE AT LEEDS.—Lady Swinton
on June llth opened a new health centre at Middleton.
It is the first of its kind in Leeds.
FELLOWSHIP OF MEDICINE AND Post-GRADUATE
MepicaL AssociaTIon,—Post-graduate courses for July
have been arranged as follows: in proctology at
St. Mark’s Hospital (all-day, July 5th to 10th); in
dermatology, at the Hospital for Diseases of the
Skin, Blackfriars (afternoons, July 12th to 24th); in
urology, at the All Saints’ Hospital (afternoons, July
12th to 3lst); in general medicine and surgery, at
the Miller General Hospital, Greenwich (July 10th and
llth). A special demonstration on the fundus oculi for
M.R.C.P. candidates will be given on Tuesday, July 6th,
at 8.30 r.m. The courses are open only to members.
Further information may be had from the secretary of
the fellowship, 1, Wimpole-street, London, W.1.
SS same cat igs
THE LANCET]
[JUNE 26, 1937 1561
PARLIAMENTARY
HEALTH ADMINISTRATION
In the House of Commons on June 18th the
discussion was resumed in Committee of Supply of
the vote for the salaries and expenses of the Ministry
of Health. It was agreed to have a general debate
on health matters, including the work of the Board
of Control.
Some Criticisms
Mr. GREENWOOD referred to what he described as
the melancholy history of housing during the past
two years. The net result of ten years’ operation of
the Housing (Rural Workers) Act, 1926, was to have
patched up about 12,000 rural cottages. So far as he
could tell nothing had yet been done to deal with
the problem of overcrowding under the 1935 Act.
The reason he suspected was that local authorities
realising that the Act was a fraud were concentrating
their energies on the Act of 1930 where they had
scope enough to keep them busy for some time.
MENTAL HOSPITALS
Mrs. TATE asked whether the great sum of money
being spent in mental hospitals was really necessary
and whether its expenditure was touching the problem
effectively. An enormous proportion of mental
disease was of wholly physical origin, which if it had
proper treatment in the early stages would never
lead to mental treatment being necessary at all.
Almost nothing was done to treat mental disease in
its early stages. She thought that Part II of the
Board of Control’s Report was one of the most unsatis-
factory documents that had been published. In this
report there was very little discrimination between
the good hospitals and the bad; but the conditions
in the bad could only be regarded as almost too
appalling to be believed. Money spent on these was
money poured down the drain. It was quite obvious
that they must have more accommodation in many
parts of the country. If they had to enlarge some of
these hospitals could it not be done with far greater
effect at very much smaller cost? Surely it was an
experiment worth trying in one county to take some
moderate-sized country houses, modernise them, and
put a certain class of mental patient there and have
a panel of visiting doctors? The complaints were
not so much of ill treatment as of the extraordinary
lack of treatment and ghastly lack of understanding.
Where that happened the fault was in the staff of
the mental hospital. In many hospitals it was
practically impossible to-day to get staff, and the
first improvement they ought to make in the bad
hospitals was to improve the conditions under which
the staff lived and worked. The whole country
welcomed the fact that at St. George’s they were
attempting to undertake treatment of disease in the
early stages, but that should not be an isolated
instance, it should be compulsory in every State
hospital and should be urged on every voluntary
hospital. |
WALES
Mr. JAMES GRIFFITHS appealed to the Minister to
be far more generous to Wales in assisting her to
develop her social services. Making out black lists of
administrative counties in the three important and
closely related matters of maternal mortality, tuber-
culosis mortality, and overcrowding, he found that
there were seven Welsh counties on all three black
lists—Anglesea, Denbigh, Carmarthen, Pembroke,
Glamorgan, Monmouth, and Cardiff. In those seven
counties were 80 per cent. of the total population of
the principality. In the period from 1924 to 1933
maternal, mortality in Wales exceeded the rate in
England by 35 per cent., while that in the special
areas had been substantially increasing. Out of
13 administrative counties in South Wales eight had
INTELLIGENCE
no antenatal clinic yet they were among the counties
that showed the worst maternal mortality-rates. The
average tuberculosis rate for the whole country during
1936 was 692, but every county and county borough
except two in Wales was far in excess of that figure,
five administrative county boroughs having a rate
well over 8000. The local authorities were too poor
to spend more unless they were assisted.
EDUCATION OF THE PUBLIC
Captain ELLISTON congratulated the Minister of
Health on the promised campaign to educate the
people to use the health services already provided by
local authorities in all parts of the country. He was.
grievously disappointed that the Minister had missed
the opportunity of giving the House some assurance
as to the promised long-term legislation dealing with
a national milk policy. There was a consensus of
expert opinion that the case for the pasteurisation of
milk was scientifically irrefutable, and that by that
means milk could be made as safe as water was made
by chlorinisation and filtration. The real opposition
to this protection was dictated by economic con-
siderations. No doubt pasteurisation would involve
producer-retailers in extra cost, but if unfit houses —
and unsound food were prohibited was it reasonable
that they should continue to allow the marketing of
unsafe milk? The serious problem of rheumatism
was receiving the attention of a great voluntary
organisation, the Empire Rheumatic Council. If the
Minister of Health could stand aside while voluntary
bodies tackled problems of this kind, then at least he
ought to find sufficient funds for those bodies to get
on with their work. They should also help by
stimulating local authorities to do their part by
establishing clinics which could be taken advantage
of at a reasonable cost and also by providing wards
and research units in poor-law hospitals taken over
by municipalities. Again, the prospective decrease
in our population was a problem that called for
immediate recognition. It also had been handed to
a voluntary organisation, the Population Investiga-
tion Committee, which had no staff and no funds.
. He would have thought ‘a matter of this urgent
significance to the future of our race would call for
the immediate appointment of a Royal Commission
backed up by the resources of every Government
department concerned. He also hoped that they .
would hear something from the Minister about the
continued exploitation of the public by vendors of
quack medicines and appliances. Practically all the
facts were known and in the circumstances one could
not but be surprised that an abuse of that kind
should be allowed to continue.
Mr. SANDYS said he did not understand how it was
possible to conduct a progressive policy for the
improvement of national health unless one had an
estimate of human needs translated into terms of
family income. He did not understand the apparent.
unwillingness of the Government to recognise the
close connexion between spending power and adequate
feeding. The Government should collect without
further delay all the necessary information to enable
them to lay down a minimum standard of life below
which no one would be allowed to fall.
The Minister’s Reply
Sir KINGSLEY Woop, Minister of Health, replying,
said that what was first needed in connexion with the
problem of our declining population was research of a.
scientific kind, more facts, and a more satisfactory
and informative method of getting population
statistics. There were only two ways in which really
complete information could be obtained—the census
and the registration system. The latter was clearly
the best for the purpose. Existing powers, however,
only permitted of information relating to births to be
: 1562 ‘THE LANCET]
obtained for entry in the birth register, and full
copies of this register could be obtained by the
public. The objection to a proposal to ‘enter up in it
information about the date and duration of the
marriage and the number of children previously born
of the marriage would be met if it were arranged
for the necessary particulars to be given to the
registrar confidentially for statistical purposes only.
Legislation for this would, of course, be required.
The treatment of venereal disease in this country
was based on thereco mmendations of the Royal
Commission that reported in 1916. The main feature
of the scheme was the provision of centres throughout
the country where full facilities for diagnosis and
treatment were available free of charge to anyone
who suspected that he might have contracted the
disease. He would emphasise that the Royal Com-
mission reported against any system of compulsory
notification or treatment. They had built up on that
system about 180 centres in England and Wales, and
the total number of attendances by patients each
year was well in excess of 3,000,000. In 1935 the
total number of cases dealt with for the first time at
the centres was 98,000, and of those as many as
36,230 were found not to be suffering from venereal
disease. That showed that the centres were readily
used by persons who were apprehensive of having
contracted the disease and who were quite prepared
to go there freely in the confidential circumstances he
had mentioned. The policy and belief of the Ministry
of Health at present was that the greater use of these
centres could best be“ secured only by judicious
education and propaganda on the importance of
seeking early and skilled treatment. The anti-
venereal disease measures in Scandinavian countries
differed from ours essentially in having notification
and compulsory treatment. A commission sent by
the New York health authorities had recently issued
a report which attributed an important part
of the success in reducing the incidence of syphilis
in Sweden and Denmark to notification and com-
pulsory treatment. He did not intend to comment
on that report. He had seen an important article in
The Lancet which contraverted a good many of the
statements made in the report. He would leave it at
that, but this report had attracted a good deal of
attention and had, he thought, caused a revival, at
any rate in certain quarters, of the agitation for
compulsion here. In this country there had been a
decline of 36 per cent. in the figures of fresh syphilitic
infections since 1931. It was true that between
1924 and 1929 there was apparently little or no
decline, but since then the decline had been remark-
able, and the rate of fresh infection with syphilis
which was now in the region of 160 per 1,000,000 of
the population compared rather favourably with the
comparable figure of 220 per 1,000,000 in Denmark.
A further special study of one or more of the Scandi-
navian systems might yield useful results, and the
Secretary of State for Scotland and he were therefore
arranging for one of the medical officers of his depart-
ment who was particularly concerned with this
matter and one of the medical officers from the
Scottish Office, together with an administrative officer
experienced in venereal diseases, to visit Scandinavia
at an early date and report to them. That report
should enable them to give further consideration to
this problem.
Mr. TURTON: Would my right hon. friend consider
the extension of that inquiry to Holland where there
is voluntary treatment? That would enable him to
get both sides of the picture.
Sir KINGSLEY Woop said he would certainly con-
sider that suggestion. Continuing, he said that he
recognised that a great deal more had to be done
for housing and particularly rural housing. It was
to be the subject of special study by the Central
Housing Council, and he hoped that they would be
able to do something further in rural areas. In regard
to overcrowding he had made a number of inquiries
from typical local authorities in the country as to the
PARLIAMENTARY INTELLIGENCE
[JUNE 26, „19837
exact position. Without putting into operation any
of the penal provisions of the Overcrowding Act
there had been‘a reduction in some of the ten or twelve
districts with which they had communicated of some
20 per cent. That was rather interesting and pointed
to what the position would be when the Act itself
came into full operation.
HUMANISING MENTAL TREATMENT
He claimed for the mental health services that
good progress was being made in the humane and
progressive treatment of the mentally disordered and
the mentally defective people of this country. Extracts
had been given in the debate from the report of the
Board of Control regarding a number of what might
be called bad cases. Anyone who looked at that
report would also see the records of a far greater
number of good cases. He supposed that in no
other country in the world would they see such a
frank statement of the position in connexion with
these mental institutions, and what ought to be done
in the particular cases referred to. Directly the
officers ascertained these cases they were placed on
record, and the attention of the authorities concerned
was drawn to the facts and they were called upon to
do their best to remedy them. He would emphasise
three things in connexion with the mental services of
the country: there must be, first, constant vigilance
in the conduct and control of these institutions ;
secondly, unabated efforts to secure the right type of
nurse; and thirdly, vigorous investigation of any
instances reported of ill usage or bad treatment.
There was great scope for further research into the
causes of mental afflictéon, and recently he appointed
a committee under the chairmanship of Lord Radnor
to see what further could be done to advance research.
The need for providing further accommodation was
fully realised. Many schemes were in hand and in
contemplation which should overtake this. The
total amount of loan sanctions last year for the
purposes of the Lunacy and Mental Treatment Acts
was over £2,000,000 as compared with £1,700,000
in 1935-36. One of the best signs of the time in
connexion with the treatment of mental disease
was that the flow of voluntary patients had steadily
increased. Last year more than 25,000 patients
were admitted to public mental hospitals and of
these nearly 27 per cent. were voluntary admissions,
The number of out-patient clinics had now reached
a total of 165. Mrs. Tate’s suggestion about taking
over country houses had been tried and had been
found rather expensive, and not very practicable.
He assured Mrs. Tate that the importance of physical
illness as a causal factor in mental disorder was
widely recognised. Within seven days of admission
the medical superintendent was required to send to
the Board of Control a medical statement of the mental
and bodily health and condition of each patient.
They were taking steps in this country to build up
a nutrition policy. He would like the committee
to look at the report signed by all the leading men of
the country including Sir John Orr, Prof. Cathcart,
and Prof. Mellanby. Their recommendations he
was carrying out at the present time and a number of
inquiries were now in operation. In many directions
the local authorities, owing to the increased sums
of money available to them under the block grants,
were now extending their services in connexion with
milk for children and expectant mothers and matters
of that kind. Owing to individual differences,
it would be quite impossible to lay down any standard
of food requirements to be applied to all people
alike. The best that could be done in present circum-
stances was to suggest standards in relation to man
value in terms of energy requirements, the unit being
on a sliding scale according to muscular activity.
The other inquiries which the Advisory Committee
recommended were now in progress. In conclusion,
Sir KINGSLEY said that in the long and continuous
fight—which had still to go on—against disease and
ill health we were steadily gaining ground.
THE LANCET]
PARLIAMENTARY INTELLIGENCE
[JUNE 26, 1937 1563
` NOTES ON CURRENT TOPICS
The Factories Bill
On June 15th, 16th, and 17th in the House of
Commons the Report stage of the Factories Bill,
as amended in Standing Committee, was concluded.
Sir SAMUEL HOARE, Home Secretary, moved a
new clause providing that adequate and suitable
facilities for washing, including a sufficient supply
of soap and clean towels, should be provided in certain
specified factories and that it should come into
operation on July ist, 1939. After some debate
Sir Samuel said he would withdraw it on the grounds
that it was not comprehensive enough, and have it
drafted on different lines, bringing it forward when
the Bill reached the House of Lords.
Sir S. HOARE moved a new clause to ensure that
suitable accommodation in all factories should be
provided for clothing not worn during working hours
and that suitable arrangements should be made for
drying such clothing. The new clause was read a
second time. An amendment moved by Mr. MANDER
to give the Home Secretary power to prescribe also
a suitable standard of facilities for drying clothing
as agreed to and the clause as amended was added
to the Bill.
Mr. LLOYD, Under-Secretary, Home Office, moved.
a new clause providing that in any specified process
that involved a special risk of injury to the eyes from
particles or fragments thrown off in the course of
the process, suitable goggles or effective screens
should be provided. This clause was read a second
time and added to the Bill. .
A clause moved by Mr. BANFIELD to prohibit night
baking wasnegatived by 228 votes to 125 after debate.—
Mr. ELLIS SMITH moved a new clause to provide
safety-first committees in factories; but this was
negatived by 202 votes to 119.—Lieut.-Colonel
SANDEMAN ALLEN moved an amendment to Clause 2,
which deals with overcrowding to the effect that
where a room contained a gallery, a gallery should
be treated as if it formed a separate room. This
was agreed to.—Mr. RIDLEY moved an amendment
providing that it should be the duty of an employer
to post up a notice in the factory and workroom
stating the number of employees who could be
engaged there at one time within the terms of the
Act. This also was agreed to.
On Clause 14, dealing with the fencing of other
than transmission machinery, Mr. LLOYD moved an
amendment, which was agreed to, providing that the
Secretary of State might make regulations directing
that When there was a really good safety device for
any machine its use should be compulsory.—
Mr. SHORT moved an amendment to Clause 52
(underground rooms) to the effect that no work should
be carried on in any underground room unless the
room was certified to be suitable on hygienic grounds
and, in particular, as regarded construction, light,
ventilation, and adequate means of escape in case of
fire. It was negatived by 209 votes to 134.—
Mr. LLOYD moved an amendment, which was agreed
to, providing restrictions in regard to the use of
underground rooms. He said that it represented
a very considerable tightening up of the provisions
in that respect.
Mr. LLOYD moved a series of amendments to
Clause 53 (basement bakehouses) providing for
recertification or re-examination of basement bake-
houses to see whether, in the light of modern condi-
tions, they were suitable for use. This was agreed to.
On Clause 69 (General conditions as te the hours
of employment of women and young persons),
Mr. R. J. DAVIES moved an amendment providing
that it should not be lawful to employ in a factory
a young person under the age of 15. He said the
new machines and the speeded up machines in
industry were becoming too dangerous for children
to handle. Now that they were about to launch a
campaign for greater physical fitness and to pass
demands for individual young persons.
this amendment would be a great contribution,
Sir S. HOARE said the Government could not now
repudiate the policy they had adopted in the last
Education Act after the closest consideration and
exclude from beneficial employment something like
two-thirds of the young people whom they were now
discussing and who were actually employed in
factories and workshops. In a subsequent clause
in the present Bill the Government were reducing the
hours of work of these young persons by four hours
& week and were prohibiting overtime for them
altogether. He could give an assurance that cases
of exemption would be very carefully considered
and the employers would have to justify their
It would
thus be quite impossible to change the considered
policy of the Board of Education and instantly
to bring about in industry unnecessary dislocation
and in many cases harm the young persons by driving
them into unsuitable employment. After further
debate the amendment was negatived by 207 votes
to 137.—Mr. DOBBE moved an amendment to
substitute 40 hours for 48 hours as a maximum work-
ing week for women and young persons. Sir S.
HOARE said that this, if carried, would make a
tremendous change in industrial life and would
cause considerable dislocation. The amendment
was negatived by 195 votes to 128.—Mr. LLOYD
moved an amendment providing that the hour for
stopping work should not be later than 6 o’clock in
the evening in the case of young persons under 16
and 8 o’clock in other cases. This was agreed to.
On Clause 124 (Appointmént and duties of examin-
ing surgeons), Mr. R. J. DAVIES moved an amend-
ment providing that subject to the consent of the
employed person concerned the examining surgeon
should have the right to inspect the medical records
of the medical practitioner employed by the occupier
of the factory.— Mr. LLOYD said the proposal would
not be practicable. There was a serious objection
to the suggestion that the examining surgeon should
have the right to conduct a sort of roving inquiry
into records of another practitioner irrespective of his
precise duties under the Act. The Home Office
thought it would be more practicable to leave the
matter to be settled between the two doctors. The
amendment was withdrawn after an assurance from
Mr. LLOYD that this point would be borne in mind in
relation to the subsection under which the Home
Secretary may regulate the duties of the examining
surgeon.—Mr. E. SMITH moved an amendment
providing that where any person was liable to contract
an industrial disease from any process carried on in
a factory the examining surgeon should examine
such person at least once a month during working
hours and keep a record for examination’ by the
inspector.—Mr. LLOYD said that the term “ industrial
disease ” in the amendment was very vague and
might include a large variety of diseases. A vast
number of examinations would have to take place,
and it was too rigid a requirement to lay down a
month as a period for examinations. It ought to
depend on circumstances: Silicosis, for example,
developed very slowly, and a highly technical and
skilled diagnosis was required which the ordinary
doctor was not capable of carrying out. In dermatitis
the position was exactly the reverse; it developed
very quickly indeed and a monthly examination
would not be frequent enough. If the new
power which the Home Secretary possessed under
Clause 11 to require the medical supervision of
workers in all factories in certain circumstances,
was used as he was sure it would be, it might easily
prove a very important provision in preventing
industrial disease. The amendment was withdrawn.
Methylated Spirits (Scotland) Bill
In the House of Lords on June 19th the Committee
stage of the Methylated Spirits (Scotland) Bill was
concluded.
On Clause 1 (Restrictions on sale of methylated
1564 THE LANCET]
spirits), Lord ASKWITH moved the following new
subsection :
“ Nothing in the foregoing provisions of this section
shall apply to surgical spirit sold by an authorised seller
of poisons on registered premises or supplied by a duly
qualified medical practitioner, registered dentist, or
registered veterinary surgeon for the purposes respectively
specified in Subsection (1) of Section 19 of the Pharmacy
and Poisons Act, 1933, if the requirements of Sub-
sections (2) and (3) of the said section are complied with
in relation to such sale or supply of surgical spirit in like
manner as if it were a medicine,”
The amendment was agreed to. On Clause 6
(interpretation), Lord ASKWITH moved an amend-
ment providing that the expressions “ authorised
seller of poisons,’ ‘‘registered dentist,’ and
“ registered veterinary surgeon,” should have the
like meanings as in the Pharmacy and Poisons Act,
1933, and the expression “registered premises ”’
should mean premises duly registered under Part I
of that Act. This was also agreed to.
Young Persons and Health Insurance
In the House of Commons on June 22nd Sir
KINGSLEY Woop, Minister of Health, presented the
National Health Insurance (J uvenile Contributors
and Young Persons) Bill, a measure to amend the
National Health Insurance Act, 1936, so as to make
certain persons under the age of sixteen eligible for
medical benefit, to facilitate the provision of medical
benefit to such persons and to other young persons,
ane for purposes connected with the matters afore-
said.
The Bill was read a first time.
QUESTION TIME
WEDNESDAY, JUNE 16TH
Persons over 70 and Public Assistance
Mr. Lanssury asked the Minister of Health if he could
inform the House how many persons over 70 years of age
resident in the County of London were receiving grants
from the public assistance authority owing to the
insufficiency of the pension for their maintenance and the
total yearly cost to the London rates of such payments ;
and if he would give the same information in regard to
Manchester and Leeds and the counties of Glamorgan,
Monmouth, and Durham.—Mr. Bernays, Parliamentary
Secretary to the Ministry of Health, replied: The returns
made to my Department relating to persons in receipt of
poor relief do not distinguish the number of such persons
over 70 years of age. The returns do, however, show
the number of persons over 65 years of age drawing old
age pensions under the various Acts who are also in receipt
of outdoor relief. I regret that information as to the
amount of expenditure on poor relief to old age pensioners
is not available in my department. The following is a
table giving information as to the number of persons over
65 drawing old age pensions who are also in receipt of
out-door relief :—
Administrative County of London 24,787
County Borough of Manchester ne 5,609
County Borough of Leeds .. så 2,988
Administrative County of Glamorgan 8,476
Administrative County of Monmouth.. 3,477
Administrative County of Durham .. 8,015
International Red Cross and Spanish Refugees
Sir HENRY Crort asked the Secretary of State for
Foreign Affairs whether he was aware that General
Franco offered that the old men, women, and children
of Bilbao should be evacuated to a zone west of Bilbao
under guarantee from the International Red Cross, and
that such zone would not be used for military purposes ;
whether this offer was conveyed to H.M. Government ;
and whether any steps were taken to provide such an
asylum on Spanish soil under guarantee of the Red Cross
before thousands of Spanish children were taken from their
parents and removed to foreign countries.—Mr. EDEN
replied: A proposal to this effect was contained in the
PARLIAMENTARY INTELLIGENCE
[JUNE 26, 1937
reply received from the insurgent authorities to the
communication made to them by H.M. Ambassador at
Hendaye, in which notification was given of the steps
which the Government proposed to take to protect Basque
refugee ships. H.M. Ambassador accordingly inquired
of the insurgent authorities whether their proposal
constituted an offer of subsidiary action to that which
was then being taken and whether it might be put before
the Basque authorities with a view to the opening of
negotiations. At the same time, unoflicial inquiries
were made by H.M. Consul at Bilbao, from whom it was,
however, learnt that the Basque authorities did not
regard the proposal as a practicable one, on the grounds
that there were no villages between Bilbao and Santander
capable of housing large numbers of persons, no water
and no sanitary arrangements, and that the position
of refugees might become untenable in tlie event of an
insurgent advance in the direction of Santander. The
insurgent authorities, as a result of the steps which had
already been taken, subsequently made it clear that they
were themselves no longer interested in the proposal,
and it was, therefore, felt that no useful purpose would be
served by pursuing it any further.
THURSDAY, JUNE 17TH
Persons Transferred from Poor-law to U.A.B.
Mr. BaTeEy asked the Minister of Labour the number of
unemployed who had been taken from the poor-law by the
Unemployment Assistance Board in Great Britain and
also in the county of Durham; and the numbers refused
up to the latest available date.—Mr. Ernest BROWN
replied: Information in respect of local government
areas is not available but the following table shows, in
respect of Great Britain and the Unemployment Assistance
Board’s administrative district of Durham, as on May 28th,
in column (1) the number of persons in receipt of public
assistance prior to the Second Appointed Day who had
made applications for unemployment assistance allowances
and who were taken over from public assistance authorities,
and in column (2) the number of such applicants held to
be outside the scope of the Unemployment Assistance Act.
(1) (2)
Great Britain .. «> 90,237 .... 43,689
Durham district ss 2.118 - gees 1,464
Note.—Durham District includes the Board’s administrative
areas of Bishop Auckland, Chester-le-Street, Consett, Crook,
Durham, Horden Houghton-le-Spring, Pallion, Spennymoor,
and Sunderland (1) an
Children Born in Prisons
Mr. RoBeRT Morrison asked the Home Secretary
what information was placed upon the birth certjficates
of babies born in prison with regard to their place of
birth.—Sir S. Hoare replied : Governors have instructions
that the word “ prison ” is not to appear in the notification
to the Registrar, and that the name of the road or street
in which the prison is situated is to be given as the address.
Mr. WHITELEY asked the Home Secretary whether he
was aware of the strong feeling against childbirth taking
place in prison ; and whether he was prepared to introduce
legislation to abolish such practice.—Sir SAMUEL HOARE
replied : This would involve an amendment of Section 17(6)
of the Criminal Justice Administration Act, 1914, which
gives the Secretary of State power to release temporarily
a prisoner if he is suffering from disease which cannot
properly be treated in prison or if he requires to undergo
an operation which cannot properly be performed in prison.
I will, of course, see that the question is not overlooked
when any amendment of the Prison Acts and related
legislation is under consideration, but I am not prepared
to give any definite undertaking at the moment.
Ophthalmic Treatment in Schools
Mr. Day asked the President of the Board of Education
how many children had been provided with spectacles
in England and Wales under the arrangements made by
the education authorities for the 12 months ended to the
last convenient date; whether all local education
authorities had the services of a qualified and experienced
oculist; and at what periods -were children’s eyes
THE LANCET]
re-examined.—Mr. KENNETH Linpsay: During the year
1936, 166,257 children attending public elementary schools
_ in England and Wales were provided with spectacles under
arrangements made by local education authorities. With
the exception of the authority for the Isles of Scilly, all
local education authorities have arrangements for .the
treatment of defective vision by a qualified medical
practitioner who has had special experience in ophthalmic
work. All children in whom any defect of vision has been
found are re-examined from time to time, but the interval
between the examinations depends on the nature and
extent of the defect.
Official Tests of Gas Respirators
Mr. PARKER asked the Home Secretary whether, in
view of his refusal to allow Members of Parliament to
purchase Government gas-respirators for carrying out
experimental tests, he would now, in the public interest,
publish the results of official tests which had been made,—
Mr. GEOFFREY LuioyD replied: The result of exhaustive |
official tests is that the civilian protector has been shown
to protect effectively the face, eyes, and lungs against any
type of gas which, so far as is known, could be used in
war.
Notification and Compulsory Treatment of Venereal
Disease
Mr. Turton asked the Minister of Health whether,
in view of the conflict of opinion on the merits of notifica-
tion and compulsory treatment of venereal disease and the
remarkable reduction which had taken place in the
incidence of syphilis in Scandinavian countries where this
system prevailed, he would promote an inquiry to discover
how much, if any, of the Scandinavian success was
attributable to this system.—Sir KINGSLEY Woop replied :
I am giving careful consideration to this matter.
Hospitals under Public Health Acts
Mr. MEssER asked the Minister of Health how many
county and county borough councils had appropriated
hospitals under the Public Health Act.—Sir KINGSLEY
Woop replied: Eleven county councils and 39 county
borough councils in England and Wales have, since
the Local Government Act, 1929, came‘into operation,
appropriated poor-law hospitals or infirmaries, or parts
thereof, for use as general hospitals under the Public
Health Acts. In addition, 6 other county councils have
appropriated such institutions for other public health
purposes, such as tuberculosis hospitals, maternity
hospitals, convalescent homes, or epileptic homes.
Sanatorium Treatment of Tuberculosis
Mr. MESSER asked the Minister of Health, if he could
give comparative figures of cases of pulmonary tuber-
culosis treated in sanatoria under public health authorities
for the years 1934, 1935, and 1936.—Sir KinesLEY Woop
replied : The numbers of cases of pulmonary tuberculosis
treated in public health and approved residential institu-
tions during the years in question, in England and Wales,
are as follows :— .
1934 .. os
1935 ..
39,856 1936..
40,484
41,630
MONDAY, JUNE 2lsT
Medical Examination of School-children
Mr. Lyons asked the Parliamentary Secretary to the
Board of Education the number of school-children
medically examined in the city of Leicester at the most
recent convenient date; the number of medical examiners
then employed; and the number of children then found to
need medical treatment.—Mr. KENNETH LINDsay replied :
During the year ended Dec. 31st, 1936, 12,356 school;
children in the city of Leicester were examined at routine
medical inspections, and 15,882 at special inspections.
There were also 26,257 re-inspections.
The number of children found at routine medical
inspections to require treatment for defects other than
defects of nutrition, uncleanliness, and dental diseases,
was 1569. Information is not available to show the number
of children found to require treatment at special inspections,
PARLIAMENTARY INTELLIGENCE
17th);
1565
but 11,277 defects requiring treatment were found.
On Dec. 3lst, 1936, six whole-time medical officers were
employed by the local education authority in the work
of medical inspection and treatment.
[JUNE 26, 1937
TUESDAY, JUNE 22ND
Children Injured by Spiked Railings
Mr. McGovern asked the Secretary of State for Scot-
land if his attention had been drawn to the large number
of accidents in Glasgow where children had fallen on
spiked railings; and whether he would introduce legis-
lation to abolish all spiked railings on housing schemes.—
Mr. ELLIOT replied: The answer to the first part of the
question is in the affirmative. Since 1922 the erection of
spiked railings in or between back courts in Glasgow has
been prohibited; and if a provisional order now before
Parliament is confirmed, existing spiked railings in or
between back courts will become illegal after the expiry
of four years from the date of confirmation.
Protective Equipment for Miners
Mr. Tom Smrrua asked the Secretary for Mines to what
extent protective equipment in the way of helmets,
gloves, &c., was in operation in the various coalfields.—
Captain CROOKSHANK replied: The reports for 1936 of
the Divisional Inspectors and of the Safety in Mines
Research Board, which will shortly be published, contain
a good deal of information showing that satisfactory
progress has been made in the various coalfields in the use
of protective equipment; hard hats, for example, being
bought at a rate of more than 12,000 a month. I should
like to take this opportunity of expressing my appreciation
of the keenness and coöperation, shown by all sections of
the industry, which have enabled a gratifying measure of
progress to be attained.
Committee on Dangers of Celluloid Toys
Mr. CARTLAND asked the Home Secretary whether he
had yet set up the departmental committee to inquire
into the question of the danger to children and others
arising from the use of celluloid toys and other articles
and, if so, what were its terms of reference.—Mr. LLOYD,
Under Secretary, Home Office, replied: I am glad to be
able to announce that Sir Vivian Henderson, formerly
Parliamentary Under-Secretary of State at the Home
Office, has consented to act as chairman of this committee,
and my right hon. friend hopes that the composition of
the committee will soon be completed. Its terms of
reference will be: ‘‘To inquire into the use of celluloid
to any similar highly inflammable material in the manu-
facture of toys, fancy goods, articles of attire, toilet
requisites, and the like, and to consider what steps are
desirable and practicable against the danger arising to
the public, and especially to children, from such use.”
Kina GEORGE HOSPITAL, ILFORD.—A festival
dinner, at which the Duke of Gloucester was the chief
guest, was held in aid of this hospital at the Mansion
House, London, on June 10th. The-population of the
immediate area served by the hospital has increased
from 100,000 to 400,000 and the need for more accom-
modation is urgent. Over £6000 in donations was received
at the dinner.
POST-GRADUATE COURSES IN SBERLIN.— Inter-
national post-graduate courses are to be held in
Berlin on the following subjects: allergy in rheumatism
(Oct. 4th-9th) ; natural methods of treatment (Oct. 11th-
tuberculosis (Oct. 18th—23rd); intrathoracic
surgery (Oct. 25th~29th) ; infectious diseases in children
(Oct. 18th-23rd); dermatology and venereal diseases
(Oct. 18th—23rd); obstetrics and gynecology (Oct. 25th-
30th) ; homeceopathy (Oct. 11th—Nov. 6th). There will also
be a course in diseases of the ear, nose, and throat during
October. Monthly courses in all the special departments
of medical science, including practical work, are arranged.
Particulars may be had from the infommation bureaus of
the Kaiserin’ Friedrich-Haus, Robert Koch-Platz, 7,
Berlin, N.W. 7.
1566 THE LANCET] i
[JUNE 26, 1937
THE SERVICES
TERRITORIAL ARMY HOSPITALS
THe War Office announces that it has been decided
to form peace-time cadres for Territorial Army
general hospitals for home service on similar lines to
those which existed before the late war. There will
be 29 such hospital units and these will be distributed
between the various military commands. The exact
location of all of them has not yet been determined.
The serving personnel for each hospital unit will
consist of 3 officers and 24 other ranks who will be
members of the Royal Army Medical Corps, Terri-
torial Army. The officers appointed will be the
officer commanding, a registrar, and a quartermaster.
The other ranks may be enlisted for home service
only -and the upper age-limit for enlistment or `
re-engagement will be 50. In addition, medical men
will be appointed who will constitute the visiting and
resident staff on embodiment, but who will not be
required to do duty in time of peace.
It is intended that each hospital should be able to
accommodate 600 patients (including 60 officers) in
the first instance and be capable of expansion up to
2000 beds should the necessity arise. The following
statement shows the peace and war establishments of
officers :—
PEACE ESTABLISHMENT
As stated above, the officers appointed in peace-time
will be a commanding officer (lieut.-colonel), a registrar
(major, captain, or subaltern), and a quartermaster (non-
medical). The commanding officer will hold the rank of
colonel on embodiment.
ESTABLISHMENT ON EMBODIMENT
(i) The visiting civilian staff (part-time) will consist of :
2 physicians, 4 surgeons, l ear, nose, and throat surgeon,
1 ophthalmic surgeon, and 1 anzsthetist.
(ii) The resident staff (whole-time) will consist of :
1 physician (major), 1 surgeon (major), 1 pathologist
(major), 1 radiologist (major), 1 anzsthetist (captain), 4
general duties (captains or lieutenants), and 1 dental
surgeon (captain or lieutenant). The four officers on
general duties will be appointed after embodiment and
will hold temporary commissions. All the other officers
will hold T.A. commissions (Reserve of Officers) and will
be appointed in peace-time.
(iii) Additional staff—After embodiment 4 civilian
medical practitioners (who may be final-year medical
students) will be appointed to part-time employment
or general duties.
The arrangements have been drawn up with a view
to providing an adequate staff while interfering as
little as possible with the medical care of the civil
community. Proportionate increases in establish-
ments will be authorised as hospitals expand, and
hospitals for the treatment of special cases will have
appropriate staffs selected accordingly. Part-time
officers are to be not less than 50 years of age.
A further announcement will be made by the War
Office when recruiting can begin. In the meantime
application should not be made for enlistment into
these units.
INDIAN MEDICAL SERVICE
: ANNUAL DINNER |
One hundred officers of the Indian Medical Service
dined together on June 16th at the Trocadero, when
Brevet-Colonel Sir Rickard Christophers presided.
The members of the Service present were as follows :—
Major-Generals: W. V. Coppinger, C.I.E., D.8.O. ;
A. W. M. Harvey, C.B.; Sir Courtenay Manifold, K.C.B.,
C.M.G.; Sir John Megaw, K.C.I.E.; C. W. F. Melville,
C.B.; Sir Leonard Rogers, K.C.S.I., C.I.E., F.R.S.;
Sir Cuthbert Sprawson, C.I.E.; and G. Tate, C.I.E.
Colonels: H. Ainsworth; J. Anderson, C.I.E.;
Sir Charles Brierley, C.I.E.; Sir Rickard Christophers,
C.I.E., O.B.E., F.R.S.; H. M. Cruddas, C.M.G., O.B.E.;
H. R. Dutton, C.I.E.; A. B. Fry, C.B., D.S.0.; C. A.
Gil; T. A. Granger, C.M.G.; ©. R. M. Green;
W. H. Leonard, C.B.; H. M. Mackenzie, C.I.E.;
F. P. Mackie, C.S.I., O.B.E.; Sir Richard Needham,
C.I.E., D.S.0.; J. J. Pratt; A. H. Proctor, D.S.O.;
C. H. Reinhold, M.C.; A. Spitteler, O.B.E.; Ashton
Street; R. G. Turner, C.M.G., D.S.0.; and W. S.
Willmore.
Lieut.-Colonels : J. E. Ainsley ; W. P. G. Alpin, O.B.E. ;
A.C. Anderson; C. H. N. Baker; C. H. Barber, D.S.O. ;
A. C. L. Bilderbeck; R. H. Candy, C.I.E.; H. P. Cook;
D. Clyde; D. G. Crawford; J. M. Crawford, O.B.E.;
J. B. Dalzell Hunter, O.B.E.; S. C. Evans; J. K. S.
Fleming, C.B.E.; P. F. Gow, D.S.O.; V. B. Green-
Armytage; A. E. Grisewood; J. B. Hanafin, C.I.E. ;
J. B. Hance, O.B.E.; W. L. Harnett, C.I.E. ; H. Hingston;
E. H. Vere Hodge; J. M. Holmes; E. V. Hugo, C.M.G. ;
S. P. James, C.M.G., F.R.S.; M. L. C. Irvine; I. Daven-
port Jones; H. C. Keats; H. H. King, C.I.E.; M. M.
Khan; J. B. Lapsley, M.C.; J. C. H. Leicester, C.I.E. ;
C. McIver; E. C. G. Maddock, C.I.E.; W. A. Mearns ;
F. O. N. Mell, C.I.E.; S. H. Middleton-West, M.C. ;
F. O’Kinealy, C.I.E., C.V.O.; J. Rodger, M.C., O.B.E. ;
H. Ross, C.I.E., O.B.E.; H. K. Rowntree, M.C.; J. D.
Sambef; J. A. Sinton, V.C., O.B.E.; R. B. Seymour
Sewell, C.I.E.; H. B. Steen; R. Steen; W. D. H.
Stevenson, C.I.E.; H. Stott, O.B.E.; W. A. Sykes
D.S.O.; H. J. H. Symons, M.C.; C. Thomson; G. S
Thomson; E. Owen Thurston; A. G. Tresidder, C.I.E.
E. L. Ward, C.B.E.; and E. E. Waters.
Majors: H. C. Brown, C.I.E.; J. A. W. Ebden; Sir
T. Carey Evans, M.C.; A. Innes Cox; M. J. Quirke ;
and J. Scott Riddle.
eee : T. D. Ahmad; H. L. Barker; and B. M.
ao.
Officers on probation: B. J. Doran; J. R. Kerr; C. F.
Mayo-Smith ; J. D. Munroe; G. W. Palmer; S.. Shone;
W. C. Templeton; and G. F. J. Thomas.
?
The last eight mentioned were present by invita-
tion, and the other guests were Sir Frank Brown,
C.I.E. (the Times), Dr. N. G. Horner (British Medical
Journal), Maj.-General W. P. MacArthur, D.S.O.,
A.M.S., Sir Frederick Menzies, Dr. Egbert Morland
(The Lancet), Dr. H. Letheby Tidy, and Prof.
G. Grey Turner.
Sir RICKARD CHRISTOPHERS in proposing the toast
of the Service said that when a good many years ago
certain new political changes were introduced into
India, people used to think that the outlook for the
Indian Medical Service was gloomy. Things had not
worked out that way; looking round the room
to-night the Service seemed to him still going strong.
Its history was long and, medically speaking, glorious.
It had never been a service to provide merely medical
attendance. Most of us, he said, have been organisers ;
many of us have brought special qualifications- into
the service. In the past the I.M.S. had not only
served the military and civil requirements of India,
but had provided the botanists, the zoologists, and
= other scientific workers. All this had been put on
record by the historian of the I.M.S., Col. J. M.
Crawford. It seemed to him that the activities of
the I.M.S. were none the less varied and important
at the present time; witness the nature of appoint-
ments held by many of them after retirement, and
in India there were still many whose names were
well known in scientific circles. As to the future
prospects, let me refer you, he said, to the new
regulations just passed for the I.M.S., and it would
CT ara eee aS AA
THE LANCET]
be inexcusable if I did not say how much we as a
Service owe to Sir Leonard Rogers, Sir John Megaw,
and our present director-general for the way in which
our case must have been presented to the authorities
who decide these things. India offers splendid
opportunities and a great variety of interests in life
to those who go there. Probably only those who
have experienced the life realise its fullness. I have
been 30 years in the Service, almost all my time in
India, and never for one day have I been sick or
sorry I joined, nor have I seen any other service which
could have given me the same pleasure and interest
in life. We have heard a good deal about changed
conditions, but India is not the only place where
there are changes, and we cannot as a Service: expect
not to have to adapt ourselves to new things.
Lieut.-Colonel J. A. Sinton, V.C., who proposed the
health of the chairman, described him as one who
got at the basic principles of the subject he was
investigating. At the tropical school they expected
to get a whole-time worker, and they only got some-
one who worked 12 hours a day.
After that Colonel Anderson told some stories, and
the dinner secretaries, Sir Richard Needham and
Sir T. Carey Evans, received informal thanks.
INDIAN MEDICAL SERVICE
Col. H. C. Buckley, V.H.S., to be Maj.-Gen.
The undermentioned officers relinquish their temp.
commns.: Capts. T. R. Pahwa, M. A. Gaffar, M. Hafi-zuddin,
Gopal Singh, K. L. Malhautra, K. V. R. Choudari, and
Lt. A. Haq.
PUBLIC HEALTH
[JUNE 26, 1937 1567
ROYAL NAVAL MEDICAL SERVICE
Surg. Capt. P. L. Gibson to Pembroke for R.N.B.
Surg. Lt.-Comdr. (D) W. E. L. Brigham to Pembroke.
Surg. Lt. C. J. Mullen to Pembroke.
Surg. Lt. (D) H. C. Brewerton to R.M. Infirmary,
Deal.
ARMY DENTAL CORPS
Capt. H. Quinlan to be Maj.
ARMY MEDICAL SERVICES
. Lt.-Col. A. G. Biggam, O.B.E., M.D. Edin., F.R.C.P. Lond.,
R.A.M.C., has been appointed Honorary Physician to the
King (and promoted to the rank of brevet-colonel), in
succession to Col. J. Heatly-Spencer, C.B.E., whose retire-
ment was announced in THe Lancet last week,
ROYAL ARMY MEDICAL CORPS
MILITIA
Maj. S. R. Armstrong, O.B.E., ney his commn.
and retains the rank of Maj.
TERRITORIAL ARMY
Capt. G. L. Pillans, M.C., resigns his commn. and
retains his rank.
Lt. W. Bruce, from 6th Bn. Gordons, to be Capt.
T. G. Armstrong (late Cadet, Felsted Sch. Contgt.,
Jun. Div., O.T.C.) to be Lt.
ROYAL AIR FORCE
Flight Lts. W. G. S. Roberts to R.A.F. Station, Dhibban,
Iraq; H. E. Bellringer to R.A.F. General Hospital, Iraq,
Hinaidi; W. J. L. Dean to No. 84 (Bomber) Squadron,
Shaibah, Iraq; and G. H. J. Williams to No. 6 Flying |
Training School, Netheravon.
PUBLIC HEALTH
Domiciliary Service of Midwives in London
On Tuesday the London County Council approved
proposals to be submitted to the Minister of Health
under the Midwives Act, 1936. The Act makes the
L.C.C. responsible for providing an adequate service
of competent whole-time midwives for a domiciliary
service (including maternity nursing)... In so doing
the Council must have regard to any existing provision
made by voluntary or other agencies. These include
a large number of voluntary hospitals with medical
schools attached to them, voluntary maternity
hospitals, and voluntary nursing associations; while a
certain number of London boroughs have either
appointed whole-time salaried midwives or contribute
to voluntary bodies engaged in domiciliary midwifery
work. Having made suitable arrangements with these
voluntary agencies and. the borough councils, the L.C.C.
must supplement their services where necessary
by appointing whole-time midwives of its own. With
a view to efficiency London has been divided into
five areas, in each of which provision has been made:
(a) To the fullest possible extent for the existing
voluntary agencies.
(6) For those boroughs which already employ whole-
time salaried midwives.
(c) For supplementing the existing domiciliary midwifery
services by the addition of a certain number of whole-
time salaried midwives to be appointed by the L.C.C.
(d) For linking up the facilities provided by every
metropolitan borough in connexion with the Maternity and
Child Welfare Act, 1918.
(e) For the provision of hospital accommodation, both
municipal and voluntary, to whatever extent is necessary.
(f) For the application of a uniform scheme for the
assessment and collection of contributions by patients
dealt with under the scheme.
(g) For the provision of a panel of medical practitioners;
to be approved by the L.C.C., who will undertake to be
available when required by the patient in her own home.
(h) For the provision of free choice of midwife to the
fullest extent possible; and
(t) For the provision of reliefs for holiday duty, sickness
duty, and for emergencies, eye and whenever
required.
It is proposed that 42 midwives shall be employed
directly by the Council, and when the arrangements
are complete every London mother, irrespective of
her financial circumstances, will be able to call on
the service of a fully qualified midwife, and will have
a choice of midwife. The fees proposed for the
attendance of midwives are: £2 for first confinements,
£1 10s. for subsequent confinement, and £1 10s. for
maternity nursing. Reduced fees will, however, be
charged where the patient or liable relatives are
unable to pay the full fees; or the whole fee may
be remitted. |
In a separate report to the Council the hospitals
and medical services committee refer to the recovery
from patients or liable relatives of fees paid to medical
practitioners called in by midwives in emergency and
recommend that, when the new scheme is brought
into operation, no charge should be made in respect
of the doctor’s fees in these cases.
INFECTIOUS DISEASE
IN ENGLAND AND WALES DURING THE WEEK ENDED
JUNE 12TH, 1937
Notifications.—The following cases of infectious
disease were notified during the week: Small-pox, 0;
scarlet fever, 1647 ; diphtheria, 977 ; enteric fever, 19;
eae (primary or influenzal), 607; puerperal
ever, puerperal pyrexia, 125; cerebro-spinal
fever, 26; acute poliomyelitis, 8; acute polio-
encephalitis, 1; encephalitis lethargica, 4; dysentery,
33; ophthalmia neonatorum, 105. No case of
cholera, plague, or typhus fever was notified during
the week.
(Continued at foot of next page)
1568 THE LANCET]
[JUNE 26, 1937
MEDICAL NEWS
University of London
The following have been recognised as teachers in the
University and assigned to the faculty of medicine.
Mr. E. C. B. Butler (surgery, London Hospital), Mr. A. Tudor
Edwards (surgery, London Hospital, Mr. R. J. Cann (oto-rhino-
laryngology, Guy’s Hospital), Mr. F. W. Law (ophthalmology,
Guy’s Hospital), Mr. Pierce Lloyd-Williams (dental surgery,
St. Thomas’s Hospital), pe H. Courtney Gage (radiology,
St. Mary’s Hospital), Dr. Roche Lynch (forensic medicine,
St. Mary’s Hospital), Dr. Şi. T. Barron (dermatology, West-
minster Hospital), Dr. J. C. Hawksley (medicine, University
College Hospital), Mr. Robin S. Pilcher (surgery, University
College Hospital), Dr. E. B. Clayton (physical menenn King’s
College Hospital), Mr. Thomas Bedford, (hygiene and
public health, London School of Hygiene and Tropical Medicine),
Dr. Sydney Blackman (radiology, Royal Dental Hospital),
Mr. F. W. Edwards (dental metallurgy, Royal Dental Hospital),
and Dr. Janet Vaughan (pathology, British Postgraduate
Medical School). ;
The following additional examiners have been appointed :
M.D.—Dr. William Gunn (hygiene), and Mr. N. St. J. G. D.
Buxton (surgery).
D.P.H. (Part II).—Dr. William Gunn.
Dr. A. M. H. Gray and Mr. W. Girling Ball have been
appointed governors of the British Postgraduate Medical
School. Prof. W. W. Jameson has been elected repre-
sentative of the University at the Imperial Social Hygiene
Congress, and Dr. R. A. Young representative at the
twenty-third annual conference of the National Associa-
tion for the Prevention of Tuberculosis.
University of Bristol
At recent examinations the following candidates were
successful :—
FINAL EXAMINATION FOR M.B., CH.B.
Section II.—P. B. Ryan (with second class honour) Daphne
V. Dennis, J. P. M. Forde, C. R. G. Howard, Harold James,
A. D. Jones, N. R. Matheson, A. N. H. Peach (with distinction
in surgery); J. W. E. Snawdon, A. M. Spencer, Reginald
Tallack, and Paul Zimmering. 7
FINAL EXAMINATION FOR L.D.S.
M. G. Davies, J. B. Inverdale, P. H. S. Paine, H. W. Wiliams,
and J. G. Windmill.
Epsom College
The eighty-fourth annual general meeting of the
governors was held at 49, Bedford-square, W.C., on
June 18th, 1937, with Lord Leverhulme, the president, in
the chair. The results of the last election of a pensioner,
five foundation scholars, and an annuitant were announced.
Lord Leverhulme then referred to the continued increase in
the number of boys, and said that in 1936 the average
number was 446, of whom 93 were day boys. He also
referred to the royal patronage which His Majesty King
George VI had graciously consented to extend to the
college. The school had attained a fine record in scholar-
ship work—no less than five open scholarships having
been secured ; one of the boys had won the public school
quarter-mile at the White City, and one master had gained
his rugby cap for England. He drew special attention
to the paragraphs in the annual report dealing with tax-
free subscriptions to charities. He pointed out that if all
(Continued from previous page)
The number of cases in the Infectious Hospitals of the London
County Council on June 18th was 2851, which included : Scarlet
fever, 716; diphtheria, 805; measles, 116; whooping-
cough, 456; puerperal fever, 16 mothers (plus 10 babies);
encephalitis lethargica, , 282; poliomyelitis, 3. At St.
Margaret’s Hospital there were 25 babies (plus 14 mothers)
with ophthalmia neonatorum.
Deaths.—In 123 great towns, including London,
there was no death from small-pox, 2 (0) from enteric
fever, 9 (0) from meales, 0 (0) from scarlet fever,
17 (3) from whooping-cough, 24 (1) from diphtheria,
31 (6) from diarrhcea ‘and enteritis under two years,
and 16 (3) from influenza. The figures in parentheses
are those for London itself.
Four fatal cases of measles were reported from Birmingham,
2 from Leeds. There were 3 deaths from diphtheria at Liver-
pool and at Wigan.
The number of stillbirths notified during the week
was 281 (corresponding to a rate of 38 per 1000 total
births), including 43 in London.
the governors would sign the deed of agreement it would
mean an increase of from £1500 to £2000 a year for the
funds of the Royal Medical Foundation at no cost whatever
to the subscriber.
The following ten members of the council were re-elected
for a further period of three years: Dr. J. W. Carr, Dr.
Ronald Cove-Smith, Mr. F. S. Fleuret, Sir \V ‘ise Hale-
White, Mrs. Robert Hutchison, Dr. Reginald Langdon-
Down, Dr. Arnold Lyndon, Dr. Philip Manson-Bahr,
Mr. Arthur Ormond, F.R.C.S., and Mr. Julian Taylor,
F.R.C.S. Prof. John Nixon, and Dr. Henry Robinson
were elected vice-presidents of the college. Colonel
Norman Ç. King, Mr. H. H. Rew, and Mr. H. A. Deeker
were appointed auditors for the ensuing year. The
chairman of the college proposed a hearty vote of thanks
to all honorary local secretaries, the British Medical
Association, the Medical Insurance Agency, the charities
committee of the British Medical Association, numerous
panel committees, and the editors of the British Medical
Journal and The Lancet for all the work that they had
done on behalf of the Foundation.
London and Counties Medical Protection Society
The annual general meeting of the society was held
on June 16th at Victory House, Leicester-square, W.C.,
with Sir Cuthbert Wallace, the president, in the chair.
The chairman, in proposing the adoption. of the annual
report, first referred to the death of Dr. R. L. Guthrie.
Anyone who worked with Guthrie, he said, was at once
attracted to the man, and the society owed him a great
debt of gratitude for the work he did as treasurer, in
the face of great physical disability. At the chairman’s
suggestion those present stood in silence as a tribute to
Dr. Guthrie’s memory. Sir Cuthbert continuing, said
the society was prospering, for during the past year they
had elected well over 1000 new members ; the membership
standing at over 15,000. The applications for advice and
assistance from members received during the year numbered
over 1500, and the solicitors. had to deal with nearly 800
cases. He thought it was remarkable that there must
be still very many members of the medical and dental
professions who remain unprotected. During tlic year
they had admitted to membership certain of the dentists
who came in under the Act of 1921, which he thought
was & very wise proceeding. Having listened to the
proceedings in the council and its committees, one of the
things that had struck him, he said, was the complexity
of the modern operation. ‘‘ As far as I know, legally
the surgeon is still responsible for everything that happens.
at an operation, but obviously that position cannot
continue indefinitely through the years to come. The
responsibility of the anesthetist with his complicated
apparatus and the responsibility of the nurses will have to.
be recognised in future. The surgeon can no longer go
on bearing all the risks involved.” The giving of a true
certificate might require a great deal of moral courage,
and to get the true history out of a patient was one of the
most difficult things on earth. Nevertheless, he urged
those in general practice for their own protection to make
correct notes and fill up the patients’ cards properly.
` Reverting to the happenings of the year, he said the
society had most wisely made. provision for protecting
members who had retired. Possibly the most important
thing in the whole year was an alteration in the articles of
association so that they were able to protect the estate
of a deceased practitioner. The wisdom of that decision
was shown in a recent action in which for the first fime the
estate of a deceased doctor was sued, with the fina! result
that £5,000 damages was awarded; the society was able
to help the widow to that extent. Finally, Sir Cuthbert
said that silence was indeed the golden rule, especially
when it is a question of the conduct of a neighbouring
practitioner or a colleague in the same town. He urged
those who got into trouble .to consult the society at once,
and not to meddle with matters themselves before taking
its advice.
Mr. W. M. Mollison spoke on the financial side of the
report. For the first time in recent years the balance
sheet shows a deficit of £246, largely due to the heavy
THE LANCET] ,
MEDICAL NEWS.—APPOINTMENTS.
i
[JUNE 26, 1937 1569-
expenses in the case which the president had mentioned.
In an analysis of costs. per member most of them were
down except for the considerable item of adverse costs
and damages, which was increased by no less than 7s. Td.
as compared with 1935. The total cost per member worked
out at £1 5s. 7d., so that they were apparently spending
more per member than they received. The difference
between the £1 5s. 7d. spent and the £1 received, however,
was accounted for by interest on investments and
accumulated balances. A brochure was to be sent to all
members of the profession not members of the society,
which would show in a more or less readable form the
advantages of belonging to a protection society. _
Sir Cuthbert Wallace was re-elected president, and
Dr. M. Fegen secretary of the society. Dr. Marguerite
Kettle was elected to the council.
Moynihan Fellowship
The Association of Surgeons of Great Britain and
Ireland invite applications for this fellowship which may
be held for one year and is worth £350. Further informa-
tion will be found in our advertisement columns.
An Ophthalmic Group
` A meeting of ophthalmic surgeons and ophthalmic
medical practitioners will be held at 3 p.m. on Saturday,
July 3rd, at 17, Russell-square, London, W.C.1, with the
object of constituting a group to protect their status and
interests, especially in relation to unqualified prescribing
and non-prescribing opticians, and to be organised within
or with the approval of the British Medical Association,
‘ Industrial Course
A short intensive course in industrial physiology and
medical industrial psychology will be held at the London
. School of Hygiene, Keppel-street, W.C., from Feb. 7th
to 18th. It is designed for members of supervisory staffs
in industry, but it may also be of interest to industrial
medical officers. It will deal with the general principles
of industrial health and specific problems arising in
industry. Further information may be had from the
secretary of the school.
Millbrook Isolation Hospital $
A tuberculosis pavilion of 44 beds was opened at the
Isolation Hospital, Millbrook, Southampton, on June 10th
by Sir Arthur MacNalty. The new building raises the
number of tuberculosis hospital cases which the health
department can deal with at one time to 140. After the
ceremony Sir Arthur said that the town’s tuberculosis
service was making steady progress, and the medical
officer’s last annual report showed that the mortality-rate
from pulmonary tuberculosis was the lowest ever recorded
for theborough. It was still, however, above the average
rate for England and Wales. One reason for that was that
the town was a seaport, and a high proportion of seamen
suffered from tuberculosis that had been contracted else-
where. He was glad to know that in Southampton
coöperation between the medical practitioners and the
tuberculosis services of the council was extending, as was
shown by the increase in the calls made upon the
tuberculosis officer for consultation.
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.—Nigel Corbet Fletcher, M.B., Lt.-Col. Sir James
Sands Elliott, M.D., and Gregory Sprott, M.D.
As Commander. —Lt. -Col. Henry Ross, C.I.E., O.B.E.,
F.R.C.S.1., I.M.S., Arthur Barrett Cardew, M.C., M. B., F.R.C.S.
Edin., Neil McDougall, M.B., Thomas Herbert Goddard, M.B.,
Sir Henry Lindo Ferguson,- C.M. G., M.D., Eldon Pratt, M.D.
Lt.-Col. James Philip Pone Ward, M.R.C. S., Major I Edmun
William Herrington, T.D., M.R.C.S., Ernest MeIntyre, M.R.CSS.,
Capt. Alexander Campbell White Knox M.B., Charles
Ernest Salt, M.B., Major Jobn Restell Tho M.B., William
Young, M. D., Lt.-Col. Walter Rothney Battye, D.S.O., 'F.R.C. S.,
Surg. Rear-Admiral Percival Thomas Nicho 8, C.B., M.R.C.S.
As Oficer—Major Alfred Tennyson- -Smitb, M. D., Clive
Gardiner-Hill, M.B., Col. William Brooke Purdon, D.S.O.
O.B.E., R.A.M.C., Michael Herbert Watt, C.B.E., M.D., Kari
Hosking Trebilcock M.D., een Bain Thom, M.D., Col. Frederick
Arthur Maguire, C.M.G V.D., M.D., Paul Testa, M.D.,
Leopold Henry Gill, T RO p “and S., James Angel Durante,
M.R.C.S., John Wilford Cooper, L.S.A., Capt. Sydney Booth
Turner, M.R.G.S., Col. Philip Henry Mitchiner, T.D., M.D.,
Charles Ernest Cameron W json, M.B., and Sydney "Walter
Fisher, M.D.
. LANDER, F. P. L.,
Middlesex Hospital
The annual dinner of this hospital will be held on
Oct. lst at the Savoy Hotel when Dr. Douglas McAlpine
will be in the chair. A refresher course for former students
will also be held from Oct. lst to 3rd.
London Hospital
On Tuesday, J uly 6th, at 3 P.M., Sir Kingsley Wood will
distribute the prizes to the students at this hospital.
Royal Medico-Psychological Association
The annual general meeting of this association, will be
held at the County Buildings, Ayr, on July 7th, 8th, and
9th under the presidency of Dr. Douglas McRae, who will
give an inaugural address on the care of the insane.
Dr. A. Meyer, Prof. F. L. Golla, Dr. F. A. Pickworth, and
Dr. A.C. P. Campbell will take part in a symposium, on the
circulatory system and the psychoses, on the second day
of the meeting. The last day will be devoted to a
discussion of the symptomatology of vascular diseases in
the psychoses and mental deficiency. Papers will be
read by Dr. W. Mayer-Gross, Dr. E. Guttmann, Dr. A. M.
Wylie, Dr. E. Krapf, and Dr. I. Mackenzie. Dr. K.
Paddle will also speak on the prophylaxis of dysentery in
mental defectives. Further information may be had
from Dr. W. Gordon Masefield, the hon. general secretary ,
Brentwood Mental Hospital, Essex.
Health Congress at Birmingham
The Royal Sanitary Institute will hold its health congress
at Birmingham from July 12th to 17th under the presi-
dency of the Earl of Dudley. The work of the congress
is divided into eight sections (preventive medicine; engi-
neering, architecture, and town-planning; maternity,
child welfare, and school hygiene; veterinary hygiene ;
national health insurance; hygiene in industry ; tropical
hygiene; and sewage disposal). There will also be con-
ferences of representatives of local authorities, medical
officers of health, engineers, and surveyors, sanitary
inspectors and health visitors. As president of the section
of preventive medicine Sir Arthur MacNalty will give an
address, entitled a Coronation Pageant of the Public
Health, and Prof. J. M: Munro Kerr, Dr. G. F. Buchan,
and Dr. C. E. S. Flemming will open a discussion on the
development of the maternity service. Dr. Ernest Ward
will preside over the conference of the medical officers of
health, and Dr. P. L. McKinlay, Prof. R. M. F. Picken
and Dr. E. R. C. Walker will take part in a symposium
on incapacitating sickness. Dr. G. P. Crowden will read a
paper on the practical application of physiology to hygiene
in industry to that section, and Dr. James Fenton will
address the conference of health visitors on the training
of the health visitor. A health exhibition has been
arranged in connexion with the congress. Further infor-
mation may be had from the secretary of the institute,
90, Buckingham Palace-road, London, S.W.1.
Appointments
GRUNDY, FRED, M.D. Leeds, D.P.H., Medical Officer of Health
for Luton.
M.D., M.R.C.P. Lond., Hon. Assistant
Physician to the Royal Free Hospital.
MoDouGALL, JOHN, M.B.Glasg., M.R.C.P. Edin., Medical
Superintendent of the Perth District Asylum, Murthly
MAYER, G. S., M.B. Camb., F.R.C.S. Eng., Surgical Registrat
at the Southend-on-Sca General Hospital.
THomas, A. R., B.Chir. Camb., D.M.R.E., Hon. Radiologist to
the French Hospital, London.
WALLACE, E. J. B. Edin., D.P.H., Medical Officer of
Health for Weymouth and Melcombe Regis.
County Council of Middlesex.—The following appointments have
been made :—
PORTER, ELEANOR G., M.R.C.S. Eng., D.P.H., Assistant
Medical neer
, M. B. Glasg., D.P.H., Assistant Medical
STEPHEN, EFFIE S
., M.R.C.S. Eng., Assistant Medical Officer.
Officer ; and
MATTHEWS, G. B
St. Thomas’s Hospital—The following appointments are
announced :—
RUSHTON, M. A., M.B. Camb., L.D.S., Assistant Dental
Surgeon ; :
Petes W. J., M.B. Liverp., Chemical Pathologist; and
KIna, D. P., M.B. Camb., Assistant Pathologist.
Cort ying Surgeons under the Factory and Workshop Acts
H. FaLLows (Redcar District, Yorkshire, North
Riding) : ; and Dr. J.C. BYRNE (Pewsey District, Wiltshire).
\
1570 ‘THE LANCET]
VACANCIES,.-——-BIRTHS, MARRIAGES, AND DEATHS
[JUNE 26, 1937
V acancies
For further information refer to the advertisement columns
Albert Dock Hosp., Connaught-road, E.—Res. M.O., £110.
Ashford Hosp., Kent.—R.M.O., £150.
“Ashton-under-Lyne District Infirmary.—H.S., at rate of £150.
Also Cas. H.S., £180. : l
Association of Surgeons of Great Britain and Ireland.—Moynihan
Fellowship, £350.
Barney, Pe Hosp. and Dispensary.—Jun. H.S. and H.P.,
eac .
Bath, Royal United Hosp.—H.P., at rate of £250. Also two
H.S.’s, each £150.
Birmingham, Queen’s Hosp.—Res. Ansesthetist, £70—-£100. .
Bolero Hosp., Wandsworth Common, S.W.—H.P., at rate
o
Bolton, Townley Hosp., Farnworth.—Asst. M.O., £225.
Bradford Royal Eye and Ear Hospital.—Two H.S.’s, each £180.
Brighton, New Hosp. for Women.—H.S., at rate of £100.
Brighton, Royal Sussex County Hosp.—Cas. H.S., £120.
Bury Infirmary, Lancs.—Res. Surg. O., £300.
Buzton, Devonshire Royal Hosp.—H.P., at rate of £175.
Camberwell Metropolitan Borough.—Tuber. O. and Deputy
M.O.H., £750.
Cambridge, Addenbrooke's Hosp.—Res. Anesthetist and
Emergency O., at rate of £130. ; seen
Cardiff, King Edward VII Welsh National Memorial Association.
Res. Asst. Tuber. M.O., £500.
Carlisle, Cumberland Infirmary.—H.S., at rate of £155.
haring Cross Hosp, W.C.—Hon. Orthopeedic Surgeon. Also
Hon. Clin. Asst. to X Ray and LElectrotherapeutics
Dept.
cae and North Derbyshire Royal Hosp.—H.8., at rate of
Chichester, Royal West Sussex Hosp.—Jun. H.S., £125.
Croydon County Borough.—Asst. M.O.H., &c., £500.
Deva” Prince of Walcs’s Hosp.—Jun. H.S., at rate of
Durham ‘County Mental Hosp.—Locum Tenens Asst. M.O.,
1 guinea per day. f
Eastbourne Royal Eye Hosp., Pevensey-road.—H.S., £100.
Gloucestershire Royal Infirmary and Eye Institution.—H.S.
and H.P.. each at rate of £150.-
Guildford, Royal Surrey County Hosp.—H.S., at rate of £150.
Halifax, Royal Infirmary. —fFirst H.S., at rate of £200.
Hertford County Hosp.—H.S., at rate of £180.
Hosp. for Consumption and Diseases of Chest, Brompton, S.W.—
H.P., and H.P. for Sanatorium, Frimley, each £50.
Hosp. for Sick Children, Great nd-street, W.C.—Res. M.O.
for Country Branch, at rate of £200.
Hosp. for Tropical Diseases, Gordon-streetl, W.C.—Res. Med.
Supt., £400. Also Ophth. Surg.
Hospital of St. John and St. Elizabeth, 60, Grove End-road, N.W .—
es. H.P., at rate of £100.
Huddersfield, St. Luke's Hosp.—Res. M.O., £230.
Hull, Beverley-road Institution.—Asst. M.0.’s, £350.
Ilford Borough—Two Asst. M.O.H.’s, £500 and £400.
Ilford, King George Hosp.—Two H.S.’s, each £100.
Ipswich, East Suffolk and Ipswich Hosp.—Cas. O., H.S. to
Orthopedic and Fracture Dept., and H.S. to General
Surgeon and Genito-Urinary Surgeon, each £144.
Keighley and District Victoria Hosp.—Res. M.O., at rate of £180.
Kettering and District General Hosp.—H.S. and H.P., at rate of
£175 and £150 respectively.,
King’s College Hosp., Denmark-hill, S.LE.—Asst. Neurologist.
Knowle Mental Hosp., Fareham, Hants.—Jun. Asst. M.O., £350.
Leeds, Killingbeck Sanatorium.—Asst. Res. M.O., £250.
Liverpool Assoc. Football Club.—M.O.
BONET ees Hosp., Victoria Park, E.—Asst. Tuberculosis O.,
London County Council: Consultant and Specialist Services—
Part-time Consulting Dermatologist, £125.
London County Council—Temporary Dist. M.O. for Hampstead.
Also Sen. Asst. M.O.’s, Grade II, £500, and Asst. M.O.’s,
Grade I, £350.
London University. Examinerships. oi tA
Louth and District Hosp.—Hon. Consulting Orthopedic Surgeon.
Also Hon. Consulting Physician.
Manchester, Ancoats Hosp.—H.S. to Ear, Nose and Throat
Dept., at rate of £100. ;
Manchester City, Crumpsall Pathological Laboratory.—Asst.
Pathologist, £500.
Manchester Kar Hosp., Grosvenor-square.—Res. H.S., £120.
Manchester, Northern Hosp.—Res. Surg. O., £150. Also Res.
H.P. and Res. H.S., each at rate of £100.
Manchester Royal Children’s Hosp., Pendlebury.—Res. M.O. and
Res. H.S., at rate of £150 and £100 respectively.
Manchester, Withington Hosp.—Res. Asst. M.O., at rate of £200.
Marie Curie Hosp, 2, Filzjohn’s-avenue, N.W.—Asst. Director,
from £500. ,
Middlesbrough, North Riding Infirmary.—Sen. H.S. and
Third H.S., at rate of £175 and £140 respectively.
Middlesex- County Council_—Sen. Dental Officer, £700. Also
Visiting Dental Surg., 2 guineas per session.
Mogden Fever Hosp., Isleworth. Asst. Res. M.O., £250.
Newcaslle-upon-Tyne, Hosp. for Sick Children.—H.P. and H.S.,
each at rate of £100.
Neuwcastle-upon-Tyne, Royal Victoria Infirmary.— Asst. Radium
Otlicer, £350. l
Northampton County Borough Education Committee. —Asst.
School Dentist, £400.
Norwich Infirmary.— Res. Asst. M.O., £350.
Norwich, Norfolk and Norwich Hosp.—Gen. H.S., H.S. to
Ortbopædic Dept., and Cas. O., each £120.
Nottingham General Hosp.—Res. Cas. O. and H.S. to Ear, Nose,
and Throat Dept., each at rate of £150.
Oldham Municipal Hosp.—Res. Asst. M.O., at rate of £200.
Oxford, Radcliffe Infirmary.—Res. M.O. for the Osler Pavilion,
Headington, at rate of £120.
Pyma h; Prince of Wales’s Hosp.—H.S. and H.P., at rate of
Port of Spain City Council.—M.0.H., £800.
Portsmouth City Mental Hosp.—Locum Tenens A.M.O.,
7 guineas weekly. i
Queen Mary’s Hosp. for the East End, Stratford, E.—Cas. and
Out-patient O., at rate of £150. Also Anesthetist.
Queen’s Hosp. for Children, Hackney-road, E.—Additional
Visiting Aneesthetist, 1 guinea per attendance.
tomerham POD S for Ophth. and Ear, Nose, and Throat
epts., F |
cua Eee Hosp., Gray’s Inn-road, W.C.—In-patient Obstetric
8 .
Royal London Ophthalmic Hosp., City-road, E.C.—Asst. Surg.
Also Out-patient Officer, £100
Royal Masonic Hosp., Ravenscourt Park, W.—Two Res. Surg.
O.’s, each at rate of £250.
Royal National Orthopædic Hosp.—Two H.S.’s for Country
Branch, each at rate of £150.
sen Hosp., near Wickford, Essex.—Research Biochemist,
St. John’s Hosp., Lewisham, S.E.—H.S., at rate of £100.
Salford, Hope Hosp.—Asst. Res. M.O., at rate of £200. -
Salisbury General Infirmary.—Res. M.O., £250.
Sheffield Children’s Hosp.—H.S., £100.
Sheffield Royal Hosp.—Clin. Asst. to Ophthalmic Dept., £300.
Sheffield Royal Infirmary.—H.S. and Aural H.S., each at rate
ot ee Ophth. H.S., at rate of £120. Also Cas. O., at rate
(0) e
Shrewsbury, Royal Salop Infirmary.—Res. H.S., at rate of £160.
Smethwick County Borough—Sen. Asst. M.O.H., &c., £750.
Also Asst. M.O.H., &c., £350.
Southampton, Royal South Hants and Southampton Hosp.—
Cas O., and Res. Ansesthetist and H.S. to Ear, Nose, and
Throat Dept., each at rate of £150.
South London Hosp. for Women, Clapham Common, S.W.—
Two H:.S.’s, each at rate of £100.
Staffordshire Mental Hosp.—Res. Asst. M.O., £530.
Stoke-on-Trent, Longton Hosp.—H.8., £160.
Swansea General and Eye Hosp.—H S., at rate of £150.
Tilbury Hosp., Essex.—H.S., at rate of £140. |
LUNO aoe Wells, Kent and Sussex Hosp.—H.S. and Cas. O.,
Victoria Hosp. for Children, Chelsea, S.W.—H.P. and H.S., each
at rate of £100.
West End Hosp. for Nervous Diseases, Gloucester Gate.—Two
Res. H.P.’s, each at rate of £125. Also Hon. Med. Psycho-
logist and Hon. Clin. Asst.
West Ham Mental Hosp., Goodmayes.—Jun. Asst. M.O., £350.
West London Hosp., Hammersmith-road, W.—Non-Res. Cas. O.,
£250.
West Middlesex County Hosp., IsleworthSurgeon, Grade I,
£1000. Also Asst. Pathologist, £650.
Woking and District Victoria Hosp.—Res. M.O., £120.
Worksop, Victoria Hosp.—Jun. Res., at rate of £130.
The Chief Inspector of Factories announces a vacancy for a
sony ne Factory Surgeon at Shelf, Yorkshire (West
g).
Births, Marriages, and Deaths
BIRTHS :
GRAVES.—On June 13th, at Devonshire-street, London, W., to
‘Mrs. K. A. H. Graves, M.D., wife of Mr. T. C. Graves,
F.R.C.S.—a son.
HALLIWELL.—On June 16th, at Jersey, the wife of Mr. A. C.
Halliwell, F.R.C.S., of a son.
ODBERT.—On June 10th, at Louise Margaret Hospital, Aldershot,
the wife of Captain A. N. B. Odbert, R.A.M.C., of a
daughter.
MARRIAGES,
GILRUTH—HORNSBY WRIGHT.—On June 12th, at St. Mary’s,
Westerham, James Gordon Anderson Gilruth,
to Susannah Margaret, only child of Mr. and Mrs. L. B.
Hornsby Wright, of Westerham. 5
WHIGHAM—CHRISTOPHERSEN.—On June 19th, at Oslo, Jobn
R. M. Whigham, M.C., M.S., F.R.C.S., Woburn-court,
W.C., to Hildegard, only daughter of Mr. J. Christophersen,
DEATHS
of Lyngör, Norway.
LAST-SMITH.—On June 13th, at Torquay, Edward Last-Smith,
J.P., L.R.C.P. Edin.
MACKINNON.—On June 19th, at St. Thomas’s Hospital, London,
Murdoch Mackinnon, M.D. Edin., D.P.H., of East Twicken-
bam, and formerly of Nairobi, aT Ae Colony.
SWORDER.—On June 18th, at Guildford, Horace Sworder,
L.S.A., M.R.C.S. Eng., aged 83.
N.B.—A fee of 78. 6d. is charged for the insertion of Notices of
Births, Marriages, and Deaths.
‘LORD MAYOR TRELOAR CRIPPLES’ HOSPITAL, ALTON.
The Duke of Kent, on June 10th, visited this hospital
to open the Silver Jubilee treatment centre. This addition
completes the rebuilding of the hospital which was begun
eight years ago.
M.R.G.S.. .
— a ———<— a
oye J 2 ee,
THE LANCET]
EXPLOSION OF NITROUS OXIDE AND ETHER
WE learn from the Evening Standard of June 17 th
that a patient in an hospital at Baltimore, Maryland,
was killed by an explosion in his lungs during an.
operation for a carbuncle on his neck. The account
states: ‘‘ The anæsthetic, a form of gas, had just
been administered when there was an explosion.
Taylor was immediately killed instantly. Two nurses
assisting at the operation received slight injuries.
An electric cautery machine which was being used
to complete the operation is thought to have caused
the explosion. The operating surgeon, who escaped
injury, stated afterwards: ‘The gases in anesthetic
mixtures, oxygen, nitrous oxide and ether, are not
ordinarily explosive. We use them in conjunction
with cautery thousands of times a year. It was just
one of those unexplainable accidents that happen.’ ”’
In our issue of March 6th last (p. 578) we recalled
that the late Prof. H. B. Dixon drew special attention
to the unrecognised explosibility of mixtures in which
air was replaced by nitrous oxide in conjunction
with ether or other inflammable gases, and also
referred to the work of Mr. J. H. Coste and Dr. C. A.
Chaplin, undertaken for the London County Council,
and since published in the British Journal of Anes-
thesia, in which they say: ‘‘ Nitrous oxide is endo-
thermic, and it has been found that when detonated
with fulminate it decomposed with violence... .
The limits (of explosibility of nitrous oxide and
ether) are probably from 1°5 to 16 per cent. of ether
vapour in the mixture. The experiment illustrates
the danger of diathermy.” This conclusion was
reached after experiments in which a mixture
containing 7°5 per cent. of ether shattered the explo-
sion vessel. They also obtained a shattering explosion
with ether, gas and oxygen from a Boyle’s apparatus.
It appears that the heat liberated on thermal decom-
position of the nitrous oxide adds greatly to the
violence of the ether explosion. These facts cannot
be too well known to surgeons.
THE HISTORY OF CONTRACEPTION
Mr. Himes has devoted himself for the last decade
to the study of the. historical aspects and social
implications of contraception. The subject matter
of his many articles and papers has now been brought
together in a series of volumes which, if we may
judge by the first,! can justly be described as encyclo-
peedic. We are told by Sir Humphry Rolleston, who
contributes a preface, that this volume is to be
followed by two others which will deal respectively
with the social and economic aspects of contra-
ception, and with the relation of birth control to
some fundamental aspects of modern population
theories. These aspects of the question are actually
dealt with by Mr. Himes in no cursory spirit in the
sixth and concluding part of the volume under
review. The five preceding parts thoroughly fulfil
any expectations raised by the title. The first deals
with contraceptive technique before the dawn of
written history and is based on the reports of social
anthropologists; the second with the methods
employed in the period of antiquity of the Western
world—by the Egyptians, the Jews, the Greeks, and
the Romans; the third describes the practices of
Eastern cultures—China, India, and Japan; the
fourth is concerned with the countries of the West in
the Middle Ages and early modern times; the fifth
is entitled ‘‘ Democratization of technique since 1800
in England and the United States ’’; and in the sixth
part the author sets out what he believes to be the
future effects of the process of democratisation which
has been brought about by a knowledge of chemistry
and physiology, and by the vulcanisation of rubber.
Throughout Mr, Himes has drawn attention to
1 Medical History of Contraception.
By Norman Himes.
London: George Allen and Unwin. Pp. 621.
25s.
NOTES, COMMENTS, AND ABSTRACTS
[JUNE 26, 1937 1571
those writers whose prescriptions have a scientific
basis of common sense rather than of superstition
and magic; and the first of these writers in merit is
deemed to be Soranos to whom the book is dedicated.
Soranos pointed out that soft wool, introduced into
the mouth of the womb before coitus reduced the
chances of conception, and he named several astringent
substances which would probably exert a spermicidal
effect. Contrast the recommendations of Soranos
with the following prescription of an Islamic writer :
If a woman urinates on the urine of a wolf, she will
never be with child; and with the intravaginal use
by Casanova of gold balls for which he paid about
£7 apiece.
The work is illustrated by reproductions of original
Islamic texts, facsimiles of Francis Place’s celebrated
contraceptive handbills, and, in the later chapters,
by numerous figures, tables, and charts. It is not a
book to read from cover to cover; but as a work
of reference it occupies a unique place in medico-
social literature. :
SPURIOUS CHLORODYNE
A PRACTICE which is said to be spreading in the
North of England, especially in the industrial areas,
is the sale of substitutes for chlorodyne (tincture of
chloroform and morphine) which differ in important
respects from that compounded from the recognised
formula, Since the genuine preparation contains
morphine hydrochloride it can only be sold by regis-
tered pharmacists, but the substitutes may be sold
by any shopkeeper or at a stall in the market place. —
The sale of the spurious article as chlorodyne or
‘‘chlorodyne substitute ” is to be strongly depre-
cated for more reasons than one, but the most impor-
tant reason is the danger which the practice entails.
The purchaser of the morphine-free product may
take large doses of it without doing himself damage ;
but being unaware that a subsequent supply of the
medicine which he buys at a pharmacy is an entirely
different and a potent preparation he will not know
that it is unsafe to take the same large dose from the
new bottle as he took from the old one. The risk is
one that the purchaser should know how to avoid,
and if substitutes for chlorodyne are to be sold they
should be sold under an entirely different name.
It is an offence under the Food and Drugs (Adultera-
tion) Act for a shopkeeper to sell to a person requiring
true cholorodyne an article which is not true chloro-
dyne, and it may be that the appropriate authority
will take action to check the practice.
A POCKET VALVE-AMPLIFIER HEARING AID
THE Multitone Electric Company, of 92, New
Cavendish-street, W.1, have produced a valve-
amplifier hearing-aid, which can be worn on the
person with comfort and efficiency, and which
obviates the necessity of carrying a case of the size
of a small box camera. The new model, the V.P.M.,
or Vest Pocket Multitone, achieves this result by
separating the various components, which are carried
in different pockets, and has the advantage that
the receiver may be placed in the best position for
collecting sound, Once the components are bestowed,
the apparatus is invisible, except for the head-
phones, but it may be assembled in a case, or in a
lady’s handbag if preferred. The apparatus com-
prises a crystal microphone to be clipped to the
coat or waistcoat; a three-valve amplifier which
is small enough to fit easily into a waistcoat pocket
and which should be placed in some such accessible
position, for it incorporates the switch and the
volume control; a 374 volt high-tension battery in
a thin morocco case and of a flexible type for more -~
comfortable wearing; and a 6-volt low-tension dry
battery. There is no variable tone control, but
models with different tonal responses are available
to suit various forms of deafness, and individuals
1572 THE LANCET]
MEDICAL DIARY
[JUNE 26, 1937
are tested by audiometer and amplification meter
before the instrument is supplied. The Multitone
* unmasked hearing ” telephones are used, a method
which employs two headphones in one of which,
intended for use in the better ear, the lower tones
are completely eliminated; it is claimed that this
gives better definition of speech, and that the absence
of the masking effect of low tones results in gradual
improvement of the hearing. The price of the
instrument, including the double headphones as
well as a small single earpiece for’ occasions when
as inconspicuous an aid as possible is desired, is
eighteen guineas; the high-tension battery may be
expected to last for two to three months and costs
5s. 6d.; the low-tension batteries last about a week
and cost ls., or a battery of twice this capacity can
be obtained for ls. 3d. by those who do not mind
the extra weight. The makers very properly allow
a trial hire for seven days at a charge of 10s. 6d.
Since valve-aids undoubtedly give a far better and
less distorted amplification of sound than other types
of electric amplifier, a model which can be worn on
the person will supply a want, and the instrument
here described is efficient and well made.
THE FUTURE OF SEX RELATIONSHIPS
IN .the future, according to Mr. de Pomerai,!
sex relationships will be purged of the elements of
jealousy and of clumsiness by which they are
stultified to-day. Extra-marital relationships will
be permitted, but they must not detract from the
affection, companionship, and financial benefits
which should be enjoyed by the legitimate partner ;
and they will take their place in a psychological,
social, and philosophical adjustment which we shall
learn by following the Aristotelian principle of the
Golden Mean and by adopting a pantheistic attitude
to the ultimate problems of life. This formulation
does not appear to be the product of a first hand
experience of the sexual problems of others such as
might be gained by a physician ; it seems rather to
have been evolved from reading the works of modern
popularisers of science. The names of Wells, Huxley,
Jeans, Russell, and Joad appear with a chilling
frequency and the reader is finally presented, on the
last page, with a picture which some will find agreeable
of a Utopia which the author believes will be realised
—but long after his own lifetime.
AGRANULOCYTOSIS AND AMIDOPYRINE
IT appears that the risk of producing agranulo-
cytosis by giving amidopyrine is still insufficiently
appreciated. Writing in the Nederlandsch Tijdschrift
voor Geneeskunde (1937 , 81, 2328), E. Gorter describes
a case in which a boy, five years old, was admitted
to hospital in October, 1936, with profound anzemia,
fever, and enlargement of the spleen.
He had previously had a long series of illnesses; acute
otitis media a year before had been followed by recurrent
attacks of bronchitis, lymphadenitis, and an undiagnosed
infection clinically resembling osteomyelitis. At the
beginning of the year, during July, and again during
September, amidopyrine had been given by the family
doctor. A blood examination showed a hæmoglobin
content of 33, erythrocytes 14 millions, and leucocytes
150 per c.mm. The differential white-cell count showed
50 per cent. of lymphocytes. A blood transfusion of
200 c.cm. was given and a course of Pentnucleotide
begun. A second blood examination, four days later,
showed hemoglobin 44 per cent., erythrocytes 1,640,000,
and leucocytes 930 per c.mm.; the child was more lively
and its appetite was improved, but oedema of the legs
was noted. Further transfusions were followed by pro-
gressive improvement in the blood-picture. ' Progress was
interrupted by the development of an empyema from
which he made a good recovery. He was sent home at the
end of December with a leucocyte count of 3300 per c.mm.
Soon afterwards, however, he developed acute tonsillitis
and the leucocyte count fell to 1900 (lymphocytes 96 per
1The Future of Sex Relationships.
By Ralph de Pomerai.
London: Kegan Paul. Pp. 132. 3s. Gd.
cent.), and despite another blood transfusion he died
within a few days.
During his illness this boy received no drug except
amidopyrine, and Gorter believes that it must be
held responsible for the agranulocytosis.
GAS AND BACTERIAL WARFARE
Ir is doubtful whether one can further the cause
of peace by making the blood curdle over the prepara-
tions being made by the Great Powers for gas and
bacterial warfare. This is the object of the author
of a work t whose terrible theme gains nothing from
the somewhat uncritical and emotional approach,
nor from the large amount of interesting but quite
irrelevant padding ; nor are the arguments in favour
of the successful use of bacteria in war convincing.
At the same time some startling revelations are made,
of which perhaps the most interesting is of the
enormous imports of arsenic into Germany and its
presumed object. Of the invention of gunpowder,
the author puts even Macaulay’s famous schoolboy
to shame with the statement that the name of Brother
Berthold Schwarz has been taught to ‘‘every child
throughout the world.”
Medical Diary .
Information to be included in this column should reach us
in proper form on Tuesday, and cannot appear tf it reaches
us later than the first post on Wednesday morning.
SOCIETIES
ROYAL SOCIETY OF MEDICINE, 1, Wimpole-street, W.
TUESDAY, June 29th. i
Psychiatry. 8.30 P.M. Annual General Meeting. Dr.
Erich Wittkower: The Influences of the Emotions on
Bodily Function.
WEDNESDAY.
Comparative Medicine. 4 for 4.30 P.M. (National Institute
T Medical Research, Farm Laboratories, Mill-hill,
W.), 1. Dr. C. H. Andrewes, Dr. Stuart Harris,
and Dr. Wilson Smith: Current Investigations in
Influenza. 2. Mr. A. S. Parkes, F.R.S., and Mr. C. W.
Emmens: Endocrine Studies in Poultry. 3. Dr.
Wilson Smith: The Technique of Egg Inoculation
for Virus Culture. 4. Miss E. Salmon: The Sexing
of Day-old Chicks.
NATIONAL ASSOCIATION FOR THE PREVENTION OF
TUBERCULOSIS.
THURSDAY, July list, FRIDAY and SATURDAY.—Annual
Conference at Bristol. `
LECTURES, ADDRESSES, DEMONSTRATIONS, &c. .
PET POSTGRADUATE MEDICAL SCHOOL, Ducane-
roa
TUESDAY, June 29th.—4.30 P.M., Dr. D. Hunter:
tional Diseases.
WEDNESDAY.—Noon, clinical and pathological conference
(medical), 2 P.M., Dr. Belt: Pathology of Pneumo-
Occupa-
coniosis. 3 P.M., clinical and pathological conference
(surgical).
THURSDAY, July ist.—2.15 P.M., Dr. Duncan White:
Radiological Demonstration. 3 P.M., operative
obstetrics.
FRIDAY.—3 P.M., clinical and pathological conference
(obstetrics and gynecology).
Daily, 10 A.M. to 4 P.M., medical clinics, surgical clinics
and operations, obstetrical and gynecological clinics
and operations.
FELLOWSHIP OF MEDICINE AND POST- SPADATE
MEDICAL ASSOCIATION, 1, Wimpole-street,
MONDAY, June 28th, to "SUNDAY, July 4th. 2 Weer END
HOSPITAL FOR NERVOUS DISEASES, Welbeck-street,
W. Afternoon M.R.C.P. course in neurology.—
LONDON CHEST HOSPITAL, Victoria Park, E. Wed.
and Fri., 6 P.M., M.R.C.P. course in heart and lung
diseases. Sat. and Sun., week-end course in heart
and lung diseases. —BROMPTON HOSPITAL, S.W.
5 P.M., twice weekly, M.R.C.P. course in chest diseases.
—PRESTON HALL, near Maidstone, Kent Sat.
oe demonstrations for M.R.C.P. candidates.—
Open only to members of the fellowship.
HOSPITAL FOR. SICK CHILDREN, Great Ormond-street,
THURSDAY, July Ist.—2 P.M., Dr. R. S. Frew: Enuresis.
3 P.M., Dr. W. W. Payne : Control of Obesity
Out- -patient clinics daily at 10 A.M., and ward visits at
SOUTH AVEST LONDON POST-GRADUATE ASSOCIATION.
TUESDAY, June 29th.—4 P.M. (St. James’ Hospital, Ouseley-
road, S.W.), Mr. J. P. Monkhouse: Hearing-aids.
1 Death From the Skies. By Heinz Liepmann. London :
Martin, Secker, and Warburg. Pp. 286. 6s.
INDEX TO VOLUME I. 1937
REFERENCES AND ABBREVIATIONS
Readers in search of a given subject will find it useful to bear in mind that the references are in several
cases distributed under two or more separate but nearly synonymous headings.
Institutions
and Corporations with the right to the prefix Royal will be found under that prefix, with the
exception of Hospitals, which will be found under that heading ;
indexed under Societies.
. (C)
(NI) =New Inventions, (O) = Obituary, (PI)
are separately
versity, (A)=Annotation,
All
= Correspondence,
and Contract Practice, and (P)= Prognosis Series.
and Medical Societies, which
Universities are indexed under the word Uni-
(LA)=Leading Article,
= Parliamentary Intelligence, (R) = Review, (PCP)
(ML) = Medico-legal,
= Panel
A Concordance of page numbers and dates of issue will be found on page xxvi
A
Abdomen—radiography of, 985; surgery
of, history of (Sir D. Wilkie) "135; See
also Peritoneum and Tuberculosis’
Aberdeen University Club, London, 1028
Abortion—birth-rate, prosperity and,
1425; committee on (PI) 1313, 1477;
criminal, 812; fatal (Les avortements
mortels) (H. Mondor) (R) 394
Abraham, . J., over-treatment of
Ponor ee (C) 1484
Abrahams, A., athletics for women (C) 899
Absorption, see Intestine
Accidents—Accidents and Their Preven-
tion (H. M. Vernon) (R) 1340, (A) 1357 ;
Cardiff scheme for, 107, (LA) 1470;
diabetes mellitus and (O. Leyton) (C)
778; in Vienna, 229; proneness to,
705; see also Dispensing, Fractures,
Industrial medicine, Injuries, and Road
accidents
Acetyle houng; see Choline and Myasthenia
avis
Achlorhydria, see Stomach
Adams, A., on congenital cystic disease of
lungs, 325
Adams, J. (O) 1312
Adams, B., on low voltage near-.
distance X ray therapy, 1488
Addison’s disease, see Suprarenal glands
Adenomyoma, intestinal obstruction by,
Adler, A. (O) 1373;
Courses (C) 1548; influence of (Sir
W. Langdon- Brown) (C) 1433
Adolescents, see Industrial medicine (Fac-
tories Bill and hours of employment)
and Insurance, National Health
Adrenaline—blood cultures and (A) 580 ;
in pulmonary œdema, 1274; see also |
Shock and Suprarenal glands
Adler Vacation
Adrion, E. D., on physiology of sleep (A)
Advertising—curious, 306;
Ethics, medical
Africa—horse- sickness (A) 823, (C) 900 ;
nutrition in Tanganyika (PI) 1026 ;
see also
post-mortem findings in Kenya (A) All
1182; prison conditions in Kenya (PI)
1084; research in (PI) 843 ; silicosis in
gold mines, 566, 773, (LA) 764, (PI)
1145; South African health {nsurance
scheme (PCP) 1301; South African
Proprietary Medicines and Appliances
Bill (A) 938 ; tsetse fly, eradication of
(A) 939; tuberculosis in, 1129, 1186
Age, see ola age F
Agranulocytosis—amidopyrine and, 1572;
P TOn CORI flavum and (J. G. G. Borst)
151
Air-conditioning, 1401, (A) 1418
Air-raid precautions—air-raid wardens
(PI) 669, 712; asphyxiating gases,
effects of, a1 civilian ambulance ser-
vice and. (J. A. Ryle) (C) 721; gas-
proof rooms (Protection of the Public
from Acrial Attack) (Cambridge Scien-
tists’ Anti-War Group) (A) 458, (PI)
541; gas-proof shelters (PI) 605, 961 ;
hospital staffs and (PI) 728; in "Malta
(PI) 541; lectures on, 65; local
authorities and (PI) 483; pharmacists
and (PI) 357; practitioners and (PI)
419; public schools and, 967 ; respira-
tors (PI) 670, 788, 1565, arsenical gas
and (PI) 606 ,
Air transport—French air nursing service,
eke io pregnant women (F. P. Mackie)
(C)
Aird, I., on fluid loss in intestinal obstruc-
tion (A) 454
Alcohol—-alcoholism, gastric acidity and
(A) 1292, (D. Jennings) (C) 1371;
methylated spirits, sale of (PI) 484,
540, (F. C. Goodall) (C) 1251, (PI)
1563 ; neuritis, vitamin-B deficiency,
and (A) ede see also Road accidents
Alderson, G. P, (O) oo
A
Alexander, F. W. (O) 725
Allan, J., influence of school routine on
children, 674
Allen, C., dysostosis craniofacialis (C)
350; Modern Discoveries in Medica]
- Psychology (R) 816
ergy—air-conditioning and, 1401;
Allergic Diseases (R. M. Balyeat and
R. Bowen) (R) 816; catgut sensitivity
(A) 35; lipstick "cheilitis (A) 398;
nephritis and (A) 1535; Recent.
Advances in Alergy (G. W. Bray) (R)
517; skin diseases and (A)
Tissue Immunity (R. L. Kahn) (R)
ae ; See also Asthma and Hay-
ever
Almkvist, J., on syphilis (LA) 1178
Almoners, hospital, 607
Alsted, G., pernicious ansemia and cor-
rosion of stomach, 7
Alston, J. M., on Weil’s disease, 569
Altitude, effects of (A) 34, 1534
Ambulance-—and stretcher, standardisa-
tion of (R. A. W. Ford) (C) 1017, 1137,
(L. P. Lockhart) (C) 1074; change in
rules, inquest and (ML) 286; false calls
for, 17 3; journey in, death after (ML)
1068; omission to order (ML) 531;
see also Air-raid precautions and Sp ain
America, see Canada and United States of
America
American Medical Association, 1425
Amidopyrine, agranulocytosis and, 1572,
Amies, C. R., on cancer virus (A) 276 16
Amino compounds, see Chemotherapy
Ameebie dysentery in ly ee ars 640
Ansemia—hookworm (A)
Fikri and P. Chalona
sheep (A) 1415; iron and, 1404, in
infants (A) 1293 ; macrocytic, new
sector in (L. Wills, P. W. Clutterbuck,
B. D. F. Evans) 311, (A) 334, 693 ;
Pathological Physiology and Clinical
Description of the Ansemias (W. B.
Castle, G. R. Minot, and H.
Christian) (R) 448; pituitary, gastric
function, and (A) 877 » (KE. C. Dodds
800: in
‘
iv Supplement to Toe Lancet]
and R. L. AODA) AA e. pregnancy
and (W. J. and J. M.
Mackintosh) 43, ys Oe sce also—
Anemia, pernicious—bone-marrow in,
1403; in infant (F. S. Langmead and
I. Doniach) 1048, (W. C. Smallwood)
(C) 1138, 1307, (J. C. Hawksley) (C)
1202, 1370 : liver therapy in (P. Laland
and A. Klem) (C) 171, 311, (A) 334, 693,
(A) 1237, subacute combined degenere-
tion and’ (A) 580; nitric acid corrosion
of stomach and (G. Alsted) 76;
pituitary and, 636 ; stomach and, 1404 ;
see also Anæmia
Ansesthesia—barbital narcosis, intra -
cranial pressure and (J. S. Horsley)
141; endotracheal (A) 1183; ether,
discoverer of, 894; ether, warmed (A)
279; evipan (A) 97, 141, 612, 775;
explosions i in operating theatres (A) 57 8;
1183, 1571; Inhalation Ancesthesia
(A. E. Guedel) (R) 1231; intracranial
operations and (P. Ayre) 561; liver
damage, anoxremia and (A) 105; 3; pre-
medication and (A) 35; Recent
Advances in Anesthesia and Analgesia
(C. L. Hewer) (R) 697; sudden death
and, 927; vinethene (A) 40, 1122; see
also Gas-and-oxygen anwsthesia
Anesthesia, local—blood-vessels and, ase,
(A. D. Macdonald) (C) 1016;
pensing mistake and (ML) 10 06
Anesthesia, spinal, neurological sequelæ
of, 755
Anaherniin, see Ansemia
Analgesia, see Anesthesia
Anatomy—Buchanan’s Manual of Ana-
tomy, including Embryology (J. E.
Frazer) (R) 1467; Comparative Ana-
tomy (H. V. Neal and H. W. Rand)
(R) 392; conference on, 963; har
ningham’ s Text-book of Anatomy (J.C
Brash and E. B. Jamieson) (R) 815:
Manual of P actio Anatomy (T?
Walmsley) (R) 272; Surgical Anatomy
(G. Massie) (R) 1468 ; Synopsis of
Surgical Anatomy (A. L. McGregor)
(R) 816; transparent woman, 548;
see also Mor hology
Anderson, A. B., on T basal metabolism in
hyperthyroidism, 871
Anderson, A. K., Laboratory Pa porineyts
in Physiological Chemistry (R) 873
An STOR, I. A., Addison’s disease, 1039,
6
, on influenza] immuni-
sation (LA) 575
Aneurysm—arteriovenous, cardiovascular
changes following (G. B. Price) 206;
gluteal (H. I. Deitch and J. M. Rogan)
1516; hæmoperitoneum and (J. Bruce)
1451; of sinus of Valsalva (N. H.
Schuster) 507
Angina, see Agranulocytosis and—
Anginal syndrome—pneumomediastinum
and (A. M. Scott) 1327; see also
Heart disease
Angioma, see Nævoid
Animals—African horse-sickness (A) 823,
(C) 900 ; conditioned deficiency disease
in (A) 1415; diseases of, eradication of
(PI) 1376, 1439, 1440 ; Dissertation on
the Sensible and Irritable Parts of
Animals (A. von Haller) (R) 1113;
experiments on (PI) 356, 1145, research
defence and (A) 581, 1417; foot-and-
mouth disease (LA) 1290, (A) 1414;
How Animals Behave (H. G. Wells,
J. Huxley, and G. P. Wells) (R) 1468 ;
immunisation of (C) 900 ; new growths
in, 305; tuberculosis in wild voles
(A. Q. Wells) 1221, (LA) 1233; veterin-
ary education (PI) 541 5 veterinary
surgeons, shortage of (LA) 1058; wild,
diseases of (A) 703; see also Biology
and Bovine tuberculosis
Ankylostomiasis anremia (A) 456, (M. M.
Fikri and P. Ghalioungui) 800
Annual Charities Registcr, 306
Ano-rectal — Synopsis of Ano-Rectal
Diseases (lL. J. Hirschman) (R) 1231;
see also Pruritus and Rectal
Anorexia nervosa, see Pituitary gland
Anoxemia—altitudes and (A) 34; carbon
monoxide and (LA) 154; see also
Aneesthesia
Anrep, G. V., Studies in Cardiovascular
Regulation (R) 873
Antenatal care—advances in, 1465; see
also Childbirth, Obstetrics, and Preg-
nancy
Anthropology—blood pressure in abori-
ginal ethnic groups (W. R. Morse and
Y. T. Beh) 966; fossil man, duration
of life in, 675
Antifibrinolysin (A) 820
Antiseptics, see Infectious diseases and
Mercurial] antiseptics
INDEX TO VOLUME I., 1937
Aortic—arch, right-sided (A) 454; calcifi-
cation, experimental, 1478
Appendicitis—abnormal large intestine
and (J. A. Mackenzie) 1107; alarm
reaction and (H. Ocrtel) (C) 348;
enterostomy in (LA) 1177; hernio-
appendicectomy (J. T. Morrison) 625;
measles and (A) 278; tuberculous
(G. H. Colt and G. N. Clark) 125
Appendix, mucocele of, 758
Appointments, weekly lists of, 61, 124,
181, 244, 303, 364, 423, 492, 544, 610,
672; 731, 790, ’848, 906, 964, 1030, 1090,
1154, 1207, 1258, 1318, 1381, 1438,
1499, 1569
Army—blood transfusions and (PI) 1086,
(A) 1359; health of (PI) 842; Keogh
Barracks (A) 822; recruits, standard
of (PI) 358, 484, "901, varicocele and
(C. Flemming) (C) 53, i A. Hall)
(C) 410; reforms (PI) 727; see also
Royal Air Force and Services
Arephenamine, „international standard for,
Arteries—arteriography, 1260, intracra-
nial, 207, thorium dioxide in
(D. W. C. Northfield and D. S. Russell)
377; bronchial, asthma and (LA) 452 ;
carotid sinus mechanism (A) 938;
local anesthetics and, 756; (A. D.
Macdonald) (C) 1016; Passive Vascular
Exercises (L. G. Herrmann) (R) 1175;
polyarteritis nodosa (A. W. D. Leish-
man) 803; Studies in Cardiovascular
Regulation (G. V. Anrep) (R) 873;
Synopsis of Diseases of tbe Heart and
Arteries (G. R. Herrmann) (R) 450;
see also Aneurysm, Embolism, Hemor-
rhage, Nevoid, Shock, and Thrombosis
Arthritis, see Rheumatism and Strepto-
coccal
Arthrography, see Radiography
Artificial pnewnothorax, see Tuberculosis,
pulmonary, surgery of
Aschheim-Zondek and Friedman tests,
571, 1465, (P. M. F. Bishop) (C) 1546
Aschoff, L., on monocyte question, 1402
Ascorbic acid—cataract and, 1478; esti-
mation of, in urine, 48 ; storage "of, in
tissues, 1478; synthetic, 1478 ;
thyroxine and excretion of, 109
Asher, C., infant nutrition, 221
Asherson, N., intubation of maxillary
antrum, 1399; nasal sinusitis in child-
hood oe
319
Ashmore, S. A, A., destruction of ST
5
Say ak J. R., ultra-violet light meter,
Aspbyxia neonatorum (A)995, 1466
Aspirator, electric (F. Heaf) (N I) 86
Association of Registered Biophysical
Assistants, 1206
Asthma—chest deformities in (H. H.
Moll) 12; cotton-dust (PI) 419, 842,
711; fluoresccinuria and, 86; vascular
spasm and (LA) 4
Atkin, I., serum an in psychoses, 439
Atlas, see ‘Dislocation
Atmospheric pollution—in Halifax, 1299 ;
National Smoke Abatement Society,
1498 ; report on 1255
Attlee, J. (0) 8
Attlee, W. W.,
following exertion, 1400
Auscultation, see Diagnosis and Heart
disease
Austin, R. C.,
vaccination 16) 612
AUSTRALIA, CORRESPONDENCE FROM. —
Aust. ralasian College of Physicians,
1306—Infant mortality, 1307
register of,
p emoglobingria
disfigurement by
Auxiliary services, medical,
850
Ayre, P., anesthesia for intracranial
operation, 561
B. coli, see Urinary infections
Bact. tuphosum, see Typhoid fever
Bacteriology—fermentation, Pasteur’sand
Bernard’s theories of (A) 1477; Funda-
mentals of Bacteriology (M. Frobisher)
(R)932 ; immunising antigens (W. W.C.
Topley, H. Raistrick, J. Wilson,
M. Stacey, S. W. Challinor, and R. O. J.
Clark) 252, (T. C. Stainp and E. B.
Hendry) 257, ALA) 274, 368, 1228,
1318, 1420, 1479; Textbook of
Bac teriology and its Applications (C.M.
[AvevusrT 14, 1937
Hilliard) (R) 517, 676; Textbook of
Medical Bacteriology (R. W. Fair-
brother) (R) 698; sec also Blood
cultures '
Badgerow, Sir G. (O) 1201
ao O sat T., fracture of neck of femur,
Baile (Qertbook of Histology (A. Elwyn
O. Strong) (R) 517
Batnbriage and Menzies’ Essentials of
ae (H. Hartridge) (R) 815
Baird, D., on placenta prævia, 636
Bak er, H. S., drug addiction (C) 1370
Baker, S. L., urinary suppression follow-
lag -bloog transfusion, 1390, (LA)
5
Baker-Bates, E. T., bronchoscopic
clinic, 987
Ballantyne, A. J.,
of fundus oculi, 571
Balyeat, R. M., and Bowen, R., Allergic
Diseases (R) 816
Bankart, A. S. B
(C) 595
Banti’s svndrome, see Schistosomiasis
Barber, G. O., on curriculum, 1190
Barbiturates, see Anæsthesia
Barger, G. , Organic Chemistry for Medical
Students (R) 1176
on
on biomicroscopy
., manipulative surgery
Bae on tse H., manipulative surgery,
Barnard, Wy W. G., on medico-legal institute
Barnes, 6. G., overbreathing tetany
(C) 291
Borna; G. A. E., encephalitis in measles,
Barr, A., gas-and-oxygen analgesia in
labour, 1271
Barrington-Ward, Sir L., tuberculous
glands of neck in children, 980
Barsoum, G. S., on histamine (A) 456
Barwell, H., nose and throat in rbeuma-
tism, 67
Basal narcosis, see Anesthesia
Basden, M., on pregnancy toxeemia, 1365
Basque, see Spain
Bassini operation, fiftieth anniversary of,
1240, (A) 1359
Bates, J. L., continuous venous hum in
cirrhosis of liver, 1108
Bates, R., nevoid amentia, 1282
Barten, L., on children’s mealtimes,
Ager at a E. C., Hospital Law Notes
Beards, F. H. C., on rehabilitation, 705
ae P J., Public Health Act, 1936
) 8
Beattie, J., on laboratory training, 267
Beaumont, 'G. E. compressed-air baths in
emphysema, 685
Beaumont, N. C. (O) 602
Beck, H G. x on carbon monoxide poison-
ing (LA) 154
Bed-bugs, eradication of (S. A. Ashmore
and A. M. Hughes) 530, "(C) 1434,
672, (J. M. Holborn) (C) 1074, (K.
Mellanby) (C) 1372, 1548
ed-cushion, adjustable, 1504
Bed support, 909
Bedford, D. E., chest leads in electro-
cardiography (C) 779; on right-sided
aortic arc oe 454
Bedwell, C. E. A., hospital amalgamation
in Liverpool rei 51, 292; on voluntary
hospital finance (A) 768
Begg, N. D., electrocardiography in diph-
theritic myocarditis, 857
Beh, T., blood pressure amongst
aboriginal groups, 966
Behaviour—conduct disorders and, 1559 ;
How Animals Behave (H. G. Wells.
J. Huxley, and G. P, Wells) (R) 1468 ;
Reactions of the Human Machine
(J. Y. Dent) (R) 991
Beit fellowships, 790
BE S: H., Experimental Physiology (R)
Bell’s palsy, 390
Bell’s Sale of Food and Drugs (R. A.
Robinson) (R) 393
Bennett, T. I., new insulins in diabetes
(C) 662, 1319; ; non-malignant pyloric
stenosis, 552
Benzedrine, „effects of (J. H. Fisher) (C) 52
Benzyl benzoate, see Skin
Benzylaminobenzenesulphonamide,
Chemotherapy
Bergler, E., Hitschmann, E., and Weil,
P. L., Frigidity in Women (R) 697
Bermuda, unemployment and sterilisa-
tion in (PI) 1026
B A. P., Atlas of Radiographs
Besredka Prize, 671
Bigger, J. W., Handbook of Hygiene (R)
1175; on varicellisation (A) 1414
see
Supplement to THE LANOET]
INDEX TO VOLUME I., 1937:
Bigwood, E. J., on League of Nations and | Blood transfusion—continuous drip, in
nutrition, 695
Bilbao, see Spain
Bilharzia, see Schistosomiasis
Biliary—caleculi, mental disorder and
(J. Mackay) 1522; colic, morphia and
(LA) 819; diseases, 446, (A. Moss) (C)
611, turmeric in (A. Oppenheimer)
619, (E. Gallop) (C) 779, (La vésicule
biliaire et ses voies d’excrétion) (M.
Chiray and I, Pavel) (R) 873; fistula,
wanted case of, 910; operations,
T-tube for (R. Maingot) (NI) 1111;
see also Liver
Bilirubinemia, see Liver
Biochemistry—genera] (Einführung in die
Allgemeine Biochemie) (C. Oppen-
heimer) (R) 1229
Biochemical Society, 363
Biology—Biologica] Laboratory Technique
(J. B. Gatenby) (R) 1055; Reactions of
the Human Machine (J. Y. Dent) (R)
991; Statistical Methods in Biology,
Medicine and Psychology (C. B.
Davenport and M. P. Ekas) (R) 90;
see also Animals
Bion, W. R., on sex education, 568
Birch, C., on hemophilia (A) 1416
Birch, C. A., jaundice complicating pneu-
monia, 1046
w uenpecmen! (E. H. V. Hodge)
Birth, see Childbirth, Population, and
Vital statistics ,
Birth control, see Contraception
Birtbs, marriages, and deaths, weekly
lists of, 61, 120, 182, 244, 306, 364,
424, 492, 545, 608, 672, 732, 791,
849, 910, 968, 1031, 1092, 1150, 1208,
1262, 1316, 1384, 1442, 1504, 1570
Bishop, P. M. F., hormone treatment of
undescended testis (C) 598; recent
advances in obstetrics (C) 1546
Bisodol, manufacture of, 1384
Blacker, C. P. and Glass, D. V., Future of
Our Population (LA) 933
Blackham, R. A., on infant feeding, 1364
Blackmore, S., on air-raid precautions,
967; on asphyxiating gases, 810
Blackwater fever—jaundice and, 511;
pecudo-metheroeny and, 1524, (A)
Bladder—foreign body in (D. Brodie)
266; spinal injuries and, 1053; see
also Calculi, Genito-urinary, Post-
operative, and Urinary infections
Blair, V. P., on face injuries (LA) 1057
arte J. C., encephalitis in measles,
7
Bland-Sutton, Sir J. (V. Bonney) (C) 50,
(S. Hastings) (C) 50, (G. G. Turner) (C)
51, (G. Gordon-Taylor) (C) 112, (A)
1062
Blind—children, care of (PI) 1144,
(A) 1292 ; prevention of blindness, 362,
in Hungary, 1425; see also Kyes
Blood—agranulocytosis, 1519, 1572 ; alti-
tude and (A) 34, 15343 bilirubinsemia,
rôle of (Najib-Farah) 505; blood-
platelets, 1403 ; coagulation of, 1421;
diseases of, research in, 353 ; eclampsia
and (A) 333; fibrinolysis (R. `
Macfarlane) 16, antifibrinolysin and
(A) 820; Hodgkin’s disease and
(A) 217; induced fever and (A) 998;
influenza and (J. G. Willmore) (C) 347 ;
leucocyte regulation, 1404; Manual
of Blood Morphology (L. Schudel) (R)
272+ micro-chemical analysis of (E. J.
King, G. A. D. Haslewcod, and G. E.
Delory) 886; microviscosimeter and
(A) 334; monocytes, 1402; post-
operative changes in (W. W. Walther)
6, 10, (LA) 32; pseudo-methemo-
globin, 1524, (A) 1533; pulmonary
cedema and, 1274; see also Anemia,
Hemorrhage, Leukemia, Shock, and
Sulphemoglobinremia
Blood cultures—adrenaline injections and
(A) 580; Blood Cultures and their
Significance (H. M. Butler) (R) 762
Blood pressure—Bright’s Disease and
Arterial Hypertension (W. J. Stone) (R)
516; carotid sinus and (A) 938;
coronary thrombosis and (J. H.
Palmer) 741; high, magnesium in (A)
1537; high, surgery of (A) 997; in
aboriginal ethnic groups (W. R. Morse
and Y. T. Beh) 966; pulmonary
cedema and, 1274; sce also Pregnancy
and Shock
Blood-sugar—left {nframnanimary pain
and (K. S. Smith, A. 5. Hall, and J.
Patterson) 1267, (C. W. Chapman) (C)
1434; see also Diabetes, Insulin,
Pituitary gland, and Suprarenal glands
Blood tests—affiliation cases and (A)
1060 ; see also Road accidents
severe hemorrhage (A. W. Cubitt) 864 ;
hospital service for (S. C. Dyke) 1538,
1523, (LA) 1531; in Spain (A) 1359,
1523, (LA) 1531; reactions after (S. IL.
Baker) 1390, 1523, (LA) 1531; relative
as donor (E. E. Pochin) 164; stored
blood for (PI) 1086, (A) 1359, 1523,
(LA) 1531
Blumer, G., Practitioners’ Library of
Medicine and Surgery (R) 989
Board of Control—advisory committee,
1032 ; research report (LA) 212, 306
Board of Control for Scotland, 1012
Board of Education—homework report
(A) 1358; Sir A. MacNalty’s report, 59
Boils, conservative treatment of (A) 579
Bolduan, C. F., and Bolduan, N. W.,
Public Health and Hygiene (R) 89
Bomskov, C., Methodik der Hormon-
forschung (R) 151
Bone—Bones: A Study of the Develop-
ment and Structure of the Vertebrate
Skeleton (P. D. F. Murray) (A) 522;
calcifying mechanism of, 1478; disease
- of plasma phosphatase in, 87; repair
of, venous stasis and (A) 1061: rider’s
(A. Moore) 264; see also Fractures and
Osteitis
Bone-marrow, pathology of, 1403
Borst, J. G. G., agranulocytosis and
prontosil flavum, 1519
Borstal inquiry (LA) 575
Poraa IGE W. C., Meditatio Medici (R)
Bourguignon, G., and Cross, H. H. U.,
Electricity in Therapeutics (R) 989
Bovine tuberculosis—detection of B. tuber-
culosis in milk (M. L. C. Maitland)
1297; veterinary inspection and, 359,
(LA) 1058; see also Milk and Tuber-
culosis
Bowden, R., Sansum, W. D., and Hare,
R. A., Normal Diet and Healthful
Living (R) 814
Bowel, see Intestine
Bowen, R., and Balyeat, R. M., Allergic
Diseases (R) 816
Bowker, C. S. (0) 665
Bowman, K. M., Towards Peace of Mind
Boyd, A. M., thrombosis of popliteal and
femoral arteries, 3
Boyd, W., Introduction to Medical
Science (R) 991 :
Bra FORDULT, Sir H., Tavistock Clinic (C)
Brailsford, J. F., radiogram and radio-
graph (C) 233, 350 :
Brain—conduct disorders and, 1559;
disordered, histology of (A) 218;
electrophysiology of cortex (A) 767;
skul]
(C) 350;
injuries,
system
Brain, E. D., influence of animal] hormones
on plants, 1241
Brain, W. R.,on exophthal mic ophthalmo-
plegia, 1110
Brandwijk, A. C., trypsin and diphtheria
toxin, 1228, 1318
Brash, J. C., and Jamieson, E. B.,
oe Text-book of Anatomy
5 3
Bray, A ay Recent Advancesin Allergy
Breast—cancer of (LA) 153, 629, 1488,
(F. Hernaman-Jobnson) (C) 1549,
(Paget’s Disease of the Nipple) (K.
Inglis) (R) 28, splenic metastasis and
(W. H. McMenemey) 691; lymphatic
Ieukromia and (B. J. Haram) 1277;
see also Radium and X rays
Breathing, see Respiratory
Breen, G. E., prontosil in erysipelas,
1334, (A) 1357
Brewer, H. F., on blood transfusion, 1523
Bride, J. W., on sarcoma of ovary and
lung, 759
Bright's disease, see Nephritis
Brinton, L. N., and Clark, F. Le Gros,
Men, Medicine and Food in the U.S.S.R.
(A) 280
Briscoo, H. V. A., on silicosis (A) 1236
Briscoe, Lady, anti-curare action of
Substance 36, 621
a W. R., manipulative surgery,
Intracranial, and Nervous
{[Aueust 14, 1937 v
British Association (A) 1063
British College of Obstetricians and
Gynrecologists—diplomas, 847 ; fellows,
1087; Indian committees, 302 ; mem-
bers, 302; representatives, 1087
British Empire Cancer Campaign—181,
582, 964; annual report (W. Garton)
(C) 1309
British Health Resorts Association—
conferences, 713, 904, 1003; games,
sport, and sea-bathing, 1004; hand-
book (LA) 1235; industry and health
resort, 1003 ; sea climate, 714; winter-
ing in England, 713
British Hospitals Association—conference,
1351; report, 1123, (LA) 1117
British Institute of Philosophy, 421, 607
BRITISH MEDICAL ASSOCIATION.—Annua!l
meeting, 1063—Medicine advertisc-
ments in stam books (PI) 358—
Midwifery service, 1199— Research
scholarships and grants, 180—Trades
Union Congress and, 351
British Pharmacopola, see Pharmaco-
peeias
Bren Postgraduate Medical School,
9
British Red Cross Society—clinic for
rheumatism, 1260; see also Spain
British Social Hygiene Council, 1088, 1381
Broadbent, W., osteomyelitis, 564, (A) 579
Broderick, F. W., Principles of Dental
Medicine (R) 761
Brodie, D., foreign body in bladder, 266
Bronchial, see Lung and—
Bronchicctasis—in children, 1527; lobec-
tomy for, 987; postural drainage for
(H. V. Morlock) 381
Bronchoscopy—987; bronchoscope, modi-
fied (J. E. G. McGibbon) (NI) 1232 ;
see also Respiratory l
Pro MBRO, R., on ununited fractures,
Brown, H. C.,on Weil’s disease, 569
Brown, H. H., B.I.P.P. in acute osteo-
myelitis (C) 1371; on immunity and
cellular response (A) 704
Brown, J. B., on face injuries (LA) 1057
Browne-Carthew, R. H., pruritus ani
(C) 1076
Bruce, J., massive spontaneous intra-
peritoneal hemorrhage, 1451
Brucella, see Undulant fever
Bubonic plague in Paris (A) 277,
Buchanan’s Manual of Anatomy including
Embryology (J. E. Frazer) (R) 1467
BUCHAREST, CORRESPONDENCE FROM.—
Marinescu, G., retirement of, 1560—
Maternity and child welfare, 1009—
Military medicine and pharmacy, con-
gress of, 1010—Pulmonary hæmorrhage,
Congo-red for, 1559—Throat, sore,
bismuth for, 1010—Tuberculosis mor-
tality, 1559
Buchsbaum, R., and Loosli, C. G.,
Methods of Tissue Culture in Vitro
(R) 394
Buckley, C. W., Reports on Chronic
Rheumatic Diseases (A) 217; rest
honeen for rheumatoid artbritis (C)
BUDAPEST, CORRESPONDENCE FROM.—
Anthropological excavations, 776—
Blindness, prevention of, 1425—Child
welfare, 468—Dollinger, Prof., death of,
776—Fertility, prosperity and, 1425—
Influenza experiments, 776—Medical
Chamber, presidential election in, 468—
Nystagmus, caloric, 108—Pyrexial
treatment of nervous and mental
diseases, 468—Radium institute, 108—
Stiller, B., centenary of, 1426—
Suicide statistics, 109—Syphilis: cam-
paign against, 1425; experimental
immunity in, 109—Thyroxine and
vitamin C, 109 — Vesical calculi
in avitaminosis, 467
Budget (PI) 357, 1026
Bugs, see Bed-bugs
Building, see Housing
Burford, G. H. (O) 114
Burke, F. J., on extra-uterine
758; on labour obstructe
bladder, 1054
Burn, R., pulmonary cedema, 1274
Burnet, F. M., on egg membrane in virus
research (A) 279, (LA) 575; on
influenza immunisation (LA) 575
Burns—blood changes following, 6 ; hista-
AYR (A) 456; tissue toxins and
regnancy,
by feta]
vi Supplement to THE LANCET]
Burns, B. H., and Ellis, V. H., Recent
A in Orthopædic Surgery (R)
Burns, J. W., on mucocele of appendix,
75
Burstall, F. H., and Morgan; Sir G.,
Inorganic Chemistry (R) 7
Burton-Opitz, R., “Elementary Manual of
Physiology (R) 5
Bus, see London
Butler, H. M., Blood Cultures and their
Significance (R) 762
Buttle, G. A. H., diaminosulphone in
streptococcal infections, 1331, (A) 1357,
1536; p- aminobenzenesulphonamide
therapy (C) 661, 681
Byars, L. T., on facial injuries (LA) 1057
Cc
Cabot, H., Modern Urology (R) 90
ser ES: H., on cerebro-spinal rhinorrhæœa
Gacian i 478: see also Intracranial
Calcium—in pregnancy toxæmia (G. W.
Theobald) 1397, (R. H. Paramore)
(C) 1486, (J. L. Moir) (C) 1486 ; serum
and cerebro-spinal, in overbreathing
tetany (R. A . MeCance and E. Watch-
orn) 200, (J. Cumings and E. A.
Carmichacl) ‘oor, (C. G. Barnes and
R. I. Greaves) (C) 291; serum,
psychoses and (I. Atkin) 439; see also
Suprarenal glands
Calcium mandelate in urinary infections
(E. Schnobr) 1104
Calculi—gall-stones, mental disorder and
(J. Mackay) 1522; renal, diuresis and
posture for (R. O. Ward) 23; urinary,
staphylococci and (A) 996: vesical,
avitaminosis and, 467
Calendar, Ciba, 65
Calmette, A., Boquet, A., and Nègre, L.,
7 infection bacillaire et la tuberculose
Cambridge Scientists’ Anti-War Group
(A) 458, (PI) 541
Campbell, J. A., antibodies against
hormones (C) 1547 ; experimental] lung
tumours (C) 1370; "oxygen administra-
tion, 82, (C) 597; and Poulton, E. P.,
Oxygen Tent and (Nasal Catheter, 1113
Campbell, Lady (O) 1374
Canada—cancer in (A) 645; public
health in, 1133 ; radium from (A) 217 ;
Toronto anatomical session, 963 ; tuber-
culosis in, 1129, 1186
Cancer—cinematograph films on (A) 1122,
1314; Crab was Crushed (H. Graham)
734; diagnosis of, early, 1365, rapid
histology and, 871; disposition to,
204, (A) 398; Fuchs serum proteolysis
test for (D. Woodhouse) 138;
ganglio -neuroblastoma, mediastinal
Hart and P. O. Ellison) 1458;
in “animals, 305; in Canada (A) 645;
International Union Against. Cancer,
1315; lymphosarcoma (S. Keys and
W. W. Walther) 1169; melanoma,
cutaneous (J. H. Pringle) 508; nævo-
carcinoma of skin and mucous mem-
branes (I. G. Williams and L, C. Martin)
135; palliative treatment of, 968,
1488 ; sarcoma of ovary and iung,
sarcoma, retroperitoneal (H.
Waters, D. Levine, B. Myers, and
. A. Knott) 202; tarred roads and
(R. S. Creed) (C) 899; tests and treat-
ments for, 138, (P. N. Panton) 793 ;
viruses and (A) 276, 1420; see also
British Empire Cancer Campaign,
Intracranial, Radium, X rays, and—
Cancer of—colon, 988, 1283 ; lip (LA) 153:
liver, thorotrast and (C. Elman and
E. Haworth) 981; nervous system (A)
458, 1458; cesophagus (R. Pilcher) 73,
(A) 96, radon-seed introducer for
(F. J. Cleminson) (NI) 30; ovary and
lung, 759; pancreas, diabetes and
(F. Pygott, and H. Osborn) 1461;
pituitary gland (A) 455, (H. Cohen and
J. H. Dible) (C) 597, dwarfism and (B.
Zondek) 689 ; rectum, 988, lymphatic
spread in (Operations of Surgery) (R.
P. Rowlands and P. Turner) (R) 209,
(W. H. Ogilvie) (C) 290; skin, 135,
508, 758; spleen. 69] ; Ssuprarenal
gland, 851; thyroid gland (A, Haas)
1155; uterus (LA) 153, 893, ostrin and,
435; vagina and urethra, Stent
composition in radium treatment of
(C. White) 1462 ; see also Breast, Lung,
and Stomach
INDEX TO VOLUME I., 1937
Canning, see ‘Food
Cannon, A. T., insulin shock treatment of
schizophrenia, 1101
Capon, N. B., hemorrhagic disease of new-
born, 431
Carbaminoylcholine, see Post-operative
Carbohydrate metabolism, see Blood-
sugar
Carbon monoxide poisoning (LA) 154
Cardiac, see Heart
Cardiff accident scheme, 107, (LA) 1470
Carey Coombs memorial, 1028
Cargill, W. P., bacteriological diagnosis
of diphtheria, 751
Caricatures and cartoons, medical, 1258
Carling, E., more and safer milk (C) 412;
prisoners and captives (C) 1203
Carlton, H., ean (C) 1252
Carmichacl, E. (O) 1374
Carmichael, E. A., overbreathing tetany,
Carotid sinus fainting attacks (A) 938
Carr, F. H., protamine insulin (C) 290
Carrel, A., Man, The Unknown (R) 210
Carroll, D., on unwilling patient, 25
Carver, J., on genito-urinary tubercu-
losis, 1336
wart ede Sir M., cardiac ischeemia (C)
Castle, W. B., Minot, G. R.,and Christian,
H. A., Pathological Physiology and
Clinical Description of the Aneemias (R)
44
Cataract, see Eyes
Catgut, nee Sutures
Cathcart, P., and Murray, A. M. T.,
Dietary pees 293
catheter, irrigation (P. P. Cole) (NI)
1286
Catin, C. H., diet in urinary infection,
Cattell, R.
family ag 1475
ma J., on tupercülosis in West Africa,
1
Cawthorne, T., on facial paralysis, 391
Cecil houses, 1261
Cecil, R. L., Diagn onie and Treatment of
Arthritis (R) 1409
Central Midwives Board (A) 214, 963,
(LA) 1116, 1199, 1285
Cerebral, see Brain and Intracranial
Cerebro- spinal fever, see Meningitis
Cerebro-spinal fluid—cerebro-spinal rhin-
orrhea (A) 1183 ; eS ole d of (Cytologic
au liquide céphalo- rachidien normal
chez l'homme) (H. Jessen) (R) 1113 ; in
acromegaly, 1421; tryptophane reac-
tion in (J. Spillane) 560; see also
Calcium and Intracranial
Cervix, see Uterus
Chadwick a a 302, 1207
Chadwick, N. , on housing, 1364
Challinor, S. we” immunisation with Bact.
typhosum, 252, (LA) 274
Chamberlain, Sir A., death of (LA) 701
Chambers, J. W., Wishart, G. M., and
Cuthbertson, D. P., Practical Physio-
logical Chemistry (R) 873
Chamings, A. J. W. (O) 537
Chandler, F. G., internal pncumolysis,
83; ritual purgation (C) 535
Chapman, C. W., left inframammary pain
(
Che ices 2heye (PI) 483;
306
Charles, J. A., on food of Newcastle
families (A) 94
Cheesman, J. E., school routine (C) 838
Cheiropompholyx, see Skin
Chemistry— Enzyme Chemistry (H.
Tauber) (R) 990; Inorganic Chemistry
(Sir G. Morgan and F. H. Burstall)
(R) 760; Laboratory Experiments in
Physiological Chemistry (A. K. Ander-
son) (R) 873; Organic Chemistry for
Medical Students (G. Barger) (R) 1176;
Practical Physiological] Chemistry
(G. M. Wishart, D. P. Cuthbertson, and
J. W. Chambers) (R) Aer 4 reas to
Chemistry (J. Read) (R) 8
Chemists, see Pharmacists
Chemotherapy of bacterial infections (H.
Proom) 16, (A. T. Fuller) 194, (LA) 211,
(G. L. Robinson) 509, (L. D. B. Frost)
510, (A) 525, 612, (A) 579, (J. W hitting-
dale) (C) 599, (G. Discombe) 626, (T. B.
Layton) (C) 658, (H. Proom and
G. A.H. Buttle) (C) 661, (G.A.H. Buttle,
H. J. Parish, M. McLeod, and D.
Stephenson ) 681, 710, (Sir D. Wilkie)
735, (1. Vitenson ‘and G. Konstam) 870,
(A) 1061, (J. P. J. Paton and J. C.
Eaton) 1159, (C) 1369, (A) 1183, (B. A.
Peters and R. FV. Havard) 1273,
(G. A. H. Buttle, D. Stephenson, S.
Smith, T. Dewing, and G. E. Foster)
1331, (G. E. Breen and I. Taylor) 1334,
, on intelligence and size of
register of,
[AueustT 14, 1937
(A) 1357, 1466,
mond) (C) 1484, (L. B: H,
517, (JI. G. G. Borst)
1476, (J. A. J. Ham-
Whitby)
1519, (A)
deformities, asthma and (H. H.
Moll) 12
Chick, H., on nutrition and disease, 811,
(C) 900
Chickenpox, varicellisation and (A) 1414
Childbirth—face presentation, 1174;
induction (A) 1417; locked twins,
758; obstructed by fatal bladder,
1054; pelvic kidney and, 269 ; placenta
previa, 636; precipitate (W. B.
Crawford) (C) 954: retention of urine
after, doryl in (C. Moir) 261, (A) 276;
ruptured uterus and, 269: sequels to
(A) 218; thrombosis of mesentery and
(G. G. Turner) 802: see also Gas-and-
oxygen aneesthesia, Maternal mortality,
Midwifery, Obstetrics, and Puerperal
infection
Children—Bilbao (A) 1239, (R. W. RB.
Ellis and A. E. Russell) 1303, (C) 1371,
(PI) 1313, (A. F. MacCallan) (C) 1310,
(PI) 1378, 1383, (PI) 1441, (A) 1418,
(PI) 1495, 1564; Birch’s Manageo-
ment (E. H. V. Hodge) (R) 698;
blind, training of (PI) 1144: blood
pressure, pulse- and respiration-rates
in, 531; boy injured in paddling-
(ML) 466; bronchiectasis in,
Care of Children from One to
hive Seana (J. Gibbens) 611; causes of
death in, 299; Child Guidance Council,
243, 1028; conference on preventive
peediatrics, 905; cretinism (A. Lewis,
N. Samuel, and J. Galloway) 1505;
deaf, hearing-aids for, 1528; Diseases
of Infancy and Childhood (W. Sheldon)
(R) 516; facial expressions of. in
illness, 1427; Government depart-
ment for (A) 97 e Handbook on Diseases
of Children (B. Williamson) (R) 5163
heart disease in, congenital, 324:
hospitalisation of, cross infection an
(A 9; Institute of Child Psychology
(A) 1062: Keeping Your Child Normal
(B. Sachs) 850; leprosy and (A) 160s
mesenteric cyst in (R. C. Jewesbury
1170; myopia in (A) 159; otitis in,
Livt, (LA) 1234,- (G. H:
Newns) (C)
1310, (W._N.
Leak) (C) 1434, 1527:
= i
Pediatric Nursing (J. Zahorsky and
B. L. Hamilton) (R) 697; pneumonia
in (A) 334 ; precocious (C. R. Croft) 62 ¢
psychology of, 491, 792, mealtimes and,
1153; pulmonary fibrosis in (M. O,
Raven) 80; Save the Children Fund,
362, Factories Bill and, 1087 ; sinusitis
in (LA) 93, (N. Asherson) (C) 170,
(W. A. Troup) (C) 233, (C. H. Thomas)
(C) 351, bronchiectasis and, 1527 :
syphilis in, diagnesis of, 388; taking
temperature in (D. Paterson) (C) 724,
(C. E. Donaldson) (C) 777: traffic
lights for, 824; tuberculin-testing of,
in France, 1132: tuberculosis, chronic
miliary,in (A) 997 ; tuberculous glands
of neck in (Sir L. Barrington-Ward)
980; winter care of (A) 158; Your
Child’s Health (D. H. Scott) G11: see
also Corporal punishment, Infants,
Maternity and child welfare,
and School-children
Chiray, M., and Pavel, I., La vésicule
pines et ses voies d’excrétion (R)
Nutrition,
í
Chiropody — Incorporated
Chiropodists, 1088
Chlorodyne, spurious, 1571
Chloroform, sce Ansesthesia
Choking, see Foreign body
Cholecystitis, see Biliarv
Cholera—Snow on Cholera (B. Ww.
Richardson and W. H. Frost) (R) 992 i,
(LA) 993
Choline—derivatives, 261, 263, (A) 276,
940 ; see also Myasthenia gravis
Chorea—fever therapy in, 1007 ;
rheumatic (A) 581
Chorionic villi, cystic degeneration of
(C. Hollósi) 808
Choyce, C. C. (O) 902, 957
Christian, n. À., Castle, W. B., and
Minot, G. Pathological Physiology
and ( TER, De scription of the Anremias
Society of
none
(R) 448
Christie, A. C., on cancer of lung (A)
Christopher, F., Minor Surgery (R) 574
Churchill, S., ritua] purgation (C) 599
Cinematograph filnns— Conquest of Cancer
(A) 1122; inflammable, children and
(PI) 729; non-inflammable (PI) 842
objectionable (PI) 296, 483
Circulation, see Arteries, Heait, and
Veins
Supplement to THE LANCET]
í
INDEX TO VOLUME [I., 1937
[Auacust 14, 1937 vii
Clark, A. R., High Wall, 850
Clark, F. Le Gros, and Brinton, L. N.,
Men, Medicine and Food in the U.S.S.R.
280
G. N., tuberculous abdominal
typhosum, 252, (LA) 274
A., and Hill, C., What is Osteo-
pathy ? (A) 881, 932
Cleminson,. F
(NI) 30 ;
Climate, see British Health Resorts
Association
Clinch, A. D. (O) 412
Clough, J. (O) 666
Clutterbuck, P. W., macrocytic anremias,
311, (A) 334
Coal-tar naphthas, see Bed-bugs
cope S., Preface to Nervous Disease (R)
6
Cochrane, G. (O) 903
Cochrane, W. A., postural deformities of
Spine (C) 1015; rest houses for rheu-
matoid arthritis (C) 346
Coghlan, C. W. (O) 666 |
Cohen, H., basophil pituitary carcinoma
(A) 455, (C) 597; on gastritis, 757;
on hepatitis and cholecystitis, 446;
paratyphoid A, 1521
Colds—How to Escape Colds and Influ-
enza, 306; research on (PI) 788;
see also Respiratory
Cole, G. D. H., and M. I., Condition of
Britain (LA) 1411
Cole, L. G., on diagnosis of malignant
gastric lesions (LA) 329
Cole, P. P., irrigation catheter (NI) 1286
Coles, C. (O) 1014
College of Physicians and Surgeons of
Bombay, 1087
Collins, F. G. (O) 956
Coane, R. J., on tuberculosis in Canada,
Colon—cancer of, 988, 1283; diseases of,
635, 1283; diverticulitis (W. T.
Cooke) 84; microcolon, congenital,
813; polyposis of, congenital (A) 94;
prolapsed and inverted, hernia in
(P. G. Harvey) 384; radiography of,
986; ulcerative cotitis, deficiencies in
(A) 937 ; see also Purgation
Colonies—Colonial Service (A) 1240;
health in (A) 278
Colour-blindness, see Eyes
Colt, G. H., tuberculous abdominal glands,
125, (C) 474
Commercial Art Centre, 1209
Commonwealth Fund Fellowships, 1314
Complement or Alexin (T. W. B. Osborn)
Compressed-air baths in emphysema
(G. E. Beaumont and J. F. Dow) 685
CONFERENCES AND CONGRESSES.—Anat-
omy, 963—Cancer, 582—Circulation,
61—Contraception, 930—Fever therapy,
179, 1007— Forthcoming, 1498—Gastro-
enterology, 1111—Hæmatology, 1402—
Health, 1569—Health resorts, 713, 904,
1003—Hormones, 905—Hospitals, 61,
486, 1351—-Industrial medicine, 1088
Journées Médicales de Bruxelles, 964—
Journées Médicales Internationales de
Paris, 1111—Leprosy, 1206—Maternity
and child welfare, 181, 1258, 1431,
1547—Medical, 229, 243, 1138, 1560—
Menta] hygiene, 848, 1384—Micro-
biology (A) 1473—Military medicine
and pharmacy, 1010—Milk Scheme,
359—Nursery Schools Association (A)
97—Ophthalmology, 789, 962, 1437—
Pediatrics, 905—VPeace,1206—Prostitu-
tion, 968—Psychotherapeutics, 1031—
Public health and Hygiene, 1257, 1312,
1364, (A) 1418—Radiology, 420, 847,
1029—Rheumatism, 1206, (A) 1418—
Royal Sanitary Institute, 359—Short-
wave therapy, 848, 1134—Silicosis,
1380—Surgery, 180—Tuberculosis, 362,
532, 905, 1129, 1185
Connell, F. G., on precautionary enteros-
tomy (LA) 1177
Consolidated World Research Society,
peo: (ML) 341, (C. M. Fegen) (C)
Constipation, see Colon and Purgation
Contraception—clinics for, deputation on,
363; conference, 930; importance of
(A) 1475; in Iceland, legislation and,
1317; in U.S.A., 1317; in U.S.S.R.,
648; lectures and demonstrations,
119, 303, 487, 672, 847, 1315; Medical
History of Contraception (N. Himes)
1571; modern obstetrics and, 1466;
Mothers’ Clinics, 904; National Birth
Control Association’s report (A) 157;
Voluntary Parenthood (EK. F. Griffith)
1209; see also Population
Convalescent homes, free, 611
ee J. J., Text-book of Medicine
Cook, S. F., Elementary Human Physio-
logy (R) 1176
Cooke, R. C., hospital closed for strepto-
coccal infection (C) 664
Cooke, W. E., on congenital microcolon,
one à pulmonary œdema and eserine,
Cooke, W. T., diverticulitis with pple-
phlebitis simulating Weil’s disease, 84
Cookery, see Food
coom Ds, H. I., diet in urinary infection,
Coope, R., on lobectomy, 987; toxremias
of pregnancy, 121
Copeman, W. S. C., gold therapy, 554;
on rheumatism, 229
Coppleson, V. M., and Miller, D., Clinical
Handbook for Residents, Nurses, and
Students (R) 932
Corker, T. M. (O) 601
Corneal, see Eyes
Coronary, see Heart disease
Coronation—(LA) 1115; see also Honours
Coroners—duties of (PI) 901, 1018;
post-mortem examinations and (PI)
1084; see also Inquests
Corporal punishment of children (PI)
787, 1085, 1144, 1378
Corpus luteum, see Sex hormones
Cosens, W. B., ergotamine tartrate in
migraine (C) 839
Cost of living, see Nutrition
Cotton-dust, see Asthma
Cowell, S. J., on nutrition, 811, 1365
Cox, E. T., presentation to Sir F, Hobday
(C) 1548
Cramer, W., male gonads and adrenal
gland, 1330; on disposition to cancer
(A) 398
Cramp, A. J., Nostrums and Quackery
(R) 573, (LA) 817
Cranium, see Skull
Crawford, G. J., bacteriological diagnosis
of diphtheria, 751
Orawtord, W. B., precipitate labour (C)
oroi Ta S., invention of road tarring
Cremation—certificates (PCP) 1248 ; pro-
gress of, 905
Cresswell, R., (O) 666
Cretinism in London (A.) Lewis, N.
Samuel, and J. Galloway) 1505
Crichton-Miller, H., on psychotherapist’s
training, 367
Crime—delinquency in childhood (A) 97,
Borstal vocational inquiry and (LA)
575; manslaughter, negligence and
) 1069; medico-legal institute
(LA) 639, (PI) 961; mental disorder
and (ML) 48, 49, 1114, psychotherapy
and, 25, 280, (ML) 1114; statistics of
(PI) 844; see also Corporal punish-
ment and Prisons
Critchley, M., on facial paralysis, 390;
on musicogenic epilepsy (A) 1236;
on neurological sequelæ of spinal
aneesthesia, 755
Croft, C. R., precociaus people, 62
Crohn’s discase (J. C. Hodgson) 926,
985, (H. I. Goldstein) (C) 1547
Crooks, J., on sinusitis in childhood
(LA) 93
Cross, H. H. U., and Bourguignon, G.,
Electricity in Therapeutics (R) 989
Crowe, H. W., postural deformities of
spine (C) 1015
Crowley, J. H., ergotamine tartrate in
migraine (C) 954
Cruickshank, R., on acute enteritis, 444
Cubitt, A. W., drip blood transfusion, 864
Cullinan, E. R., hemorrhage in gastric
and duodenal ulcer (C) 111
Culture bottle for preparation of vaccines
(S. G. Rainsford) (NI) 1528
ones J. N., overbreathing tetany,
Cunningham, A. A., meningococcal and
streptococcal meningitis, 198, (LA) 211
Cunningham, R. N., vitamin B and
diphtheria, 563
Cunningham’s Text-book of Anatomy
as Brash and E. B. Jamieson) (R)
Curare, see Myasthenia gravis
Curcumin, see Biliary
Curette and uterine sound (G. L. Foss)
(NI) 698
Curriculum, see Education, medical
Currie, J. R., Manual of Public Health
Laboratory Practice (R) 761
Cushing’s syndrome, see Pituitary gland
a3
Cushny’s Text-Book of Pharmacology and
Therapeutics (C. W. Edmunds and J. A.
Gunn) (R) 1112
Cuthbertson, D. P., Wishart, G. M., and
Chambers, J. W., Practical Physio-
logical Chemistry (R) 873
Cysticercosis, epilepsy and (R. L. H.
Minchin) 865, (D. W. Smithers) (C) 1016
D
d’Abreu, A. L., diaphysectomy in acute
osteomyelitis, 1454; urethral rupture
without extravasation (C) 232
Dacryoadenitis (B. Rogol) 982
Dalrymple-Champneys, Sir W., infection
and disinfection, 102; surgical brucel-
losis (C) 839
Daly, I de B., on asthma (LA) 452
Dangerous drugs—addiction, Sherlock
Holmes and (D. P. S. Conan Doyle) (C)
292; addiction, treatment of (M.
Vivian) 1221, (A) 1239, (H. S. Baker)
(C) 1370, (A) 1536; Morphine Habit
and its Painless Treatment (G. L.
Scott) (R) 1529; opium-smoking in
Far East (A) 1415; regulations, 1152 ;
traffic in, in Egypt (A) 1473; world
requirements of (A) 95, 400
Davenport, C. B., and Ekas, M. P.,
Statistical Methods in Biology, Medi-
cine and Psychology (R) 90
Davidson, A. H., on face presentation,
Davideon: S., on rheumatism, 229, (LA)
Davidson, S. G., hormones in menstrua-
tion, 861
Devla; H. W., on cerebral arteriography,
Davics, J. L. (O) 782
Davies, P. V., death of, 49
Davis, E. D. D., on orbital cellulitis
due to sinus infection, 1526
Davis, J. E., and Dunton, W. R., Recrea-
tonai Therapy for the Mentally Ill (R)
Dawson, Lord, cardiac ischemia, 185;
on pasteurisation of milk (PI) 1142
Deaf—care of, cost of (A) 1292;
munication in ‘wre: 699, 1528;
Children (Schoo] Attendance) Bill (PI)
786; hearing-aids for, 65, 340, (LA)
395, (M. Yearsley) (C) 411, 711, (LA)
699, 1092, 1209, 1528, 1571; Medical
Research Council on, 711; see also
Ear and Speech
Death—causes of, notification of, 947,
disease nomenclature and, 1245 (M.
Greenwood) (C) 1308; sudden, 927,
adrenal gland and (C. K. Simpson) 851 ;
see also Inquest and Vital statistics
Deficiency disease—in sheep (A) 1415;
protein loss in ulcerative colitis (A3
937 ; see also Vitamins
RO pony: of the Plague (E. J. Holland)
Degrees, see Universities
Dehydration, see Water balance
Deitch, H. I., gluteal aneurysm, 1516
DeLee, J. B., and Greenhill, J. P., Year
Book of Obstetrics and Gynecology
(R) 991
Delinquency, see Crime
Delory, G. E., micro-chemical blood
analysis, 886
Dent, J. Y Reactions of the Human
Machine (R) 991
Dental, see Teeth and—
Dentists Register—additions to (A) 641 3
foreign dentists and (PI) 1378 ; medical
practitioner, pane] dentistry, and (ML)
1541; names erased and restored,
1342 ; unregistered dental practitioner
(A) 1356; voluntary romoval from
(A) 1360
Department of Scientific and Industrial
Research, 733, 1255
Depressed areas—Iimployment and the
Depressed Areas (H. P. Greenwood) (R)
29; hospitals in (PI) 297; means test
and (PI) 297; public kitchens in (PI)
*669, 729; report on (A) 37: Second
Industrial Survey of South Wales (A)
769; Special Areas Bill (PI) 541;
see also Unemployment
Dermatology, see Skin
Dermoid cyst, radiography of (C) 662
} Detwiler, S., Neuro-embryology (R) 89
viii Supplement to THE LANCET]
INDEX TO VOLUME I., 1937
[Aueust 14, 1937
Devenish, E. A., tuberculous bilateral
cystic swellings, 869
Dewing, T., diaminosulphone in strepto-
coccal infections, 1331, (A) 1357, 1536
Diabetes—accidents and (O. Leyton)
(C) 778; coma in (E. F. Skinner) 627 ;
cysticercosis, opiepey, and (R. L. H
Minchin) 865; L.C.C. clinic for, 893
pancreatic cancer and (F. Pygott
and H. Osborn) 1461; pregnancy and,
1173; pulmonary cedema and, 1274;
see also Blood-sugar and Insulin
Diagnosis—Medical Diagnosis (S. L.
Simpson) (R) 516; of malignant
gastric lesions (LA) 329; Physical
Diagnosis (R. H. Major) (R) 873;
physical signs in, 1464; Principles of
Diagnosis, Prognosis, and Treatment
(R. Hutchison) (A) 879 ; rapid histology
and, 871
Diaminosulphone, see Chemotherapy
Diarrbeea, see Amcebic dysentery, Colon,
Gastro-enteritis, and Rectal
Diary, hospital, 1209 F
Dible, J. H., basophil pituitary carcinoma
(A) 455, (C) 597
Diet—fatigue and (A) 877; Food and
the Principles of Dietetics (R. Hutchison
and V. H. Mottram) (R) 29; Hay diet
(A) 1534; in childhood, 1365; in
urinary infection (H. I: Coombs, C. H.
Catlin, and D. Reader) 1043 ; ketogenic,
among Eskimos (E. C. Fountaine) (C)
1075; Normal Diet and Healthful
Living (W. D. Sansum, R. A. Hare, and
R. Bowden) (R) 814; see also Deficiency
disease, Food, N utrition, and Vitamins
Digestive tract, see Duodenum, Intestine,
Ccsophagus, and Stomach
Digitalis—international standard for, 653 5
sce also Heart disease
Dillon, L. G. (0) 1140
Dinitrosulphone, see Chemotherapy
DINNERS.— British Association of Radio-
logists, 1499—Harveian Society, 1498—
Hunterian Society, 543—Incorporated
Society of Chiropodists, 1088—Indian
Medical Service, 1566—Irish Free
State Medical Union, 1428—Medical
Society of London, 671—Medical Super-
intendents’ Society, 790—National Hos-
pital, Queen-square, 1148—Royal Col-
lege of Surgeons Hunterian Festival,
475—Royal London Ophthalmic
(Moorfields) Heep ie 731—Society of
Apothecaries of ondon, 542—Society
of Radiographers, 543—Treloar Hos-
ital and College, 1149—University of
: ponon Medical Graduates’ Society,
T EE of (R. M. F.
icken) 1445; bacteriological diagnosis
of (W. P. Cargill and G. J. Crawford)
N D. Begg) 857, 1465 ;
hemiplegia and (J. M. Todesco) 85;
immunisation 389, 664,
(T. W. G. Kelly) (C) 723, (PI) 729,
LA) 934, 947, (J. C. Saunders) 1064,
eath following, 1305, 1480 ; immunisa-
tion against, fees for, 1427; toxin,
research on, 1479; toxin, trypsin and
(A. C. Brandwijk and A. Tasman) 1228
1318; vitamin B and (B. A. Peters and
R. N. Cunningham) 563
Disability, see Fractures, Industrial medi-
cine, and Workmen’s Compensation
Disclaimer (C) 1252
Discombe, G., fluoresceinuria, 86; sulp-
hemoglobinsemia and sulphaniJamide
treatment, 626
Disinfection, see Infectious diseases and
Mercurial antiseptics
Dislocation—congenital, of hip (A) 1119;
pathological, of atlas and hip (G. H.
Steele) 441
Dispensing—mistake in, death following
(ML) 1006 ; see also Pane] and Contract
Practice
ah VT Teena sclerosis, fever therapy in,
751; heart in
against,
Dissociation, see Psychology
Distressed areas, see Depressed areas
District medical service (PCP) 167
Diuresis, sce Calculi
Diverticwitis—pylephlebitis and (W. T.
Cooke) 84, see also Colon and Duodenum
Divinyl ether, see Ansesthesia
Divorce, see Marriage
Dixon, W., and Smart, W. A. M., Manual
of Pharmacology (R) 696 `
Dobbs, R. H., medicinein U.S.S.R., 648
Doctors, see Practitioners
Dodds, E. C., anemia and the pituitary
(C) 953
Dodson, G. E. (0) 1254
Dollinger, Prof., death of, 776
5 $e
Donald, A., death of, 1000, (O) 1078
Donald, A. B., on whooping-cough, 565
Donaldson, C. E., taking of children’s
temperatures (C) 777
Donati, M., on duodenal diverticula,
Donations and bequests, 109, 510, 1028,
1108, (A) 1418, 1419, 1549
Doniach; I., pernicious anæmjia in infant,
Donor, see Blood transfusion
Dorsal, see Posture and Spine
Doryl, see Post-operative
ON (C. E. Kindersley)
Dougal, D., on pseudomucinous ovarian
cyst, 447
Douthwaite, A. H., convalescent serum
in influenza (C) 172
Dow, F., compressed-air. baths in
emphysema, 685
aan ey G. B., on allergy and skin
Downes, J., on tuberculosis control
(A) 216
Doyle, D. P. S. Conan, Sherlock Holmes
(C) 292
Drake, B., Nutrition : a Policy of National
Health (A) 399
Drinker, C. K., on carbon monoxide
poisoning (LA) 155
Drugs—advertisements of, in stamp
books (PI) 358; American Pharma-
ceutical Association Year Book (R)
1468; Bell’s Sale of Food and Drugs
(R. A. Robinson) (R) 393 ; chlorodyne,
spurious, 1571; cost of (F. C. Goodall)
(C) 53: Drug Fund (PI) 962; hawking
of, in France, 946; Maclean’s Stomach
Powder (ML) 1423; Materia Medica,
Toxicology and Pharmacognosy (W.
Mansfield) (R) 1288; Medicine Stamp
Duties, 591, (LA) 576, 817, (PI) 901,
(LA) 935, (A) 1000, 1184; misleading
labels and (A) 213; nostrums, sale of,
in United States (Nostrums and
Quackery) (A. J. Cramp) (R) 573,
legislation on (LA) 817; South African
Proprietary Medicines and Appliances
Bill (A) 938; Trade Marks (Amend-
ment) Bill (PI) 1376; seealso Dangerous
drugs, Dispensing, Pharmacology, and
Prescribing
Dukes, C., on diagnosis of gonorrhea, 387
Dunlop, B., trend of population (C) 1017
Dunn, C. W., anorexia nervosa (C) 723
Dunton, W. R., and Davis, J. E., Recrea-
pone Therapy for the Mentally Ill (R)
Duodenum—diverticulum, of, 1522 ; duo-
denitis, surgery of (G. Garry) 1512;
movements of, during opaque meal,
490; obstruction of (K. S. Nigam)
144; perforation of, gastric polyposis
and (C. C. Holman) 24; see also
Hemorrhage and Peptic ulcer
Dupuytren’s contracture (A) 157
Dust, see Industrial medicine and Mines
Duthie, . S., acquired hemolytic
jaundice, 1167
yke, S. C., blood transfusion service,
1538, 1523, (LA) 1532; clinical patho-
logist, 365
Dysentery, see Ameebic dysentery, Colon,
and Gastro-enteritis
Dysostosis craniofacialis (C. Allen) (C) 350
Dystrophia myotonica, mental changes
and (O. Maas and A. S. Paterson) 21
E
Eagle, A., Philosophy of Religion versus
Philosophy of Science (A) 880
Eagles, G. H., poliomyelitis, 462
Ear—bathing and (LA) 1412; Disease of
the Nose, Throat, and Ear (I. S.
Hall) (R) 1055; labyrinth, tilt test
and (A) 642; lymphatic cyst of
(M. Sein) 1281; non-suppurative dis-
eases of, treatment of, 1528; nystag-
mus, caloric, 108 ; Physical Therapeutic
Methods in Otolaryngology ( ;
Hollender) (R) 874; Practitioners’
Library of Medicine and Surgery:
Vol. XI, Eye, Ear, Nose, and Throat
(G. Blumer) (R) 989; tinnitus, 1528;
Year Book of the Eye, Ear, Nose, an
Throat (R) 449; see also Deaf, Noise,
and Otitis
Eui T., on congenital heart disease,
Easterbrook, C. C., on preservation of
mental] health, 1153
Eastwood, C. G., Handbook of Hygiene
for Students and Teachers (R) 29
Eaton, J. C., sulphemoglobinemia and
methzeemoglobinemia after sulphanil-
amide, 1159, (C) 1369
Ebbell, B., Papyrus Ebers, 734
Ebbs, J. H., on bronchiectasis, 15273;
on otitis media, 1171, (LA) 1234
Eclam psia—albuminuria and, 1365 ; blood
in (A) 333; hemiplegia and (M. Hajkis)
628; pathology of,123 ; sex hormones
in 1121 ; see also Pregnancy
Edge, F. (O) 1311
Edge, . (0) 1140
dge, P. G., on colonial vital statistics
(A) 278
mediabures Medical Missionary Society,
Edington, G. H., on fracture paralysis, 871
Edmunds, C. W., and Gunn, J. A.,
phe et Text-book of Pharmacology
and Therapeutics (R) 1112
Education, sce Board of Education,
Physical education, School-children,
ana—
Education medical—curriculum, 1189 (C)
1252, 1349, (Sir E. Graham-Little) (C)
1544; in psychotherapy, 367; in
surgery (Sir D, Wilkie) 735 ; laborator
training and, 267; of women (N. H.
Schuster) (C) 954, (M. E. Shaw) (C)
016; see also Students, medical and
1
Universities
C., carcinoma of stomach
Edwards, H.
(C) 1308
Edwards, J. L., “ fixation ” abscess of
bone due to brucella, 385
Edwards, J. T. R., instrument for drain-
ing quinsies (NI) 272
Egyptian medical document, 734
Ehlers, E. L., death of (A) 1418
Ehlers-Danlos syndrome (A) 458
Ekas, M. P., and Davenport, C. B.,
Statistical Methods in Biology, Medi-
cine and Psychology (R) 90
aay J: obstetrics in general practice
seca treatment, see Physical treat-
men
Electrocardiogram, see Heart
Electron microscope (A) 454
Electrophysiology of cortex (A) 767
Elkeles, A., on retinal staining (A) 157
Elja Sachs Plotz Foundation, 302
Elliot, Sir J., Scalpe] and Sword (R) 991
lis, G. R., on, congenital microcolon,
8
Ellis, R. W. B., four thousand Basque
children, 1303, (C) 1371, (A) 1419
8, V ., and Burns, B. H., Recent
ec vanopg in Orthopedic Surgery (R)
1055
Ellison, P. O., mediastinal ganglio-
neuroblastoma, 1458
Elman, C., thorotrast, 981
Elwyn, A., and Strong, O., Bailey’s Text-
book of Histology (R) 517
Emanotherapy, see Radium
Embolism—fat (A) 1181; pulmonary,
injection treatment of varicose veins
and, 1260
Embryology—Buchanan’s Manual of
Anatomy including Embryology (J. E.
Frazer) (R) 1467 ; experiments) surgery
and (Sir D. Wil e) 735; Neuro-
embryology (S. Detwiler) (R) 89
erson, C. P., Text-book of Medicine
(R) 931
Emery, E. S., on intestinal adsorbents
(LA) 453
Empirme Compres eai baths in
. E. Beaumont and J. F. Dow)
635 ; sec also Mediastinal
Empire Rheumatism Council (A) 1418
Employment, see Depressed areas and
nemployment
Empyema, sce Maxillary sntrum
Encephalitis—in Japan (A) 940; measles
and (G. A. E. Barnes, J. C. Blake, J.C.
Hogarth, and M. Mitman) 687; mumps,
Wassermann reaction and (W. Smith)
754; non-suppurative (R. L. Knaggs)
745, (A) 767; post-encephalitic parkin-
sonism, benzedrine in (A) 1475;
research in, 180
Encephalography, see Intracranial]
Encyclopædias— British Encyclopædia of
Medical Practice (Sir H. Rolleston) (R)
760, 1341, (A. Abrahams) (C) 899;
on instalment system (ML) 341, (C. M.
Fegen) (C) 660; world (A) 36
Endocarditis, see Heart disease
Endocrine system—mental disorder and,
442, (LA) 519, (T. D. Power) (C) 599 >
surgery of, 735; see also Hormones
Endometrioma of vulva (F. Riggal] and
C. Riggall) (C) 475
| Enemata, see Purgation and Rectal
Supplement to THE LANOET]
INDEX TO VOLUME I., 1937
[Aveust 14, 1937 ix
Enteric fever, see Paratyphoid and
Typhoid fever
Enteritis, see Gastro-enteritis
Enterostomy, see Intestine
Epilepsy—conduct disorders, 1559 ; crim-
inal responsibility and (ML) 1114;
cysticercosis and (R. L. H. Minchin
865, (Di W. Smithers) (C) 1016;
epiloia and tumours of nail-beds
(S. G. James) 1223; institutional
treatment of, in Scandinavia, 1260;
international journal of (A) 822 3
Marriage Bill and (PI) 417; musico-
genic (A) 1236; neevoid
(R. Bates) 1282, (F.
rae ae ch oie in,
‘ox) 385;
(ML) 1243
Epsom College, 1568
Equilibration, see Ear
Erdheim, J., death of, 1244
Ergot, artificial (A) 37
Ergotamine tartrate, see Migraine
Erysipelas—prontosil in (A) 525, 612,
(G. E. Breen and I. Taylor) 1334, (A)
1357 ; see also Streptococcal infections
Erythema multiforme (C) 792
Eserine pulmonary œdema and (W. E.
Cooke) 1052 ; see also Myasthenia gravis
Eskimos, ketogenic diet among (E. C.
Fountaine) (C) 1075
Esterase, see Myasthenia gravis
Ether, see Anæsthesia
Ethics, medical- autobiographical
sketches, advertisement and,
Me a Prac MOREE Communications
Bill (Sir E. Graham-Little) (C) 349,
a 417, (LA) 396, (Sir J. Withers)
Ethyl s etry chnine as respiratory stimulant
amentia and
P. Weber) (C) 1370 3
dangers of (J. T.
workmen’s compensation and
;
Ete% in Pncophalography (LA) 1355
Eugenics Society (A) 215, 1475
aayeR Ce B.D. F., macrocytic ansemias, 311,
Eo L., and Hartridge, H., Starling’s
Principles of Human Phy siology (R)
Evans, Sir E., on medical prota on: 611
Evans, G., Latent Syphilis (R) 1530
Everidge, J., on dorsal decubitus, 634
Evipan, see Anesthesia
Ewing, A. W. G., and Ewing, I. R., on
hearing-aids, 340, (LA) 395, 711
Exanthemata, see Infectious diseases
Exophthalmic, see Thyroid gland
Ex-Services Welfare Society, 1257
Eyes—cataract, vitamin C and, 1478;
colour blindness, hreemophilia and, 611,
(A) °1416; colour perception tests
(C. E. R. Norman) (C) 900; corneal
grafting (T: H. S. Tizzard) 1106,
from cadavers’ eyes (V. P.
1395; dacryoadenitis (B.
Diseases of the Eye (E.
Filatov)
Rogol) 982;
Wolfe) (R)
1467; exophthalmic ophthalmoplegia,
1110; fundus oculi, biomicroscopy of,
571; myopia in childhood (A) 1593
night blindness (A) 769; ophthalmia
neonatorum, 359, (A) 1119, fever
therapy in, 1008; ophthalmic group,
1569 : ophthalmological congresses,
789, 962, 1437; optic atrophy, nutri-
tional retrobulbar neuritis and (D. Ys
Moore) 1225, 1444; orbital cellulitis,
sinusitis and, 1526 ; papilloedema,
1109; Practical Orthoptics in the
Treatment of Squint (K. Lyle and S,
Jackson) (R) 1341; Practitioners’
Library of Medicine and Surgery:
Vol. XI, Eye, Ear, Nose, and Throat
(G. Blumer) (R) 989; retinal detach-
ment, 1109; retinal staining (A) 157;
spectacles, jeweller’s rouge for (C) 2453
spectacles, opticians and (A) 213,
ophthalmic benefit and (PI) 298, 357,
788, (LA) 1469, (PI) 1491, 1495;
syphilitic interstitial keratitis, fever
therapy in, 1008; Year Book of the
Eye, Ear, Nose, and Throat (R) 449;
see also Blind, Nystagmus, an
Trachoma
F
Face presentation, 1174
Facial—expression of sick child, 1427;
Facial Neuralgias (W. Harris) (R) 1340 ;
injuries (LA) 1057 ; paralysis, 3
Factories, see In dustrial medicine
Fæcal, see Intestine
Fainting, carotid sinus and (A) 938
Ea a H. A. T., on ununited fractures,
Fairley, N. He
Fae f S Pa
Farmer, E., on accident proneness, 705
Feri, on medical statistics, 1308, (LA)
Fat embolism (A) 1181
Fatigue—physical efficiency and (A) 877;
see also Industrial medicine
Fatty infiltration, 306
Faulds, J. S., mi canciineon, 949
Fayrer, Sir J. (O) 1
Nutritional Factors in
Fearon, W. R.,
Disease (R) 814
Fediaevsky, V., Nursery School and
Torent Education in Soviet Russia,
Fegen, C. M., oneone area World
Research Society, Ltd. (C) 660
Fellowship of Medicine—mock trial, 694 ;
see also Post-graduate courses
Femoral artery, thrombosis of (A. M.
Boyd) 382
Femur—neck of, fracture of (E. T.
Bailey) 375, (C) 536, (W. Gissane) (C)
a Pei plated, brucella infection
L. Edwards) 385, (Sir W.
Dale able: Champneys) (C) 839
Fenton, J., on misleading labels (A) 213
Ferguson, F, R., on neurological sequelæ
of spinal anæsthesia, 756
Fermentation, Pasteur’s and Bernard’s
theories of (A) 1477
Fernald, R., inquiry concerning (C) 234
Fertility—male, estimation of (A) 1238,
spermicidal rubber and (R. M. Ranson)
1400; see also Population, Sterility, and
Vital statistics
Fever, sec Infectious diseases, Tempera-
ture, and—
Fever therapy—blood after (A) 998;
congress of, 179, 1007, (A) 998; in
gonorrhea, 1008 ; in mental and
nervous diseases, 468, 1008; in
ophthalmology, 1008; in rheumatism,
1007: in syphilis, 1068; physiological
effects of, 100
ffolliott, A. a C., paratyphoid A, 1521
Fibrinol ysis, see Blood
ancylostoma anæmia, 800
Filatov, yi 'P., transplantation of cornea
from cadavers’ eyes, he
Films, see Cinematograph fil
Finger Pe D, P jennings) (C) 660;
apnormal aes
iniefs š elin shock treatment
of schizophrenia (C) 1251
Fi eee Christian a Holmes, Man
1 Physician (R) 11
Fishy E W., on oral oer (LA) 31,
(
Fish, R. ree on cbronic miliary tuber-
culosis (A) 9
Fisher, A. G. W., manipulative surgery
(C) 595; rheumatism, 1162
Fisher, J. H., cardiovascular effects of
benzedrine (C) 52;
tions, 623
Fistula—biliary, wanted case of, 910;
menstrual (R. G. Maliphant) 1509
Fitness, see Nutrition and Physical
education
Fitzgerald, F. P., plaster bed, 18
Fitz-Patrick, D. J. G., tropical cheiro-
pompholyx, 25
ae aie ca C., standard of Army recruits
Flemming, E. L., creoenne tartrate in
migraine (C) 839
Fletcher, Sir W. M.,
Floods in Ohio (A) 3
Fluid, see Water balance
Fluoresceinuria (G. Discombe) 86
Fluorine poisoning (A) 937, (Fluorine
Intoxication) (K. Roholm) (R) ase
Focal sepsis—rheumatism and (H. Bar-
well) 67 ; see also Oral
Földes, | anacidity and longevity
Food—Bell’s Sale of Food and Drugs
(R. A. Robinson) (R) 393; eat
salmonella infec-
ea one to, 1419
1092, (Canning Practice and Control
(O. Jones) (Ra 1530 ; commercial
irradiation of, 3 eggs, examination
of (PI) 541; Foo A ee ration Board,
733; laboratory for testing, 242;
Manual of Naval Cookery, 612; mis-
leading labels and (A) 213; synthetic
vinegar (ML) 1541; vitaminised marga-
rne. 847; see also Diet, Nutrition,
Food poisoning—bacteriology of, se
salmonella infections an
Fisher) 623
Foot—Kdhler’s disease (A) 1182
Fox, R. F.,
Eraoiurah
Fraser, F.
Fraser-Harris,
Frazer, J. BE.,
Frederick, R.,
Freeman, E.
Freezing and
821
Friel, S. S., and Hewer, J. L.,
Frobisher, M., Funda:
R) 932
Foot-and-mouth disease
1414
Forbes, D.
pox, 174
Ford, R. A. W.
(C) 1017, 1137
Forearm and wrist fractures, extension
apparatus for (R. Shackman) (NI) 572
Foreign body—in bladder (D. Brodie) 266 ;
in lung, bronchoscopy and, 987;
in csophagus, unusual case of choking
and (S. Sharman) 1227
Forsyth, D., on heredity
ment (A) 215
Foss, G. L., curette and uterine sound
(NI) 698
Fossil man, duration of life in, 675 <
Foster, G. E., diaminosulphone in strepto-
coccalinfections, 1331, (A) 1357, 1536
Fountaine, E. C., ketogenic diet among
Eskimos (C) 1075
Fox, J. T. (O) 781; phenobarbitone,
385
dangers of,
Arthritis in Women (LA)
- British Health Resorts (LA) 1235
(LA) 1290, (A)
, vaccination in control of small-
, ambulances and stretchers
and environ-
Fractures—(R. S. Woods) 307, (H. E.
Griffiths) (C) 472: Cardiff scheme for,
107, (LA) 1470; fat embolism and
(A) 41181; re habilitation clinics (LA)
92. 572. 785, 790, 894, 1419, (LA) 1470;
ununite d, 6: 31 see also Bone and—
of—fe moral neck (EK. T.
aile y)? 37 T (C) 536, (W. Gissane) (C)
472, 596 ; femur, bruce lla infection and
(J: i Edwards) 385, (Sir W. Dalrymple-
Champneys) (C) 839; forearm and
wrist, extension apparatus for (R.
Shackman) (NI) 572: humerus, para-
lysis and, 871; patella (G. O. Tippett)
(C) 1308
t., On exophthalmic ophthalmo-
plegia, 1110
D. F., death of, 98
č., Buchanan’s Manual of
including Embryology (R)
on air-conditioning, 1401
T., electrocardiogram in
coronary disease, 499, (A) 524
Anatomy
467
Freeman, W., on mental pl Order and
endocrine activities (LA) 519
thawing the tissues (A)
Fremantle, Sir F., on curriculum, 1189
Freudenberg, R., insulin shock treatment
of schizophrenia, 110
Freund, L., work of, 539
Friedman test, see Aschheim-Zondek
Our Baby :
For Mothers and Nurses, 909
Frigidity in Women (E. Hitschmann,
E. Bergler, and P. L. Weil) (R) 697
mentals of Bacterio-
Frost, D. B., sulphæmoglobinæmia
following on A iTe ptocoogal chemo-
therapy, 510, (A) 5
Frost, : H., and f charäsón; B. W.,
Snow on Cholera (R) 992, (LA) 993
Fuchs ET aa test (D. L. Wood-
house
ler, A. T., p-aminobenzenesulphon-
pee in prontosil therapy, 194, (LA)
Funk, E. H., and Gordon, B., Chronic
Diseases of the Respiratory Tract (R)
logy
Gadd, H. W., oran a the British
Pharmacopceia (R) 11
seer ag D., new anun in diabetes,
Gall. Pladder, see Biliary
Galletly, J. (O) 1140
Gallone g E., turmeric in biliary diseases
Ga ANA J.,cretinism in London, 1505
Gall-stones, see Biliary
Garry, G., duodenitis and its surgical
reat cni, 1512
Garton, W. „limited field of cancer research
(C) 1309
Gas, see Air-raid precautions and War
Gas -and -oxygen anæsthesia—fatalities
following (A) 158; in midwifery (C
Moir) 615, ( o) 662, (J. Riddell) (Gy 723,
(A. Barr and A. Tindal) 1271, 6 ;
ha renia surgery and (P. Ayre) 561°
Gask, G., on John Hunter (A) 457
x Supplement to THE LANCET]
INDEX TO VOLUME I., 1937
‘[Avaust 14, 1937
Gastric, see Peptic ulcer, Stomach, and—
Gastro-enteritis—acute, 444; infant
nutrition and (C. Asher) 221; otitis
and,in infancy, 1171, (LA) 1234, (G. H.
Newns) (C) 1310, 1527 ; see also Food-
poisoning
Gastro-enterology, congress of, 1111
Gatenby, J. B., Biological Laboratory
Technique (R) 1055
Gates al R. R., genetics information service
(
Gauvain, Sir H., on surgical tuberculosis,
General Medical
report, 1304, 1349;
i diplomas, 1351; penal cases, 1342,
1405; Pharmacopceia, 1351; presi-
dential address, 1304; see also Medical
Register
General paralysis of insane, see Neuro-
syphilis
General Resistor Office, see Vital statistics
Genetics—cancer, familial Spe OD and
(A) 398, achlorbydria and (A. E.
Levin and B. A. Kuchur) 204 ; charac-
teristics. transmission of (A) 215;
colour-blindpness and haemophilia, 611,
(A) 1416; declining -national intelli-
gence (A) 1475; finger-prints, twin
research and (D. Tennes) (C) 660 ;
information service in (R. R. Gates)
Council—curriculum
Indian medical
(C) 234; polyposis of colon, heredity
and (A) 94; resistance to infection,
inheritance of (LA) 818
Genito-urinary—intranuclear inclusionsin
male genital tract (J. R. Gilmour) 373 ;
surgery (Tiro rte à la chirurgie
genito-urinaire) (E. E. Lauwers) (R)
638; tuberculosis (M. C. Wilkinson)
314, (F. Harvey) 316, (LA) 329, (R.
Reid and M. C. Wilkinson) (C) 411,
(V. A. J. Swain) 868, 1336, giant ureter
and, 813; unit, L.C.C., 894; see also
Gonorrhcea and "Urinary infections
Gereb, S., buffer action in gastric dis-
orders (C) 172 l .
r P., ancylostoma anæmia,
Gibbens, J., Care of Children from One
to Five Years, 611
Gill, A. M., new insulins in diabetes, 1319
Gillies, Sir H., on facial paralysis, 390
Gilmour, J. R., intranuclear inclusions
in genital tract, 373
er reas G. R., on dorsal decubitus,
3
EEN W.» fracture of neck of femur
)
Gittins, R. a , memorial to, 181
Glasgow University Club, London, 1087
Glass, D. V., and Blacker, C. P., ‘Future
of our Population (LA) 933
Glover, L. G Oe Medical Benevolent
Fund (C
Glycerin, ar iiieation of toxins by, 1479
Goitre, see Thyroid gland
Gold, see Rheumatism
Gold’ mines, see Mines
Goldblatt, W. M., on industrial diseases,
27
Goldsmith, W. N., on allergy and skin
(A) 524
Goldstein, H. I., regional ileitis (C) 1547
Golla, F. Li, on mental disorder and endo-
crine glands, 442
Gonadotropic, sce Hormones and Sex
hormones
Gonorrhæa—amino compoundsin (A) 525,
1476, 1536; fever enereDy in, 1008 ;
laboratory ‘diagnosis of, 387; over-
treatment of (M. F. Nicholls) (C) 721,
(A. M. Simpson) (C) 899, (R. Roper)
(C) 1016, (J. J. Abraham) (C) 1484,
(H. M. Hanschell) (C) 1545, (A. J.
King) (C) 1546; see also Eyes and
Venereal disease’
Goodall, E. W., disputed will (C) 1252
Goodall, F. C., dearer drugs (C) 53;
Methylated Spirits (Scotland) Bil) (C)
12
Goouene: G. W., on diagnosis of gonor-
rhea, 387: on retinal staining (A) 157
Goodman, Ü., Cosmetic Dermatology
(R) 762
Gordon, B., and Funk, E. H., Chronic
Diseases of the Respiratory Tract (R)
638
Gordon, R. G., on disorders of conduct,
155
559
Gordon- anes G., Sir J. Bland-Sutton
(C) 112
Gosse, P., Traveller’s Rest, 850
Gough, Ae on adenomyoma causing
intestinal obstruction, 1054
Gould, C. A., population of England and
Wales during next 100 years, 944
Gould, E. P., on negligence actions, 145
Grace, W. H., on criminal abortion, 812
Graham, E. A., Year Book of General
Surgery (R) 638
Graham, G., pulmonary œdema, 1274
Graham, H., A Crab was Crushed, 734
Graham-Little, Sir E., legal position
of herbalists (C) 291; medical curri-
culum (C) 1544; Medical Practitioners’
Communications Bill (C) 349, 472,
(LA) 396
GRAINS AND SORUPLES.— (C) 54—A Public
Health Clinician (Ernest Ward) 55,
110, 169, 231, 287—A Rover (Lord
Horder) 344, 408, (C) 474, 477, 783—
A Rusticating Pathologist (A. E.
Boycott) 533, 593, 656, 718, (C) 899,
(C) 899—A Taddygaddy (F. G. Layton)
835, 896, 952, 1010, (C) 1076, (C) 1138,
(C) 1203, (C) 1204—A Medical Econo-
mist (R. McNair Wilson) 1070, 1135,
1191, 1246, 1300—Twelfth Man (D.
Hubble) 1367, 1428, 1482, 1542
Graves’s disease, see Thyroid gland
Gray, J. P. (O) 903
arene R. I. N., overbreathing tetany
Green, C. D., death of, 964
Greenfield, J. G., on diagnosis of syphilis,
Greenhill, J. P., and DeLee, J. B.,
Year Book of Obstetrics and Gynæ-
cology (R) 991
Greenwood, A. (O) 54
Greenwood, H. P., Employment and
the Depressed Areas (R) 29
Greenwood, J. M., eaa jejuno-
gastric intussusception, 266
Greenwood, M., “ popular” names of
diseases (C) 1308
Gresham College, 1148
Grimi, E. F., Voluntary Parenthood,
Grim DS, H. E., Sinclair foot-piece (C)
Grimmett, L. G., on pneumatic trans-
ference of radium (A) 580
Grinnell, R., on suppurative tenosyno-
vitis (A) es
uedar, A. E., Inhalation Anæsthesia (R)
Gunn, J. , [Introduction to Pharmaco-
logy a Therapeutics (R) 1112; and
Edmunds, C. W., Cushny’s Text- -book
T P narmacology and Therapeutics (R)
Gunn, W., on whooping-cough, 566
Gunther, R. aa Early Science in Cam-
bridge (R) 1409
Gurney, R. W., Ionsin oe (R) 872
Guthrie, R. L. (O) 1013
Guy’s Hospital Medical School, 301
Gynæcology—radiotherapy in (Radio-
thérapie gynécologique) (R. Mathey-
Cornat) (R) 1287; Year Book of
Obstetrics and Gynecology (J.
DeLee and J. P. Greenhill) (R) 991
H
Haas, A., malignant disease of thyroid
gland, 1155
Hackett, EA W., Malaria in Europe (R)
573
Hæmoglobin, see Blood, Sulphæmoglobin-
temia, and Urine
Hwmophilia, see Heemorrhage
Hremopoiesis, see Anamia
Hremorrhage—dental, medical interven-
tion and (PCP) 345, (PI) 420, (PCP)
1519; hemophilia, colour-blindness
and, 611, (A) 1416; hemorrhagic
diathesis, 570, 1403; hemorrhagic
disease of new-born (N. B. Capon)
431, (V. M. Métivier) (C) 779; intra-
peritoneal (J. Bruce) 1451; pul-
monary, Congo-red in, 1559; sce also
Blood transfusion and Peptic ulcer
Hemorrhoids—new remedy for, 1261,
(C. C. A. Monro) (C) 1310; see also
Pruritus
Hagedorn, H. C., on protamine insulin,
148, (LA) 577
Hajkis, M.,eclamptic hemiplegia, 628
Halban, J., death of, 1244
Hall, Sir A., venous hum in cirrhosis of
liver (C) 1202
Hall, A. S., left inframammary pain,
267
Hall, I. S., Diseases of the Nose, Throat,
and Ear (R) 1055
Hall, P. A., standard of Army recruits
(C) 410
Haller. A. von, Dissertation on the
eae and Irritable Parts of, Animals
(R) 1113
Hallowes, K. R. C., on wintering in
Iingland, 713
Hamilton, B. E., and Zahorsky, J.,
Pediatrie Nursing (R) 697
Hammond, J. A. J., sulphseemoglobin-
mmia and methremoglobinsemia after
sulphanilamide (C) 1484
Hampson, A. C., hormone treatment of
undescended testis (C) 598
Handley, W. S., on irradiation in malig-
nant disease, 629
Hands—artificial (A) 1476; tumours of
(A) 880; see also Infections, Nails, and
Tenosvnovitis
Hanschell, H. M.,
ronorrhcea (C) 1545
Haram, B. J.. lymphatic
mammary changes, 127
Hare, R. A., Sansum, W. D. „and Bowden,
» Normal Diet and Healthful Living
(R) 814
Hargrave-Wilson, W., osteopathy (C)
1017
over-treatment of
leukæmia w ith
Harris, K., heart disease and pregnancy,
TT
Hare, Leslie, on vitamin C and infection,
12
Harris, Lyn, on sex education, 567
Harris, R. W., and Sack, L. S., Medical
Insurance Practice (PCP) 469, 720
Harris, S. H. (O) 412
Harris, W., Facial Neuralgias (R) 1340;
on occupational therapy (A) 1359;
on writing for THE LANCET (C) 112
Harrison, G., on jaundice, 511
Hart, F. D., mediastinal ganglio-neuro-
blastoma, 1458
Hart, P. M. D., pulmonary tuberculosis,
969, 1033, 1093, (LA) 1117
Hartridge, H., Bainbridge and Menzies’
Essentials of Physiology (R) 815: and
Evans, C. L., Starling’s Principles of
Human Physiology (R) 393
Harvey, F., genito-urinary tuberculosis,
316, (LA) 329
Harvey, E. G. ., Strangulated hernia and
colostomy, 3834
Harvey, W., work of, 735
Harvey, W. C., Milk Products
Harvey, W. F. (O) 1435
Hasler, J. K., on neurological
of spinal anæsthesia, 755
Haslewood, G. A. D., micro-chemical
blood analysis, 886
Hastings, S., memory Bland-
Sutton (C) 50
Havard, R. V.,
coccal infections,
Hawksley, J. C., pernicious anæmia in
infant (C) 1202, 1370
Haworth, E., thorotrast, 981
Hawthorne, C. O., on milk and disease,
515
Hay, J. D., on fatty infiltration, 306
Hay fever—Hay Fever (C. Shields) (R)
(R) 1409
sequelæ
of Sir J:
proseptasine in strepto-
1273, (A) 1357
449; ionizer for, 1210; plantain
(A) 1416
Hay, W. H., on diet (A) 1534
Haynes, F. W., on circulatory collapse
(LA) 993
Head injuries—mental disorder and, 9283
see also Intracranial
Heaf, F., clectric aspirator (NI) 86:
on care of tuberculosis, 1130
Health education—national campaign,
7853 Science Fights Death (D. 3.
Murray) 910: see also Hygiene
Health resorts—TlIrench, tour of, 582 ;
fund for treatment of poor persons at,
1114; Russian, 45; see also British
Health Resorts Association and Rheu-
matism
Health services—administration of (PI)
603, 1439, 1491, 1561; health centres,
612, 1374, 1380, 1560 ; in America, 834,
1133, 1479; in Colonies (PI) 1440; in
Ireland, 294, 947 ; in Russia, 45, (R. H.
Dobbs and A. E. Russell) 648, (G. G.
Sheriff) (C) 733, 1000 ; National Council
of Social Service, report (A) 39: see
also Maternity and child welfare.
Public health, and Public medical
service.
Hearing, see Deaf and Ear
Heart—carotid sinus and (A) 933;
electrocardiogram, posture and (A) 578:
Studies in Cardiovascular Regulation
Anrep) (R) 8733; syncope,
choking and (s. Sharman) 1227;
see also Benzedrine and—
Heart discase > angina pectoris, supra-
renals NiS, 1244; auscultation, appara:
tus for (C. V. Henriques) 686, (C. Lian)
(C) 955; cardiac ischemia, surgery of
(L. O'Shaughnessy and Lord Dawson)
Supplement to THE LANCET]
185, (G. G. Turner) (C) 292, (Sir M.
Cassidy) (C) 470, (H. Upcott) (C) 535 ;
care of, in Austria, 1134; Clinical Heart
Disease (S. A. Levine) (R) 637 ; Clinical
Use of Digitalis (D. Luten) (R) 392;
congenital, 324; coronary thrombosis,
blood pressure after (J. H. Palmer) 741 ;
diphtheria and (N. D. Begg) 857, 1465;
electrocardiogram in coronary disease
(E. T. Freeman) 499, (A. Willcox and
J. L. Lovibond) 501, (A) 524, (I. G. W.
Hill) (C) 659, (D. E. Bedford) (C) 779;
histamine and (A) 456; left infra-
mammary pain and (K. S. Smith, A. S.
Hall, and J. Patterson) 1267, (C. W.
Chapman) (C) 1434; nervous (A) 399;
oral sepsis and (A) 822; pericardium,
adherent, surgery of (R. Pilcher) 1323,
(A) 1358; pregnancy and (K. Harris)
677; rapid heart-beat and (A) 1295;
scurvy and (S. Taylor) 973; sudden
death and, 927; Synopsis of Diseases
of the Heart and Arteries (G. R.
Herrmann) (R) 450; vitamin B
deficiency and (A) 878; see also
Aneurysm and Rheumatism
Heath, A. D. (O) 1374
Hehir, Sir P. (O) 1139
Heilmeyer, L., on anæmias, 1404
Hemiplegia, see Paralysis
Henderson, F. L., on X ray dosage, 87
Hendry, E. B., immunisation with hemo-
lytic streptococci, 257, (LA) 274, 368
Hendry, J.. on placenta prævia, 636
Henningsen, E. J., poliomyelitis, 462
Henriques, C. V., phonostcthograph, 686
Henry, C. B., cysts of nasopalatine
canal, 1326
Henry, G. M. (0) 116
Hepatic, see Liver
Herbalists, see Unregistered practitioners
Herd, D. A., pneumothorax needie-
holder (NI) 208
Heredity, see Genetics
Hernaman-Johnson, F., after-care of
cancer of breast, 1488, (C) 1549
Hernia—Bassini operation, fiftieth anni-
versary of, 1240, (A) 1359; hernio-
appendicectomy (J. T. Morrison) 625;
injection treatment of (A) 1294 ; retro-
peritoneal, radiography of, 985; stran-
gulated, prolapsed colostomy and (P. G.
Harvey) 384
Herrmann, G. R., Synopsis of Diseases
of Heart and Arteries (R) 450
Herrmann, L. G., Passive Vascular
Exercises (R) 1175
Hertzler, A. E., Surgical Pathology of
Thyroid Gland (R) 1467
Hewer, C. L., Recent Advances in Anæs-
thesia and Analgesia (R) 697
Hewer, J. L., and Friel, S. S., Our Baby :
For Mothers and Nurses, 909
; . B., artificial pneumothorax
(C) 535; medical statistics, 41, (LA)
31, 99, 161, (LA) 153, 219, 281, 337,
402, 459, 527, 583, 646, 706, 771,
825, 883, 941, 1001, (LA) 994, (A) 1473,
(LA) 1531
Hill, C., and Clegg, H. A., What is Osteo-
pathy ? (A) 881, 932
Hill, I. G. W., chest leads in electro-
cardiography (C) 659
Hill, Sir L., physical treatment, 1035
Hilliard, C. M., Text-book of Bacterio-
logy and its Applications (R) 517, 676
Hilton, R., oxygen tents (C) 471; and
Langdon-Brown, Sir W., Physiological
Principles in Treatment (R) 209
Himes, N., Medical History of Contracep-
tion, 1571
Hinds, A. V. J., hospital amalgamation
in Liverpool (C) 232
Hine, T. G. M. (O) 1080
Hip—lesions of, 871 ; see also Dislocation
Hire-purchase, see Encyclopedias
Hirschman, L. J., Synopsis of Ano-
Rectal Diseases (R) 1231
Histamine—heart frilure,
(A) 456 3 see also Shock
Histology—Bailey’s Text-book of Histo-
logy (A. Elwyn and O. Strong) (R)
5173 sce also Diagnosis
History, medical— Bassini, ©., 1240,
(A) 1359; Christian R. Holmes, Man
and Physician (M. Fischer) (R) 1113;
Development of Modern Medicine
(R. H. Shryock) (R) 392; Disserta-
tion on the Sensible and Irritable
Parts of Animals (A. von Haller)
(R) 113; Early Science in Cambridge
(R. T. Gunther) (R) 1409; family
doctoring in xvii and xviii centuries
(A) 702, (G. Ward) (C) 778, (Life in
a Noble Household) (A) 523; General
‘Register (LA) 1531, death certifica-
tion, popular names of diseases
and, 1245, (M. Greenwood) (C) 1308 ;
burns, and
INDEX TO VOLUME I., 1937
History of Chinese Medicine (K. C.
Wong and W. Lien-Teh) (R) 271;
History of Modern Morals (M. Hodann)
(R) 518; History of the Acute Exan-
themata (J. D. Rolleston) (R) 1229;
Hunter, John (R. K. Howat) 351,
(A) 457, (Lord Horder) 587, 735;
LANCET, THE, 100 years ago, 1077,
1145, (A) 1119, 1205, 1245, (M. Green-
wood) (C) 1308, 1312, 1352, 1431,
1487; Medical History of Liverpool
(A) 37; Medical Modes and Morals (H.
Roberts) 792; of contraception, 1571:
Papyrus Ebers (B. Ebbell) 734;
Pasteur, Claude Bernard and (A) 1477 ;
Silicosis legislation, 773, (LA) 764;
Snow on Cholera (B. W. Richardson
and W. H. Frost) (R) 992, (LA) 993;
Stiller, B., centenary of, 1426; surgery,
experimental outlook in (Sir D. Wilkie)
735; surgery 100 years ago (R. E.
Kelly) 1361; tuberculosis dispensary
(A) 1416; William the Conqueror,
medical history of (R. R. James) 1151;
workhouse conditions in 19th century,
4145, (A) 1119
Hitschmann, E., Bergler, E., and Weil,
P. L., Frigidity in Women (R) 697
Hittman, Prof., on blood-platelets, 1403
Hobday, Sir F., presentation to (E. T.
Cox) (C) 1548
Hodann, M., History of Modern Morals
(R) 518
Hodge, E. H. V., Birch’s Management
(R) 698
Hodgkin’s disease, see Lymphadenoma
Hodgson, J. C., Crohn’s discase, 926
Hogarth, J. C.,encephalitisin measles, 687
Hogg, F. S. D. (0) 955
Holborn, J. M., eradication of bed-bugs
(C) 1074
Holland, E. J.,
Plague (C) 474 ;
Hollender, A. R., Physical Therapeutic
Methods in Otolaryngology (R) 874
Hollósi, C., cystic degeneration of
chorionic villi, 808 ;
Holman, C. C., acute osteitis (C) 1485;
diffuse gastric polyposis, 24
Holmes, C. R.—Christian R. Holmes,
ee and Physician (M. Fischer) (R)
Holmes, G., on papillceedema, 1109
Holmes, G . and Ruggles, H. BE.,
Roentgen Interpretation (R) 637
Holt, R. L., on gastritis, 757
Homosexuality, psychotherapy and, 26
Honours—Coronation, 1204, (A) 1184;
New Year, 352, (LA) 331
Hookworm, see Ankylostomiasis
Horder, Lord, Hunter as researcher, 587 ;
Defoe’s story of the
on food and exercise (A) 882; on
wintering in England, 713
Horm»nes—antibodies against (I. W.
Rowlands and A. S. Parkes) 924, 1462,
(LA) 1471, (J. A. Campbell) (C) 1547;
congress on, 905; plant development
and (E. D. Brain) 1241; research on
(A) 276, (Methodik der Hormonfor-
schung) (C. Bomskov) (R) 151; see also
Endocrine system and Sex hormones
Horning, E. S., male gonads and adrenal
gland, 1330 ;
Horse-sickness, African (A) 823, (C) 900
Horsfall, H. V. (O) 1141
Horsley, J. S., intracranial pressure during
barbital narcosis, 141
Hosford, J. P., University of London
Medical Graduates Society (C) 598
Hospital contributory schemes—532 ;
Birmingham, 1031 ; Merseyside, 906
Hospital pay beds (A) 821
Hospital Saving Association, 608
HospitaJs—adininistration of, lectures in,
422; air-raid precautions and (PI)
541, 728; almoners, work of, 607;
Athens maternity hospital, 150; Birm-
ingham hospitals centre, 1438; blood
transfusion service (S. C. Dyke) 1538,
(LA) 1531; Bristol, amalgamation of
(C) 1123; conferences, 61, 486, 1351;
crosg-infection (A) 39, (LA)1234 ; diary,
1209: emblem, 180, (R. H. P. Orde)
(C) 412; finances of (A) 521, 768, 785,
1027 ; fire precautionsat, 65; Glasgow,
230; Hospital Law Notes (W. E. C.
Baynes) (R) 1410; hours of employ-
mentin (PI) 1024; Indian leprosy hos-
pital, 1306; in Newfoundland (PI)
1086; insurance patients and (PCP)
1247, 1430; Irish, 406, 510, 834, 948,
1379, 1428; kitchens in (A) 996;
Library Association and (A) 160, 1443 ;
Liverpool, amalgamation of (C. E. A.
Bedwell) (C) 51, 292, (A. V. J. Hinds)
(C) 232, 422; London, emergency
service and, 358; London County
Council, 225, 420, 538, (A) 768, 785,
{Aucust 14,1937 xi
893, (A) 882, 1027, 1087; L.C.C.
Pharmacopeeia (R) 152, (LA) 153 ;
motor service for, 422; Oxford,
coordination of (A) 156; planning and
development of, 225; psychiatric
clinics in (LA) 875, 904; publicity
and, 1351; radiotherapeutic depart-
ments in (A) 1059; rates and, 905;
Spanish fever hospital, 1438; special
areas (PI) 297; spectacles, supply
of (A) 213; Staffordshire, reorganisa-
tion of (PI) 961, 1144, 1314; strepto-
coccal infection, hospital closed for
(R. C. Cooke) (C) 664 ; strike reported
in, 426; Territorial Army, 1566;
University Grants Committee and
(A) 160; voluntary and municipal
(A) 768, (PI) 1198; Voluntary Hos-
pitals Commission report, 1123, (LA)
1117, 1352; see also Ambulance,
Fractures, King Edward’s Hospital
Fund, Mental hospitals, and Nurses
HOSsPITALS.—Battersea Hospital (ML)
49, (A) 98, 245—Birmingham Ear and
Throat Hospital, hay-fever clinic, 1149
— Bristol Royal Infirmary, bicentenary
(E. Watson-Williams) (C) 1487—
Brompton Hospital, report on thoraco-
plasty (LA) 519—Cardiff Royal In-
firmary, centenary, 1436—Christie Hos-
pitaland Holt Radium Institute (A) 332
—Dublin Fever Hospital, 155— Edin-
burgh Royal Infirmary, 166, 351, 1009
—Glasgow Royal Infirmary, 167, 484—
Glasgow Western Infirmary, 407—
Greenock Royal Infirmary, 135—
Hillingdon County Hospital, omnibus
service for, 747—King’s College Hos-
pital, new wing, 586—Leeds General
Infirmary (A) 97, 173—Manchester
Royal Infirmary, labour exchange and
(PI) 670, 844, (A) 877, (PI) 1027—
Marie Curie Hospital, 724, (A) 770—
Middlesex Hospital, lecture, 1155—
Millbrook Isolation Hospital, 1569—
National Hospital, Queen-square, ban-
quet, 1148—Queen Charlotte’s Hos-
ital, obstetrical textbook (R) 88—
Royal Eye Hospital, Southwark, 351—
Royal London Ophthalmic (Moorfields)
Hospital, dinner, 731—Royal Nationa]
Hospital for Rheumatic Diseases (A)
333—Royal Sussex County Hospital,
1172—St. Charles’ Hospital, Kensing-
ton, 488—St. George’s Hospital: dona-
tion, 848; psychiatric clinic (LA) 875,
904—St. Mark’s Hospital. London, 785
—St. Mary Abbots Hospital, Kensing-
ton, 243—St. Marylebone Hospital for
Nervous Diseases (A) 1359-—-St. Mary’s
Hospital, Manchester, hormone clinic,
447—Southmead Hospital, Bristol (PI)
484—Treloar Hospital and College,
dinner, 1149—University College Hos-
pital, fellowship, 1435—-Westminster
Hospital, new building, 360, 1076—
Willesden Maternity Hospital, 300
Housing—basement dwellings in London
(PI) 358; Housing Improvement
Association, 245; in Scotland (PI)
841, 898, (PI) 962, 1314, 1496 ;in United
States, trailer and, 1480; overcrowd-
ing and slum clearance (PI) 843, 962,
1364, (PI) 1439, 1491, 1561; pul-
monary tuberculosis and (P.M.D. Hart)
969, noe 1093, (LA) 1117; scientific,
487, 675
Houston, W. R., Art of Treatment (R) 760
Howard, C., Physic and Fancy, 612
Howard, C. P., Pneumonia (R) 696
Howat, R. K., John Hunter (C) 351
Howe, E. G., War Dance (R) 1410.
Howell, B. W., on dorsal decubitus, 634
Howell, W. H., Textbook of Physiology
Hubert, W. H. de B.,
patient, 26 =
Hueck, W., Morphologische Pathologie
(IQ) 872
Hughes, A. W. M., destruction of bed-
bugs, 530, (C) 1434
Hunierus, fracture of, paralysis and, 871
Humphris, F. H., and Williams, L.,
Emanotherapy (R) 1231
Huo D., Occupational Diseases (R)
1 t
Hunter, John (R. K. Howat) 351, (A) 457,
(Lord Horder) 587, 735 fa
Hunter, J. W. A.. on hormone clinic, 447
Hunter, W. (0) 235
re E., on carly diagnosis of cancer,
365
Hurst, Sir A., peptic ulcer (C) 1369,
1484, hemorrhage in, 1; on diseases of
colon, 635
on unwilling
xii Supplement to THE LANCET]
INDEX TO VOLUME I., 1937
[Aucusr 14, 1937
Hutchison, R., Principles of Diagnosis,
Prognosis, and Treatment (A) 879;
and Mottram, V. H., Food and Prin-
ciples of Dietetics (R) 29
uxley, J., Wells, H. G., and Wells, G. P.,
How Animals Behave (R) 1468
Hygiene—Handbook of Hygiene (J. W.
Bigger) (R) 1175; Handbook of
Hygiene for Students and Teachers
(C. G. Eastwood) (R) 29; Synopsis of
Hygiene (W. W. Jameson and G. S.
Parkinson) (R) 151; see also Public
health i
Hyperglycemia, see Blood-sugar
Hyperthyroidism, see Thyroid gland
Hypoglycemia, see . Blood-sugar
Insulin
Hypophyseal, see Pituitary gland
and
Iceland, contraception in, 1317
lleitis, regional, see Crohn’s disease
Immunity—cellular response and (A)
704; see also Bacteriology
Impotence, surgical relief of TA) 335
India—medical aid for (C) 1252 ;_ nutri-
tion inquiry in (A) 1474; 'Punjab
University diplomas, 1351; tuber-
culosisin, 1129, 1187
INDIA, CORRESPONDENCE FROM.—Leprosy
hospital, 1306
Indigestion, sce Stomach
Induction of premature labour (A) 1417
Industrial Health Research Board (LA)
699, 908, 1151, (LA) 1233, (A) 1418
Industrial edane aie: conditioning,
1401, (A) 1418; bakehouses and factory
regulations (PI) 299, 542; Bedeaux
system in arms factories (PI) 542;
cardroom workers’ respiratory illness
(PI) 419, 842, 711; congress on, 1088 ;
course in, 1569 ; dermatitis, glass
silk and (PI) 604; efficiency engineer
A - Factories Bill (LA) 211,
: PI
(PI) 604, 667, (A) 6
840, 9 1023, 1081, 1087, (PI) "1192,
1375, (A) 1356, (PT) 1563,
advisory council and (A) 766; fatigue
and boredom, music and, 908’; health
resorts and, 1003; holidays with pay
(PI) 787; home employment of
children (PI) 1494; hours of employ-
ment (PI) 670, 787, of women and
yo ung persons (PI) 669, 728, 787, 788;
ondon omnibus dispute, i151, (LA j
1233 ; nursing and (PI) 606; Occupa-
tional Diseases (D. Hunter) (R) 1112;
fnjured ae in, 362; rehabilitation of
Uuni workmen, 705; rheumatism
229; tuberculosis and (P. M. D.
y 969, 1033, 1093, (LA) 1117, in
France, 1426 ; ; Weil’s disease and (PI)
843; Work and Rhythm, Food and
Fatigue (E. R. Williams) 124; sce also
Accidents, Depressed areas, Fractures,
Mines, Poisoning, and Workmen’s
compensation
Infant mortality, see Vital statistics
Infantile paralysis, sce Poliomyelitis
Infants—asphyxia neonatorum (A) 995;
hemorrhagic disease in (N. B. Capon)
431, (V. M. Mectivier) (C) 7793; lipoid
pneumonia in (A) 1239 ; mnicrognathia
in (C. P. Lapage) 323; nutrition of
(C. Asher) 221, 1364, gastro-enteritis
and, 444; Our Baby: For Mothers
and Nurses (J. L. Hewer and S. 8.
Friel) 909; pemphigus neonatorum,
397; premature (A) 615; pyloric
stenosis in (A) 216; tuberculosis in
(A) 769; tuberculous vulvovaginitis
in infant, 868; see also Anwmia,
pernicious, Children, and Eyes
Infections, acute, treatment of (A) 579,
l: B. Lay ton) (C) 658, (Sir D. Wilkie)
The oùs disease, weekly statistics, 60,
» 177, 241, 301, 360, 407, "461,
539, 592, 655, 726, 788, 844, 906,
950, 1011, 1086, 1138, 1200, 1256,
1310, 1374, 1436, 1490, 1567
Infectious diseases— History of the Acute
IKixanthemata (J. D. Rolleston) (R)
1229; hospital for, in Spain, 1438;
in children, hospital cross-infection
and (A) 39: infection and disinfection
in (Sir W. Dalrymple-Champneys) 102,
(G. B. Page) (C) 170 ; Medical Research
Council on, 711; nutrition and, 811
(H, Chick) (C) $00; quarantine and
) 335; resistance *to, inheritance of
(LA) 818; second attacks of (A) 704;
treatment of, 389; see also Milk
Infiluenza—epidemic of, 117, 175, 240,
301, 360, 421, 1073; How to Escape
Colds and Influenza, 306; immunisa-
yon against (A. H. Douthwaite and
F. A. Knott) (C) 172, (LA) 575 ; leuco-
penia and (J. Willmore), (C) 347;
research on, 709, 776, (PI) 7
Infra-red rays, see Physical AS RER
Inglis, Ee Paget’s Disease of the Nipple
Ingram, J. T., dermatitis and motor
fumes (C) 347 ; pruritus ani (C) 1137
Inhalation therapy—in carbon monoxide
poron ne (LA)154; oxygenadministra-
tion (J. Campbell) 82, (C) 597, (R.
Hilton, W. J. Pearson, and E. P.
Poulton) (C) 471, (E. Poulton) (C)
9; Oxygen Tent ia Nasal Catheter
(J. A.Campbelland E. P. Poulton) 1113;
see also Asphyxia neonatorum
Injuries—of face (LA) 1057; see also
Accidents, Fractures, Head injury,
Shock, and Workmen’s compensation
Inquests—diphtheria immunisation death,
1305, 1480; press persecution and (PT)
298, "419, 483, 604; see also Coroners,
Medicine and the Law, and Negligence
Insanity, see Mental disorder
Institute of British Surgical Technicians,
1028
Institute of Hospital Almoners, 607
Institute of Hygiene, congress, 1257,
1312, 1364, (A) 1418
Institute of Medical Psychology, see
Psychology
Institute of Ray Therapy, 1028
Insulin—gastric secretion and, 692, (H.
Levy) 1137; in mental disorder (L. W.
Russell) 747, (C) 1204, (H. P. Strecker)
(C) 840, (G. W. ae: James, R. Freuden-
bere, and A. Cannon) 1192, 1210,
(B. Shaw) és) 1251, (L. A. Finiefs)
(C) 1257. (E. Larkin) (c) 1371: > inter-
national standard for, 652: new
insulins, 148, (F. H. Carr) (C) 290,
(C) 596, (LA) 577, (T. a Bennett)
(S) 662, (T. I. Bennett, T . M. Davie,
Gairdner, and A. M. Gill) 1319,
Pias. see also Diabetes and Road
accidents
Insurance—in Austria, 228;
294; South African (PCP) 1301; see
also Life assurance, Pensions, and—
in Ireland,
INSURANCE, NATIONAL HEALTH (see also-
Panel and Contract Practice).—
Approved societies (PI) 1377—Capita-
tion fee (PCP) 60, 168, (PI) 598,
604, (PCP) 720, (PI) 729, (PCP) 1071,
(PI) 1195, (A) 1183 (LA) 1353, (A)
1414, (PI) "1564—Dental treatment and
(PI) 420, (ML) 1541—Drug Fund FR
962—Drugs, cost of (F. C. Goodall
o? 53—National Health Insurance
Amendment) Bill (PI) 603—Ophthal-
mic benofit (PI) 298, 357, 788, (LA)
1469, (PI) 1491, 1495— Practitioners,
number of (PI) 729—Referees (PI) 962
—Sickness statistics in Scotland, 898
Intelligence—size of family and (A) eee `
tests of, in rural community (A) 123
International Faculty of Sciences, 1 314
International League against Rheuma-
tism (A) 1418
Intestine—Absorption from the Intestine
(F. Verzar and E. J. McDougall) (R)
210; Crohn’s disease, 926, 985;
enterostomy in appendicitis (LA) 1177 $ °
flora of (P. Kouchakolt) 425, kaolin
and (W. Smith) 438, (LA) 452; large,
abnormal (J. <A. Mackenzie) 1107;
movements of, during opaque meal,
490 ; obstruction of (A) 454, (LA) 639,
by adenomyoma, 1054; radiography of,
490, 985; resection of, during labour,
Pinchot of mesentery and (G. G.
Turner) 802 ; urctero-intestinal
implantation (A) 879; volvulus, lym-
Phatic cyst of mesentery and (R. C
Jewesbury) 1170; see also Colon,
Duodenum, Gastro-enteritis, Purga-
tion, and Rectal
Intracranial—abscess (A) 643; calcifica-
tion, nrevoid amentia and (R. Bates)
1282, (F. P. Weber) (C) 1370 ; gliomas
(LA) 818: pressure, barbital narcosis
and (J. 5. Horsley) 141; pressure,
hypertonic sucrose and (LA) 10583
pressure, papilladema and, 11093
radiography, 207, (D). W. C. Northfield
and D. S5. Russell) 377, (LA) 1355,
1489; surgery, 735, anwsthesia for
(P. Ayre) 561; see also Brain and Head
injuries
Intranuclear inclusions in genital
(J. R. Gilmour) 373
Intussusception, retrograde jejunogastric
(J. M. Greenwood) 266
Ionizer for hay fever, 1210
Ions in Solution (R. W. Gurney) (R) 872
Ircland—Institute of Sanita Science,
ee Irish Medical Research Council,
tract
IRELAND, CORRESPONDENCE FROM. —Civie
Guard, medical attendance on, 895—
Diphtheria immunisation : death
. follo » 1305, 1480; fees for, 1437
—Heal services, 294, 947—Hos-
pitals: books for, 343; collaboration
between, 834, 1379; Dublin, situation
of, 406, 948, "1428 : sweepstakes, 834,
1380—Irish Free State Medical Union:
dinner, 1428; meeting, 1427—-Medical
appointments residence bar to, 1131,
1245—Medical Research Council, 343,
467—Road accidents, 467—Serum insti-
tute, 1072—Trinity College, Dublin,
Medical School, 343—Tuberculosis, 1481
Iron, see Ansremia
Irradiation, see Vitamins
Isaacs, S., on sex education, 567
Jackson, Pag H., death of: 526, (O) 601
Jackson, J. L. (0) 1
Jackson, Ig, . and tele, K., Practical
Orthoptics in the Treatment of Squint
(R) r34]
Jacoby 9 Waa F hyslcian, Pastor, and
Patient (R) 762
James, G. W. B., mapli shock treatment
of schizo hrenia, 1 101
James, R. R., eE a] history of William
the Conqueror, 1151
James, S. G., epiloia with tumours of
nail beds, 1223
James, S. P., on malaria parasite (LA)
Jameson, W. W., and TT a G. S.,
Synopsis of Hygiene R) 151
Jamieson, E. B., and Brash, J. C.,
anin ingham’ s Text- book of Anatomy
Japan——encepbalitis in (A) 940
Jaundice—51]1; aeaaea eee ee S.
Duthie) 1167; plasma phospha tase in,
87; pneumonia and (C. A. Birch) 1046 ;
see also Biliary, Liver, and Weil’ s
disease
Jauregg, W. von, homage to, 717
Jaw, see Ariero athia
A . å., on obstructed labour,
Jejunogastric e pron; retrograde
(J. M. Greenwood) 2
Jennings, D., A E rints (C) 660;
gastric pacity and onic alcoholism
Jensen, ann on diphtheria anmanleátion
(LA) 934; poliomyelitis, 4
Jessen, H., Cytologie du Nautde céphalo-
rachidien normal chez l’homme (R) 1113
Jewesbury, R. C., lymphatic cyst of
mesentery and volvulusin child, 1170
Jews—mortality of (A) 1295, see also
Refugees
Joint Tuberculosis Council (A) 399,
789, 1029, 1438
Jona, J. L. , Kidney Pain (R) 990
Jones, a R., on food poisoning, 1364
Jones, J A. (O) 845
Jones, M. S., ostradiol benzoate at
OODI 320
TS j anng Practice and Control
Jones, o. y. . On œstrin content of blood
and urine, 571
JOURNALS (reviewed).—British Journal of
Anesthesia (A) 1183—British Journal
of Children’s Diseases, 30, 574, 1410—
British Journal of Surgery, 328, 1056—
British Medical] Journal (A) 156—
Epilepsia (A) 822—Journal of the
University of Manchester (A) 999—
Medical Press and Circular (A) 156—
Mikrochemie, 1209— Nature (A) 156—
Practitioner (A) 156—Quarterly Jour-
nal of Medicine, 394, 1288—Veterinary
Journal (LA) 1058
Just, T. H. (O) 485
Supplement to TuE LANCET]
INDEX TO VOLUME I., 1937
[Auaust 14, 1937 xiii
K
Kahn, R. L., Tissue Immunity (R) 573
Kaolin, see Intestine
Karki-Pahwa, R. R. D., extra-uterine
pregnancy, 1228
Keith, T. S., on sudden death, 928
Kekwick, A., on blood transfusion, 1524
Roon, c E., on allergy and nephritis
Kean i Die “ atypische ” Pneumonie
Kelly, R. E., surgery 100 years ago, 1361
Kelly, T. W. G., diphtheria immunisa-
tion (C) 723; ergotamine tartrate in
migraine (C) 777, (LA) 763
Kenawy, M. R., continuous venous hum
in cirrhosis of liver, 1281
Kennon, R., on tuberculous kidney with
giant ureter, 813 l
Kenny, M., remote effects of puerperal
sepsis, 14, (A) 218
Kenya, see Africa
Keogh, Sir A., memorial to (A) 822
Kerr, A. S., on tuberculous kidney with
giant ureter, 813 .
Kerr, J. M. M., obstetrics in general
practice (C) 1250
Koriidge, P., on speech in deaf (LA) 700,
Kestner, O., on sea climate, 714
Ketchen, J. G., death of (A) 1537
Kettle, E. H., memorial to (C) 1307
Koruen G., perforated gastric ulcer (C)
Beye; S., lymphosarcoma simulating
uodenal ulcer, 1169
Kidney—histamine, shock and (A) 821;
Kidney Pain (J. L. Jona) (R) 990;
nephrostomy (Sir W. Wheeler) 440;
pelvic, labour and, 269; renal sympa- |’
theticotonus, eserine in, fatality follow-
ing (W. E. Cooke) 1052; see also
Calculi, Genito-urinary, Nephritis,
2
g, A. J., over-treatment of gonor-
rhea (C) 1546
King Edward’s Hospital Fund, 303, 645,
(A) 401, 821, 1372, 1537
ert E. J., micro-chemica] blood analysis,
King, E. S. J., on gastrostomy (A) 1296
King George V Memorial Fund (A) 276
King George VI, coronation of (LA) 1115 ;
medical appointments to, 608
Kinnear, Sir W.,retirement of (PCP) 168
Kipling, doctors and (V. Bonney) 1501
Kissmeyer, A., benzyl benzoate lotion in
scabies, 21
Klein, S., death of. 1244
Klem, A., purified liver extracts (C) 171
Knaggs, R. L., non-suppurative encepha-
litis, 745, (A) 767
Knott, A., convalescent serum in
influenza (C) 172; retroperitoneal
sarcoma, 202
Kohler’s disease (A) 1182
Koll, I., Medical Urology (R) 1230
Konstam, G., prontosi] in streptococcal
meningitis, 870
Kormiiller, A. E., on electrophysiology
of cortex (A) 767
Körösy, F., buffer action in gastric dis-
orders (C) 172
Kouchakoff, P., flora of intestine, 425
Krohn, P. L., on water balance and
menstrual cycle (A) 522
Kuchur, B. A., inheritance in gastric
cancer, 204
Kummell, H.. death of (A) 644
Kuno, Y., retirement of, 426
L
i
Labour, see Childbirth, Industrial medi-
cine, and Needs l
Labyrinth, see Ear
Lacry mal gland, see Eyes
Lactation (A) 1060, 1443, 1478
Laidlaw, Sir P., honour for, 1206
Lakin, C. E., on jaundice, 511;
physical signs, 1464
Laland, P., purified liver extracts (C) 171
LANCET, THE—on writing for (A) 40,
(W. Harris) (C) 112; 100 years ago,
1077, 1145, 1205, 1245, (M. Greenwood)
(C) 1308, 1312, 1352, 1431, 1487; see
also Radiography
on
Landry’s paralysis (A. V. Russell) 143
Lane, C., on hookworm anæmia (A) 456
Lane, R. E., on industrial diseases, 27
Langdon-Brown, Sir W., Adler and the
general practitioner (C) 1433; anorexia
nervosa (C) 473; on medical psycho-
logy (A) 1474; on mental disorder and
endocrine glands, 442; on sea climate
715; and Hilton, R., Physiological
Principles in Treatment (R) 209
Langley, G. J., serum treatment of pneu-
monia, 795, (A) 1121 -
Langmead, F. S., pernicious ansemia in
infant, 1048
Lapage, C. P., micrognathia, 323
Larkin, E., insulin therapy in mental
disorder (C) 1371
Lauwers, E. E., Introduction àla chirurgie
genito-urinaire (R) 638
Layton. g B., dangers of over-statement
5
LEADING ARTICLES
Ameebic dysentery in Chicago, 640—
. Asthma, vascular spasm and, 452
Bacteria, immunising antigens of, 274,
368—Biliary colic, morphia and, 819
—Blood transfusion, 1531—Borsta]
training, 575
Capitation fee, 1353—Carbon monoxide
poisoning, 153—Cerebral: gliomas,
818; injury, hypertonic sucrose in,
1058 ; radiography, 1355—Chamber-
lain, Sir A.,death of, 701—Circula-
tory collapse, 993—Climate and
health, 1235—Coronation, 1115—
Crime: Borstal vocational inquiry,
575; medico-legal institute, 639
Deaf: communication in, 699; hearing
aids for, 395—Diphtheria immunisa-
tion, 931—Drugs: hospital pharma-
copeias, 153; Medicine Stamp
DEER 576, 935: sale of nostrums,
Epidemiology, Snow’s work in, 993—
Ergotamine tartrate for migraine,
763—Ethylene, new use for, 1355—
Eyes, second best care of, 1469
Face, injuries of, 1057—Fluid :
operation, 32; circulatory collapse
and, 993; intestinal obstruction and,
639—Foot-and-mouth disease, 1290
— Fracture clinics, 92, 1470
General Register Office, 1531
Honours, medical, 331—-Hormones:
administration of, 1354; antibodies
against, 1471; mental disorder and
519—Hospitals: British Hospital
Association, report,1117 ; drug com-
pounding in, 153; psychiatry in, 875
Industrial medicine : efficiency engineer
699; Factories Bill, 211, adolescent
and, 451; London bus dispute, 1233;
silicosis, 764; wages and health,
1411—Influenza immunisation, 575—
Intestine: adsorbents and, 452;
enterostomy in appendicitis, 1177;
obstruction of, 639
King George VI, coronation of, 1115
Local government service, superannua-
tion in, 1471—-Lung tumours, experi-
ments on stiology of, 1291
Malaria parasite, 764—Medical Practi-
tioners’ Communications Bill, 396—
Medical Research Council’s report,
701—Medical statistics, 31, ;
1531—Meningitis, mixed bacterial,
211—Menta] disorder: Board of Con-
trol, report, 212; endocrines and,
519; L.C.C. report, 396; treatment
of, in voluntary hospitals,
Middle-ear disease: bathing and,
1412 : in infancy, 1234—Milk, pasteur-
isation of, 1179
Obstetrics in general] practice, 1116—
Olfactory mucosa, infection through,
875, 1532—0Oral sepsis, 31
Pathology, penny-in-the-slot, 329—
People’s League of Health, 876—
Poliomyelitis, 875, 1532—Population
trends, 933, 1413—Posture, improve-
ment of, 936 — Prognosis Series
(THE LANCET) 1177—Protamine zinc
insulin, 577
Radium, survival after, 153—Resistance
to infection, inheritance of, 818—
Rheumatoid arthritis, 273—Road
accidents, 1290— Rockefeller bounty,
1289—Russian trials, 330
Sinusitis in childhood, 93—Spain, relief
for, 1118—Stomach: cancer of, diag-
nosis of, 329; gastroscopy, 520—
Sucrose, hypertonic, 1058
Tuberculosis: among wild voles, 1233;
attendance on, risk of, 91; future of,
1117; pulmonary, thoracoplasty in,
519; renal, 329
after
Venereal disease: control of, 33, 700:
four phases in syphilis, 1178—
Veterinary surgeons, shortage of,
Wages and health, 1411—Wellcome,
Sir H., will of, 275
League of Nations—biological standards,
652; evacuation of Madrid (PI) 298;
nutrition and, 608, 695, 1317 ; see also
Dangerous drugs
HAR W. N., middle-ear disease (C)
3
Leat hea, J. B., on medical curriculum,
Lees, R., on tabes dorsalis, 655: and
Lees, D., Venereal Disease (R) 872
Leete, H. M., heart in diphtheria, 1465
Le Fleming, E. K., Introduction to
General Practice (R) 210; on physical
education and nutrition, 147
Left inramammary paa K. S. Smitb,
A. S. Hall, an . Patterson) 1267,
(C. W. Chapman) (C) 1434;
Anginal syndrome
Pelshnan, A. W. D., polyarteritis nodosa,
8
Leith, R. F. C. (0) 114
Le Play Society, 1318
Leprosy— British Empire Leprosy Relief
Association, 943; children’s suscepti-
bility to (Å) 160; conference, 1206 ;
nonpital for, in India, 1306; in Paris,
Leptospiral jaundice, see Weil’s disease
Leucopenia, see Blood
Leukemia—lymphbhatic,
changes (B. J.
of, 1403
ae A. E., inheritance in gastric cancer,
Levine, D., sarcoma,
202
mre 7 A., Clinical Heart Disease
Levitt, W. M., on irradiation in malignant
disease, 630
A oe and gastric secretion
Lewis, A., cretinism in London, 1505
Lewis, C. J. (O) 413
eys, D., gastric and duodenal ulcer,
1217, (C) 1433
Leyton, O., accident and diabetes (C)
778: on protamine insulin, 149
Lian, C., collective auscultation (C) 955
Libraries—classification of, 1504; Lib-
rary Association (A) 160, 1443
Liddell, J. (O) 725
Lien-Teh, W., and Wong, K. C., History
of Chinese Medicine (R) 271
Life assurance—cancer and (A) 398;
ta g ereulosis and (O. May) 493, (LA)
5
Lightwood, R., acute rheumatism, 613
Lips—lipstick cheilitis (A) 398 ; see also
Mouth
Lister, J., work of, 735
Lister Institute, report, 1420, 1478
see also
with mammary
aram) 1277 ; pathology
retroperitoneal
Littler, T. S., on hearing aids, 340,
(LA) 395, 711
Liver—anesthetics and (A) 705; bili-
rubinemia in pneumococcal infection
(Najib-Farah) 505; cancer of, thoro-
trast in diagnosis of (C. Elman and E.
Haworth) 981; cirrhosis of, staphylo-
coccal] septicssmia and (F. A. Philipps)
1050; cirrhosis of, venous hum in
(J. L. Bates) 1108, (Sir A. Hall) (C) 1202,
(M. R. Kenawy) 1281; hepatitis, 446,
(A. Moss) (C) 611, exercise and (A) 40;
cedema of (A) 524; products of, duties
on (PI) 296; see also Ansmia, Biliary,
Jaundice, Omentopexy, and Weil’s
discase
Liverpool, medical history of (A) 37
Lobectomy, see Bronchiectasis, Lung, and
Respiratory
Lobeling in asphyxia neonatorum (A) 995,
6
Local authorities — Cardiff accident
service, 107, (LA) 1470 ; care of tuber-
culous and orthopedic cases (PI) 1314;
employees of, superannuation scheme
for (PI) 1492, (LA) 1471; examination
under Lunacy Act (ML) 1422; Local
Government (Financial) Provisions
Bill (PI) 603, 10253; social services and
(A) 39; see also Midwifery and School-
children
Lockhart, L. P., ambulancesand stretchers
(C) 1074
Lockhart-Mummery, J. P., on diseases of
colon, 1284: rectal bougie (NI) 874
Loeser, A., on hyperthyroidism and
thyrotropic hormone of pituitary,
1462, (LA) 1471
-
xiv Supplement to THE LANCET]
London—atmospheric pollution in, 1255 ;
basement dwellings in (PI) 358 ;
cretinism in (A. Lewis, N. Samuel,
and J. Galloway) 1505; district nurs-
ing scheme, 964, 1029, 1258 ; hospita]
emergencies, clearing "house tor 358 ;
insurance statistics (PCP) 836; Metro-
politan Man (R. Sinclair) 1153; omni-
bus dispute, 1151, (LA) 1233 ; starlings
in (A) 1122; water-supplies (A) 38
705; see also King Edward’s Hospital
Fund and London County Council
London and Counties Medical Protection
Society, 1568, (A) 1535
London County Council—ambulances,
false calls for, 173 ; appointment, 730 ;
hospitals, 225, 420, 538, (A) 768, 785,
893, (A) 882, 1027, 1087; L.C.C.
Pharmacopeia (R) 152, (LA) 153;
London’s green belt (A) 95: maternity
and child welfare scheme, 844; medical
members of, 670, 785; mental disease,
report on (LA) 396 ; mental hospital,
malariotherapy at (A) 1236; midwifery
service ee “ special establishmen 5
and ( 83
London School of Hygiene and Tropical
Medicine—annual report (A) 218;
course, 488; Langley Memorial Prize,
545 ; studentship, 1087
Long, J. E. (O) 23
Longevity, see ola age
Loosli, C. „ and Buchsbaum, R.,
Mernodg of Tissue Culture in Vitro (R)
Louttit, C. M., Clinical Psychology (R) 88
Lovibond, J. L., electrocardiogram in
coronary disease, 501, (A) 524
Lono enfeld, M., on emotions of children,
Lumsden, R. B., on tuberculous otitis,
1172, (LA) 1234
Lunacy, see Mental disorder
Lung—cancer of, 759, (A) bene 987,
esporimental. (LA) 1291, (J. A. Camp-
bell) (C) 1370 ; cancer of, lobectomy for,
987 ; congenital cystic disease of, 325;
embolism, injection treatment of vari-
cose veins and, 1260; emphysema,
compressed- a baths in (G. E. Beau-
mont and J. F. Dow) 685; fibrosis of,
in children (M. ‘O. Raven) 80:
rhage, from, Congo-red in, 1559;
(W. Miller) (R) ae cedema of
(G. Ge uae and Burn) 1274,
escrine and (W. E ` Cooke) 1052 ;
phonostethograph and (C. V. Henriques)
686; sarcoma of ovary and, 759;
see also Asthma, Bronchicctasis,
Bronchoscopy, Industrial medicine,
Pneumonia, Pneumothorax, Respira-
tory, and Tuberculosis .
Luten, D., Clinical Use of Digitalis (R)
392
Addison’s 1039
Lyall, A.,
A) 1063
Lyle, K., and Jackson, S., Practical
ie in Treatment of Squint
Ly ae vay eu Popa in (A) 217;
pathology of, 1403
Lymphatic—cyst of ear (M. Sein) ae a
cyst of mesentery, volvulus and (R. C
Jewesbury) 1170; lcuksemia with
mammary changes (B. J. Haram)
1277: system, study of (A) 999;
sce also Tuberculosis
Lymphogranuloma inguinale (A) 704
Lymphosarconia simulating duodenal ulcer
(S. Keys and W. W. Walther) 1169
hip A. C., perforated peptic ulcer,
9
Lysholm, E., on ventriculography, 1489
disease,
M
/
Maas, O., dystrophia mvyotonica, 21
Maberly, A., Common Sense and Psycho-
logy (R) 816
MeAll, P. L. (0) 782
McAllister, A. H., Clinical
Speech Therapy (A) 939
Me he E. D., Disability Evaluation
(R) 327
MacCallan, A. F., Trachoma (R) 448;
trachoma in refugee children (C) 1310
MacCallum, W. G., Textbook of Patho-
logy (R) ‘151
MeCance, R.
200
McCleary, G. F., conference on maternity
and child welfare (C) 1547: Menace of
British Depopulation (L.A) 933
Studies in
A., overbreathing tetany,
INDEX TO VOLUME I., 1937
Macdonald, A. D., on vee AA and
blood-vessels 756, (C) 1
McDougall, E. J., and Vera F., Absorp-
ton from the Intestine (R) 210
McDougall, W., on dissociation and
repression, 1338
Macrarlane; R G., fibrinolysis following
eure: va choline esterase activity,
eration
McGibbon, J. E. G., bronchoscope (NI)
1232: -on bronchoscopic clinic, 987;
spasms of csophagus, 1385
McGregor, A. L., Synopsis of Surgical
Anatomy (R) 816
MacGregor, T. N., cestradio]l benzoate
at menopause, 320
Mackay, J., gall-stones, 1522
Mackay, W., serum treatment of pneu-
monia, 795, (A) 1121
Mac konzi, J. A abnormal large intestine,
Mackenzie, M., When Temperaments
Clash (R) raan
McKerron, R. G. (O) 781
MacKie, F. P., Air transport of pregnant
women (C)
McKinlay, P., on are welfare work, 512
Mackintosh, J. M., anemia in pregnancy,
43, (A) 96
Maclay, W. S.,
474
Maclean, J., on oral sepsis (LA) 31
Maclean’s Stomach Powder (ML) 1423
Macleod, J. J. R., and Seymour, R.
Ose of Human Physiology
10
McLeod, M., 7-aminobenzenesulphon-
amide in non-streptococcal infections,
McM bance W. H., metastasis in spleen,
McNally, W. J., on tilt test (A) 642
Mac Nay, Sir A., on care of tuberculosis,
McNee, J. W., on hepatitis and chole-
cystitis, 446
McPhedran, F., duodenal ulcer, 260
Macrae, A., and Oakley, C. A., Handbook
of Vocational E: 909
MacWilliam, A. (O) 236
Magnesium ite ae alate sulphate
in cephalic tetanus (P. B. Wilkinson)
753; vascular ot and (A) 1537
Magnitier, useful, 6
Maingot, R., T- tabe for gall-bladder
operations (NI) 1111
Maitland, M. L. C., rapid detection of
tubercle bacilli in milk, 1297
Mogor, R. H., Physical Diagnosis (R)
Malaria—Malaria in Europe (L. W.
Hackett) (R) 573 ; Sanasite, life Tee of
(LA) 764; syphilis and (A) 12
Malcolm, J. D. (O) 845
Maliphant, R. G., menstrual fistule, 1509
Malnutrition, see. Depressed areas, Nutri-
tion, and Unemployment
Malta, hospital provision in (PI) 541
Man, The Unknown (A. Carrel) (R) 210
Manchester Medical Students’ Society,
Manipulative surgery, see Orthopedics
Mansfield, W., Materia Medica, Toxico-
logy and Pharmacognosy (R) 1288
Manson-Bahr, P. H., on jaundice, 512
Manuel, A. (QO) 602
Mapother, E., on
Hospital, 476
Marr, G. S., Sex in Religion (R) 1468
Marrack, F survey of diets (C) 410
Marriage—Divorce (Scotland) Bih (PI)
482; Marriage Bill (PI) 56, 417, 1024;
venereal diseuse and (A) 643
SITTA H. L., on blood transfusion,
li
Marshall, J. C.,
1109
Martin, L. C., nevocarcinoma of skin and
mucous membranes, 135
Masetield, W. G., prisoners and captives
(C) 1076
Mason, N., leptospiral jaundice in guinea-
pig, 564
Massie, G., Surgical Anatomy (R) 1468
suite! ia Medica, see Drugs and Pharmaco-
ogy
Maternal mortality—in Edinburgh and
Glasgow (PI) 357; in England and
America, 1431: in Willesden, 300;
Minister of Health on, 1360, (PI) 1439,
1496; Ministry of Health reports,
1091, 1125, obstetrics in general
practice and (LA) 1116, 1199, (J. M. M.
Kerr) (C) 1250, 1285, (J. Elam) (C)
1307, (C) 1372, (E. Nash) (C) 1549;
sce also Abortion, Midwifery, Obstetrics,
and Puerperal infection
work at Maudsley
on retinal detachment,
anorexia nervosa (C)
fAvcust 14, 1937
child welfare—1466 5
conference, 181, 1258, 1431; economics
of, 512; history of welfare move-
ment, 143], (G. F. McCleary) (C) 1547 5
in backward areas, progressive legisla-
Maternity and
tion and, 1432; in Hungary, 4685
in London, 844; in Rumania, 10095
in Somerset, ‘‘ flying clinics” and,
1256; in United States, 1133; in
U.S.S.R., 648, 967: provision of milk
and meals, 363, (PI) 729, (A) 824, 881,
(PI) 1196, (C) 1203, (PI) 1491 ; see also
Health services and Maternal mortality
Mather, J. H., spasm of csophagus,
1385
Mathey-Cornat, R., Radiothérapie gynéco-
logique (R) 1287
Maxillary antrum, intubation of (N.
Asberson) 1399
Maxwell, J. S., dory] in
urine, 263, (A) 276
May, B., death of, "112! 25
May, O., tuberculosis and life a
493, (LA) 519
retention of
(O) 120]
ssurance,
Means test, see Depressed areas, Needs,
and Unemployment
Measles—appendix and (A) 278; bron-
chiectasis and, 1527 encephalitis and
(G. A. B: Barnes, J. C. Blake, J. G.
Hogarth, and M. Mitman) 687; treat-
ment of, 389
Measurement, vital system of, 491
Mecholyl, see Choline
Mediastinal—emphysema, anginal syn-
drome in (A. M. Scott) 1327; ganglio-
neuroblastoma (F. D. Hart and P. O.
Ellison) 1458
Medical Annual (A) 1063
Medical Art Society, 1537
Medical Diary, 66, 120, 181, 243, 304,
363, 422, 489, 544, 609, 673, 731,
790, 848, 907, 965, 1030, 1089, 1154,
"1381, 1444, 1500,
He 10, 1259, 1318,
572
Medical Insurance Practice (R WwW.
Harris and L. S. Sack) (PCP) 469, 720
Medical Peace Campaign (J. A. Ryle) (C)
1250, (A) 1240
Medical Prayer Union, 1252
Medical press, international association of
) 937
(A
Medical Register—additions to (A) 641;
voluntary removal from, 1348, (A)
1360; see also General Medical Council
Medical Research Council—annual report,
709, (LA) 701; artificial pneumo-
thorax, 711; bed-bugs, destruction of
(S. A. Ashmore and A. W. M. Hughes)
530 ; clinical research, 709; cotton-dust
asthma, 711; deafness, 340, (LA) 395,
711, (LA) 700; dietary surveys, 293,
(J. Marrack) (C) 410, 709; epidemio-
logy, 711 ; influenza, TOS.» puerperal
infection, 710; silicosis (PI) 961:
teeth, vitamin D and, 710 ; tropical
711, fellowships in, 1206;
Hei alth Research
Foundation
and Life
medicine,
see also "Industria |
Board and Rockefelle:
Medical Sickness, Annuity
Assurance Society, 1258
MEDICAL STATISTICS, PRINCIPLES OF (A. B
Hill).— (LA) 31, 994, (A) 1473. (LA)
1531—Aim of statistical method, 41—
Coefficient of correlation, 583, 1001-
Fallacies and ditticulties, 706, 771,
825—Life tables and survival afte r
treatment, 6460— Presentation of statis-
tics, 161, (LA) 153 Sampling g, problems
of, 251, 337, 102, 459, 527—Selection,
99—Standard ecient, calculation of,
94l1— summary and conclusions, 883 .
Variability of observation, 219 - SEC
also Vital statistics
Medicine — American Medicine, 894:
British Encyclopædia of Medical Prac-
tice (Sir H. Rolleston) (R) 760, 1341,
(A. Abrahams) (C) 899: conference of,
in Austria, 1560 ; conference of, in
switzerland, 11: Practitioners”
Library of Medicine’ and Surgery (G
Blumer) (R) 989: System of Clinical
Medicine (T. |). Savill and A. Savill)
(R) 516; Textbook oÍ Medicine
(J. J. Conybeare) (R) 697 Textbook
of Medicine (C. P. Emerson) (R) 931-
see also Health services, Peace, Statis-
tics, and Therapeutics
LAW.—
LUGS ;
MEDICINE AND THE Ambulance :
journey, death after, omission to
order, 531 ; service and hospital rules,
286—Battersea Hospitallitigation, 49
Dispensing mistake, 1006—E pile DSY:
and criminal responsibility, 1114: and
workmen’s compensation, 12
Maclean’s Stomach Powder, 142:
Supplement to Tae LANCET]
INDEX TO VOLUME I., 1937
[Aueust 14,1937 xv
Mental disorder: crime and, 48, 49,
1114; examination under Lunacy Act,
1422—Mental hospitals boards: dis-
missal of official, 1481; negligence
actions against, for release of patients,
716, 1481—Motorists: asleep at wheel,
1069; insulin and, 7 16; manslaughter
and negligence, 1069—Mushroom
poisoning, 590—Paddling pools, perils
of, TOG harmad, use of description,
108—Practitioners : * fees, non-payment
of, 466, 1006; hire- purchase research
for, 341; A negligence actions against,
531, 589, 716, 1481; panel dentistry
and, 1541—Practitioner’s widow, dam-
ages against, 1005—Radiologist’s report,
patient and, 833—Rhabdomancr, 228
—‘* Special establishment, 2 unlicensed,
833—Swabs, counting of, 589—
Synthetic vinegar, 1541—Tonsillec-
tomy, incomplete, 531—Unregistered
Droo tonera, 166, '285—Will, disputed,
Medico-legal, see Crime and Medicine and
the Law
M otitis media in early childhood,
Melæna, see Hæmorrhage
Melanoma, see Cancer
MADDIY K.,
1372,
Menincitio. sinaptococeal: amino com-
ounds in (H. Proom and G. A. H.
uttle) (C) 661, (I. Vitenson and G.
Konstam) 870; tuberculous (J. Spil-
lane) 560; see also—
Meningococcal—and streptococcal] menin-
gitis (A. A. Cunningham) 198, (LA) 211;
infection, amino compounds in (H.
Proom) 16, (LA) 211, (H. Proom and
G. A. H. Buttle) (C) 661, 681, (A) 1061,
1183, 1357, 1476, (L. E. H. Whitby)
1517, (A ) 1536; meningitis, treatment
a 389; strains, mucin and virulence of,
eradication of bed-bugs (C)
Menopause, cestradiol benzoate at (M. S
ae T. N. MacGregor, and H. Tod)
Meno eh Pl luteum hormone
and (T. N. Morgan and S. G. Davidson)
861; . uterine fistula and (R. G.
Maliphant) 1509; water balance and
522
Mental ability, see Intelligence
Mental After-Care Association, 607
Mental deficiency—care of, cost of (PI)
730, (A) 1292 ; course on 119; dystro-
phia myotonica and Maas and
S. Paterson) 21; in (Gaited States,
fied: London County Council report
on (LA) 396 ; research on, donations
1419; survey of, in rural com-
y voluntary sterilisa-
tion and (PI) 961, 1019; see also
Board of Control, Epilepsy, and Mental
Hospitals
Menta ord alged: disputed will
and (ML) 1189, (E. W. tinea (C)
1252; benzedrine in (J. Fisher) (C)
52, (A) 1475; a mvyotonica
and (O. Maas and A. S. Paterson) 21;
Daorn system and, 442, (LA) 519,
(T. D. Power) (C) 599; fever therapy in,
468; gall-stones and (J. Mackay)
1522 ; head injuries and, 928 ; histology
of (A) 218; Home Care of Mental
Patient (A. Querido) 734; in women,
fund for, 492; Lunacy Act, examina-
tion under (ML) 1422; marriage and
(PI) 56, 417, 482, 1024; menopausal,
estradiol benzoate in (M. s. Jones,
T. N. MacGregor, and H. Tod) 320;
mental hygiene clinics (PI) 670, 844;
mental hygiene congress, 848, 1384;
occupational therapy in (A), 1359;
operative treatment of (Tentatives
opératoires dans le traitement de
certaines psychoses) (E. Moniz) (A) 156 ;
Recreational Therapy for the Mentally
IN (J. E. Davis and W. R. Dunton)
(R) 272; schizophrenia, hypoglycemic
shock in (L. W. Russell) 747, (C) 1204,
(H. P. Strecker) (C) 840, (G. W. B.
James, R. Freudenberg, oe A.
Cannon) 1101, 1210, (B. H. Shaw) ©
1251, (L. A. ieta) (C 1251, (E.
Larkin) (C) 1371; serum calcium and
(I. Atkin) 439; see also Board of Con-
trol, Crime, Nervous disorder, Neuro-
syphilis, Psychiatry, Psychology, and—
Mental hospitals—(PI) 1561; conditions
in, 1010, (W. G. Masefield) (C) 1076,
(C) 1138, (E. Carling) (C) 1203, (H. F.
Stephens) (C) 1204; dismissal of
official (ML) 1481: ex-Service men
in (PI) 1441; Friern Hospital for
Nervous and Mental Disorders, 422 ;
High Wall (A. R. Clark) 850; Holly»
wood, staff of (PI) "357: Lancashire (PI)
605, 1100; Lebanon Hospital for
Mental Diseases, 543; London County
Council (LA) 396, malariotherapy in
(A) 1236; Maudsley Hospital, 476,
487; model diet in (PI) 843; negligence
actions and (ML) 7 1481 ; > old age
ensioners in (Pry irre ; Runwell
ental Hospital, 1472, 1487; : Scottish,
nurses’ hours in (PI)’ 1496; statistics
of (PI) 787; suicide in, 850
ae a Sir F., on hospital planning,
5
Mercurial antiseptics, intravenous (A)
Mesenteric—vessels, spontaneous hæmo-
peritoneum and, 1451; see also Intestine
Metheemoglobineemia, ” see Sul pheemo-
globinemia
Methylated spirits, see Alcohol \
Métivier, V. M., hseemorrhagic disease of
new-born (C) 779
Meucueracn, E., on pernicious ansemia,
Microbiology, congress of (A) 1473
Microchemica] Club, 730
Microchemistry, doyen of, 1209
Microcolon, congenital, 813
Micrognathia (C. P. Lapage) 323
Microscope, electron (A) 454
Microscopy— Biological Pa boreuery. Tech-
nique (J. B. Gatenby) (R) 1055
Microviscosimeter (A) 334
Midwifery—evipan in, 612; London
service of, 1567; Maternity Services
(Scotland) Bill (PT) 354, 418, 539, 1025,
1143, 1436; Midwives Act (A) 214,
1199, appointments under (PI) 844;
Midwives Act, district nurse and
(C) 53; Smethwick scheme, 421;
see also Childbirth, Gas- and-oxygen
aneesthesia, Maternal mortality
Maternity and child welfare, an
Obstetrics
Migraine, ergotamine tartrate in (T. W. G.
Kelly) (C) 777, (LA) 763, (W. B.
Cosens) (C) 839, E. L. Flemming)
(C) 839, (J. H. Crow ey) (C) 954
Milbank Memorial Fund, 421
Miles, A., and Wilkie, D. "Pp. D., Operative
Surgery (R) 931
wervict <eaaeas and pharmacy, congress
o
Milk—accredited scheme (PI) 1439, con-
ference on, 359; consumption of, 363,
price and, 607; diseases conveyed by
(PI) 297, 357, 513, (PI) 670, 898,
safety of su pply and, 363, (E. Carling)
(C) 412, (C) 432) (A) 824, pasteurisation
5, 669, 1012, (PI) 1084, (uA)
1058, (PI) 1141, 1196, (LA) 1179,
1379, (a) 1417, PI ) 1491; examina-
tion of (J. S? Faulds) 949 ; Milk
Products (W. C. Harvey) (R) 1409;
production of (PI) 1439, problems of
(C) 722, 1364; rawand boiled, nutritive
value of, 1503: skim- milk, nutritive
value of, *for Indian children’ (A) 1474;
tuberculin-tested (PI) 1441; see also
Bovine tuberculosis, Lactation,
Maternity and child welfare, and School-
children
Miller, A., on lesions of hip, 871
Miller, D., and Coppleson, V. M., Clinical
Handbook for Residents, Nurses, and
Students (R) 932
Miller, E., on mind a child, 491
Miller, J. H. (O) 602
Miller, S. C., Oral pipe nosis and Treat-
ment Planning (R) 117
Miller, W. S., The Lung R) 1340
Milligan, C. J. (O) 239
Mimpruss, T. W., gonadotropic hormones
in undescended testis, 497, (C) 778
Minchin, R. L. H., cysticercosis and
epilepsy, 865
Minerva: Jahrbuch der Gelehrten Welt,
453
Mines—boys in (PI) 542, 1145 ; explosions
in (PI) 842; pit-head baths (PI) 57;
protective equipment in (PI) 1565;
safety in (PI) 298; silicosis (PI) 239,
566, 773, (LA) 764, (PI) 961, (Occupa-
tional Diseases) (D. Hunter) (R) 1112,
(PI) 1145, (A) 1236, (PI) 1378, tuber-
culosis and, 773, (LA) 764
wine F. C., on milk and disease,
5
Ministry of Health—annual report (PCP)
116; appointment, 1360; Midwives
Act (A) 214, regulations, 1199; polio-
myclitis, 176; radiothera peutic hospital
departments (A) 1059; staff, accom-
modation of (PI) 297; venereal] disease,
publicity for, 1253 ; see also Insur ance,
National Health, Maternal mortality,
and Nutrition
Minot, G. R., Castle, W. B., and Christian,
H. Pathological Physiology and
Clinical Description of the Anæmias
Mitman, M., encephalitis in measles,
687; on acute enteritis, 444
Moir, C., doryl in retention of urine,
261, (A) 276; nitrous oxide analgesia
n obstetrics, 615
L., pregnancy toxæmia (C) 1486
Molesworth, E. at Introduction to
Dermatology (R) 8
Molisch, H., Blehtioth: birthday, 1209
Mol; H. H., chest deformities in asthma,
Molloy, L. (O) 537
Moncrieff, A.» on children in winter
(A) 158; . and Rolleston, Sir H.,
Favourite Prescriptions (R) 152, (LA)
153
Mondor; H., Les avortements mortels (R)
4
Moniz, E., Tentatives opératoires dans
(A traitement de certaines psychoses
Monocytosis, 1402
Monro, C. C., A remedy for hæmorrhoids
(C) 1310
Monro, T. K., on summer vacation, 775
Monypeny, A. M. D. (O) 238
Moore, A.,
Moore, A
631
Moore, D. F.,
neuritis, 1225,
Moore R. F., on retinal detachment,
11
Morals—History of Modern Morals (M.
Hodann) (R) 518
Morgan, B., on ear, nose, and throat
infections in children, 1527
Morgan, Sir G., and Burstall, F. H.,
Inorganic Chemistry (R) 760
rider’s bone, 264
M. A., on ununited fractures,
nutritional retrobulbar
Moreen, T. N., hormones in menstruation,
MS A., artificial pneumothorax
Morlock, H. V., postural drainage, 381
Morphia—biliary colic, and’ (LA) 819;
see also Dangerous drugs
Morphology— Bones : Study of the
Development and Structure of the
Vertebrate Skeleton (P. D. F. Murray)
(A) 522; pathological (Morphologische
Pathologie) (W. Hueck) (R) 872
Morris, Sir E., death of, 1360
Morris, H.J., future of teeth (C) 52
Morris, I.. B., on retinal staining (A)
Morris, N., on plasma phosphatase in bone
disease and jaundice, 87
Morrison, J. T., hernio-appendicectomy,
Morse, W. R., blood pressure amongst
aboriginal groups, 966
Morann, C., on closed prostatectomy,
5
Mortality, see Vital statistics
Mortgages, see Practice, medical
ey A., hepatitis and cholecystitis
T E R at wheel (ML) 1069;
manslaughter, negligence, and ( ML)
1069; sce also Road accidents
Motor- vehicles, noisy, 909
Mottram, .. and Hutchison, R.,
Pood ind the Principles of Dietetics
(R) 2
oath nr of, 135, (LA) 153;
nasopalatine cysts (C. B. Henry) 1326 ;
tuberculous ulceration of, 1527; see
also Lips, Oral, and Teeth
Mowat, G: T., on rapid SIRET DEN in
diagnosis, 871
Moynihan Fellow ship, 1
Moynihan memorial (C. SSidfcld) (C) 1487
Mucocele of appendix, 758
Muir, E., on fight against leprosy, 943
Mumps, Wassermann reaction and (W.
Smith) 754
ME M., Consequences of Philosophy
) 335
Municipal Year Book, 368
Murder, see Crime
Murray, A. M. T., and Cathcart, E. P.,
Dictary Survey "293
Murray, D. S., Science Fights Death, 910
Murray, F., ‘on obstetrical emergency
service (A) 998
Murray, D. F., Bones: Study of the
Development and Structure of tbe
Vertebrate Skeleton (A) 522
Muscle, see ratigue
Mushroom poisoning (ML) 590
Music—epilepsy and (A) 1236;
industrial boredom, 908
eee H. S., Rural Health Practice
(
for
xvi Supplement to THE LANCET]
INDEX TO VOLUME I., 1937
[fAuaustT 14, 1937
Myasthenia gravis—choline esterase acti-
vity and (M. McGeorge) 69 ; Prostigmin
and physostigmine in (A) 276, 526;
Substance 36, anti-curare action of
(Lady Briscoe) 621
Myers, B., on tuberculosis in New Zealand,
1187 ; retroperitoneal sarcoma, 202
Mygind, S. H., on aural medicine, "1528
mn R. B. - radiogram and radiograph
E R see Heart disease
Myopia, see Eyes
Nævoid—amentia (R. Bates) 1282, (F. P.
Weber) (C) 1370 ; see also Cancer
Nails—Diseases of the Nails (V. Pardo-
Castello) (R) 450; : tumours of nail-
beds, epiloia and (S. G. James) 1223
Naish, "A. E. ., disclaimer, 968
Najib- Farah, bilirubinsemia in pneumo-
coccal infection, 505
Naphtha, see Bed- -bugs
Narcosis, see Anæsthesia
Narcotics, see Dangerous drugs
Nasal, see Nasopalatine and Nose
Nasb, E., on future of obstetric practice,
1285, (C) 1549
Nasmyth, T. G. (0) 238
Nasopalatine canal, cysts of (C. B. Henry)
13 l
National Institute of Industrial Psycho-
logy) (LA) 576, 905, 909, 1149, (LA)
National Physical Laboratory, 1206,
annual report, 1032
Naval cookery, manual of, 612
Naval Medical Compassionate Fund, 789
Neal, H. V., and Land, H. W., Compara-
tive Anatomy (R) 392
Needle holder, see New Inventions
Mede ae on of Britain (G. D. H.
and M. Cole) (LA) 1411; Human
Needs of ‘Labour (S. Rowntree) (LA)
1411, (PI) 1441; see also Depressed
areas, Nutrition, and Unemployment.
Negligence—actions for, 145, against
mental hospitals boards (ML) 716, ie
actions for, Public Authorities Protec-
tion Act and, 64; allegation of, with-
drawn (ML) 589; alleged, tonsillectomy
and (ML) 431; doctor’s failure to
visit (PCP) 1071; doctor’s widow,
damages against (ML) 1005 ; man-
slaughter and (ML) 1069; paddling-
pool, borough council and. (ML) 466 ;
swabs, checking of, responsibility for
(ML) 589; tetanus and, 342
Nègre, L., Calmette, A., and Boquet, A.,
L’infection bacillaire et la tuberculose
(R) 931
Neill, Sir T., death of, 1419
Nephritis—allergy and (A) 1535; Bright’s
moe and Arterial Hypertension
(W. Stone) (R) 516; Truth about
MAR s Disease (W. R. Ohler) (R) 327;
sce also Kidney, oe and Uræmia
Nepbrostomy, see Kidn
Nervous digorder==avolaanee of, 1153;
Common Neuroses—Their Treatment
by Psychotherapy (T. A. Ross) (R)
1230; Graves’s disease and (A) 521;
heart disease and (A) 399; non-
rheumatic chorea and (A) 581; When
Temperaments Clash Oy Mackenzie)
(R) 1530; see also Mental] disorder,
Pituitary gland, and Psychology
Nervous system—autononiic, syphilis and
(Latent Syphilis) (G. Evans) (R) 1530 ;
diseases of, fever therapy in, 468;
diseases of, ‘occupational therapy in (A)
1359 ; Dissertation on the Sensible and
Irritable Parts of Animals (A. von
Haller) (R) 1113; Facial Neuralgias
(W. Harris) (R) 1340; ganglio-neuro-
blastoma, 1458: neuritis, vitamin B
deficiency and (A) 159, 12253; Neuro-
embryology (S. Detwiler) (R) 89;
nutritional retrobulbar neuritis (D. F.
Moore) 1225, 144/43; peripheral nerve
injuries, 386; Preface to Nervous
Disease (S. Cobb) (R) 638; spinal
anesthesia and, 755; surgery of, 735;
tumours of (A) 458, 1458; see also
Brain, Neurosyphilis, Paralysis, and
Sympathbectomy
Neuralgia, sce Nervous system
Neuritis, see Nervous system
Neurology, see Nervous system
Neurosis, sce Nervous disorder
Neurosyphilis—diagnosis of, 388; fever
therapy in, 468, 1008; ‘malaria and
(A) 1236; stovarsol in (R. Pakenham-
Walsh and A. T. Rennie) 982; tabes
dorsalis, 655
Neustatter, L., on rheumatism and
nervousness (A) 581
New growths, see Cancer
NEW INVENTIONS. = paonchoseane (J.E.G.
McGibbon) 1232—Culture bottle for
vaccines (S. G. Rainsford) 1528—-Curette
and uterine sound (G. L. Foss) 698—
Douching attachment (C. E. Kindersley)
932— Electric aspirator (F. Heaf) 86—
Forearm and wrist fractures, extension
apparatus for (R. Shackman) 572—
Gall-bladder operations, T-tube for
(R. Maingot) 1111—Irrigation cane
(P. P. Cole) 1286—Needle holder: (G. L
ETATON de for pneumothorax (D. A
Herd) 2 "tor prostatectomy (J. C.
Ross) A E E instrument for
draining (J. T. R. Edwards) 272—
Radon-seed introducer (F. J. Cleminson)
30—Rectal bougie (J. P. Lockhart-
Mummery) 874
Newns H., middle-ear disease in
Diany Fij 1310
NEW PREPARATIONS. —Acrosone (James
Woolley Sons and Co.) 910—Anti-
hesin (Allen and Hanburys) 426—
Benerva Brand Vitamin (Roche
Products) 246— Bilron (Eli Lilly and
Co.) 910—Bismuth therapy (May and
Baker) 1261,. 1384—Ca cium-Sandoz
(Sandoz Products) 1261—Examen
(Glaxo Laboratories) 1383—Folinerin
(Schering Ltd.) 1384—Gabasol] (Gale,
Baiss and Co.) 246—-Kinoo Pure Silk
Baby Powder (Kinu Ltd.) 1384 —
Navigan (Roche Products) 1383—
Orheptal (Savory and Moore) 910—
Phospho-Mandelate (Crookes Labora-
tory) 1261—Prophyll Atomiser (Pro-
phyll Co.) 1261—Salicylysin Liniment
and Ointment (Allen and Hanburys)
246—Soluseptasine (May and Baker)
910—Streptocide (Evans Sons Lescher
and ae 426—Syrup. Ammonii
Mandelat (C. J. Hewlett and Son) 426—
“Tabloid” Brand Sulphonamide-P
(Burroughs Wellcome and Co.) 426—
“ Tabloid”? Calcium Gluconate and
Iron (Burroughs Wellcome and Co.)
246—Tannol (Clav and Abraham) 426—
Testoviron (Schering Ltd.) 426—
Vita Live Natural Grape Juice (Vita
Products) 246—Viteolin (Glaxo Labora-
tories) 910 — “ Wellcome ” Brand
Whooning-cough Vaccine (Burroughs
Wellcome and Co.) 1384—Zephiran
Concentrate (Bayer Products) 1384
New Zealand, tuberculosis in, 1187
Nicholls, M. F., over- -treatment of
gonorrhoea (C) 721
Nigam, K. S., duodenal obstruction, 144
Night- blindness (A) 769
Nissen, K. I., plaster bed, 18
Nitric acid poisoning, 76
Nitrous oxide, see Anesthesia and Gas-
and-oxygen 'anæsthesia
Noble, R. L., anemia, gastric secretion
and pituitary, 692, (C) 953
Noguchi, H., memorial to, 1315
Noise—epilepsy and (A) 1236:
on, 1032
Norman, C. E. R., colour perception tests
(C) 900)
Norman, V., Essentials of Modern Medical
Treatment (R) 89
research
Northfield, D. W. C., thorotrast in
cerebral arteriography, 377
Norwayv—tuberculosis survey in (A) 643;
see also Vencreal discase
Nose—cerebro-spinal rhinorrhea (A)1183:
Diseases ar the Nose, Throat, and
Ear (I. S. Hall) (R) 1055: infection
tbrough (A) 455, (LA) 875, (A) 940,
(F. A. Pickworth) (C) 1076, 1548,
(G. W. Rake) (C) 1433, (LA) 1532
oily solutions injected into, PAMONA
and (A) 1239; Practitioner’s Note
of Medicine and Surgery :
Eve, Ear, Nose, and Throat (G. lamor
(R) 989; Year Book of the Eye, Ear,
Nose, and Throat (R) 449: see also
Hav- fever, Respiratory, and Šinusitis
Nostrums, see Drugs
Nursery schools—Nursery School and
Parent Education in Soviet Russia
(V. Fedinevsky) 967; Nursery Schools
Association (A) 97; Save the Children
Fund and, 368
Nurses—air, in France, 946; Clinical
Handbook for Residents, Nurses, and
Students (V. M. Coppleson and D.
Miller) CR) 932 district (C) 53, in
London, 964, 1029, 1258; General
Nursing Council, new building for,
1541; home for, in Glasgow, 167 ;
hours of, in Scottish mental hospitals
(PI) 1496 ; industrial (PI) 606; ortho-
peedic, 885; Pediatric Nursing (J.
Zahorsky and B. E. Hamilton) (R)
697; Practical Preparations, Mainly
Medical (N. W. Powell) (R) 393;
state registered (A) 279; status of,
1351; tuberculosis in (LA) 91, (A) 525,
1033, 1132
Nursing- pig Sep hat of, 850 ; super-
vision of (PI) 962
Nutrition—Advisory Committee’s report
(A) 824, 881, cost of living inquiry and
(PI) 962 1021, 1195, (C) 1203, (PI)
1377, (LA) 1411 1; foot-and-mouth
disease Maa Vay 1414; infant (C. Asher)
221, anemia and (A) 1293; infectious
disease and, 811, (H. Chick) (C) 900,
1365; in Tanganyika (PI) 1026;
League of Nations and, 1608, 695,
1317, (LA) 1411; Medical Research
Council on, 709 "Men, mio dicine, and
Food in the U.S.S. R. Le Gros
Clark and L. N. Brinton) (A) 280:
eee a Policy of National Health
. Drake) (A) 399; Nutritional
factors ip Disease (W. R Fearon) (R)
814; Army recruits (PI) 358;
of childen mealtime difficulties and,
1153; overfeeding and protein metabol-
ism, "1508 ; pregnancy anæmia and
(A) 96; pulmonary tuberculosis and
(P. M. D. Hart) 969, 1033, 1093,
(LA) 1117; surveys of (A) 94, 293,
(J. Marrack) (C) 410 ; wages, needs and
(PI) 729, (LA) 1411, (PI) 1441; Work
and Rhythm, Food and Fatigue
R. Williams) 124; see also Diet,
tilk, Physical education School-
children, Unemployment, and Vitamins
Nystagmus, caloric, 108
O
Oakley, C. A., and Macrae, A., Handbook
of Vocational Guidance, 909
OBITUARY
Adams, J., 1312—Adler 1373-
Alderson, G. P., 236—Alexander,
r. W., 7a Avdrey, H., 846—
Attlee, J. 846
PREEN, Sir G., 1201—Beaumont,
C., 602—Booysen, C., 956—
. 5., 665—Burford, G. H.
1
Campbell, Lady, 1374—Carmichael,
1374—Chamberlain, Sir A. (LA) “or
—Chamings, A. J. W., 537—Choyce,
C. C., 902, 8957 —Clinch, A. D., 412—
Clough, J. 666— Cochrane, G., 903—
Coghlan, ’C. W., 666—C —Coles, C.,
1014—Collins, F. G., 956— Corker,
T. M., 601—Cresswell R.
Davies i 782—Davics, fp. v.
10S bilon, D.G, L Ap TOB ot
Bowker, ©
14
. F., 98
Galletiy, J., 1140—Gray, J. P., 903
Greenwood, A., 54—Guthrie, R. L.
Harris, S. H., 412—Harvey, W. F.
1435—Heath, A. D.,
Sir P., 1139—Henry, G. M., 116—
Hine, T. G. M., 1080—Hogg, F. S. D.,
ea H. V., 1141—Hunter,
Jackson, Sir H., 601—Jackson, J. L.,
1141— Jones, J. A., 845—Just, T. H.,
_ Ketchen, J. G. (A) 1537—Kummell,
H. (A) 644
Leith, R. F. C., 114—Lewis, C. J.,
41; 413—Liddell, JS 725—Long, J. E.,
MCAT, P. L., 782—McKerron, R. G.,
78 1—MacWŴiliam, A., 236—
Malcolm, J. 845—Manuel, A.
602—May, B., v 1201—Miiller, J. H.,
602—Milligan, cen J., 239—Molloy, L.
537—Monypeny, A. M. D., 238
Nasmyth, T. G., 238
a Pa e a ai ks
Supplement to THE LANCET]
INDEX TO VOLUME I., 1937
[Aucust 14, 1937 xvii
ouver, w. J., 237—Osborn, H. A.,
Paget-Tomlinson, W. S., 485— Paine,
M., 846—Parker, G., 1139— Patrick,
N. C., 1014— Pinkerton, R. L., 65—
Poland, J., 1311
Ransom, F., (G02 Richards, P. A. E.,
54—Roberts, H. C.,
Sainsbury, H., 40,
M., 4i3—Scott B., 781—Semple,
Sir D., 178—Shaw, W. V., 295—
Sieger, A. S., 486—Smart, D., 1014—
Smith, Sir "E., 113, 19 pence,
G. H., 90 4—Sprigge, Sir Squir
1550—Stansfield, F. W., 666—Stur.
rock, A. C., 903
Taylor, J., 1014—Thackrah, M., 288—
Thompson, A. H., 237—Tonks, H.
(A) 160
Warnock, J. M., 486—-Webb, C. H. S.,
1435— Wenyon, E. J., 72 5— Whit-
tington, R., 956—Wiggins, W. D.,
665—Wilkinson, J., 116—Wiliams,
R., 115—W ae R. T., 1311—
Wilson, S. A. K. 253—W iltshire,
H. W., 295—Winch, che , 1374
Yarr, Sir T., 1080
O’Brien, B., in radermal tests for whoop-
ing-cough, 1
Onar emaki service for (A)
998; Management of Obstetric Diff-
culties (P. Titus) (R) 574; premature
baby and (A) 6453 Quecn Charlotte’s
Textbook of Obstetrics (R) 88; recent
advances in. 1465, (P. M. F. Bishop)
C) 1546; Williams’ Obstetrics (H. J.
tander) (R) 28; Year Book of
Obstetrics and Gyneecology (J. B.
DeLee and J. P. Greenhill) (R) 991;
see also Childbirth, Maternal mortality,
Midwifery, and Pregnancy
Occupational therapy (A) 1359, 1427
Odlum, D. M., school routine (C) 723 ;
marae H, appendicitis and alarm reaction
3
11 eE
Œsophagus—cancer of (R. Pilcher) 73,
oe 96, radon-seed introducer for
(F.J Cleminson ) (NI) 30 ; movements
of, during opaque meal, 490 ; non-
sphincteric spasm of (J. E E. G. McGibbon
and J. H. Mather) 1385; s
Foreign body
Œstrin—cervix uteri and (S. Zuckerman)
435; hypophyseal dwarfism, tumour
growth, and (B. Zondek) 689; in
blood and urine, pregnancy and, "571:
cestradiol benzoate at menopause (M.S.
Jones,T. N. Macgregor, and H. Tod) 320;
see also Sex hormones
Ogilvie, W. H., lymphatic spread in
rectal cancer (C) 290
hler, W. R., Truth about Bright’s
Disease (R) 327
Old age—anacidity and E Földes) (C)
411; surgery in (A) 1180
Oldfield, C., Moynihan memorial (C) 1487
Olfactory, see Nose
‘Oliver, J., on blood transfusion, 1523,
(LA) 1532 ; on diagnosis of gonorrhea,
387
Oliver, W. J. (O) 237
Omentopexy (L. 0O’ OUEN and
et Dawson) 185, (G. G. Turner) (C)
Omnibus, see London
Operations, sce Anresthesia, Negligence,
Post-operative. and Surgery
Ophthalmic, see Eyes
Opium, see Dangerous drugs
see also
Oppenheimer, A., turmeric (curcumin)
in biliary diseases, 619
Oppenheimer, C., Einführung in die
Allgemeine Biochemie (R) 1229
Opticians, see Eyes
Oral—Oral Diagnosis and Treatment
Planning (S. ©. Miller) (R) 1175;
Oral Diugnosis and Treatment Plan-
ning (K. H. Thomas) (R) 1175; sepsis
(LA) 31, 67, (A) 822; see also Mouth
and Teeth .
Orbit, see Eyes
Orde, R. H. P., bospital emblem (C) 412
Order of St. John of Jerusalem—appoint-
ments, 119, 1569; promotions, 1569
Ormerod, F. C., on tuberculosis of mouth
and pharynx, 1527
Orthopædics—course in, 422; in general
practice (Alltagsorthopadie’ des Prakti-
schen Arztes) (S. Romich) (R) 815;
manipulative surgery, Sir H. Barker’s
demonstration of (wv. R. Bristow)
546, (A. G. T. Fisher) (C) 595, (A. S. B.
Bankart) (C) 595, (Sir H. Barker) (C)
59; nursing certificate in, 3585;
Rennt Advancesin Orthopædic Surger y
(B. H. Burns and V. H. Ellis) (R)
1055; scholarship in, 1257
|
Orton, H., on investigation of alimentary |
tract, 985
Osborn, H A., death of, 275, (O) 353;
pancreatic cancer with diabetes, 1461
mT W. B., Complement or Alexin |
O’Shaughnessy, L., cardiac ischæmia, 185
Osteitis—(W. Broadbent) 564, ae 579:
B.I.P.P. method in (J. H. Saint
1211, 1263, (H. H. Brown) (C) 1371,
(C. CG. Holman) (C) 1485; „ apbysec-
tomy in (A. L. d@’Abreu) 14
Osteopathy—What is Ortenpate4 (C.
Hill and H Clegg) (A) 881, 932,
(W. Hargrave-Wilson) (O) 1017, 1383
Otitis—bathing and (LA) 1412; in
infancy, 1171, (LA) 1234, (G. H.
Newns) (C) 1310, (W. N. Leak) (C)
1434, 1527, bronchiectasis and, 1527;
see also Ear and Streptococcal infections
Otolaryngology, see Ear and Throat
Ovary—adenomyoma of, 1054; 5 cysts of,
heemoperitoneum and, 1451; pseudo-
mucinous cyst of, 447 : : sarcoma of
lung and, 759 ; see ‘also Sex hormones
Overbreathing, see Tetany
eee ane and protein metabolism,
Over- o ement, , dangers of (T. B. Layton)
Owen, T., duodenal ulcer, 260
Oxidation-reduction potentials, colori-
metric determination of, 1154
Oxygen, see Anesthesia, Anoxemia,
and Inhalation therapy
Pacifism, see Peace
Be a B., infection and disinfection
Pagel, W., reactivation of tuberculous
focus, 1279
Paget lecture (A) 1417, 1477
eee Disease of the Nipple (K. Inglis)
Paget-Tomlinson, W. S. (O) 485
Paine, M. (0) 846
Pakenham Walsh. R.,
syphilis, 982
Palmer, H., blood pressure after
coronary thrombosis, 741
p- aminobenzenesulphonamide, see Chemo-
therapy
Pancreas see Diabetes
stovarsol in neuro-
PANEL AND CONTRACT PRACTICE (see also
. Insurance, National Health).—Accept-
ance forms, delayed, 1430— Benefit
regulations, "469, 720, *784—Capitation
fee, 60, 168, 720, 1071, 1430, practi-
tioners’ fund and, 837, 1136-—Certif-
cates : cremation, 1248; messages
about, 420; patient’s name and,
420—Complaints against practitioners
951, 1071—Dental extraction, medical
treatment and, 345, 1549— District,
medical service, 167—Essex public
medical service, 1549—Fees: com-
promise over, 600 : inadvertent over-
charge, 720—Hospital treatment :
approved societies and, 1430 ; insurance
practitioners and, 1247—Kinnear, Sir
W., retirement of, 168—London firures,
836—Ministry of Health, report, 116—
Mortgages, medical, 420, 784—Partner-
ship: dissolved, choice of doctor and,
1439; mixed, 897: requirements of,
1366— Patient’ 8 fitness for removal,
cost of, 116, 600,
836, 951; for hospital patients, 1247—
Prescriptions : disallowed, 837 ; urgent
469—Scotland, dispensing in. 951—
South African health insurance Seu mA;
1301—Specialist treatment, 600—
Surgery visitation, 1366— Widows’,
Orphans’, and Old’ Age Contributory
Pensions Bil, 897
Panton, P. N., cancer tests and treat-
ments, 793
Papilleedema, 1109
Papworth Village Secttlement—deeths at
PI) 357; employment of patients at
(PI) 357; funds for, 608, 1029: non-
TIPERETION unemployed men at (PI)
Papyrus Ebers (B. Ebbell 734
Paralysis—acute ascending flaccid (J.
Shafar) 1275; facial, 390 : fracture,
871; hemiplegia, diphtheritic (J. M.
Todesco) 85; bemip egia, eclamptic
(M. Hajkis) 628 ; andry’s (A. V.
-| Russell) 143 :
| Paramore, R. H., pregnancy toxemia
(C) 1486 i 7
| Paratyphoid A (H. Cohen, A. G. ©.
ffolliott, and H. D. Wright) 1521
Pardo-Castello, V., Diseases of the Nails
(R) 450
| Paris, bubonic plague in (A) 277
PARIS, CORRESPONDENCE FROM.— Drugs,
hawking of, 946— Examiners, 654—
Ex-votive offerings, 8&34— Hospital,
first-aid, 406—Irradiation of foods,
342—-Laennec, monument to, 406—
Leprosy, 1132—Medical school build-
ing, new, 48—Negligence, tetanus
and, 342—Nursing in the air, 946
—Practitioners: autobiographical
sketches and, 343; death certification,
vagueness in, 947; foreign, 1426;
payment of medical services by, 775;
unregistered practitioner, 1244—Pro-
fessorships in medicine, 1132—Prostitu-
tion: licensed, 590; venereal disease
and, 47—Silk sutures, 654—Sodium
evipan intravenously, 775—Students,
medical: compulsory vaccination of,
947; foreign, 1426—vTuberculosis: in-
dustrial campaign against, 1426; pul-
monary, surgery of, 1426: sanatoriums
or sanatoria. 833: tuberculin -testing,
1132—Undulant fever, 590—Venereal
disease legislation, 47—-Water-supplies,
chlorination of, 590
Parish, H. J., y-aminobenzenesulphon-
ca in non- -streptococcal infections,
Parker, G. (0) 1139
Parkes, A. S., anti-gonadotropic serum,
4
Parkes, K., on recent advances in
obstetrics, 1465
Parkinson, G. S., and Jameson, W. W.,
Synopsis of Hygiene (R) 151
Parkinson, J., on right-sided aortic arch
(A) 454
PARLIAMENTARY INTELLIGENCE
Abortion, committee on, 1313, 1477—
Africa: nutrition in Tanganyika,
1026; prison conditions in Kenya,
1084: research in, 843—Air-raid
precautions, 357, 419, 483, 541,
605, 606, 669, 670, 728, 788, 961,
1565—Alcohol : drink traffic, State
and, 357: drunkenness, 843, 1440;
methylated spirits, sale of, 484,
540, 1563; road accidents and, 357,
728, 787-—Animals : diseases of,
1439, eradication of, 1376, 1440;
experiments on, 356, "1145; veterin-
ary education, 541—Army : blood
transfusions and, 1086; health of,
842; milk rations for boys, 1441;
new reforms i in, 727; officers invalided
out of, 1314; recruits, standard of,
358, 484, 901°
Blind, care of, 298, 670, 1144—Bose,
S., condition of, 419—Budget, 1026,
family allowances and, 357
Charities, bogus, 483—Children : Bilbao,
1313, 1378, 1441, 1495; blind,
training of, 1144; born in prison,
728, 1564; Bristol day and night
nursery, 1086; celluloid toys and 541,
1565 ; cinematograph films and, 296,
729; corporal punishment, 787,
1085, 1144, 1378: employment of,
at home, 1494: Home Office branch
for, 358: injured by spiked railings,
1565—Cinematograph films, 296, 483,
729, 842—Coroners: duties of, 901,
1018 ; post-mortem examinations
and 1084; press intrusion and, 298,
419, 483, 604—Cremation, 729—
Crime: corporal punishment, 787,
1085, 1144, 1378: medico-legal]
institute, 961 ; statistics of, 844
Diphtheria immunisation, 541, 729—
rugs: advertisements of, in books
of stamps, 358 ; dangerous, thefts of,
297: Medicine Stamp Duties, 901;
Trade Marks (Amendment) Bill,
1376—Duke-kFingard treatment, 1378
Food: bread, handling of, 1198;
ergs, examination of, 541; perish-
able,’ 728 ; prepared fruit juice, 844
Health education, 419—Health services:
administration of, 1439, 1491, debate
on, 1561; Colonial, 1440; Local
Government Bill, 603—Hospitals:
air-raid precautions and, 541, 728;
Liver products,
Marriage :
xviii Supplement to THE LANCET]
coöperation between, 1198; Hilling-
don Hospital, omnibus services for,
1084; hours of employment in,
1024: infectious diseases hospital,
for Retford and Worksop, 843;
in Gibraltar, 1496; in Malta, 541;
in Newfoundland, 1086 ; in special
areas, ae in ‘Staffordshire, 961
1144, 1314; Manchester Royal
Infirmary, labour exchange and,
670, 844, 1027; Public Health Acts
and, 1565; Southmead Hospital
Bristol, 484—Housing : basemen
dwellings in London, 358; in
Scotland, 841, 962, 1314, 1496 :
overcrowding and slum clearance,
843, 962, 1439—Humidity in Great
Britain, 669
Industrial medicine: bakehouses and
factory regulations, . 299, 542;
Bedeaux system in arms factories,
542; cardroom workers and respira-
tory illness, 419, 842; dermatitis,
604; Factories Bill, 354, 478, 604,
667, 727, 786, 840, 959, 1023, 1027,
1081, 1192, 1248, 1314, 1375, 1563;
holidays with pay, 787 ; mines, health
and safety in, 57, 239, 298, 542,
842, 961, 1086, 1145, 1378, 1565:
noise, effect of, 239, 1495; Weil’s
disease, 843; workers’ hours, 669,
670, 728, 787, 788, 1027; workmen’s
compensation, International Con-
vention and, 60 5—Infantile morili y;
1085—Influenza and common cold
research on, 788—Insurance, National
Health : approved Societies, 484, addi-
tional benefit and, 605, 728, 1377; R
capitation fee, 298, 604, 129, 1086,
1195, 1495, 1564 ; dental treatment,
doctor and, 420; drug fund, 962 :
Irish casual labour and, 1084; Mid-
wives Act and, 1144; physical
training, insurance committees and,
1027; National Health Insurance
(Amendment) Bill, 603; ophthalmic
benefit, opticians and, 298, 357,
788, 1495; referees, 962; statistics
of, 729, 844
imported, duties on,
Divorce (Scotland) Bill,
482; Marriage Bill, 56, 417, 1024—
Maternal mortality, "1085, 1145
1496, in Scotland, 357—Mental
deficiency: expenditure on, 730;
statistics of, 787; sterilisation and,
961, 1019—Mental disorder: clinics
for, 670, 844; divorce and, 56, 417,
482, 1024; statisties of, 787;
treatment of, 1561—Mental hospitals:
ex-Service men in, 1441; Holy-
wood Mental Hospital, 3573 Lanca-
shire, 605; model diet in, 843 ;
nurses’ hours in, 1496; old age
pensioners in, 1144—Midwifery :
Maternity Services (Scotland) Bill,
354, 418, 539, 1025, 1143; Midwives
Act, appointments under, 844;
Midwives Act, maternity benefit
and, 1144—Milk: accredited, 1439;
diseases conveyed by, 297, 357,
670, pasteurisation and, 605, 669,
1084, 1141, 1196, 1491; for boys in
services, 1441, 1491; for mothers and
children, 729, 1196, 1491 ; for school-
children, 240, 298, 414, 1196;
tuberculin-tested, 1441; watered,
729, 1378, 1441—Mines: boys in,
512, 1145; explosions in, 842; pit-
head baths and, 57; safety in, 298,
1565 ; Silicosis, 239, 061, 1086, 1145,
of Health : scientists
employed by, 1441; staff, accom-
modation of, Fae 358—Mortuaries,
provision of, 108 83
Neuro-lymphomatosis, cure for, 298—
Nursery schools, 962—Nursing :
industrial, 606; in Scottish mental
hospitals, 1496— Nursing homes: in
Marylebone, 728; supervision of,
962—Nutrition: family budgets,
729, 1441, Advisory Committee’s
report and, 962, 1021, 1195, 1377
1441: in Tanganyika, 1026 ; physic ‘al
education and, 416, 957; provision
of meals and milk, 240, 298, 414,
729, 843, 1085, 1196, L491
Ollices : basement, | Government
employeesin, 297, 358 sinspection of,
240
Papworth Sanatorium: deaths at,
357; employment of patients, 307 4
unemployed men at, 483—Pensioners:
ex-Service, 350, 1441: old age, in
poor-law and mental hospitals, 1144
— Pensions: Contributory Pensions
Bill, 419, 959, 1198; Local Govern-
INDEX TO VOLUME I., 1937
ment Bill, 1492—Physical education :
insurance committees and, 1027;
Members of Parliament and, 670;
national plan for, 239, 358, 416,
419, 957, 1493—Population, trend of,
481, 728, 1439—Post Office employees
illness among, 605—Practitioners :
foreign, admission of, 1378; in
Nigeria, 1027 ; Medical "Practitioners
Communications Bill, 417—Prisons :
children born in, 728, 1564: condi-
tions in, 666, 1084; deaths in Armley
Gaol, Leeds, 1085; service in, tests
for, 1313— Public assistance : persons
over 70 and, 1564; persons trans-
ferred to U.A.B., 156:
Regency Bill, 416, 539— Road accidents:
alcohol and, 357, 728, 787; school-
children and, 297
St. John Ambulance Brigade, Corona-
tion and, 541—Scarlet fever, milk-
supply and, 297, 357, 605, 669—
School-children : anthropometric sur-
veys of, 1085; Deaf Children (School
Attendance) Bill, 786; nutrition of,
240, provision of milk and meals
and, 240, 298, 414, 843, 1085, 1196 ;
medical examination of, in Leicester,
1565; medical records and, 419;
ophthalmic treatment for, 1564;
physical education for, 239, 358,
416, 419, 957, 1493; road safety and,
297: school medical service, 1494;
tuberculosis and, 1086—Scotland :
distress in, 58; Divorce (Scotland)
Bill, 482; housing in, 841, 962,
1314, 1496: maternal mortality, 357 ;
maternity services, 354, 418, 539,
1025, 1143; mental hospitals, nurses’
hours in, 1496: mental hygiene
clinics, 670; methylated spirits,
sale of, 484, 540, 1563; new block
grants for, 1025: ophthalmic benefit,
298; public health law and, 484;
tuberculous, crippled and ortho-
pædic cases, local authorities and,
1314—Small-pox at Oldham, 297—
Spain: British hospital ship and,
787; evacuation of Madrid, 298;
Red’ Cross and, 1564; refugee
children, 1313, 1378, 1441, 1495—
Sterilisation: in Bermuda, unem-
eg and, 1026; voluntary,
Telephone : facilities and urgent illness,
729; kiosks, ventilation of, 1378;
mouthpieces, cleaning of, 1 144—
Tuberculosis: ex-Service man and,
1027; in Wales, 1377; local authori-
ties and, 1314:
Papworth settle-
ment, 357, 483;
Royal Marines and,
1494 ; sanatorium treatment of,
1565; school-children and, 1086—
Typ hoid, milk-supply and, 670,
1684, 1141, 1145, 1
Unemployment : assistance regulations,
57, means test and, 297, 1086;
dental treatment and, 1495; hos-
pitals in depressed areas, 297;
meals at instruction centres, ae
Papworth, unemployed men
483: public kitchens in A E
arcas, 669, 729; Special Areas Bill,
541; sterilisation and, in Bermuda,
1026; Unemployment Assistance
Board. public assistance and, 1564—
Unregistered practitioners, 419
Vaccination, deaths following, 788,
1027—Venereal disease, notification
and compulsory treatment of, 1565—
A of House of Commons,
Water-supplies, pollution of, 605
Parotitis—uremia and (R. T. Payne)
867; see also Mumps
Parsons, F.. Gateway of Speech (A) 939
par ee B. T., on sudden death
927
Pask, E. H. A., tuberculous abdominal
glands (C) 234
Pasteur, Claude Bernard and (A) 1477
Patella (G. O. Tippett) (C) 1308
Paterson, A. S., dystrophia mystonica, 21
Paterson, D., taking of children’s tempera-
tures (C) 724
Paterson, J. R. K., on irradiation in
malignant disease, 631
Pathology—clinical pathologist (S. C.
Dyke) 365; Elementary Pathology
(K. S. Thompson) (R) 2713 Introduc-
tion to Medical Science (W. Boyd) (R)
9913 morpbological (Morphologische
Pathologic) (W. Hueck) (R) 872;
Textbook of Pathology (W. G.
MacCallum) (R) 151; see also Diagnosis
and Post-mortem
fAucust 14, 1937
Patients—Physician, Pastor, and Patient
(G. W. Jacoby) (R) 762; radiologist’s
report and (ML) 833; unwilling,
psychotherapy and, 25; see also
Panel and Contract Practice
Paton, si P. J., diagnosis of whooping-
cough, 132 ; sulpheemoglobineemia after
sulphe inilamide, 1159, (C) 1369
Paton, R. Y., sacro-iliac strain, 1051
Patrick, N.C. (O) 1014
Patterson, J., left inframammary
1267
Patterson, S. W., on neoplasm of colon,
988
pain,
Pavel, I., and Chiray, M., La vésicule
biliaire et ses voies d’excréetion (R) 873
Pavlov, I. P., reminiscences of, 713
Payne, R. T., acute parotitis and latent
uremia, 867
p-benzylamino-benzene-sulphonamide, see
Chemothera py
Peace—congress on, 1206; lectures on
pacifism, 422: see also Medical Peace
Campaign and War
Pearl, R., on elements of population (LA)
1413
Pearson, W. J., oxygen tents (C) 471
Pediatrics, see Children and Infants
Pellagra, ætiology of, 811, (H. Chick) (C)
900. 1422
Pelvic inclination (P. Wiles) 911, (LA) 936
Pemberton, H. S., gold the A (C) 662
Pemphigus, see Skin
Penrose, L. S., congenital
monovular twin, 322
Pensioners—-ex-Service, 356, 1441; old
age, in poor-law and mental hospitals
(PI) 1144
Pensions —for black coated workers (PCP)
897, (PI) 959, 1198; see also Local
authorities
Poppie League of Health, 362, (LA)
7
syphilis in
Peptic ulcer—diagnosis and treatment of
(D Levey) EZT Or Lasser (ew 0;
Edwards) (C) 1308, (Sir A. Hurst) (C)
1369. 1484: duodenal (F. McPhedran
and T. Owen) 260, lymphosarcoma
simulating (S. Keysand W. W. Walthber)
1169; gastritis and, 757 ; hæmorrhage
in (SIr A. Hurst ana J: AL Ryle) 2:
(E. R. Cullinan) (C) 111, purgation and
(iy. J Witts) 27: jejunogastric
intussusception and (L. M. Greenwood)
266; modified Billroth I operation for,
245; perforated (A) 216, (G. Keynes)
(C) 291, (G. G. Turner) (C) 348, (A. ©.
Lysaght and W. B. Williams) 809
Percussion, see Diagnosis
Pericarditis, see Heart disease
Peritoneum—drainage of (A) 878 : hemor-
rhage into (J. Bruce) 1451: peritonitis
(A) 579, precautionary enterostomy and
(LA) 1177: retroperitoneal hernia,
radiography of, 985; retroperitoneal
sarcoma (H Waters, D. Levine, B.
Myers, and F. A. Knott) 202
Perry, B., on congenital heart disease, 324
Perurethral, sce Urethra
Peters, B. A. , proseptasine in streptococcal
infections, We iS Pa \) 1357: vitamin B
and diphtheria, 56:
Pharmaceutical Saciets ot Great Britain,
302, (A) P4154, eda
Pharmacists—anti-gas wo! S aa (PI) 357-
medicine duties kta (L 935: use of
description (ML) 108
Ph: SANAK. $ Cushbnv'’s Text-book of
Pharmacology and Therapeutics (C. W.
bLdmunds and J. A. Gunn) (R) 1112
Introduction to Pharmacology and
D EEA tics (J. A. Gunn) (R) 1112
Manual of Pharmacology (W. Dixon
aud W A. M. Smart) (R) 696: see also
Drugs, Therapeutics, and-
Pharniacopa@ias British Pharmacop@ia
\ddendum \) 90, LSL $ British
Pharmacopœia ( omĖImnission, 1351 s
Ibxtra Pharmacopaia Martindale (R)
327: L.C.C. Pharmacopæia Ry: “152:
(LA) 153; Synopsis of the British
Pharmacopeia (H. W. Gadd) (R) 1176
Pharynx, see Throat
Phenobarbitone, dangers of (J. T. Fox)
3835
fare)
Philip, Sir R., work of (A) 1416
Phillips, F. A., relapsing staphylococcal
septicemia, 1050
Philosop hv Consequences Ol Philosophy
(M Mundłak) (A) : - Meditatio
Medici (W. C. Bosanquet (R) 1176:
Philosophy of Religion versus Philo-
sophy of Science (A. Eagle) (A) S80
Phonostethograph EWES, ae Henriques) 686,
C. Lian) (C) 955
Ph: sphatases, 87, (A) 1062
Photography—clinical camera outfit, 1261
Physic and Faney (C. Howard) 612
Supplement to THE LANCET]
INDEX TO VOLUME I., 1937
[Aueust 14, 1937 xix
Physical education—for women (A. Abra-
hams) (C) 899; health resorts and,
004; in Scotland, 671; insurance
committees and (PI) 1027 ; Members of
Parliament and (PI) 670; national
scheme for (PI) 239, 358, 419, 487,
fp 1493, nutrition and, 147, (PI) 416,
A) 400, 882, (PI) 957, 1365
Physica] efficiency, see Fatigue
Physica) signs, see Diagnosis
Physical treatment—(Sir L. Hill) 1035;
“ Brevis ” ionizer, 1210 ; Electricity in
Therapeutics (H. H. U. Cross and
. Bourguignon) (R) 989; Institute
of Ray Therapy 1028 ; Physical Thera-
peutic Methods in Otolaryngology
(A. R. Hollender) (R) 874: short-wave
therapy (H. Taylor) (C) 1075,
congress of, 848, 1134; ultra-violet
light meter, 484; see also Fever
therapy and Health resorts
Phvsiology— Bainbridge and Menzies’
Essentials of Physiology (H. Hartridge)
(R) 815; Elementary Human Physio-
logy (S. F. Cook) (R) 1176 ; Elementary
Manual of Physiology (R. Burton-
Opitz) (R) 574; Experimental Physio-
logy (G. H. Bell) (R) 1468; Funda-
mentals of Human Physiology (J. J. R.
Macleod and R. J. Seymour) (R) 1056 ;
Human Physiology (P. G. Stiles) (R)
574; Laboratory Experiments in
Physiological Chemistry (A. K. Ander-
son)((R) 873; Physiological Principles
in Treatment (Sir W. Langdon-Brown
and R. Hilton) (R) 209; Practical
Physiological Chemistry (G. M. Wishart,
D. P. Cuthbertson, and J. W. Chambers)
(R) 873; Starling’s Principles of
Human Physiology (C. L. Evans and
H. Hartridge) (R) 393; Textbook of
Physiology (W. H. Howell) (R) 450
Physostigmine, see Myasthenia gravis
Picken, R. . F., change in age of
mortality from diphtheria, 1445
Pickworth, F. A., infection through
olfactory mucosa (C) 1076, 1548
Pilcher, R., cancer of cervical cesophagus,
73, (A) 96; pericardial resection for
constrictive pericarditis, 1323, (A) 1358
Pineal gland, precocity and, 62
Pinkerton, R. L. (O) 665
Pinnock, D. D., rectal trauma due to
rigid nozzle, 205
Pituitary gland—anorexia nervosa, blood-
sugar, and (J. H. Sheldon) 369, (Sir
W. Langdon-Brown) (C) 473, (W.
Sargant and W. S. Maclay) (C) 474,
(LA) 519, (C. W. Dunn) (C) 723;
basophil carcinoma of, Cushing’s syn-
drome and (A) 455, (H. Cohen and J. H.
Dible) (C) 597; gastric function and,
692, (H. Levy) (C) 1137, anemia and,
636, (A) 877, (E. C. Dodds and R. L.
Noble) (C) 953; cestrin, dwarfism,
tumour growth and (B. Zondek) 689;
posterior lobe pituitary, international
standard for, 653; see also Hormones
and Sex hormones
Placenta prævia, 636
Plague—Great Plague, Defoe and (E. J.
Holland) (C) 474 ;
Plant—development, animal hormones
and (E. D. Brain) 1241; viruses
(R. N. Salaman) 827
Plaster bed (F. P. Fitzgerald and K. I.
Nissen) 18 ;
Plastic surgery—L.C.C. unit for, 893;
of face (LA) 1057 S k
Platt, H., on peripheral nerve injuries, 386
' Pneumococcal infection —— amino com-
pounds in, 681, (A) 1061, 1476, 1517,
(A) 1536; bilirubinæmia and (Najib-
Farah) 505; see also Pneumonia
Pneumolysis, see Tuberculosis, pulmonary,
surgery of ;
Pneumomediastinum, see Mediastinal
Pneumonia—atypical (Die ‘‘ atypische ”
Pneumonie) (F. Kellner) (R) 761;
in childhood (A) 334, bronchiectasis and,
1527 ; jaundice and (C. A. Birch) 1046 ;
lipoid (A) 1239; Pneumonia (C. P.
Howard) (R) 696; serum treatment of
(G. J. Langley, W. Mackay, and L
Stent) 795, (A) 1121; tuberculous
focus and (W. Pagel) 1279; see also
Pneumococcal infectionand Respiratory
Pneumothorax—needle-holder for (D. A.
Herd) (NI) 208; see also Tuberculosis,
pulmonary
Pochin, E. E., relative as donor,164
Poison gas, see Air-raid precautions
Poisoning—carbon monoxide (LA) 154;
fluorine (A) 937, (Fluorine Intoxication)
(K. Roholm) (R) 1287; industrial, 27,
(Occupational iseases) (D. Hunter)
(R) 1112; mushroom (ML) 590;
nitric acid, 76 ,
a ee eee TESE
SS —— eee
Poisons, see Drugs and Pharmacology
Poland, J. (O) 1331
Poliomyelitis —- convalescent serum in
(G. H. Eagles, C. Jensen, and E. J.
Henningsen) 462; Ministry of Health
Memorandum on, 176; route of
infection in (A) 455, (LA) 875, (F. A.
Pickworth) (C) 1076, 1548, (G. W.
Rake) (C) 1433, neutralising anti-
bodies and (LA) 1532
Polvarteritis, see Arteries
Polyneuritis, see Nervous system
Polyposis of colon, congenital (A) 94
Pomerai, R. de, Future of Sex Relation-
ships, 1572
Poor-law—schools, 19th century, 1145,
(A) 1119; see also Public assistance
Popliteal artery, thrombosis of (A. M.
Boyd) 382
Population—birth-rate and, 531, 1364,
proper iy and, 1425; Future of Our
opulation (C. P. Blacker and D. V.
Glass) (LA) 933; Menace of British
Depopulation (G. F. McCleary) (LA)
933; trends of (PI) 481, 728, (C. A.
Gould) 944, (B. Dunlop) (C) 1017,
(LA) 1413, (PI) 1439 ; see also Contra-
ception, Sterility, and Vital statistics
Portal vein, see Diverticulitis
Porter, F. J. W., pruritus ani (C) 1202
Post-graduate courses: Aberdeen, 487;
Berlin, 61, 1565; Birmingham, 963;
British Postgraduate Medical School,
1258; Edinburgh, 895; Fellowship of
Medicine and Post-Graduate Medical
Association, 6, 181, 270, 343, 421,
469, 600, 730, 905, 1088, 1148, 1315,
1438, 1560: Glasgow, 1240; Joint
Tuberculosis Council, 118; Paris, 421;
Ocoy of Medical Officers of Health,
Post-mortems—coroners and (PI) 1084;
findings in Kenya (A) 1182; need for,
in sudden deaths, 927 ; physical signs
and, correlation of, 1464; Post-
mortem Appearances (J. M. Ross)
(R) 517
Post-operative—blood changes, dehydra-
tion and (W. W. Walther) 6, (LA) 32;
fibrinolysis (R. G.‘Macfarlane) 10;
results of splenectomy, 426; retention
of urine, doryl in (C. Moir) 261, (J. S.
Maxwell) 263, (A) 276, 940
Post ure—dorsal decubitus, 633; drain-
age by (H. V. Morlock) 381; electro-
cardiogram and (A) 578; renal calculi
treated by (R. Ward) 23; spinal
deformities and (P. Wiles) 911, (LA)
936, (W. A. Cochrane) (C) 1015, (H. W.
Crowe) (C) 1015, (C. Sparger) (C) 1076
Potassium, serum, intestinal obstruction
and (LA) 639
Poulton, E. P., oxygen tents (C) 471,
599; and Campbell, J. A., Oxygen
Tent and Nasal Catheter, 1113
Powell, D. A., on tuberculosis, 1185
Powell, N. W., Practical Preparations,
Mainly Medical (R) 393
Power, Sir D’Arcy, Royal Medical
Benevolent Fund (C) 661
Power, T. D., mental disorder and endo-
crine activities (C) 599
Practical Preparations, Mainly Medical
(N. W. Powell) (R) 393
Practice, medical—Introduction to
General Practice (E. K. Le Fleming)
(R) 210; mortgaging of (C) 52, (PCP)
420, 784; orthopeedics in general
practice (Alltagsorthopiidie des Prak-
tischen Arztes) (S. Romich) (R) 815;
perspective and poise in (A) 11380;
see also Maternal mortality, Public
medica] service, and—
Practitioners—Adler and, 1373, (Sir W.
Langdon-Brown) (C) 1433, (C) 1548 ;
air-raid precautions and (PI) 419;
ambulance not ordered (ML) 531;
Antarctic exploration and, 611 ; defence
societies, 1568, (A) 1535; dismissal of,
under Lunacy Act (ML) 1481; Doctor
at Work and Play (S. H. Snell) (R) 991 ;
examination by, under Lunacy Act
(ML) 1422; foreign, admission of
(PI) 1378; hire-purchase research
and (ML) 341, (C. M. Fegen) (C) 660 ;
insurance (PI) 729, dental work and
(PCP) 345, (PI) 420, (PCP) 1549,
(ML) 1541; Irish, residence bar and,
1131, 1245; Kipling and (V. Bonney)
1501; Meditatio Medici (W. C.
Bosanguet) (R) 1176; ophthalmic
group of, 1569; payment of (ML)
466, 1006, by colleagues, 775;
Physician, Pastor, and Patient (G. W.
Jacoby) (R) 762 ; Practitioners’ Library
of Medicine and Surgery: Vol XI.
(G. Blumer) (R) 989 ; Scalpel and Sword
(Sir J. Elliott) (R) 991; scholarships
`
for, in United States, 835; Traveller’s
Rest (P. Gosse) 850 ; Viennese, numbers
of, 1560; will, doctor’s evidence and
(ML) 1189, (E. W. Goodall) (C) 1252;
see also Ethics, medical, History,
medical, Negligence, Panel and Con-
tract Practice, and Practice, medical
Precocity (C. R. Croft) 62
Pregnancy —air trapsport in (F. P
Mackie) (C) 475; anæmia in (W. J. S.
Reid and J. M. Mackintosh) 43, (A) 96 ;
diabetes and, 1173; extra-uterine,
758, (R. R. D. Karki-Pahwa) 1228,
hæmoperitoneum and, 1451; beart
disease and (K. Harris) 677; in
U.S.S.R., 648; neuritis, vitamin B
deficiency and (A) 159; toxæmias of
(R. Coope) 121, 1466, calcium and
vitamins in (G. W. Theobald) 1397,
(R. H. Paramore) (C) 1486, (J. L.
Moir) (C) 1486; varicose veins in,
1173; see also Aschheim-Zondek,
Eclampsia, Obstetrics, and Œstrin
Prescribing—Favourite Prescriptions (Sir
H. Rolleston and A. Moncrieff) (R)
152, (LA) 153; see also Panel and
Contract Practice and Pharmacology
Prest, E., presentation to, 607
Preston, G. L., needle holder (NI) 992
Price, G. B., cardiovascular changes
following arteriovenous aneurysm, 206
aa A. D., on care of tuberculosis,
Pringle, J. H., cutaneous melanoma, 508 |
Prisoners and captives, see Mental
hospitals
Prisons—Armley Gaol, Leeds, deaths in
(PI) 1085; children born in (PI) 728,
1564; conditions in (PI) 666; Kenya,
deaths in (PI) 1084; service in, tests
for (PI) 1313; see also Crime
Privilege, see Ethics, medica]
Prognosis—Principles of Diagnosis, Prog-
nosis, and Treatment (R. Hutchison)
(A) 879; Prognosis (THE LANCET)
(LA) 1177
Prolapse, operation for, 759
Prontosi], see Chemotherapy
Proom, H.,p-amino benzene sulphonamide
in bacterial meningitis (C) 661 ; p-amino-
benzenesulphonamide in meningococcal
infection, 16, (LA) 211
Proseptasine, see Chemotherapy
Prostate—perurethral operations and (A)
277, 1053; prostatectomy, 326, 1052,
needle-holder for (J. C. Ross) (NI) 150 ?
see also Genito-urinary
Prostigmin, see Myasthenia gravis
Prostitution—conference ` on, 968 ;
TE 590 ; venereal disease and,
Protamine, see Insulin
Protein—in ulcerative colitis (A) 937;
see also Milk and Nutrition
Pruritus ani (J. W. Riddoch) 919, (C)
1138, 1251, (A) 995, (R. H. Browne-
Carthew) (C) 1076, (J. T. Ingram) (C)
1137, (F. J. W. Porter) (C) 1202
Pseudo-methxmoglobin, 1524, (A) 1533
Psittacosis (A) 1120
Psychiatry—American Psychiatric
Association, 1424 ; demonstrations, 49 ;
in voluntary hospitals (LA) 875, 904;
Preface to Nervous Disease (S. Cobb)
(R) 638; Theory and Practice of
Psychiatry (W. S. Sadler) (R) 151;
see also Mental disorder and—
Psychology—Adler, A. (O) 1373, (Sir
W. Langdon-Brown) (C) 1433, (C) 1548 ;
Borstal vocational inquiry (LA) 575;
Clinical Psychology (C. M. Louttit)
(R) 88; Common Sense and Psycho-
logy (A. Maberly) (R) 816; dissociation
and repression, 1338; Health of the
Mind (J. R. Rees).(R) 991; industrial
medicine and, 362; Institute of
Medical Psychology (Tavistock Clinic
543, 847, 904, (Sir H. Brackenbury
(C) 953, (A) 1000 ; Man, The Unknown
. Carrel) (R) 210; medical, 363,
487, (A) 1474, 1525, congress of, 1031 ;
Modern Discoveries in Medica] Psycho-
logy (C. Allen) (R) 816; primitive
social relations, lectures on, 363;
Statistical Methods in Biology, Mcdi-
cine and Psychology (C. B. Davenport
and M. P. Ekas) (R) 90; Towards
Peace of Mind (K. M. Bowman) (R)
931; unwilling patient, 25; see also
Behaviour, Children, Mental disorder,
Nervous disorder, and War
Psychoses, see Mental disorder
Psychotherapy, see Psychology
Public assistance—district medical service
(PCP) 167; institutions, old age
pensioners in (PI) 1144; persons over
70 and (PI) 1564; persons transferred
from, to U.A.B. (PI) 1564
xx Supplement to THE LANCET]
INDEX TO VOLUME L., 1937
[Aueust 14, 1937
Public Authorities Protection Act, 64
Public shealth—congress, 1257, 1312,
1364; Manual of Public Health
Laborator Practice (J. R. Currie) (R)
761; c Health o 1936 (D.
Pol T CR) outs Public Health ani
Hygiene (C. F. Bolduan and N. W.
Bolduan) (R) Rural Health
Practice (H. S. Santana) (R) 874;
see also Health services and Vital
statistics
PUBLIC HEALTH.—Atmospheric pollution,
1255, 1299—Chlidren, causes of
death in, 299—Diphtheria epidemic,
664—Fracture clinic, 785—Health :
indices, 476; national campaign for,
785—Influenza epidemic, 117, 175,
240, 301, 360, 421, 1073—London
County Council : hospitals, 538, 785;
maternity and child welfare scheme,
844; medical members of, 785;
midwifery service, 156 7—Maternal mor-
tality Willesden, 300; Ministry
of Health's circular on, 1 i99—-Maternity
and child welfare: in London, 844;
in Somerset, 1256—Mental disorder : :
Board of Control for Scotland, 1012;
Maudsley Hospital report, 47 6—Mid-
wifery: London service of, 1567;
Scottish service of, 1436; Smethwick
scheme for, 421;
wives, 1199—Milk : accredited, 359;
examination of (J. S. Faulds) 949,
(M. L. C. Maitland) 1297 ; compulsory
pasteurisation of, 1012; "typhoid out-
break and, 1379—Ophthalmia neona-
torum, 359—Poliomyelitis, 176—Public
Health Act, 664—Refresher courses,
1490—School-child, health of, 59—
Scotland: Board of Control], 1012;
maternity services, 1436; sickness
statistics, 898—Small-pox : in Fails-
worth, 360 ; vaccination | and (D.
Forbes) 17 4-—Streptococcal infection,
hospital closed for, 664—Typhoid fever
in Bournemouth, 898, 1379—Venereal
diseaee, publicity for, 1255—Vital
statistics for, 1936, 240—Welsh tuber-
culosis scheme, 359°
eee: medical service in Essex (PCP)
Puerperal infection—(PI) 1491; ambu-
lance journey and (ML) 1068 ; inactivity
in treatment of, 1154; L.C. C. unit for,
893; Medical Research Council on,
710; prevention and treatment of,
1466; ; remote effects of (M. Kenny) 14,
(A) 218; see also Maternal mortality
and Streptococcal infections
Pulmonary, see Lung
Pulvertaft, R. J. V., on reactions after
transfusion, 7
Purgation (L. Witts) 427, (LA) 453,
(F. G. Chandier) (C) 535, (V. Small-
O 298 (C) 535, (S. Churchill) (C) 599,
ura, see Hæmorrhage
Dee ocystitis, see Urinary infections
Pygott, F., pancreatic cancer
diabetes, 1461
Pylephlebitis, see Diverticulitis
Pyloric, see Stomach
Pyorrheea, s see Ora]
Pyrexia, see Fever therapy and Tem-
perature
Q
Quarantine, limited: (A) 335
Queen’s Univers Club, London, 905
Querido, Home Care of the Mental
Rte 734
Quinsy, instrument for (J. T. R. Edwards)
(NI) 272
R
Rabies in United States, 1424
Race—disease and (Rasse und Krankheit)
(J. Schottky) (R) 1230 ; Jews, mortality
of (A) 1295; see also Anthropology
Racker, D. C., on ruptured uterus, 269
Ra diography—Atlas of Radiographs (A.P.
Bertwistle) (R) 637; Manual of
Radiological Diagnosis qd. ©. Cc.
Tehaperoft) (R) 1529; of alimentary
tract, 490, 985; of congenital dis-
location of hip (A) 119; of dermoid
supervision of mid- Rainsford, S. G.,
.Rectal—bougie (J. P.
with.
cyst (C) 662; of right-sided aortic
arch (A) 454; physical signs and,
1464; radiogram and radiograph LE
Brailsford) (C) 233, 350, (C) 233,
(Q 293, (S. C. Shanks) (C) 350, (O) 412,
R. B. Myles) (C) 66l; radiologist’s
report, patient and (ML) 833; Roentgen
Interpretation (G. W. Holmes and
H E. Ruggles) (R) pole Roentgeno-
graphic Technique (D Rhinehart)
(R) 210; tomograph, manoel Y
1294 ; Urological Roentgenology (M. B
Wesson and H. E. Ruggles) (R) 209 :
see also Arteries, Intracranial, Thoro-
trast, Tuberculosis, and—
Radiology—congress ‘ot, 420, 847, 1029;
see also Radiography and X rays
Radiotherapy, see X rays and—
Radium—(Sir L. Hill) 1035; Canadian
(A) 217; Emanotherapy (F. H.
Humphris and L. qr amna) (R) 1231;
ncer (LA) (A) 332, 629,
$93, “987, (A) 1059, 1309, 1462, 1488 ; in
Dupuytren’ S contracture (A) 157; i
in gynæcology (Radiothérapie gynéco-
logique) (R. Mathey-Cornat) (R) 1287;
pneumatic transference o (A) 580;
radon-seed introducer (F. J . Clemingon)
(NI) 30; research, 733, 10. 32; supply
of, 183; see also Thorotrast
Rae, J. B., on problem of war (A) 1240
culture bottle for
vaccines (NI) 1528
Raistrick, H., immunisation with Bact.
typhosum, 252, (LA) 274
Rake, G. W., infection through olfactory
mucosa (C) 1433
Rand, H. W., and Neal, H. V., Com-
parative Anatomy (R) 392 -
Rankin TERTS Fund, 543
Ransom, F. (O) 602
Ranson, R. M.,
survival, 1400
Rasmussen, H., on Graves’s disease (A)
rubber and sperm-
pulmonary fibrosis in
Reactions of the Human Machine (J. Y.
Dent) (R) 991 -
Read, J., Prelude to Chemistry (R) 89
Reader, D., diet in urinary infection, 1043
Lockhart-
Mummery) (NI) 874; cancer, 988,
lymphatic spread in (Operations of
Surgery) (R. P. Rowlands and P-
Turner) (R) 209, (W. H. Ogilvie) (C)
290; evipan (A) 97; trauma, due to
rigid nozzle (D. D: Pinnock) 205;
see also Ano-rectal and Purgation
Red age see British Red Cross and
Spain
Rees, J. R., Health of the Mind (R) 991
Refugees—medical, admission of (PI)
1378: see also Spain
Regency Bill (PI) 416, 539
Registrar-General, see Vital statistics
Rehabilitation, see Accidents, Fractures,
and Industrial medicine
Reid, H., on lobectomy, 987
Reid, R., ’ renal tuberculosis (C) 411
Reid, Ve J. S., aneemia in pregnancy,
Renal, see ‘salovli, Genito-urinary, and
ey
RNE: he T., stovarsol in neurosyphilis,
REPORTS AND ANALYSES.—Vermouth
coo Red and Dry (Stambois, Ltd.)
Reprints, page Pum pers on (J. H.
Sequeira) (C) 10
Research—Beit tellowships, 790 ; Depart-
ment of Scientific and Industrial
Research, 733, 1255; director of,
1154; Hunter’s work’ (Lord Horder)
587; in East Africa (PI) 843; in
Ireland, 343; surgery (Sir D.
Wilkie) 735; in United States (A) 702;
National Physical Laboratory, report,
1032; on discases of blood, 353;
on encephalitis, 180; on rheumatism
(A) 1418; Royal College of Surgeons’
laboratories, 284; Schorstein Research
Fellowship, 108 88; see also British
Empire Cancer Campaign, Tadustrial
Health Research Board, Medical
Research Council, Rockefeller Founda-
tion, Scholarships, and—
Research Defence Society—(A) 581;
Paget lecture a 1417, 1477
Respiratory—Chronic Diseases of the
Respiratory Tract (E. H. Funk and
B. Gordon) (R) 638; Diseases of
Respiratory Tract (R) 992 ; efficiency
infection, endotracheal anæs-
(A) 879;
thesia and (A) 1183: infection, in
ee a a a, a el
children, 1527; infection, suscepti-
bility to (A) 64, nutrition and, 811;
system, asphyxiating gases and, 810;
see also Colds, Inhalation therapy,
Lung, Nose, Tetany, and—
Respiratory stimulants—ethyl strychnine
(A) 1000 ; in asphyxia neonatorum (A)
995, 1466
Retention, see Post-operative
Retina, see Eyes
Retroperitoneal, see Peritoneum
Reynolds, R. J., on movements of
digestive tract, 490
Rhabdomancy (ML) 228
Rheumatism—eetiology of, 1420; British
Committee’s report on (C. W. Buckley)
(A) 217; campaign against, 1366,
(A) 1418; Charterhouse Rheumatic
Clinic Original Papers (A) 581; clinic
for, 1260 ; congress on, 1206 ; Diagnosis
and Treatment of Arthritis (R.
Cecil) (R) 1409; fever therapy in,
1007; gold in (W. S. C. Copeman and
W. Tegner) 554, (H. S. Pemberton) (C)
662; L.C.C. unit for, 893; nose and
throat in (H. Barwell) 67; pathology
of (A. G. T. Fisher) 1162, 1366; rest
nour. for, 229, ( AT UPREIS in Women)
(R. F. Fox) (L A) 273, (W. A. Cochrane)
(C) 346, (B. Se hiesigen) (C) 347,
(A. W oodmansey) (3) 2475 (Cu “ve
Buckley) (C) 410 : see also—
Rheumatism, juvenile—zetiology of, 1420 ;
antifibrinolysin and (A) 820; chorea
and (A) 581; fever therapy in, 1007 ;
heart disease and, convalescence and
after care of, 229, 1032; heart disease,
vitamin C and, 973: nodules, spon-
taneous and induced (A) 766; patho-
logy of (A. G. T. Fisher) 1162 ; pneumo-
coccus and (Najib-Farah) 505 ; treat-
ment of (R. Lightw ood) 613
Rhinehart, D. A
toentgenographic
Technique (R) 210
eign take E., on effects of spinal irrita-
ion
Richards, Pa E. (O) 54
Richardson, B. W., and Frost
Snow on Cholera (R) 992, (LA) 993
Riddell, J., nitrous oxide analgesia in
obstetrics (C) 723
Riddoch, J. W., pruritus ani, 919, (A)
995, Ċ) 1138, 1251
Rider’s bone (A. Moore) 264
Riggall, C., and Riggall, F., endometrioma
of vulva (C) 475
Road accidents—alcohol and, 183, (PI)
357, 787, insulin and, 694, ML) 716 ;
ambulance rules and L) 286;
Commissioner of Police report on (LA)
1290, Men 1357; hospital coöperation
and, 358; in Treland, 467; school-
children KEW (PI) 297, 824; see also
Accidents and Motorists
Ronda, aring of, 718, (R. S. Creed) (C)
9, (A. L. Vischer) (C) 899
Roberts, H., Medical Modes wad Morals,
7
Roberts, H. C. (O) 782
Robinson, G. L., pronto, an strepto-
coccal infection, 209, (A) 5
Robinson , Bell’s 8 Sale ee Food and
Drugs RD 303°
Roche, H., artificial pneumothorax Ay des FA
Rockefeller Foundation, 543,
1088, (A) 1181, (LA) 1289, ters
Rockefe er, J. D., death of (LA) 1289
Rodger, T. R., on otitis medla, 1171,
, on atmosphere of Halifax,
Roentgenology, see Radiography
Rogan, J. M., gluteal aneurysm, 1516
Rogers, L., urethral rupture without
extravasation (C) 232
Rogol, B., dacryoadenitis, 982
Roholm, K., Fluorine Intoxication (R)
7
Rolleston, Sir H., British Encyclopædia of
Medical Practice (R) 760, 1341; and
Moncrieff, A., eee Prescriptions
(R) 152, (LA) 15
Rolleston, D., History of the Acute
Exanthemata (R) 1229, (A) 1414
Romich, S., Alltagsorthopadie des Prak-
tischen Arztes (R) 815
Ronaldson, G. W., on appendix in
measles (A) 278
Roper, R., over-treatment of gonorrhcea
(C) 1016
Rosenthal, D. B. striæ atrophicre cutis, 557
Ross, J. È., needle-holder for prostatec-
tomy (NI) 150
Roe, Es M., Post-mortem Appearances
Ross, T. A., Common Neuroses—Their
Treatment by Psychotherapy (R) 1230 ;
on the psychological approach, 1525
Supplement to THE LANCET]
'
INDEX TO VOLUME I., 1937
[Avaust 14, 1937 xxi
Rowlands, I. W., anti-gonadotropic
serum, 924
Rowlands, R. P., and Turner, P., Opera-
tions of Surgery (R) 209
Rowntree, S., Muman Needs of Labour
(LA) 1411, (PI) 1441
Royal Air oree—health of (A) 332; see
also Service
Royal College rot oL ayet iinn of Edinburgh
— fellows, 206; fellowships,
1028, EnA foison lectures, 1559;
pass list, 36
Roya! College of Physicians of London—
appointments, 361, 789; British Com-
- mittee on Chronic Rheumatic Diseases,
report (A) 217; carbon monoxide
poisoning (LA) 155; diplomas, 242,
Bel, 730, 789, 963, 1147, 1497; - elections,
361, 765, 789, 1148; fellows, 1147 ;
hospitals "approved, 487 : lectures, 361,
458, 582, 1147, 1240; licences, 361,
789, 1147; members, 361, 14
Milroy lectures, 969, 1033, 1093, (LAS
1117; Mitchell lecture, 247 ; presi-
dential election, 765 ; Prophit’ scholar,
7
Royal College of Surgeons of Edinburgh—
diplomas, 1257; fellows, 1257; pass
list, 362
Royal College of Surgeons of England—
appointments, 242, 487; demonstra-
tions, 607; diplomas, 242, 361, 487,
730, 963, 1147, 1257, 1497: election,
730; examiners, 1497 ; fellows, 963,
1257: ; hospitals approved, 487, 730,
963, 1257; Hunterian Festival Dinner,
475: Hunterian lectures, 911, 1211,
1263: lectures, 61, 118, 185, (A) 457,
490, 607, 851, 904; licences, 361, 730,
1147; ‘medals, 963, 1257 1497:
pass list, 1497; prizes, 242, 963, 1257;
research "laboratories, 242, 28
Royal Faculty of Physicia ns and Surgeons
of. Glasgow—fellows, 180, 1087, 1148,
1437; pass list, 362
Royal Institute of Public P caith, 1149,
1257, 1312, 1364, (A) 1418
Royal Institution of Great Britain, 118,
9
Royal Medical Benevolent Fund (Sir
D’Arcy Power and L. G. Glover) (C)
661, 672, (A) 770, 1293
Royal Microscopical Society, 180, 422
Royal Navy Medical Club, 847
Royal Sanitary Institute, 242, 303, 359,
1028, 1207, 1569 1146;
Royal
fellows,
Royal Society of Arts, 118, 303, 1206,
1209, 1378
Royal Society of Edinburgh, 336
Royal Surgical Aid Society (A) 1059
Royal Veterinary College (PI) 541, 672
Ruggles, H. E., and Holmes, ’G. W.,
Roentgen es abe ( R) 637 ;
and Wesso M. B, Urological
Roentgenolory (R) 209
st. J., Your Stammer and
Society—conversazione,
(R) 874
Russell, A. E., four thousand Basque
children, 1303
(9) 1371, (A) 1418;
medicine oe U.S.S , 648
sks A.V ‘Lange 8 paralysis, 143
Russell, D. S., thorotrast in cerebral
arteriography, 377
Russell, L. W., ADOR yanig shock in
schizophrenia, 747, (C) 120
1354; health
Russia—birth-rate in,
resort in, 45; maternity and child
medicine in (R. H.
welfare in, 867 $
Dobbs and A. Russell) 648, (G. G.
ea, Me oo
Sherriff) (C) 733, 1000:
and Food in the U.S.S
Gros Clark and L. N. Brinton) ( E 280
State trials (LA) 330 ; oes medical,
1438; tuberculosis in (P. M . D. Hart)
651, 969; women in, 892
Ryle, A., civilian ambulance ae
(C) 721; heemorrhage in peptic ulcer, 1
Medical Peace Campaign (C) 1250 ; :
on iaboratory training, 267
S
Sachs, B., Keeping Your Child Normal,
. Sack, L. S., and Harris, R. W., Medical
Insurance Practice (PCP) 469, 720
Sacro-iliac strain (R. Y. Paton) 1051
Sadler, W. S., Turory and Practice of
Psychiatry (R) 15
Sainsbury, H., death oE 40, (O) 115
Sain. Ace F. M., Surgical Note-taking
Saint, Sana? B.I.P.P. in acute osteitis,
121 1,
Hospital “Medical
St. Bartholomew’ 8
St Morar ae
en ence Brigade, golden
jubilee, 114
St. Mary’s Hocpital medical school, 549
Salaman, R. N., plant viruses, 827
wens eae therapy—(A) 998; see also Water
ala
Salmonella ES H. Fisher) 623;
see also Food poiso
Samuel, N., cretinism in London, 1505
Sanatorium, see Papworth
Sandiland, E. L., on tuberculosis, 1366
Sansum, W. D. are, R. A., and Bowden,
R, Normal Diet and Healthful Living
Sarcoma, see Cancer
Sargant, W., anorexia nervosa (C) 474
Saunders, J. C., alum-precipitated toxoid
in diphtheria prevention, 1064
Savage, W. G., on future of obstetric
e 1285; on milk and disease,
Savatard, L., on tumours or e skin, 758
Savill, A. apd Savill, T. , System of
Clinical’ Medicine (R) 516.
Scabies, see Skin
Scalpel and Sword (Sir J. Elliott) cu a31
Scaphoid, Köhler’s disease and (A) 1
Scarborough, H., on ascorbic aaa” =
urine, 48
Scarlet fever—milk and (PI) 297, 357,
513, (PI) 605, 669; treatment of, 389 ;
wards, cross-infection in (LA) 1934:
see. also Streptococcal
Scheel, O., tuberculin reactions and radio-
logical findings, 922
Schistosomiasis—Banti’s syndrome and
(A) 642; continuous venous hum in
R. Kenawy) 1281
Schizophrenia, see Mental disorder
Schlesinger, B., rest houses for rheumatoid
arthritis (C) "347
Schlesinger, M. (O) 413
Schnohr, E., calcium mandelate in
urinary infections, 1104
Schoemaker, J., on modified Billroth I
operation, 245
Scholarships—British Medical Associa-
tion, 1 180 ; Dickinson Scholarship Trust,
847 ; for practitioners, in Unite States,
835; Grocers’ Company, 303; Tata
Memorial, 1499
School-children—air-raid precautions and
967 ; Deaf Children (School Attendance)
Bill (PI) 786; health and nutrition of
(PI) 240, Board of Education repor
on, 59; homework and (A) 1358;
meals and milk for (A) 39, 59, (PI) 240,
298, 363, (A) 399, (PI) 414, 515, (A)
824, (PI) 843, 898, (PI) 1085, 1196; open-
air schools for, 368; poor-law, 1145,
(A) 1119; road safety and (PI) 297;
routine and health of (J. Allan) G74,
(D. M. ee and G. Somerville)
(C) 723, (J. E. Cheesman) (C) 838;
special schools (A) 1292; tuberculosis
and (PI) 1086; see also Diphtheria,
Nursery schools, Physical education,
and—
School medical vier 59, (PI) 419,
(A) 1292, (PI) 1494, 1565
Schorstein Research Fellowship, 1088
T aed a , Rasse und Krankheit (R)
Schrötter, L. von, centenary of, 243, 717
echudo L., Manual of Blood Morphology
on pathology of bone-
Schultz, W., on aplasias, 1403
Schuster, N. H., aneurysm of sinus of
Valsalva, 507; medical education of
women NA 954.
Sciatic scoliosis (E. N. Wardle) 749
en ey Science, in Cambridge
(R. T. Gunther) (R) 1409: peace and,
TIT Philosophy of Religion versus
Philosophy: of Science aese) oy
880: Science Fights Death ;
Murray) 910 ; What Science Stands For
(R) 991; see also Pathology and
Research
Scoliosis, see Posture and Spine
Scotland— Department of Health, 671,
898; distress in (PI) 58; Divorce
(Scotland) Bill (PI) 482 ; housing in
(PI) 841, 962, 1314, 1496: insurance
prescribing (PGP ) 951; Local
Government (Financial Provisions)
(Scotland) Bill (PI) 1025; maternal
mortality in (PI) 357; Maternity
Services (Scotland) Bill (PI) 354
418, 539, 1025, 1143, 1436; mental
health in (PI) 670, 1012; mental hos-
pitals, nurses’ hours in (PI) 1496;
methylated spirits, sale of (PI) 484,
540, 1563; milk, pasteurisation of,
1012 ; ophthalmic benefit in (PI) 298;
physical training in, 671
SCOTLAND, CORRESPONDENCE FROM.—
Ascorbic acid in urine, 48—Cerebral
degeneration, experimental, 1559—
Curriculum, reform of, 1189—Dis-
orders of conduct, 1559— Edinburgh
toyal Infirmary, 166, 1009—Edin-
burgh University Hall, 1009—Ether
anesthesia, discoverer of, 894—Facial
expression of sick child, 1427— Glasgow:
hospitals, 230, 407 nurses’ home,
167—Occupational therapy, 1427—
Post-graduate teaching, 895—Public
dispensaries, 40 7— Rheumatism, 229—
Royal Medical Society, bicentenary of,
654—Summer vacation, 775, (C)1252—
Tabes dorsalis, 655
Scott, A. M., anginal syndrome in
pneumo mediastinum, 1327
Scott, B A 781
Scott, D » Your Child’s Health, 611
Scott, Ga DA Morphine Habit "and its
Painless Treatment (R) 1529
Scowen, E. F., hormone treatment of
undescended testis (C) 663
Scurvy—carditis and (S. Taylor) 973;
see also Ascorbic acid and Hæmor-
rhage
Seamen’s Hospital Society, 1100
Secrecy, see Ethics, medical
Sein, M., lymphatic, Cyst of ear, 1281
Semple, Sir D. (O
Sensitivity, see e e
Sepsis, see Or
Septicæmia, see Chemotherapy
Staphylococcal infection
and
mk ores . H., page numbers on reprints
(C) 101
SERVICES, THE.—Army Medical Services,
468, 606, 663, 837, 895, 948, 1029, 1077
1256, 1496, 1567—Colonial Medical
Service : 230, 409, 726, 948, 1200,
1496—Deaths in the Services : 49, 231,
Le we an 537, O 895, 948, 1
468, 537 780, S38.
1146, 1200, Obst, 1299, 1352, 1432,
1496, 1567 dinner,
reorvatiaation of, 837, 1077 Toya Air
1029, 1077, 1146; 1200,
1352, 1432, 1496, "1567 Royal Ac
Medical Corps : 49, 109, 177, 330. 2 B88,
352, 409, 468, 537, 606, 663, 726, 780,
838, 895, 948, 1029, 1077, 1146, "1200,
1256, 1299, 1352, 1432, 1496, 1567—
Royal Naval Medical Service : 49, 109,
177, 230, 288, 352, 409, 468, 537, 606,
663, 726, 780, 837, 895, 948, 1029, "1077,
1146, 1200, 1256, 1299, 1352, 1432,
ae 1567—Territorial Army Hospitals,
J
Sex—education in, 567; Frigidity in
Women (E. Hitschmann, E. Bergler
and P. L. Weil) (R) 697; Future of
Sex Relationships (R. de Pomerai)
1542; History of Modern Morals (M.
Hodann) (R) 518; Sex in Religion
(G. S. Marr) (R) 1468; see also Homo-
sexuality and—
Sex hormones—corpus Iutenn hormone
and menstruation (T. N. Morgan and
S. G. Davidson) 861; ‘in Pee
(A) 1121; in sterility (A) 383
undescended testes (T. W. Mimprias)
497, (C) 778, (P. Wiliams) (C) 597
(P. M. F. Bishop and A. C. Hampson)
(C) 598, (A. W. Spence and E. F.
Scowen) (C) 663, 737, 1053; lactation i
and (A) 1060, 1443, 1478; male, .
research on, 1421; > Manchester hor-
mone clinic, 447 ; method of administer-
ing (LA) 1354; ovarian tumour,
change in sex characters and, 1134:
precocity and, 62; suprarenal gland
and (W. Cramer and E. S. Horning)
1330; uterine contractions and (A)
457; see also Endocrine system
Hormones, Œstrin, and Popa oe pend
Seymour, R. J., and Macleod
Fundamentals of Human phsclolong
Shackman, R., extension apparatus for
forearm and wrist fractures (NI) 572
Shafar, J., acute ascending flaccid
paralysis, 1275
xxii Supplement to THE LANCET]
INDEX TO VOLUME I., 1937
[AucustT 14, 1937
Shanks, S. C., on radiography of alimen-
tary tract, 986 ; : ee and radio-
graph (C) 350
T S., unusual “case of choking,
7
Shaw, B. H., insulin shock treatment of
schizophrenia (C) 1251
Shaw, F., on varicocele in female, 759
SAAN nie E., medical education of women
Shaw, W., on cee to childbirth (A) 218
Shaw, W. V. (O) 29
Sheldon, J.
(LA) 519
Sheldon, W., Diseases of Infancy and
Childhood (R) 516; on diet in child-
hood, 1365
Sherlock Holmes (D. P. S. Conan Doyle)
(C) 292
SHON t G. G., medicine in Russia (C)
7
Shields, C., Hay Fever (R) 449
Shock— theories of (A) 214, 456, 821, (LA)
993: sec also Post- -operative and Water
balance
mercer R. E., on influenza immunisation
Shore, B. FR., on palliative treatment of
cancer, 968
Short waves, see Physical treatment
Shryock, R. H., Development of Modern
Medicine (R) 392
Sieger, A. S. (O) 486
Signy, A. G., on congenital syphilis, 388
Silicosis, see Mines,
Simmonds’s disease, see Pituitary gland
Simpson, A. M., over-treatment of
gonorrhea (C) 899
Simpson, C. K., adrenal gland and sudden
death, 851
Simpson, S. L., Medical Diagnosis (R)
516; on mental disorder and endocrine
glands, 443
Sinclair, R., Metropolitan Man, 1153
Sinclair foot-p iece (R. S. Woods) 307;
(H. E. Gritiths) (C) 472
Sere teak K., ambulance in Spain
)1
Sinusitis—in children (LA) 93, (N.
Asherson) (C) 170, (W. A. Troup) (C)
233, (C. H. Thomas) (C) 351, bronchiec-
tasis and, 1527; orbital cellulitis and,
1526 ; rheumatism and (H. Barwell)
67; see also Maxillary antrum and
Nasopalatine
Sinus of Valsalva, see Aneurysm
Skeleton, see Bone
Skin—alLergy and (A) 524; and mucous
membranes, neevocarcinoma of (I. G.
Williams and L. . Martin) 135;
cancer of, 135, 508, 758; cheiro-
pompholyx, tropical (D. Fitz-
Patrick) 25; Cosmetic Dermatology
(H. Goodman) (R) 762; Ehlers-Danlos
syndrome (A) 458; epiloia, tumours
of nail-beds and (S. G. James) 1223;
erythema multiforme (C) 792 ; Introduc-
tion to Dermatology ; Moles-
worth) (R) 88; pres cheilitis
(A) 398; melanoma, of (J. H. Pringle)
508; motor fumes, dermatitis and
(A. Whitfield) 265, (J. T. Ingram)
. (C) 347 ; pemphigus neonatorum, 397 ;
scabies, benzyl benzoate in (A. ’' Kiss-
meyer) 21; striæ atropbicæ cutis (D. B.
Rosenthal) 557; Year roe of Derma-
tology and Syphilology (F. M
M. B. Sulzberger) (R) 990;
Pruritus
Skinner, E. F., diabetic coma, 627
Skull—craniofacial dysostosis (C. Allen
(C) 350; see also Head injuries an
Intracranial
Sleep, physiology of E ore
Sleeping sickness (A) 9
Sloan, E. P., The eycoil (R) 518
Smallpiece, V , ritual purgation (C) 535
Smali- pas eat Failsworth, 360; at
Oldham (PI) 297; vaccination in
contro] of (D. Forbes) 174; see also
Vaccination ;
Smallwood, W. C., pernicious anæmia
in infant (C) ae 1307
Smart, D. (O) 101
Smart. W. A. M., nad Dixon, W.,
of Pharmacology (R) 696
Smirk, F. H., on histamine (A) 456
Smith, E., on sudden death, 927
Smith, Sir G. (O) 113, 179
Smith, K. S., left inframammary pain,
1267
Smith, S., diaminosulphone in strepto-
coecal infections, 1331, (A) 1357, 1536
Smith, Sydney, on curriculum, 1190
Smith, S. W., on sea climate, 715
Smith, William, kaolin, kaolin- alumina,
and. fecal bacteria, 438, (LA) 453;
mumps and Wassermann reaction, 7ot
H., AEEA nervosa, 369,
. Wise and
see also
Manual
ec ts UA yf
Smith, Wilson, on influenza immunisa-
tion (LA) 575
Smithers, D. W.,
epilepsy (C) 1016
Smoke, see Atmospheric pollution
Snel, o> Doctor at Work and Play
Snow on Cholera (B. W. Picher ison and
W. H. Frost) (R) 992, (LA) 9
Social services, see Health betes
cysticercosis and
SOCIETIES, MEDICAL
ASSOCIATION OF CLINICAL PATHO-
LOGISTS.—Blood transfusion, 1523,
(LA) 1531, 1538; Serre *patho-
logist, future status of (S. C. Dyke)
365; demonstrations, Boo gonor-
rhea, laboratory diagnosis "of, 387;
meeting, 302 ; syphilis, diagnosis of,
ASSOCIATION OF INDUSTRIAL MEDICAL
OFFICERS.—Accident proneness, 705;
industrial psychology, 362; re-
habilitation, 705
ASSOCIATION OF PUBLIC VACCINATORS.
—Meeting, 548
BRITISH ASSOCIATION OF RADIO-
LOGISTS.—Cancer of breast, after-
care of, 1488, (F. Hernaman- Johnson)
(C) 1549; dinner, 1499; low
voltage near-distance X ray therapy,
1488; meetings, 303, 1314; ventri-
culography, 1489; wave-length in
radiotherapy, 1488
BRITISH INSTITUTE OF RADIOLOGY.—
Cerebral arteriography, 207
BRITISH PSYCHQLOGICAL SOCIETY.—
Dissociation and repression, 1338;
psychotherapist’s training, 367; sex
pucao, 567; unwilling patient,
CAMBRIDGE UNIVERSITY MEDICAL
Boe eben SI ReUMEe (R. S. Woods)
EDINBURGH OBSTETRICAL SOCIETY.—
Placenta previa, 636
EDINBURGH PATHOLOGICAL CLUB.—
Ascorbic acid in urine, 48; experi-
mental cerebral degeneration, 1559
GERMAN HÆMATOLOGICAL SOCIETY.—
Ansemias, 1404; aplasias, 1403;
blood-platelets, 11403: bone-marrow,
athology of, 1403; congress, 1402;
eucocytes, 1404: monocytes, 1402 ;
parasitology, 1404
HARVEIAN SOCIETY.—Buckston Browne
dinner, 1498; lecture, 735
HUNTERIAN SOCIETY.—Banquet, 302 ;
dinner, 543; Hunterian lecture, 245;
a Oration, 397, 587; medal,
INSTITUTE FOR THE SCIENTIFIC TREAT-
MENT OF DELINQUENCY.—Lectures,
280; unwilling patient, 25
J gh HOSPITAL MEDICAL SOCIETY.—
LISTERIAN SOCIETY.—302
LIVERPOOL MEDICAL INSTITUTION .—
Abortion, criminal, 812; broncho-
scopic clinic, 987 ; centenary, 1184,
1362; cystic disease of lungs,
congenital, 325; gastritis, 757;
hepatitis and cholecystitis, 446 ;
lobectomy, 987; microcolon, con-
genital, 813 ; cestrin content of blood
and urine, 571; prostatectomy with
closure, 326; skin, tumours of,
758; eh ee kidney with giant
ureter, 813
MANCHESTER MEDICAL SOCIETY.—Colon,
neoplasm of, 988; gastritis, 757;
h:emorrhagic diathesis, 570; indus-
oe: diseuses, 27; skin, tumours of,
75
MEDICAL OFFICERS OF SCHOOLS
ASSOCIATION. —Air-raid precautions,
967; physical education and nutri-
tion,
MEDICAL SOCIETY OF INDIVIDUAL
PsycHoLoGcy.—Adler, A., influence
of (Sir W. Langdon-Brown) (C) 1433 ;
emotions of children, 792; mind of
child, 4191; psychological "approach,
1525
MEDICAL SOCIETY OF LONDON.—Dinner,
671: dorsal decubitus, 633; facial
paralysis, 390 ; jaundice, 511 :Jabora-
tory training, 267; Lettsomian
lectures, 401 ; perspective and poise
in medical practice (A) 11380
MEDICAL SUPERINTENDENTS’ SOCIETY.
— Dinner, 790
MEDICAL WOMEN’S FEDERATION. —
Fevers, treatment of, 389 ; obstetrics,
adyances in, 1465
MEDICO-CHIRURGICAL SOCIETY OF EDIN-
BURGH.—Facial expression of sick
child, 1427 ; tabes dorsalis, 655
MEDICO-LEGAL SOCIETY.— Blood groups
in atliliation cases (A) 1060 ; silicosis,
566
NATIONAL ASSOCIATION FOR PREVEN-
TION OF TUBERCULOSIS.—Conference,
487, 905
NORTH OF
ENGLAND OBSTETRICAL
AND GYNECOLOGICAL SOCIET Y.—
Adenomyoma causing intestinal
obstruction, 1054: hormone clinic,
447: labour, obstructed, 269, by
fetal bladder, 1054; mucocele of
appendix, 758; pregnancy, extra-
uterine, 758; prolapse, operation
for, 759; pseudomucinous ovarian
cyst, 447 ; ruptured uterus, 269;
sarcoma of ovary and lung, 759;
twins, locked, 758; varicocele in
female, 759
OPHTHALMOLOGICAL SOcIETY.—Exoph-
thalmic ophthalmoplegia, 1110:
Nettleship -medal, 1111; papill-
cedema, 1109; retinal detachment,
09
ROYAL ACADEMY OF MEDICINE IN
IRELAND.—Diabetes and pregnancy,
1173; face presentation, 1174;
varicose veins in pregnancy, 1173
RoYAL MEDICAL SocireTy.—Bicen-
tenary, 654
ROYAL MEDICO-CHIRURGICAL SOCIETY
OF GLasGcow.—lI*undus oculi, bio-
microscopy of, 571; hip, lesions of,
871; histology, rapid, in diagnosis,
871; hyperthyroidism, basal meta-
bolism in, 871 paralysis, fracture,
871; plasma phosphatase in bone
disease and jaundice, 87: X ray
dosage, 87
ROYAL MEDICO-PSYCHOLOGICAL
ASSOCIATION.— Examinations, 1148;
meeting, 1569
ROYAL SoomtTY OF MEDICINE. —
Sections of: Comparatiye medicine,
811 Epidemiology, 569, (LA) 934,
1401 POFYUROIORT (A) 1183, 1526—
Medicine, 24, 442, 513, (LA) 519,
S10, 140 1- “Neurology, 755—Obste t-
trics and eyneecology (A) 995—
Odontology (A) 8&22—Ophthalmo-
logy (A) 157—Orthoprdics, 631—
Otology (A) 642, 1171, (LA) 1234,
1526—Proctology, 1283—Psychiatry,
radiology, 629,
629—Thera-
1462—Urology,
442, (LA) 519, 928
985—Surgery, 386,
peutics, 148, 692,
- 1052, 1336
Subjects of discussion: Air condi-
tioning, 1401; alimentary tract,
investigation of, 985; ancemias,
macrocytic, liver and yeast in, 693:
anesthesia, spinal, neurological
sequel of, 755; asphyxia neona-
torum (A) 995; aspbyxiating gases,
respiratory system and, 810; aural
medicine, problems of, 1528; bron-
chiectasis, early, in children, 1527 ;
cerebro-spinal rhinorrhea (A)
1183- colon, diseases of, 1283:
deaf children, hearing and speech
in, 1528; diphtheria immunisation
(L.A) 934: ear, nose, and throat in
children’s diseases, 1527 fractures,
ununited, 631; heart disease, con-
genital, 324; hyperthyroidism and
thyrotropic hormone of pituitary,
1462: malignant disease, irradiation
in, 629: mental disorder and endo-
crine glands, 442, (LA) 519; mental
disorder and head injury, 928 :
milk and disease, 513 ; nerve injuries.
peripheral, 386: nutrition, infectious
disease and, 811; orbital cellulitis
due to sinus infection, 1526; otitis
media in childhood, 1171, (LA) 1234:
perurctbral operations, 10: 53°
pituitary and gastric secretion, 692 ;
prostatectomy, closed, 1052: pro-
taumine insulin, 148, (LA) S77:
pvorrhaa (A) 822; retinal staining
(A) 157; spinal injuries and bladder,
1053: testis, undescended, 1053:
tilt test (A) 642 ; tinnitus, physical
aspects of, 1528 ; tuberculosis, genito-
urinary, 1336; tuberculous ulcera-
tion of mouth and pharynx, 1527
`
Supplement to THE LaNceET]
INDEX TO VOLUME I., 1937
[Avavsr 14,1937 xxiii
Weil’s disease, 569—Address, 362;
Coronation reception (A) 1184;
Nichols fellowship, 119
SOCIETY FOR THE STUDY OF INEBRIETY.
—Alcohol and motor accidents, 183
SOCIETY OF MEDICAL OFFICERS OF
HEALTH.—Child welfare, 512; elec-
tion, 1314; enteritis, acute, 444;
heart in diphtheria, "1465; infant
nutrition (C. Asher) 221; obstetric
practice, future of, 1285; ’ whooping-
cough, 565
. SOCIETY OF
Dinner, 543
SOUTHAMPTON MEDICAL SOCIETY.—
Plant viruses, 827
RADIOGRAPHERS.—
SOUTH-WEST LONDON MEDICAL
SocrEeTy.—Meeting, 1148; physical
signs, 1464
TUBERCULOSIS ASSOCIATION .—- Life
assurance and tuberculosis (O. May)
493, (LA) 519; meeting, 1149, 1315
UNIVERSITY OF LONDON MEDICAL
GRADUATES SOcIETY.—(C) 598 ;
_ dinner, 905
WEST KENT £IMEDICO-CHIRURGICAL
SOcIETY.—Dinner, 1148
WEST LONDON MEDICO-CHIRURGICAL
SOcIETY.—Cavendish lecture (A)
1474; colon, diseases of, 635;
negligence actions, 145; sudden
death, 927
Society for Relief of Widows and Orphans
of Medical Men, 181, 1029, 1315
Society of Apothecaries of London—
dinner, 542; diplomas, 61, 302, 542,
847, 1148; examinations, 904; pass
rte 61, 302, 542, 847, 1148, 1380,
143
Society of Public Analysts, 242, 487
Sodium metabolism, seeSuprarenal glands
Solomons, E., on varicose veins in
pregnancy, 1173
Somerville, G., school routine (C) 723
Sorsby, A., on retinal staining (A) 157
Soviet, see Russia
Soya bean, nutritive tests of, 1563,
in Indian children (A) 1474
Spain—ambulance in (K. Sinclair-Loutit)
PIC) 1188, (C) 1252; Bibao child
refugees (A) 1239, (R. W. B. Ellis and
A. E. Russell) 1303, (PT) 1378, 1383,
(PI) 1441, (A) 1418, (PI) 1495, 1564,
trachoma’ and (PT) haat (A. F.
MacCallan) (C) 1310, (R. B. Ellis
and A. E. Russell) (C) i371, (A) 1418 ;
blood transfusion for wounded in
(A) 1359, 1523, (LA) 1531; British
hospital ship and (PI) 787; evacuation
of Madrid (PI) 298; fever hospital in,
1438; Red Cross in, 184, 1028, (PI)
1564; relief for (LA) 1118; Spanish
Medical Aid Committee, 98; surgeons
wanted in (Lady Young) (C) 663,
Ser of honour and (Sir G. Young) (C)
“DET et postural deformities of spine
Spas, see Health resorts and Rheumatism
Special areas, see Depressed areas
Spectacles, see Eyes
Speech—Clinica] Studies in ° Speech
Therapy (A. H. McAtlister) (A) 939;
Gateway of Speech (F. Parsons) (A)
939 ; a our Stammer and How to Cure
It (Å. St. J. Rumsey) (A) 939; see also
eaf
Spende, A. W.. hormone treatment of
undescended testis (C) 663
Spencer, G. H. (0) 904
Sperm-survival, see Fertility
Spillane, J., tryptophane reaction in
ccrebro-spinal fluid, 560
Spinal cord, see Anæmia and Nervous
system
ee ar pathological dislocation of
(G. H. Steele) 441; injuries of, bladder
and, 1053; sciatic scoliosis’ (E. N.
Wardle) 749; ; see also Posture
Spleen—enlarged, staphylococcal septi-
cæmia and (F. a Phillips) 1050 ;
metastasis in (W. H. McMenemer) 69] ;
splenectomy, results of, 426; see also
Schistosomiasis
Sprawson, Sir C.,
1129, 1187
Sprigge, A. B. S., on lip-reading and
speech in deaf (LA) 700
Sprigge, Sir Squire (O) 1550
Spriggs, Sir E., on diseases of colon, 1283
Squint, see Eyes
Stacey, M., immunisation with Bacé.
typhosum, 252, (LA) 274
on care of tuberculosis,
Stamp, T. C., immunisation with hsmo-
lytic streptococci, 257, (LA) 274, 368
r H. J., Williams’ Obstetrics
Stansfield, F. W. (O) 666
Staphylococcal infection—relapsing, cir-
rhosis and (F. A. Phillipps) 1050;
urinary calculi and (A) 996; see also
Otitis
Starlings in London (A) 1122
Statistics—Statistical Methods in Biology,
Medicine, and Psychology (C. B.
Davenport and M. P. Ekas) (R) 90;
see also Medical statistics and Vital
statistics
Stebbing, G. F., on irradiation in malig-
nant disease, 630 ; on wave-length in
radiotherapy, 1488
Steele, . pathological dislocation
of atlas, 441
Stent, L., serum treatment of lobar
pneumonia, 795, (A) 1121
Stent composition, see Urethra
Stephens, H. F., prisoners and captives
(C) 1204 l
Stepbenson, D., diaminosulphone in
streptococcal infections, 1331, (A) 1357,
1536; P- -aminobenzene- sulphonamide
in non-streptococca! infections, 681
Sterilisation—in Bermuda, unemployment
Ta (PI) 1026; voluntary (PI) 961,
1
e ee of (A) 38; dict and,
1478; aed eee infection and (M.
Kenny) 4, (A) 218; see also Fertility
Stewart, C. P., on ascorbic acid in urine,
48
Stewart, Sir H., trust fund (A) 336
Stiebeling, H., on League of Nations
and pute 695
Stiles, P. G., Human Physiology (R) 574
Stiller, B., centenary of, 1426
Stomach—acidity of (S. Gereb and F.
Körösy) (C) 172, 204, (A) 215 (E. Földes
(C) 411, alcoholism and (A) 1292,
(D. Jennings) (C) 1371: cancer of
(LA) 329, 757, get 985, (D. Leys) 1217,
(C) 1433, (H. C. *Edwards) (C) 1308,
(Sir A. Hurst) (C) 1369, 1484, familial
achlorhydria and (A. . Levin and
B. A. Kuchur) 204 ; Chronic Indigestion
(C. J. Tidmarsh) (R) 449; gastritis,
757; peste ecoRy (LA) 520 ; gastros-
tomy (A) 1296 ; movements of, during
opaque meal, 490 ; pituitary gland and,
692, insulin ‘and (H. Levy) (C) 1137;
polyposis of (C. C. Holman) 24;
pyloric stenosis (A) 216, (T. I. Bennett)
552 ; see also Anremia, Gastro-enteritis,
Heemoprhage, and Peptic ulcer
Stone, J., Bright’s Disease and
Arterial Hypertension (R) 516
Stovarsol, see Neurosyphilis
Strecker, H. P., hypoglyceemic shock in
schizophrenia XC) 840
Streptococcal—and meningococcal menin-
gitis (A. A. Cunningham) 198, (LA)
211; fractions, immunising activity of
ere? Stamp and E. B. Hendry)
257, (LA) 274, 368; sera, typing of,
14793; see also—
Streptococcal infections—chemotherapy
of (A. T. Fuller) 194, (LA) 211, (G. L.
Robinson) 509, (L. D. B. Frost) 510,
(A) 525, 612, (A) 579, (J. Whittingdale)
(C) 599, (G. Discombe) 626, (T. B.
Layton) C) 658, (H. Proom and
G. uttle) (C) 661, 710, (Sir D.
Wilkie) 735, (I. Vitenson and G.
Konstam) 870, (A) 1061, (J. P. J.
Paton and J. C. Eaton) 1159, C) 1369,
(B. A. Peters and R. : avard)
1273, (G. A. H. Buttle, D. Stephenson,
S. Smith, T. Dewing, and G. E. Foster)
1331, (G. E. Breen and I. Taylor)
1334, (A) 1357, 1466, 1476, (J. J.
Hammond) (C) 148 4, (L. E. U. Whitby)
1517, (A) 1536; hospital closed for
R. C. Cooke) (C) 664; see also Oral,
titis, Puerperal infection, Rheuma-
tism, and Scarlet fever
Strie atrophicæ cutis (D. B. Rosenthal)
557
Strike, report. o in a hogpkal, 426
Strong, O., Elw = Bailey’ 8
Textbook of Histology aa 517
Students, medical—Clinical Handbook
for Residents, Nurses, and Students
(V. M. Coppleson and D. Miller) (R)
932; compulsory immunisation of,
947; numbers of (A) 641; Organic
Chemistry for Medical Students (G.
Barger) (R) 1176; summer vacation
and, 775, (C) 1252 ; tuberculosis in,
1033, 1093; see also Education,
medical
Stuffiness, see Air-conditioning
Sturrock, A. C. (O) 903
Subacute combined degeneration, see
Anemia, pernicious
Substance 36, see Myasthenia, gravis
Sucrose, hypertonic (LA) 10
Suicide—Buda est Sarai of, 109;
in mental hospitals, 850; see also
Poisoning
2u Pan mo Op es and methæmo-
globinæmia (L. D. B. Sron 510, (A)
525, 612, (G. Discombe) 626, (J. P.
Paton and J. C. Boton) 1159, (C) 1369,
1331, (A) 1476, (J. A. J. Hammond)
(C) 1484, 1517
Sul phanilamide, see Chemotherapy
Sulzberger, M. B., and Wise, F. M.,
Year Book of Dermatology and
Syphilology (R) 990
Suprarenal glands—Addison’s disease,
hypoglycemia and (I. A. Anderson
and A. Lyall) 1039, (A) 1063 ; Addison’s
disease, potassium and (LA) 639;
angina pectoris and, 1244; male
gonads and (W. Cramer and E. S.
Horning) 1330; precociiy and, 62;
sudden death and (C. K . Simpson) $51
Surgery—congress, 180; experimental
outlookin (D: Wilkie) 735; hundred
years ago (R. Kelly) 1361 ; Minor
Surgery (F. Chrictopier) (R) 574 ;
old age and (A) 1180; Operations of
Surgery (R. P. Rowlands and P.
Turner) (R) 209, (W. H. Ogilvie) (C)
90; Operative Surgery (A. Miles
and D. P. D. Wilkic) (R) 931; Practi-
tioners’ Library of Medicine and
Surgery (G. Blumer) (R) 989; Royal
Surgical Aid Society (A) 1059 ; ‘Surgical
Note-taking (C. F. M. Saint) YR) 271;
Surgical Pathology of the Thyroid
Gland (A. E. Hertzler) (R) 1467;
Year Book of General Surgery (E. A.
Graham) (R) 638; see also Anatomy,
Orthopeedics, Plastic surgery, Post-
operative, and—
Sutures—catgut sensitivity (A) 35; silk,
in France, 654
Swain, V. A. J.,
vaginitis, 868
Sweating, abnormalities of (A) 1120
Sweepstakes, Irish hospitals, 834, 1380
Symonds, C. P., mental disorder and
head injury, 928
Sympathectomy—in disease of’ colon,
1283; in hyperpiesia (A) 997; in
thrombo-angiitis obliterans, 549
Sym patheticsystem, see Nervous system
SA Re ONECA, 388, 894, in mono-
vular twin (L. Penrose) 322; diag-
nosis of, 388; z phases in (LA)
1178; Latent Syphilis (G. Evans) (R)
1530 ; neoarsphenamine and immunity
in, 109: Year-Book of Dermatology
and Syphilology (F. M. Wise and M. B.
Sulzberger) (R) 990 ; see also Aneurysm,
Neurosyphilis, Venereal disease, and
Wassermann reaction
tuberculous vulvo-
T
Tabes dorsalis, see Neurosyphilis
Tarsal, see Foot
Tasman, A., trypsin and diphtheria
toxin, 1228, 1318
ma Aomoria grants and scholarships,
Tauber, H., Enzyme Chemistry (R) 990
Tavistock Clinic, see Psychology
Taylor, H., on gastroscopy (LA) 520
Taylor, H. J., short-wave therapy (C) 1075
Taylor, I., prontosil in erysipelas, 1334,
(A) 135
Taylor, J. (O) 1014
Taylor, S.; scurvy and carditis, 973
Tchaperoff, I. C. C., Menua of Radio-
logical Diagnosis (R) 1529
Teeth—amalgam for, 733; Dental
Surgery and Pathol (T. W. Widdow-
son and E. V. B. Widdowson) (R) 637 ;
deputation pes 1498; dict and, 710;
disease of, prevention of (H. J. Morris)
(C) 52; extraction of, medical treat-
ment and (PCP) 345, (PI) 420, (PCP)
1549; impacted third nolar (A) 579;
of school- children, report on, 59;
Principles of Dental Medicine (F. W.
Broderick) (R) 761; structure of,
1032; see also Dentists register,
Mouth, and Oral
Tegner, W., gold therapy, 554
Teora, E. D., thrombo-angiitis obliterans,
xxiv Supplement to THE LANCET]
INDEX TO VOLUME I., 1937
Temperament, see Nervous disorder and
Psychology
Temperature, taking of, in children
(Bs ETSN) (C) 724, (C. E. Donaldson)
Tenosynovitis, lea care (A) 768
Testis—undescended surgery of, 1053;
sce also Sex hormones
Tetanus—cephalic ee . Wilkinson) 753 ;
negligence and,
Tetany, pe erprcni hing (R. y McCance
and E. Watchorn) 200, (J. N. Cumings
and E. A. Carmichael) 201, (C.
Barnes and R. DN le TRANGE) (C) 291
Thackrah, M. (O) 2
Theobald, G. W., alci and vitamins A
and D in toxemia, 1397
Therapeutics—Art of Treatment (W. R.
Houston) (R) 760; Essentials of
Modern Medical Treatment (V. Norman)
(R) 89; Physiological Principles in
Treatment (Sir W. Langdon-Brown and
R. Hilton) (R) 209; Practical Prepara-
tions, Mainly Medical (N. W. Powell)
(R) 393; Principles of Diagnosis, Prog-
nosis: and Treatment (R. Hutchison)
(R) 879; trend of (A) 276; see also
Pharmacology and Physical ‘treatment
ahs, , cystic swellings of (E. A. Devenish)
Thoma, K. H., Oral Dibgrosls and Treat-
ment Planning (R) 1
Thomas, C. H., nasal aE in child-
hood (C) 351 ; on tinnitus, 1528
Thompson, A. H., death of, 155, (O) 237
Thompson, K. S., Elementary Pathology
Thomson-Walker, Sir J., on
injuries and bladder, 1053
Thoracoplasty, see Tuberculosis, pul-
monary, surgery of
Thorotrast—fate of, in cerebral arterio-
graphy (D. W. C. Northfield and D. S.
Russell) 377; value and dangers of
(C. Elman and E. Haworth) 981
Throat—Diseases of the Nose, Throat,
and Ear (I. S. Hall) (R) 1055; intlam-
mation of, dislocation of atlas and,
l; Physical Therapeutic Methods
in Otolaryngology (A Hollender)
(R) 874; Practitioners’ Library of
Medicine’ and Surgery: Vol. XI.
Eye,’ Kar, Nose, and Throat (G.
Biumer) (R) 989; rheumatism and
(H. Barwell) 67; sore, bismuth for, 1010 ;
tuberculous ulceration of, 1527; Year
Book of the Eye, Ear, Nose, and
Throat (R) 449; see also Tonsils and
Streptococcal infections
Thrombosis—of mesentery, labour and
G. Turner) 802; of popliteal and
fomoral arteries (A. M. Boyd) 382;
thrombo-angiitis obliterans (E. D.
peor 549, choline derivatives in
(A) 940; see also Arteries and
Iembolism
Thyroid gland—cancer of (A. Haas) 1155;
exophthalmic ophthalmoplegia, 1110;
Gravos’s disease (A) 521; hyper-
thyroidism, basa] metabolism and, 871 ;
hyperthyroidisin, suprarenal atrophy
und (I. A. Anderson and A. Lyall)
1039, (A) 1063; L.C.C. goitre clinic,
spinal
$93; surgery of, 735, (Surgical Patbo-
logy’ of the Thyroid Gland) (A. E.
Hertzler) (R) 1467; The Thyroid
(E. P. Sloan) (R) 518: vitamin C and,
109; see also Cretinism and Hormones
‘Tidmarsh, C. J., Chronic Indigestion
(R) 449
Tighe, H. V., on diabetes and pregnancy,
1173
T:
Tindal, A., gas-and-oxygen analgesia
in labour, 1271
Tinnitus, physical aspects of, 1528
Tippett, G. O., patella (C) 1308
Tissue—permeability and local ee
1479; Tissue Immunity (R. L. Kahn)
73
Tissue culture—Mecethods of Tissue Culture
in Vitro (R. Buchsbaum and C. G.
Loosli) (R) 394
Titus, P., Management of Obstetric
Diffieulties (R) 574
Tizzard, T. H. S., corneal grafting, 1106
Tod, H., cestradiol benzoate at meno-
pause, 320 ;
Todesco, J. M., diphtheritic hemiplegia,
5
8
Tomograph, improved (A) 12914
Tongue, see Mouth
Tonks, H., death of (A) 160
Tonsils— incomplete removal of (ML)
531: see also Quinsy, Streptococcal
infections, and Throat
Topley, W. W. C., anti-Vi phage in
typhoid, 319; immunisation with
Bact. typhosum, 252, (LA) 274
Topping, A., on treatment of fevers, 389
Tours, medical, 543, 582, 1438
Toxicology, see Drugs and Pharmacology
Trachoma—Trachoma (A. F. MacCallan)
(R) 4483 see also Spain
Trade marks, see Drugs
Trades Union Congress, British Medical
Association and, 351
Trail, R. R., prognosis of pulmonary
tuberculosis, 247
Transurethral, see Urethra
Trauma, see Injuries and Shock
Traveller’s Rest (P. Gosse) 850
Treatment, see Therapeutics
Tropical medicine—blackwater_ fever,
pseudo-methrmoglobin in, 1524 ey
1533; cheiropompholyx (D. J.
Fitz-Patrick) 25; jaundice and ionini
discases, 512 ; research, 711, 1206
Troup, W. A. , nasal sinusitis in childhood
(C) 233
Tryptophane, see Tuberculosis
Tsetse, eradication of (A) 939
Tuberculin tests—exposure to infection
and, 1033; radiological findings and
(A) 525, (O. Scheel) 922 : ; report on, in
France, 113
Tuberculosis—after care of, 1366; con-
trol of, examination of (A) 216;
cystic swellings of thighs and (E. A.
Devenish) 869;
tion and, 1305, 1480; dispensary
service, 1093, (LA) 1117, (A) 1416;
Empire Conference, 1129, 1185; in
France, industrial campaign against,
1426; in infancy (A) 769; in Norway,
survey of (A) 643; in Rumania, 1559 ;
in school-children (PI) 1086: in
Sweden, 1149; International Union
against Tuberculosis, 532, 1206, 1257,
1315; in U.S.S.R., 651, 969 : in
Wales, 359, 1185, (PI) 1377; in’ wild
voles (A. Q. Wells) 1221, (LA) 1233;
life assurance and (O. May) 493,
(LA) 519; local authorities and (PT)
1314; meningeal, tryptophane reaction
and (J. Spillane) 560; of abdominal
eke atic Sonan e (G. E. Colt and G. N.
o 125, (E. H. A. Pask) (O) 234,
(M. C. Wilkinson) (C) 290, (G. H . Colt)
(C) 474; of cervical glands (Sir L.
Barrington-Ward) 980; of hip, 871;
of mouth and pharynx, 1527 ; of
suprarenal gland, 851; otitis and,
1172, (LA) 1234; surcical, 1186 ;
tubercle bacillus and (L’ infection bacil-
laire et la tuberculose) (A. Calmette,
A. Boquet, and L. Nègre) (R) 931;
vulvovaginal (V. A. J. Swain) 868;
see also Bovine tuberculosis, Genito-
urinary, Papworth, Tuberculin, and—
Tuberculosis, ulmona ry—attendance on,
risk of (LA 91, 1033; early diagnosis
of, 1366; focus reactivated by pneumo-
coccus (W. Pagel) 1279; miliary, chronic
(A) 997; prevention. of (P. M. D.
Hart) 969, 1033, 1093, (LA) 1117;
prognosis in (R. R.: Trail) 247, after-
care and (R. S. Walker) (C) 410 ;
sce also Mines and—
Tuberculosis, pulmonary, surgery of—
artificial pneumothorax (A) 399, a
Morland) (C) 473, 493, (LA) 519, (A. B
Hill) (C) 535, (H. Roche) (C) 597, 711,
electric aspirator for (F. Heaf) 1NI) 86;
artificial ppeumothorax refills (A) 1238 ;
in France, 1426; in Ireland, 1481;
L.C.C. unit for, 893; pneumolysis,
internal (F. G. Chandler) 83; prognosis
of (R. R. Trail) 247; thoracoplasty
(LA) 519
Tularemia in Austria, 717
Tuimours—endometrioma of vulva (F.
Riggall and C. Riggall) (C) 475;
of hand ral 880; of nail-beds, epiloia
and (S. G. James) 1223; of nervous
system (A) 4583 size of, 491:
Cancer and Totracrapial
POTE see Biliary
Turner, G., intubation for perforated
ae ee (C) 348; labour compli-
cated by thrombosis of mesentery, 802 ;
omentopexy (C) 292; on Paget tradi-
tion (A) 1417, 1477 : on undescended
testis, 1053 ; Sir J. Bland- Sutton (C) 51
Turner, P., and Rowlands, R. P., Opera-
tions of ‘Surgery (R) 209
Mareen E. W., on improved tomograph
Tra ee 755; monovular, con-
genital syphilis in (L. S. Penrose) 322;
see also Geneties
Typhoid fever—blood-cultures in, adrena-
line and (A) 580; chemotherapy of
typhoid infections (G. A. H. Buttle,
H. Parish, M. McLeod, and D.
Stephenson) 681, (A) 1061, 1536 ;
compulsory vaccination against, in
see also
diphtheria immunisa-.
UNIVERSITIES.— Aberdeen :
I
1189, (E. W. Goodall) (C) 1252;
milk and, 513, (PI) 670, 898, (PI) 108:
1141, 1379, (PI) 1491; Vi antigens
immunity and (W. W. C. Topley, I
Raistrick, J. Wilson, M. Stacey, S W.
Challinor, and R. O. J. Clark) 25
(LA) 274, (I. N. Asheshov, J. Wilsor
and W. W. C. Topley) 319, 1420
France, 947 ; disputed will and (ML)
EF to
Ultracentrifuge observations, 1421
Ultra-violet, see Physical treatment
Underwood, E. A., on
prophylactic
immunity in fevers, 389 N
Undulant fever—abscess of bone and
(J. L. Edwards) 385, (Sir W. Dalry mple-
Champneys) (C) 839; carly diagnosis
of, 590; in United States, 936; milk
and, 513
Unemployment—assistance regulations
(PI) 57, workmen's compensation and
(PI) 1086; dental treatment and (PI)
1495; in Bermuda, sterilisation and
(PI) 1026; meals at instruction centres
(PI) 669; Papworth, unemployed men
at (PI) 483; Unemployment Assistance
Board, persons transferred to, from
ublic assistance (PI) 1564; see also
epressed areas, Needs, and Nutrition
United States—Alvarenga prize, 529:
American Ideal (A. Bryant) 124:
American Pharmaceutical Association
Year Book (R) 1468; amcebic dysen-
tery in Chicago (LA) 649 ; Bureau of the
Census reports (A) 997; contraception
in, 1317; fever therapy congress, 179,
1007, (A) 998; floods in Ohio (A) 336;
nostrums, sale of (Nostrums and
Quackery) (A. J. Cramp) (R) 573,
(LA) 817; Surgeon-Gencral’s report
(A) 702; undulant fever in, 936;
venereal disease in (LA) 33, 425, 700
UNITED STATES, CORRESPONDENCE FROM.
—American Medical Association, 1425—
American Psychiatric Association, 1 124
— Births, diseases, and deaths, 1424—
Children’s bureau, 1133—Medical care
report on, 894—Nationa! Tuberculosis
Association, 1425— Public health, 834,
1133, 1479—Rabies, 1424- Scholar-
ships for practitioners, 835— Trailers,
1480—Venereal disease, 466
Universities—directory of (Minerva :
Jahrbuch der Gelehrten Welt) 453;
Parliamentary election for, 592; Uni-
versity Grants Committee (A) 160
appointment,
242; degree, 904; diploma, 904;
donation, 1028— Birmingham : Appoint-
ment, 542; lectures, 904, 963; post-
graduate courses, 963—Bristol, pass
list, 1568—-Cambridge : appointments,
242, 607, 671, 847; degrees, 242, 302,
421, 542, 730, 1028, 1147, 1206, 1257,
1380, 1437, 1497, M.B. thesis and (A)
3355 i arly Science in Cambridge
. Gunther) (R) 1409; elections,
: lecture, 1087; members,
coépted, 487 pass list, 421; prize,
s scholarship, 1437; vacancy,
242-—Dublin: lecture (A) 1296: pass
list, 904—Durham, degree, i
Edinbur: h: prize, 302; students”
362— Egypt, appointment.,
1314- Glasgow : appointment, 542:
degrees, 1087; lectures, 905, 1380
— eeds ; appointments, 789; dona
tions, 61; election, 789; fellow,
789; pass list, 817; readerships, 243—
Liverpool : lecture, 362: pass list,
789—London : appointments, 421, 542,
671, 765, 789, 963, 1314, 1568: con-
verrazione, roa degree, 1380:
examiners, 963, 15635; EROA 118,
180, 671, 963, 1028; medals, 671 ;
pass lists, 118, 180, 242, 847, 963,
1147, 1437; readership, 302 repre-
sentative, 1568; research grants, 421,
847; studentships, 302, 421, 1437:
teachers, 180, 671, 1568—Manchester :
appointinents, 487. 730; grant, 1148;
Journal of tbe University of Man-
chester (A) 999 ; medical library, 946—
Oxford: appeal, 407, medical graduates
and (A) 1182; appointments, 361,
730, 1497; degrees, 302, 607 ; elections,
Supplement to Toe LANCET]
730; lectureship, 1380; Nuffield
appointments, 607, 730, 789, 1087,
1314, 1437 Old Ashmolean Museum
(A) 820, 1237; Parliamentary election,
106, 607 : senior students, 1380;
studentship, 302——-St. Andrews: chair
‘ of dental surgery, 421 ; extension, 421—
Sheffield: appointments, 1257, 1498;
pass list, 904; prize, 1257—Wales,
‘pass list, 1498
Unregistered practitioners (ML) 166,
285, (Sir E. Graham-Little) (C) 291,
(PI) 419, 1244, of dentistry (A) 1356
Upcott, H., cardiac ee (C) 535
Unremia, parotitis and (R. T. Payne) 867
Ureters—im plantation of, in bowel (A)
879; see also Genito- urinary
Urethra—cancer of, Stent composition in
radium treatment of (C. White) 1462 ;
irrigation catheter for (P. P. Cole) (NI)
1286 ; rupture of,witboutextravasation
(L. Rogers and A. L. d’Abreu) (C) 232 ;
transurethral operations (A) 277, 1053
Urinary infections—amino compounds in
(A) 525, agranulocytosis following
(J. G.G. Borst) 1519; calcium mande-
late ae (E. Schnohr) 1104; diet in
(H. Coombs, C. H. Catlin, and D.
ader 1043, (E. C. Fountaine) (C)
1075; see also Calculi, Genito-urinary,
Kidney, Urethra, and—
Sl ar uoresceinuria (G.
86; hemoglobinuria following exertion
(W, H.W. eriat A, suppression of,
blood transfusion and (S. L. Baker)
1390 ; suppression of, saline therapy in
(A) 998; see also Ascorbic acid,
Aschheim- Zondek, and Post-operative
Urology—Medical Urology (I. Koll) (R)
aoe Modern Urology (H. Cabot) (R)
Urological Roentgenology (M.
Wesson and H. E. Ruggles) (R) 209
U.S.S.R., see Russia
Uterus—cancer of, 893, cervical (LA)
153 ; contractions of (A) 4573; curette
and sound for (G. L. Foss) (NI) 698 ;
oystie degeneration of chorionic villi
(C. Hollósi) 808 ; eyste endometrium,
ovarian cyst and, 447; menstrual
fistula and (R. G. Maliphant) 1509 ;
cestrin-stimulation and cervix S.
Zuckerman) 435; prolapse of, 759;
ruptured, 269
Discombe)
V
vaneen; weekly lists of, 66, 119, 184,
246, 368, 424, 488, "545, 610, 676,
732, 791, 849, 906, 964, 1030, 1089,
1150, 1208, 1261, 1315, 1382, 1441,
1499, 1570 f
Vaccination—Association of Public
` Vaccinators, 548; deaths following
(PI) Ee 1027 ; disfigurement by
(R. . Austin) (C) 612; see also
Cral. ne
Vaccines, ee bottle for (S. G. Rains-
ford) (NI) 15
sole cancer. at Stent composition in
radium treatment of (C. White) 1462 ;
see also Vulva
Varicocele—in army re (C. Flem-
ming) (C) 53, (P. A. Hall) (C) 410;
in female, 759
Varrier-Jones, Sir P., on care of tuber-
culosis, 1131
Vascular, see Arteries,
and Veins
Vaughan, Di on blood transfusion, 1523,
Veins—stasis in, repair and (A) 1061;
Studies in Cardiovascular Regulation
(G. V. Anrep) (R) 873; varicose, in
pregnancy, 1173; venous hum (J. L.
Bates) 1108, (Sir A . Hall) (C) 1202,
Blood pressure,
(M. R. Kenawy) 281; see also
Aneurysm, Diverticulitis, Embolism,
and Thrombosis
Venereal disease—control of (LA) 33,
47, 425, 466, (LA) 700, 1425, (PI) 1562,
1565, publicity and, 1255; marriage
and r 417, (A) 643; On Your
Guard (C. Warren) 1209 ; ” prostitution
and, 1438; Venereal Disease (D. Lees
and R. Lees) (R) 872; see also Gonor-
thea and Syphilis
Ventilation, see Tndustital medicine
Vereen see Intracranial
Vernon Accidents and Their
Prevention (R) 1340, (A) 138573 on
alcohol and motor accidents, 183
INDEX TO VOLUME I., 1937
Verzar, F., and McDougall, E. J., Absorp-
tion from the Intestine (R) 210
Veterinary, see Animals
Vi-antigens, sec Typhoid fever
VIENNA, CORRESPONDENCE FROM.—
Accidents, 229—Birth-rate, 531—Blood
prenut pulse- and respiration-rates
n children, 531—C Congresses, medical,
229—Prdheim, J., death of, 1244—
Hajek, M., birthday of, 229—-Halban,
J., death of, 1244—Health insurance,
228—Heart - disease, 1134—Jauregg,
W. von, homage to, 717—Klein, S.,
death of, 1244—Medical Society of
Vienna, centenary, 1560—Mortality
statistics, 532—Practitioners, numbers
of, 1560—Radiotherapist, first, 532—
Schrétter, L. von, centenary of, 717—
Sex characters, double change of, 1134
—Short waves, congress on, 1134—
Suprarenals and angina pectoris, 1244—
Tulareemia, 717
Vinethene, see Anesthesia
Viruses—cancer (A) 276, 1420; egg
membrane technique and (A) 279;
horse-sickness (A) 823, (C) 900;
influenza, 172, (LA) 575, 709; plant
(R. N. Salaman) 827; ‘poliomyelitis,
olfactory route and (A) 455, 462,
(LA) 875, (F. A. Pickworth) (C) 1076,
1548, (G. W. Rake) (C) 1433, (LA)
1532: rheumatism, 1420; vaccinia,
1479; variation in (A) 35
bee ag L., invention of road tarring
Vital statistics—American (A) 702, 997,
1424; Austrian, 531, 532; causes of
death in children, 299, 512; colonial
(A) 278; General Regi ister Office,
i245, 1308, (LA) 1531 ; infant mortality
(PI) 1085, 1431, in Hungary, 468;
Irish, 947; Jews, mortality of (A)
1295 ° Registrar-General’s statement
for 1936, 240 Russian birth-rate,
1334; Scottish, 898; see also Maternal
mortality and Population
Vitamin A—estimations ot 1421;
pregnancy toxemia (G. Theobal ald)
1397, (R. H. Paramore) O 1486, (J.L
Moir) (C) 1486 ; night- blindness and
(A) 769; vesical calculi and, re
Vitae 2 B—diphtheria and (B. A
and R. N. Cunningham) 563;
discase and (A) 878; neuritis and
(A) 159; research on, 1422, 1478;
retrobulbar neuritis and (D. F Moore)
1225, 1444; see also Anemia and
Pellagr a
Vitamin í C, see Ascorbic acid and sae is
Vitamin *D—calcification and, 14
in pregnancy toxsemia (G. W. Theobald)
1397, (R. H. Paramore) (C) 1486, (J. L
Moir) (C) 1486 ; teeth and, 710, 1365
Vitamins—irradiated foods and, 342 ;
vitaminised margarine, 847; see also
Nutrition
Vitenson, I., prontosil in streptococcal
meningitis, 870
Vivian, M., u OTO Tapy for drug
addiction, 1221, (A) 12
Vivisection, see anaes
Vocational guidance—Borstal inquiry
(LA) 575; ee of Vocational
. erence (C. A. Oakley and A. Macrae)
Voles, wild, ene in (A. Q. Wells)
1221, (LA) 12
Volvulus, see Tat tine
Vulva—endometrioma, of (T. Riggall and
C. Riggall) WA 475 ; tuberculous vulvo-
Swain) 868
. Peters
heart
vaginitis (V. A. J.
Wages, see Needs
Wales—hbealth services in
maternal mortality in, 1125, (LA)
1116; Second Industrial Survey of
South Wales (A) ee tuberculosis in,
359, 1185, (PI) 137
Walker, A Ais on materi in Willesden,
Walker, K., on perurethral operations,
1053
Walker, Sir N., presidential address, 1304
Walker, R. S., after-care in pulmonary
tuberculosis (C) 410
Walmsley, T., Manual
Anatomy (R) 272
(PI) 1561;
of Practical
[Auaust 14, 1937 xxv
Walther, W.
W., blood changes after
surgical operations, 6, (LA) 32:
lymphosarcoma simulating duodenal
ulcer, 1169
War— Death from the Skies (H. Liep-
mann) L572; population trends and
(LA) 1413; problem of, psychology
and (A) 1240, 1474; War Dance (E. G.
Howe) (R) 1410; see also Air-raid
precautions, Peace, and Spain
Ward, G., doctors’ notebooks of long ago
(C) 778
“eo J. F., on hemorrhagic diathesis,
Ward, R. O., arenai calculi, 23
Wardie, E , BCiatic scoliosis, 749
Wards, see Hoépitais
Warnock, M. (O) 486
Warren, ol ‘On Your Guard !, 1209
Wassermann reaction Complement, | or
Alexin (T. W. B. orn) (R) 9
mumps and (W. Smith) 754
Watchorn, E., overbreathing tetany, 200
Water balance—eclampsia and (A) 333;
intestinal obstruction and (A) 454,
(LA) 639 ; menstruation and (A) 522;
suprarenal and, 851 see also Post-
operative, Purgation, and Shock
Water colours, exhibitions of, 792
Water divining (ML) 228
Waterlow, H., death of, 218
Water supplies amæbic dysentery and
(LA) 64 chlorination of, in France,
590 ; London (A) 38;
and fauna of (A) 705;
491, (PI) 605
Waters, H., retroperitoneal sarcoma, 202
Watson, A. J., on fat embolism (A) 1181
Watson-Williams, E., bicentenary of
Bristol Royal Infirmary (C) 1487
Webb, H S. (O) 1435
Weber, F neevoid amentia (C) 1370;
on Thlers- s-Danios syndrome (A) 458
Webster, L on inheritance of resist-
ance to ifecilon (LA) 818
Weil, P. L., Hitschmann, E., and Bergler,
E., Frigidity in Women (R) 697
Weil’s disease—569; as industrial disease
(PI) 843; diverticulitis and pyle-
DEDANS simulating (W. T. Cooke)
4; in guinea-pig (N. Mason) 564
Weiss, S., on circulatory collapse (LA) 993
Wellcome, Sir H., will of (C) 289, (LA)
micro-flora
pollution of,
‘Wells, A. G., on speech in deaf (LA) 700
Wells, A. Q., tuberculosis in wild voles,
1221, (LA) "1233
wae C., on ao tated ons with closure,
Wells, H. G., on world oao peta
o 36; and Huxley, J., 8,
“How Animals Behave (R) 1468
Weld National School of Medicine, 790
Wenyon, E. J. (O) 725
Wesson, B., and Ruggles, H. E.,
Urological ‘“Roentgenology (R) 209
Westwater, J. S., intradermal tests in
whooping-cough (C) 289
Wheat-germ, sce Ansemia
eee Sir W., nephrostomy, 440
Whitby, L. E. H., amino compounds,
A) 1536
White, Stent composition in radium
treatment of cancer of vagina and
urethra, 1462
Whitfield, A., dermatitis due to motor
fumes, 265
Whittingdale, J., streptococcal infections
(C).5
Whittington, R. (0) 956
W hooping-cough — bronchiectasis and,
1527; control of, 565; lutradermal
tests for (B. O’Brien) 131, (J. P. J.
Paton) 132, ne S. Westwater) (C) 289
W ldnon nan V. B., and Widdowson,
.- T. Dental Surgery and Patho-
TA TR) 6
Wiggins, a sh. (O) 665
x .„ On tuberculosis in Tan-
ganyika, St 86
a ona deformities of spine,
911, (LA ) 936
Wilkie, Sir D., experimental outlook in
surgery, 735; on treatment of acute
infections (A) 579
Wilkie, D. P. D., and Miles, a Operative
Surgery (R) 931
Wiens, r W., on circulatory collapse
Wilkinson, J. (O) 116
Wilkinson F., on heemorrhagic dia-
thesis, si
Wilkinson, M
genito-urinary tuber-
culosis, 314, EA 329, (C) 411; tuber»
,culous ‘abdomina lands (C) 290
Wilkinson, P. B., cephalic tetanus, 753
Willcox, A. , electrocardiogram in coronary
disease, 501, (A) 524
xxvi Supplement to Tor LANCET]
William the Conqueror, medical history of
(R. R. James) 1151
Williams, I. G., newvocarcinoma of skin
and mucous membranes, 135
Williams, L., and Humphris, F. H.,
Emanotherapy (R) 1231
Williams, P., hormone treatment of
undescended testis (C) 597
Williams, R. (O) 115
wives, W. B., perforated peptic ulcer,
Williams’s Obstetrics (H. J. Stander)
(R) 28
Williamson, B., Handbook on Diseases
of Children (R) 516
Williamson, R. T. (O) 1311
Willmore, J. G., influenza and _ leuco-
penia (C) 347
ills 311,
» L., macrocytic anemia,
(A) 334, 693
Wilson, J., anti-Vi phage in typhoid, 319;
immunisation with Bact. typhosum,
252, (LA) 274
Wilson, J. G., on housing, 1364
Wilson, R. A., on asphyxia
natorum (A) 995
Wilson, S. A. K. (O.) 1253
Wilson, St. G., on operation for prolapse,
759
Wiltshire, H. W. (O) 295
Winch, G. H. (O) 1374
Winter—children in (A) 158; see also
British Health Resorts Association
Wise, F. M., and Sulzberger, M. B.,
Year Book of Dermatology and
. Syphilology (R) 990 .
Wishart, G. M., Cuthbertson, D. P., and
Chambers, J. W., Practical Physio-
logical Chemistry (R) 873
Withers, Sir J., medical privilege (C) 536
Witts, L. J., purgation, 427, (LA) 453
Wodehouse, R. E., on care of tuberculosis,
Wolff, E., Discases of the Eye (R) 1467
Wolff, P., on protamine insulin, 1443
neo-
l
INDEX TO VOLUME I., 1937
Women—athletics for (A. Abrahams) (C)
-899 ; Cecil Houses for, 1261 ; Frigidity
in Women (E. Hitschmann, E. Bergler,
and P. L. Weil) (R) 697; in Russia,
892; medical education of (N. H.
Schuster) (C) 954, (M. E. Shaw) (C)
1016 ; transparent woman, 548 ; work-
ing, holidays for, 1504; see also
Industrial medicine
Wong, K. C., and Lien-Teh, W., History
of Chinese Medicine (R) 271
Woodhouse, D. L., Fuchs
proteolysis test for cancer, 138
Woodmansey, A., rest houses for rheuma-
toid arthritis (C) 347
serum
Woods, R. S., fractures, 307
Woods, Sir R., on peripheral nerve
injuries, 386
Woodwark, Sir S., on nutrition and
physical training, 1365
Work, see Industrial medicine and—
Workmen’s compensation — Disability
Evaluation (E. D. McBride) (R) 327;
cpilepsy and (ML) 1243; Inter-
national Labour Convention and (PI)
605; means test and (PI) 1086;
Silicosis and (PI) 239, 566, 773, (LA)
764, (PI) 1378; see also Industrial]
medicine
Wounds, see Blood transfusion, Infections,
Injuries, and Shock
Wright, H. D., paratyphoid A, 1521
Wright, W. S., on locked twins, 758
‘
X
X rays—(Sir L. Hill) 1035; Freund, L.,
work of, 532: in cancer (A) 96, 332,
629, 1059, (W. Garton) (C) 1309, 1488,
dosage of, 87; in cancer, wave-length
CONCORDANCE
[AveusT 14, 1937
and, 1488; in gynæcology (Radio-
thérapie in gynécologique) (R. Mathey-
Cornat) (R) 1287; low voltage near-
distance, 1488; research on, 10323
see also Radiology
Yarr, Sir T. (O) 1080
Yearsley, M., hearing-aids (C) 411
Yeast, see Anremia
Young, F. H., on (LA)
Young, Sir G., debt of honour (C) 1485
Young, Lady, Spanish ambulance (C)
3
Young, R.
in medical practice (A)
tuberculosis, 1366
Young, W. A., memorial to, 1315
thoracoplasty
A., on perspective and poise
1180; on
Zahorsky, J., and Hamilton, B. E.
Pediatric Nursing (R) 697
Zondek, B., tumour growth in
physeal dwarfism, 689
Zoology, see Anatomy
Zuckerman, S., cestrin-stimulation ana
cervix uteri, 435; on water balance and
menstrual cycle (A) 522
Zunz fund, 730
hypo-
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